INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1458.  PROVIDER NETWORK CONTRACT ARRANGEMENTS

SUBCHAPTER A.  GENERAL PROVISIONS

Sec. 1458.001.  GENERAL DEFINITIONS.  In this chapter:
(1)  "Affiliate" means a person who, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with another person.
(1-a)  "Anti-steering clause" means a provision in a provider network contract that restricts the ability of a general contracting entity to encourage an enrollee to obtain a health care service from a competitor of the provider, including offering incentives to encourage enrollees to use specific providers.
(1-b)  "Anti-tiering clause" means a provision in a provider network contract that:
(A)  restricts the ability of a general contracting entity to introduce or modify a tiered network plan or assign providers into tiers; or
(B)  requires a general contracting entity to place all members of a provider in the same tier of a tiered network plan.
(2)  "Contracting entity" means a person who:
(A)  enters into a direct contract with a provider for the delivery of health care services to covered individuals; and
(B)  in the ordinary course of business establishes a provider network or networks for access by another party.
(3)  "Covered individual" means an individual who is covered under a health benefit plan.
(4)  "Express authority" means a provider's consent that is obtained through separate signature lines for each line of business.
(4-a)  "Gag clause" means a provision in a provider network contract that restricts the ability of a general contracting entity or provider to disclose:
(A)  price or quality information, including the allowed amount, negotiated rates or discounts, fees for services, or other claim-related financial obligations included in the contract, to a governmental entity as authorized by law or its contractors or agents, an enrollee, a treating provider of an enrollee, a plan sponsor, or potential eligible enrollees and plan sponsors; or
(B)  out-of-pocket costs to an enrollee.
(4-b)  "General contracting entity" means a person who enters into a direct contract with a provider for the delivery of health care services to covered individuals regardless of whether the person, in the ordinary course of business, establishes a provider network for access by another party.  The term does not include a health care provider or facility unless the provider or facility is entering into the contract in the provider's or facility's role as a health benefit plan.
(5)  "Health care services" means services provided for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease.
(5-a)  "Most favored nation clause" means a provision in a provider network contract that:
(A)  prohibits or grants an option to prohibit:
(i)  a provider from contracting with another general contracting entity to provide health care services at a lower rate; or
(ii)  a general contracting entity from contracting with another provider to provide health care services at a higher rate;
(B)  requires or grants an option to require:
(i)  a provider to accept a lower rate for health care services if the provider agrees with another general contracting entity to accept a lower rate for the services; or
(ii)  a general contracting entity to pay a higher rate for health care services if the entity agrees with another provider to pay a higher rate for the services;
(C)  requires or grants an option to require termination or renegotiation of an existing provider network contract if:
(i)  a provider agrees with another general contracting entity to accept a lower rate for providing health care services; or
(ii)  a general contracting entity agrees with a provider to pay a higher rate for health care services; or
(D)  requires:
(i)  a provider to disclose the provider's contractual reimbursement rates with other general contracting entities; or
(ii)  a general contracting entity to disclose the general contracting entity's contractual reimbursement rates with other providers.
(6)  "Person" has the meaning assigned by Section 823.002.
(7)(A)  "Provider" means:
(i)  an advanced practice nurse;
(ii)  an optometrist;
(iii)  a therapeutic optometrist;
(iv)  a physician;
(v)  a physician assistant;
(vi)  a professional association composed solely of physicians, optometrists, or therapeutic optometrists;
(vii)  a single legal entity authorized to practice medicine owned by two or more physicians;
(viii)  a nonprofit health corporation certified by the Texas Medical Board under Chapter 162, Occupations Code;
(ix)  a partnership composed solely of physicians, optometrists, or therapeutic optometrists;
(x)  a physician-hospital organization that acts exclusively as an administrator for a provider to facilitate the provider's participation in health care contracts; or
(xi)  an institution that is licensed under Chapter 241, Health and Safety Code.
(B)  "Provider" does not include a physician-hospital organization that leases or rents the physician-hospital organization's network to another party.
(8)  "Provider network contract" means a contract between a contracting entity and a provider for the delivery of, and payment for, health care services to a covered individual.
Added by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.
Amended by: 
Acts 2023, 88th Leg., R.S., Ch. 639 (H.B. 711), Sec. 1, eff. June 12, 2023.