SB 926

relating to certain practices of health benefit plan issuers to
encourage the use of certain physicians and health care providers
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1.  Subchapter I, Chapter 843, Insurance Code, is
amended by adding Section 843.322 to read as follows:
Sec. 843.322.  INCENTIVES TO USE CERTAIN PHYSICIANS OR
PROVIDERS.  (a)  A health maintenance organization may provide
incentives for enrollees to use certain physicians or providers
through modified deductibles, copayments, coinsurance, or other
(b)  A health maintenance organization that encourages an
enrollee to obtain a health care service from a particular
physician or provider, including offering incentives to encourage
enrollees to use specific physicians or providers, or that
introduces or modifies a tiered network plan or assigns physicians
or providers into tiers, has a fiduciary duty to the enrollee or
group contract holder to engage in that conduct only for the primary
benefit of the enrollee or group contract holder.
SECTION 2.  Section 1301.0045(a), Insurance Code, is amended
(a)  Except as provided by Sections [Section] 1301.0046 and
1301.0047, this chapter may not be construed to limit the level of
reimbursement or the level of coverage, including deductibles,
copayments, coinsurance, or other cost-sharing provisions, that
are applicable to preferred providers or, for plans other than
exclusive provider benefit plans, nonpreferred providers.
SECTION 3.  Subchapter A, Chapter 1301, Insurance Code, is
amended by adding Section 1301.0047 to read as follows:
Sec. 1301.0047.  INCENTIVES TO USE CERTAIN PHYSICIANS OR
HEALTH CARE PROVIDERS.  (a)  An insurer may provide incentives for
insureds to use certain physicians or health care providers through
modified deductibles, copayments, coinsurance, or other
(b)  An insurer that encourages an insured to obtain a health
care service from a particular physician or health care provider,
including offering incentives to encourage insureds to use specific
physicians or providers, or that introduces or modifies a tiered
network plan or assigns physicians or providers into tiers, has a
fiduciary duty to the insured or policyholder to engage in that
conduct only for the primary benefit of the insured or
SECTION 4.  Section 1460.003, Insurance Code, is amended by
amending Subsection (a) and adding Subsection (a-1) to read as
(a)  A health benefit plan issuer, including a subsidiary or
affiliate, may not rank physicians or[,] classify physicians into
tiers based on performance[, or publish physician-specific
information that includes rankings, tiers, ratings, or other
comparisons of a physician's performance against standards,
measures, or other physicians,] unless:
(1)  the standards used by the health benefit plan
issuer to rank or classify are propagated or developed by an
organization designated by the commissioner through rules adopted
(2)  the ranking, comparison, or evaluation:
(A)  is disclosed to each affected physician at
least 45 days before the date the ranking, comparison, or
evaluation is released, published, or distributed to enrollees by
the health benefit plan issuer; and
(B)  identifies which products or networks
offered by the health benefit plan issuer the ranking, comparison,
or evaluation will be used for; and
(3)  each affected physician is given an easy-to-use
process to identify discrepancies between the standards and the
ranking, comparison, or evaluation as propagated by the health
benefit plan issuer [the standards used by the health benefit plan
issuer conform to nationally recognized standards and guidelines as
required by rules adopted under Section 1460.005;
[(2)  the standards and measurements to be used by the
health benefit plan issuer are disclosed to each affected physician
before any evaluation period used by the health benefit plan
[(3)  each affected physician is afforded, before any
publication or other public dissemination, an opportunity to
dispute the ranking or classification through a process that, at a
minimum, includes due process protections that conform to the
[(A)  the health benefit plan issuer provides at
least 45 days' written notice to the physician of the proposed
rating, ranking, tiering, or comparison, including the
methodologies, data, and all other information utilized by the
health benefit plan issuer in its rating, tiering, ranking, or
[(B)  in addition to any written fair
reconsideration process, the health benefit plan issuer, upon a
request for review that is made within 30 days of receiving the
notice under Paragraph (A), provides a fair reconsideration
proceeding, at the physician's option:
[(i)  by teleconference, at an agreed upon
[(ii)  in person, at an agreed upon time or
between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;
[(C)  the physician has the right to provide
information at a requested fair reconsideration proceeding for
determination by a decision-maker, have a representative
participate in the fair reconsideration proceeding, and submit a
written statement at the conclusion of the fair reconsideration
[(D)  the health benefit plan issuer provides a
written communication of the outcome of a fair reconsideration
proceeding prior to any publication or dissemination of the rating,
ranking, tiering, or comparison.  The written communication must
include the specific reasons for the final decision].
(a-1)  If a physician submits information to a health benefit
plan issuer under Subsection (a)(3) sufficient to establish a
discrepancy, the health benefit plan issuer must remedy the
(2)  the 30th day after the date the health benefit plan
issuer receives the information.
SECTION 5.  Section 1460.005(c), Insurance Code, is amended
(c)  In adopting rules under this section, the commissioner
may only designate [shall consider the standards, guidelines, and
measures prescribed by nationally recognized] organizations that
meet the following requirements:
(1)  the prescribing organization is bona fide and
unbiased toward or against any medical provider;
(2)  the standards to be used in rankings, comparisons,
(A)  are nationally recognized, or based on
expert-provider consensus or leading clinical evidence-based
(B)  have a publicly transparent methodology; and
(C)  if based on clinical outcomes, are
(3)  the prescribing organization has an easy-to-use
process by which a medical provider may report data, evidentiary,
factual, or mathematical errors for prompt investigation and, if
appropriate, correction [establish or promote guidelines and
performance measures emphasizing quality of health care, including
the National Quality Forum and the AQA Alliance.  If neither the
National Quality Forum nor the AQA Alliance has established
standards or guidelines regarding an issue, the commissioner shall
consider the standards, guidelines, and measures prescribed by the
National Committee on Quality Assurance and other similar national
organizations.  If neither the National Quality Forum, nor the AQA
Alliance, nor other national organizations have established
standards or guidelines regarding an issue, the commissioner shall
consider standards, guidelines, and measures based on other bona
fide nationally recognized guidelines, expert-based physician
consensus quality standards, or leading objective clinical
SECTION 6.  This Act takes effect September 1, 2025.