Texas Insurance Code
§ 843.322 — INCENTIVES TO USE CERTAIN PHYSICIANS OR PROVIDERS
IN § 843.322Title 6. ORGANIZATION OF INSURERS AND RELATED ENTITIES · Part C. LIFE, HEALTH, AND ACCIDENT INSURERS AND RELATED ENTITIES · Ch. 843. HEALTH MAINTENANCE ORGANIZATIONS · Art. I. RELATIONS WITH PHYSICIANS AND PROVIDERS
Statute text
View on source(a)A health maintenance organization may provide incentives for enrollees to use certain physicians or providers through modified deductibles, copayments, coinsurance, or other cost-sharing provisions.
(b)A health maintenance organization that encourages an enrollee to obtain a health care service from a particular physician or provider, including offering incentives to encourage enrollees to use specific physicians or providers, or that introduces or modifies a tiered network plan or assigns physicians or providers into tiers, has a fiduciary duty to the enrollee or group contract holder to engage in that conduct only for the primary benefit of the enrollee or group contract holder.
(c)A health maintenance organization violates the fiduciary duty described by Subsection (b) by offering incentives to encourage enrollees to use a particular physician or provider solely because the physician or provider directly or indirectly through one or more intermediaries controls, is controlled by, or is under common control with the health maintenance organization.
(d)Conduct that violates the fiduciary duty described by Subsection (b) includes:
(1)using a steering approach or a tiered network to provide a financial incentive as an inducement to limit medically necessary services, encourage receipt of lower quality medically necessary services, or violate state or federal law;
(2)failing to implement reasonable procedures to ensure that:
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Legislative history
Added by Acts 2025, 89th Leg., R.S., Ch. 787 (S.B. 926), Sec. 1, eff. September 1, 2025.