2023 Texas Statutes › 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 › Section 1458.001. General Definitions

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.