HB1225 - Relating to the establishment of a bundled-pricing program to reduce certain health care costs in the state employees group benefits program.

  89R3370 SCL-D     By: Gates H.B. No. 1225       A BILL TO BE ENTITLED   AN ACT   relating to the establishment of a bundled-pricing program to   reduce certain health care costs in the state employees group   benefits program.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Chapter 1551, Insurance Code, is amended by   adding Subchapter K to read as follows:   SUBCHAPTER K. BUNDLED-PRICING PROGRAM           Sec. 1551.501.  DEFINITIONS.  In this subchapter:                 (1)     "Facility-based provider" has the meaning   assigned by Section 1551.229.                 (2)     "Program" means the bundled-pricing program   developed under this subchapter.           Sec.   1551.502.     BUNDLED-PRICING PROGRAM. (a) The board of   trustees shall develop a cost-positive bundled-pricing program for   health benefit plans provided under the group benefits program.           (b)     The program must be designed to reduce health care costs   in the group benefits program by contracting with a health care   facility, physician, or health care provider at a consolidated rate   for an inpatient or outpatient surgery procedure that is a covered   health care or medical service under a health benefit plan provided   under the group benefits program.           (c)     A consolidated rate described by Subsection (b) must   include all fees related to the covered surgery procedure,   including fees for a health care facility, physician, health care   provider, laboratory, anesthesia, perioperative service,   prescription drug, or pharmacy service.           (d)     The board of trustees shall contract with a third-party   administrator to administer the program. The program administrator   may be independent from the administrator of a health benefit plan   under the group benefits program.           Sec.   1551.503.     PARTICIPATION; COST-SHARING OBLIGATION.   (a) A participant may have only an inpatient or outpatient surgery   procedure under the program.           (b)     Except as provided by Subsection (c), the board of   trustees or a participating health care facility, physician, or   health care provider may not require a participant to pay a   deductible, copayment, coinsurance, or other cost-sharing   obligation for a covered surgery procedure provided under the   program.           (c)     The board of trustees may require a participant in the   state consumer-directed health plan established under Section   1551.452 to meet the participant's deductible before the plan pays   for a covered surgery procedure provided under the program.           Sec.   1551.504.     PROVIDER PARTICIPATION. (a) A health care   facility, physician, or health care provider is not required to   participate in the program.   To participate, a health care   facility, physician, or health care provider must voluntarily and   expressly agree in writing to participate.           (b)  A health care facility may not directly or indirectly:                 (1)     coerce a facility-based provider or physician to   participate in the program or accept a lower rate for an inpatient   or outpatient surgery procedure;                 (2)     condition a physician's staff membership or   privileges on the physician's participation in the program;                 (3)     consider a physician's participation or lack of   participation in the program in credentialing the physician;                 (4)     offer preferential scheduling to a participating   physician as compared to a physician who elects not to participate;   or                 (5)     terminate or otherwise penalize a physician or   health care provider for an election to not participate in the   program.           (c)     The board of trustees, a health benefit plan, an   administrator of a health benefit plan provided under the group   program, or a health benefit plan issuer may not directly or   indirectly:                 (1)     coerce a health care facility, physician, or   health care provider to participate in the program;                 (2)     condition any plan participation on participation   in the program; or                 (3)     terminate or otherwise penalize a health care   facility, physician, or health care provider for electing not to   participate in the program.           Sec.   1551.505.     PROCEDURE APPROVAL. (a)   Before scheduling   a procedure under the program, a participating health care   facility, physician, or health care provider must apply for   approval from the program administrator in the form and manner   prescribed by the board of trustees.           (b)     The approval application must include the consolidated   rate for the procedure and any other information determined   necessary by the program administrator.           (c)     In determining whether to approve a procedure under this   section, the program administrator shall:                 (1)     ensure that the quality of care is comparable to   the care provided by a network provider for a health benefit plan   under the group benefits program;                 (2)     ensure that the procedure's cost is lower than the   procedure's cost if performed outside of the program; and                 (3)     if there is not a quality differential and   multiple health care facilities, physicians, or health care   providers apply to perform the same procedure for a participant,   consider the procedure's consolidated rate and the time the   procedure will be performed as the most important factors.           Sec.   1551.506.     PAYMENT. (a)   The board of trustees shall   ensure that a participating health care facility, physician, or   health care provider receives payment for a covered surgery   procedure not later than the 30th day after the date the program   administrator receives a claim for the procedure that includes, at   a minimum, each current procedural terminology code associated with   the bundled procedure and each ICD-10 code associated with the   patient.           (b)     The program must include the methods by which payments   are allocated among a participating health care facility,   physician, or health care provider. If the consolidated bundled   payment is to be paid to an entity for further distribution to other   participating health care facilities, physicians, or health care   providers, the entity receiving the consolidated payment must be a   physician-led organization and have contracting authority on   behalf of the other participating facilities, physicians, and   providers.           (c)     A participating health care facility, physician, or   health care provider may submit a request for payment to the   administrator for unanticipated services required to be provided   while performing a procedure under the program. The request must   include information on the reason the services were required.           Sec.   1551.507.     BUNDLED-PRICING DISCLOSURE. (a) A   participating health care facility, physician, or health care   provider shall provide a written disclosure to a participant or the   participant's representative of the consolidated rate for a   procedure provided under the program before scheduling the   procedure.           (b)     A health care facility, physician, or health care   provider that participates in the program may disclose a   consolidated rate for an inpatient or outpatient surgery procedure   on the facility's, physician's, or provider's Internet website and   marketing materials.           Sec.   1551.508.     PUBLICATION OF INFORMATION. The board of   trustees shall publish information on the program, including a list   of participating health care facilities, physicians, and health   care providers and the consolidated rates offered by each   participating facility, physician, and provider, on the Employees   Retirement System of Texas website.           Sec.   1551.509.     UNAUTHORIZED PRACTICE OF MEDICINE   PROHIBITED. This subchapter may not be construed to authorize:                 (1)     a lay person or entity to supervise or otherwise   control the practice of medicine as prohibited under Subtitle B,   Title 3, Occupations Code;                 (2)     a person or entity to engage in the unauthorized   practice of medicine in this state;                 (3)     a person or entity to misrepresent that the person   or entity is entitled to practice medicine; or                 (4)     a violation of Section 155.001, 155.003, 157.001,   164.052, or 165.156, Occupations Code.           Sec.   1551.510.     RULEMAKING. The board of trustees may adopt   rules as necessary to implement this subchapter.          SECTION 2.  This Act takes effect September 1, 2025.