Insurance Code § 1458.001

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.