Texas § IN.1301.0047 - INCENTIVES TO USE CERTAIN PHYSICIANS OR HEALTH CARE PROVIDERS

§ IN.1301.0047. INCENTIVES TO USE CERTAIN PHYSICIANS OR HEALTH CARE PROVIDERS

INCENTIVES TO USE CERTAIN PHYSICIANS OR HEALTH CARE PROVIDERS. (a) An insurer may provide incentives for insureds to use certain physicians or health care providers through modified deductibles, copayments, coinsurance, or other cost-sharing provisions. (b) An insurer that encourages an insured to obtain a health care service from a particular physician or health care provider, including offering incentives to encourage insureds 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 insured or policyholder to engage in that conduct only for the primary benefit of the insured or policyholder. (c) An insurer violates the fiduciary duty described by Subsection (b) by offering incentives to encourage insureds to use a particular physician or health care 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 insurer. (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: (A) preferred providers that insureds are encouraged to use within any steering approach or tiered network are not of materially lower quality than preferred providers that insureds are not encouraged to use; and (B) the insurer does not make materially false statements or representations about a physician's or health care provider's quality of care or costs; and (3) failing to use objective, verifiable, and accurate information as the basis of any encouragement or incentive under this section. (e) An encouragement or incentive authorized by this section may not: (1) be based solely on cost; or (2) impose a cost-sharing requirement for out-of-network emergency services that is greater than the cost-sharing requirement that would apply had the services been furnished by a preferred provider. (f) This section does not apply to a vision care plan, as defined by Section 1451.157 . Added by Acts 2025, 89th Leg., R.S., Ch. 787 (S.B. 926 ), Sec. 3, eff. September 1, 2025.