TITLE: Relating to the application of direct primary care fees to insurance deductibles in certain state health benefit plans.

SUMMARY: Relating to the application of direct primary care fees to insurance deductibles in certain state health benefit plans.

FULL TEXT:
AN ACT relating to the application of direct primary care fees to insurance deductibles in certain state health benefit plans. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTION 1. Chapter 1551, Insurance Code, is amended by adding Subchapter Kto read as follows: SUBCHAPTER K. DIRECT PRIMARY CARE SERVICES Sec. 1551.501. DEFINITIONS. In this subchapter: (1) "Direct fee" means a fee charged by a physician to a patient or a patient's designee for primary medical care services provided by, or to be provided by, the physician to the patient. The term includes a fee in any form, including a: (A) monthly retainer; (B) membership fee; (C) subscription fee; (D) fee paid under a medical service agreement; or (E) fee for a service, visit, or episode of care. (2) "Direct primary care" means a primary medical care service provided by a physician to a patient in return for payment in accordance with a direct fee. The term includes telemedicine medical services and telehealth services, as those terms are defined by Section 111.001, Occupations Code, provided using a technology platform. Sec. 1551.502. APPLICATION OF DIRECT PRIMARY CARE FEES TO DEDUCTIBLES. (a) A direct fee paid to a direct primary care provider must apply to a participant's deductible for a health benefit plan provided under the group benefits program. (b) Notwithstanding Subsection (a), if the board of trustees believes that applying a direct fee paid to a direct primary care provider for a participant's deductible under this subchapter would cause the high deductible health plan, as that term is defined by Section 223, Internal Revenue Code of 1986, to no longer qualify for a health savings account under that section, the board of trustees shall seek an opinion from the attorney general regarding the applicability of this subchapter to that high deductible health plan. If the attorney general confirms that the high deductible health plan would be disqualified, this subchapter will not apply to the high deductible health plan. SECTION 2. Chapter 1575, Insurance Code, is amended by adding Subchapter Lto read as follows: SUBCHAPTER L. DIRECT PRIMARY CARE SERVICES Sec. 1575.551. DEFINITIONS. In this subchapter: (1) "Direct fee" means a fee charged by a physician to a patient or a patient's designee for primary medical care services provided by, or to be provided by, the physician to the patient. The term includes a fee in any form, including a: (A) monthly retainer; (B) membership fee; (C) subscription fee; (D) fee paid under a medical service agreement; or (E) fee for a service, visit, or episode of care. (2) "Direct primary care" means a primary medical care service provided by a physician to a patient in return for payment in accordance with a direct fee. The term includes telemedicine medical services and telehealth services, as those terms are defined by Section 111.001, Occupations Code, provided using a technology platform. Sec. 1575.552. APPLICATION OF DIRECT PRIMARY CARE FEES TO DEDUCTIBLES. (a) A direct fee paid to a direct primary care provider must apply to an enrollee's deductible for a basic plan provided under the group program. (b) Notwithstanding Subsection (a), if the trustee believes that applying a direct fee paid to a direct primary care provider for an enrollee's deductible under this subchapter would cause the high deductible health plan, as that term is defined by Section 223, Internal Revenue Code of 1986, to no longer qualify for a health savings account under that section, the trustee shall seek an opinion from the attorney general regarding the applicability of this subchapter to that high deductible health plan. If the attorney general confirms that the high deductible health plan would be disqualified, this subchapter will not apply to the high deductible health plan. SECTION 3. Chapter 1579, Insurance Code, is amended by adding Subchapter Hto read as follows: SUBCHAPTER H. DIRECT PRIMARY CARE SERVICES Sec. 1579.351. DEFINITIONS. In this subchapter: (1) "Direct fee" means a fee charged by a physician to a patient or a patient's designee for primary medical care services provided by, or to be provided by, the physician to the patient. The term includes a fee in any form, including a: (A) monthly retainer; (B) membership fee; (C) subscription fee; (D) fee paid under a medical service agreement; or (E) fee for a service, visit, or episode of care. (2) "Direct primary care" means a primary medical care service provided by a physician to a patient in return for payment in accordance with a direct fee. The term includes telemedicine medical services and telehealth services, as those terms are defined by Section 111.001, Occupations Code, provided using a technology platform. Sec. 1579.352. APPLICATION OF DIRECT PRIMARY CARE FEES TO DEDUCTIBLES. (a) A direct fee paid to a direct primary care provider must apply to an enrollee's deductible for a health coverage plan provided under this chapter. (b) Notwithstanding Subsection (a), if the trustee believes that applying a direct fee paid to a direct primary care provider for an enrollee's deductible under this subchapter would cause the high deductible health plan, as that term is defined by Section 223, Internal Revenue Code of 1986, to no longer qualify for a health savings account under that section, the trustee shall seek an opinion from the attorney general regarding the applicability of this subchapter to that high deductible health plan. If the attorney general confirms that the high deductible health plan would be disqualified, this subchapter will not apply to the high deductible health plan. SECTION 4. The changes in law made by this Act apply only to a plan year that commences on or after January 1, 2026. SECTION 5. This Act takes effect September 1, 2025.