Sec. 843.322. INCENTIVES TO USE CERTAIN PHYSICIANS OR PROVIDERS. (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: (A) participating providers that enrollees are encouraged to use within any steering approach or tiered network are not of materially lower quality than participating providers that enrollees are not encouraged to use; and (B) the health maintenance organization does not make materially false statements or representations about a physician's or 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 participating provider. (f) This section does not apply to a vision care plan, as defined by Section 1451.157 .
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