HB 5099

relating to establishment of a shared savings program for certain
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1.  Subtitle C, Title 8, Insurance Code, is amended
by adding Chapter 1276 to read as follows:
CHAPTER 1276. SHARED SAVINGS PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1276.001.  DEFINITIONS.  In this chapter:
(1)  "Health care provider" means a health care
practitioner or health care facility that provides health care
services or supplies under a license, certificate, registration, or
similar authorization issued by this state.
(2)  "Managed care plan" means a health benefit plan
under which health care services or supplies are provided to
enrollees through contracts with health care providers and that
requires enrollees to use contracting providers or that provides a
different level of coverage for enrollees who use contracting
(3)  "Out-of-network provider" means a health care
provider of any health care service or supply that does not have a
contract under an enrollee's health benefit plan.
(4)  "Program" means the shared savings program
established under this chapter.
Sec. 1276.002.  APPLICABILITY OF CHAPTER.  (a) This chapter
applies only to nonemergency health care services or supplies
covered under a managed care plan.
(b)  This chapter applies only to the following health
(1)  a health benefit plan provided by a health
maintenance organization operating under Chapter 843;
(2)  a preferred provider benefit plan provided under
(3)  a basic coverage plan provided under Chapter 1551.
(c)  Notwithstanding any other law, this chapter applies to
an administrator of a health benefit plan described by this
Sec. 1276.003.  RULES.  The commissioner may adopt rules
necessary to implement this chapter.
SUBCHAPTER B. PROGRAM REQUIREMENTS
Sec. 1276.051.  PROGRAM REQUIRED.  (a) A health benefit plan
issuer or administrator to which this chapter applies shall
establish a shared savings program in accordance with this chapter.
(b)  A health benefit plan issuer or administrator shall
provide written notice to its enrollees of the program.
Sec. 1276.052.  AVERAGE CONTRACTED RATE DISCLOSURE.  (a) As
part of the program, a health benefit plan issuer or administrator
shall establish and operate a toll-free telephone number and
publicly accessible Internet website for a plan enrollee to request
disclosure of the average contracted rate paid under the plan to a
health care provider in the plan's provider network for a
particular health care service or supply in the preceding 12
(b)  A health benefit plan issuer or administrator shall
disclose to the enrollee the rate the enrollee requested under
Sec. 1276.053.  HEALTH CARE PROVIDER ESTIMATE.  An
out-of-network provider shall, on an enrollee's request, provide
the enrollee a written estimate of the final charge for a proposed
health care service or supply eligible for the enrollee's program.
The estimate must include all costs associated with the service or
supply and reflect the enrollee's final out-of-pocket cost
associated with the proposed service or supply.
Sec. 1276.054.  SHARED SAVINGS PAYMENT.  (a) Except as
provided by Subsection (b), if an enrollee who requests a
disclosure under Section 1276.052 elects and receives a health care
service or supply with an actual cost equal to an amount less than
the rate disclosed under Section 1276.052, the health benefit plan
issuer or administrator shall pay to the enrollee 50 percent of the
difference between the disclosed rate and the actual cost, minus
any applicable deductible, copayment, or coinsurance.
(b)  A health benefit plan issuer is not required to pay an
enrollee under Subsection (a) if the difference described by that
(c)  A health benefit plan issuer or administrator shall pay
an enrollee under Subsection (a) not later than the 30th day after
the date on which the enrollee submits a program claim.
Sec. 1276.055.  DEDUCTIBLES UNDER PROGRAM.  (a) This section
applies only to a health care service or supply for which an
(1)  a disclosure under Section 1276.052; and
(2)  an estimate under Section 1276.053 equal to an
amount at least $50 less than the rate provided under the
(b)  A health benefit plan issuer or administrator shall
apply a deductible for a health care service or supply to which this
section applies in an amount equivalent to the deductible applied
to a network service or supply.
Sec. 1276.056.  LIABILITY FOR UNFORESEEN CHARGE OVER
ESTIMATE.  If the final charge for the health care service or supply
described by Section 1276.055(a) is an amount greater than the
amount estimated under Section 1276.053 due to unforeseen
circumstances, the enrollee's health benefit plan issuer or
administrator shall pay 95 percent of the difference not to exceed
the allowed amount for the service or supply and the enrollee is
responsible for the remaining difference.
SECTION 2.  Chapter 1276, 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.