Overview
For several legislative terms, Texas has enacted legislation to explore the desirability and feasibility of mandating an all-payer claims database (APCD), while the state ran a voluntary claims data collection effort through the University of Texas Center for Healthcare Data. The medical and pharmacy claims collected from the voluntary effort account for 65% of the Texas population. In the 2021 session, the state finally passed a law to establish a statewide APCD and require health care cost disclosures by health benefit plan issuers and third-party administrators. Texas lawmakers have also enacted some surprise billing protections for consumers, requiring a hold harmless provision and no liability notice for patients that incur a balance bill from out-of-network emergency services and a hold harmless provisions for non-emergency services.
In addition to exploring pay-for-performance models in tandem with its existing rate review processes, Texas maintains a number of consumer resources for finding and using health insurance. The Lone Star state also mandates parity in telemedicine to promote the use of telehealth services. Specifically, Texas statutes require that an insurance provider or issuer cannot exclude coverage for a service provided by a healthcare provider solely because that service is provided via telemedicine and not in person. The statutes further provide parity for reimbursement and cost-sharing of telehealth services.
In provider market competition, the state limits non-compete agreement for physicians, but does not provide statutory authority for notice or review of mergers and acquisitions involving healthcare entities. Notable antitrust cases in Texas involved federal enforcement agencies, including the DOJ action against United Regional Health Care System of Wichita Falls for contracts that improperly inhibited commercial health insurers from contracting with its competitors and the FTC post-merger investigation of King’s Daughters Hospital that was joined by the Texas AG.
Texas is also the site of the latest legal challenge against the Affordable Care Act, in which 20 state attorneys general filed suit in the Northern District of Texas against the Department of Health and Human Services and the Internal Revenue Service (Texas v. U.S.) claiming that the elimination of the tax penalty voids the constitutionality of the individual mandate and the entirety of the ACA. The case was appealed to the Fifth Circuit and granted for Supreme Court review.
See below for an overview of existing Texas state mandates. Click on citation tab for detailed information of specific statutes (click link to download statute text).
State Action
Latest Legislative Session: 1/10/2023 - 5/29/2023 (2023 term). *Legislature convenes in odd number years only.
HB 1033 (see companion bill SB 875) – Texas
Introduced: 2021 Status: Enacted
Relating to prescription drug price disclosure; authorizing a fee; providing an administrative penalty. House Bill 1033 amends the Health and Safety Code to revise prescription drug price reporting requirements for pharmaceutical drug manufacturers. The bill …
HB 1063 (see companion bill SB 1518) – Texas
Introduced: 2019 Status: Enacted
Relating to telemedicine medical, telehealth, and home telemonitoring services under Medicaid.
HB 1073 (see companion bill SB 1135) – Texas
Introduced: 2023 Status: Inactive / Dead
Relating to certain health care services contract arrangements entered into by insurers and health care providers.
HB 1093 (see companion bill SB 679) – Texas
Introduced: 2021 Status: Inactive / Dead
Relating to the regulation of pharmacy benefit managers and health benefit plan issuers in relation to prescription drug coverage.
HB 1142 (see companion bill SB 1099) – Texas
Introduced: 2019 Status: Enacted
Relating to the creation and operations of health care provider participation programs in certain counties.
Tex. Gov’t Code § 531.0226. Chronic Health Conditions and Services Medicaid Waiver Program: Health and Human Services Commission – Texas
Introduced: Status: Enacted
Allows those with chronic health conditions to apply for and receive certain Medicaid waiver services.
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Tex. Gov’t Code § 531.024. Planning and Delivery of Health and Human Services; Data Sharing: Health and Human Services Commission – Texas
Introduced: Status: Enacted
The commission shall facilitate the provision of services including coordinated intake, co-location services, and coordinated case referral management.
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Tex. Gov’t Code § 531.024162. Notice Requirements Regarding Denial of Coverage or Prior Authorization: Health and Human Services Commission – Texas
Introduced: Status: Enacted
The commission shall ensure that notice sent by the commission or Medicaid managed care organization to a Medicaid recipient or provider regarding the denial of coverage of prior authorization for a service: information required by …
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Tex. Gov’t Code § 531.024163. Accessibility of Information Regarding Medicaid Prior Authorization Requirements: Health and Human Services Commission – Texas
Introduced: Status: Enacted
The executive commissioner by rule shall require each Medicaid managed care organization or other entity responsible for authorizing coverage for health care services under Medicaid to ensure that the organization or entity maintains on the …
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Tex. Gov’t Code § 531.02444. Medicaid Buy-In Programs for Certain Persons With Disabilities: Health and Human Services Commission – Texas
Introduced: Status: Enacted
The executive commissioner shall develop and implement: a Medicaid buy-in program for persons with disabilities and a Medicaid buy-in program for children with disabilities whose family incomes do not exceed 300 percent of the applicable …
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U.S. Anesthesia Partners of Texas, P.A. v. United Healthcare Insurance – Texas
District Court: 14th District Court, Dallas County Status: Decided
In late March, a group of doctors sued United Healthcare Insurance in Texas state court, alleging the insurance giant violated state antitrust laws. Plaintiffs U.S. …
Texas et al. v. United States of America et al. – California, Federal, Texas
District Court: Northern District of Texas Status: Decided
[Consolidated with California et al. v. Texas et al. for Supreme Court review] This case arises out of the Supreme Court’s decision in NFIB v. …
United States and the State of Texas v. United Regional Health Care System of Wichita Falls – Texas
District Court: Northern District of Texas Wichita Falls Division Status: Decided
On February 25, 2011, the Department of Justice’s Antitrust Division and the Texas Attorney General’s Office filed a complaint against, and proposed settlement with, United …
Additional Resources
STATE BUDGET
Texas’ biennium budget begins September 1 after each regular legislative session and ends August 31 of the following odd-numbered year.
REGULATION & ENFORCEMENT
- In 2020, Texas HHSC and AG approved a pair of purchases from Community Health Systems (CHS) using COPAs, over FTC’s objection. The first transaction involves Hendrick Health System’s purchase of Abilene Regional Medical Center and Brownwood Regional Medical Center, and the second transaction is Shannon Health System’s purchase of San Angelo Community Medical Center. Texas’ COPA law passed in 2019 shields healthcare transactions from federal antitrust oversight. The FTC sent a 70-page comment letter urging the state to deny the proposed transactions as they would create a monopoly in the markets and result in higher prices to consumers.
KEY RESOURCES
- Texas State Legislature
- Texas Office of the Attorney General
- Texas Department of Insurance
- Texas PricePoint
- Texas Health Options