Relating to certain health care services contract arrangements entered into by insurers and health care providers.

Contracts

Immediate Legal Review Required: All pending PPO and EPO provider agreements must be audited against Section 1301.0065.

• Mandatory Clauses: Contracts must now explicitly state performance measures, data sources (e.g., HEDIS), calculation periods, and stop-loss requirements.
• Prohibited Terms: Remove any clauses that assign "global capitation" (total cost of care risk) to the PCP. Risk must be limited to primary care services.
• Voidable Terms: Any provision attempting to subcontract the risk arrangement is prohibited.

Hiring/Training

• Contracting Teams: Train negotiators that they now possess a statutory right to opt-out of value-based programs without facing network termination or discriminatory fee schedules.
• Billing/Revenue Cycle: Staff must monitor remittance advice to ensure fee-for-service rates are not unilaterally reduced because the practice declined a risk-sharing arrangement.

Reporting & Record-Keeping

• Attribution Verification: Implement a workflow to validate insurer-provided patient attribution lists against internal records. You must verify the physician-patient relationship exists before accepting risk for that patient.
• Material Change Documentation: Track patient volume and service scope monthly. You must generate data to prove a "material increase" to trigger the statutory right to contract renegotiation.

Fees & Costs

• Insurance Premiums: Provider groups entering capitated arrangements may need to purchase private stop-loss insurance if the contract does not guarantee minimum payments.
• Legal Spend: Anticipate increased legal costs for the initial redrafting of Master Service Agreements (MSAs) to ensure compliance with the new transparency mandates.