SB926

SB926 allows covered health plans to offer cost-sharing incentives for using particular providers, but requires those steering and network-tier decisions to primarily benefit the patient or policyholder. For HMOs and insurers under the preferred/exclusive-provider chapter, that is a fiduciary duty—a legal duty to act for the specified beneficiary’s primary benefit. Incentives cannot be based solely on cost or solely on the provider’s ownership/control relationship with the insurer. They cannot be used to limit medically necessary care, encourage lower-quality necessary care or violate law. Plans must use objective, verifiable, accurate information and reasonable safeguards against materially lower-quality favored providers or materially false statements about quality/cost. Sections 1–3.

These incentives also cannot make out-of-network emergency cost sharing higher than the corresponding in-network amount. The new steering sections exclude limited-scope vision plans, not comprehensive medical plans merely because they cover eye care. Scope differs by provision: the preferred/exclusive-provider chapter excludes Medicaid managed care, CHIP and dental-care benefits; the separate physician-ranking chapter excludes specified Medicaid/children’s programs and Medicare supplement plans. Do not assume every health arrangement is covered by every rule. New subsections (e)–(f); Vision-plan definition; PPO/EPO scope; Dental exception; Ranking exceptions.

For covered physician rankings and performance tiers, issuers must disclose the ranking/classification and methodology at least 45 days before release, identify the products/networks using it, and provide an easy process to flag discrepancies before release and objectively verifiable false information afterward. Sufficient evidence of a verifiable discrepancy, false information or chapter violation must be remedied by the later of release or 30 days after receipt—not necessarily before publication. This replaces the old detailed reconsideration protections, including a requested telephone/in-person proceeding, representative participation and a reasoned written outcome before dissemination. The exception for an ordinary provider list that does not reflect ratings or tiers remains. Section 4; Previous process and retained list exception.

Ranking standards must come from an organization designated by the insurance commissioner: a qualifying national medical specialty society or a bona fide organization unbiased toward providers and insurers. Standards must emphasize quality, have transparent methods, use risk adjustment when based on clinical outcomes, and support error reporting/correction. The act specifies acceptable evidence/consensus sources and defines the specialty societies, including representation in the American Medical Association’s house of delegates. If the commissioner finds a pattern of the specified discrepancies, falsehoods or violations, the issuer must be barred from using a ranking/classification system for at least 12 consecutive months. Existing sanctions remain. Signed June 20, 2025, the law took effect September 1, 2025. Sections 5–7; Existing enforcement; History.