HB 3943

relating to prohibited conduct of a health benefit plan issuer in
relation to affiliated and nonaffiliated providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1.  Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1462 to read as follows:
CHAPTER 1462. AFFILIATED PROVIDERS
Sec. 1462.001.  DEFINITIONS.  In this chapter:
(1)  "Affiliated provider" means a health care provider
that directly, or indirectly through one or more intermediaries,
controls, is controlled by, or is under common control with a health
(2)  "Nonaffiliated provider" means a health care
provider that does not directly, or indirectly through one or more
intermediaries, control and is not controlled by or under common
control with a health benefit plan issuer.
Sec. 1462.002.  APPLICABILITY OF CHAPTER.  This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is offered by:
(2)  a group hospital service corporation operating
(3)  a health maintenance organization operating under
(4)  an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5)  a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6)  a stipulated premium company operating under
(7)  a fraternal benefit society operating under
(8)  a Lloyd's plan operating under Chapter 941; or
(9)  an exchange operating under Chapter 942.
Sec. 1462.003.  EXCEPTION TO APPLICABILITY OF CHAPTER.  This
chapter does not apply to an issuer, provider, or administrator of
(1)  the state Medicaid program, including the Medicaid
managed care program operated under Chapter 540, Government Code;
(2)  the child health plan program under Chapter 62,
(3)  a basic coverage plan under Chapter 1551;
(4)  a basic plan under Chapter 1575;
(5)  a coverage plan under Chapter 1579;
(6)  a plan providing basic coverage under Chapter
(7)  a workers' compensation insurance policy or other
form of providing medical benefits under Title 5, Labor Code.
Sec. 1462.004.  REIMBURSEMENT OF AFFILIATED AND
NONAFFILIATED PROVIDERS.  (a)  A health benefit plan issuer may not
offer a higher reimbursement rate to a health care practitioner who
is a member of a nonaffiliated provider based on a condition that
the practitioner agrees to join an affiliated provider.
(b)  A health benefit plan issuer may not pay an affiliated
provider a reimbursement amount that is more than the amount the
issuer pays a nonaffiliated provider for the same health care
(c)  This section does not apply to value-based or capitation
Sec. 1462.005.  PROHIBITION ON CERTAIN COMMUNICATIONS.  (a)
A health benefit plan issuer may not encourage or direct a patient
to use the issuer's affiliated provider through any oral or written
(1)  online messaging regarding the provider; or
(2)  patient- or prospective patient-specific
advertising, marketing, or promotion of the provider.
(b)  This section does not prohibit a health benefit plan
issuer from encouraging or directing a patient to use an affiliated
(1)  accepts a reimbursement rate that is lower than
the rate a nonaffiliated provider would charge;
(2)  is reimbursed by a health benefit plan issuer
through a risk-sharing or capitation arrangement; or
(3)  is tiered against other providers based on
Sec. 1462.006.  PROHIBITION ON CERTAIN REFERRALS AND
SOLICITATIONS.  (a)  A health benefit plan issuer may not require a
patient to use the issuer's affiliated provider for the patient to
receive the maximum benefit for the service under the patient's
(b)  A health benefit plan issuer may not offer or implement
a health benefit plan that requires or induces a patient to use the
issuer's affiliated provider, including by providing for reduced
cost-sharing if the patient uses the affiliated provider.
(c)  A health benefit plan issuer may not solicit a patient
or prescriber to transfer a patient's prescription to the issuer's
(d)  This section does not prohibit a health benefit plan
issuer from soliciting or inducing a patient to use an affiliated
(1)  accepts a reimbursement rate that is lower than
the rate a nonaffiliated provider would charge;
(2)  is reimbursed by a health benefit plan issuer
through a risk-sharing or capitation arrangement; or
(3)  is tiered against other providers based on
SECTION 2.  Chapter 1462, Insurance Code, as added by this
Act, applies only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2026.
SECTION 3.  This Act takes effect September 1, 2025.