81R2255 PB-D
By: Watson S.B. No. 779
A BILL TO BE ENTITLED
AN ACT
relating to expedited credentialing for certain individual health
care providers providing services under a managed care plan.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1452, Insurance Code, is amended by
adding Subchapter D to read as follows:
SUBCHAPTER D. EXPEDITED CREDENTIALING PROCESS FOR INDIVIDUAL
HEALTH CARE PROVIDERS WHO ARE NOT PHYSICIANS
Sec. 1452.151. DEFINITIONS. (a) In this subchapter:
(1) "Applicant health care provider" means an
individual who:
(A) is a health care provider described by
Section 1452.101(3)(A); and
(B) is applying for expedited credentialing
under this subchapter.
(2) "Established professional group" means a legal
entity organized, jointly owned, and managed by individual health
care providers to deliver health care services.
(b) "Enrollee," "health care provider," "managed care
plan," and "participating provider" have the meanings assigned by
Section 1452.101.
Sec. 1452.152. APPLICABILITY. This subchapter applies only
to an individual health care provider who:
(1) is not a physician; and
(2) joins an established professional group of health
care providers that has a contract in force with a managed care plan
on the date the health care provider joins the group.
Sec. 1452.153. ELIGIBILITY REQUIREMENTS. To qualify for
expedited credentialing under this subchapter and payment under
Section 1452.154, an applicant health care provider must:
(1) be licensed, certified, or otherwise authorized in
this state by, and in good standing with, the agency of this state
that issues the license, certification, or other authorization
appropriate to the profession of the applicant health care
provider;
(2) submit all documentation and other information
required by the issuer of the managed care plan as necessary to
enable the issuer to begin the credentialing process required by
the issuer to include that type of health care provider in the
issuer's health benefit plan network; and
(3) agree to comply with the terms of the managed care
plan's participating provider contract currently in force with the
applicant health care provider's established professional group.
Sec. 1452.154. PAYMENT OF APPLICANT HEALTH CARE PROVIDER
DURING CREDENTIALING PROCESS. On submission by the applicant
health care provider of the information required by the managed
care plan issuer under Section 1452.153(2), and for payment
purposes only, the issuer shall treat the applicant health care
provider as if the applicant were a participating provider in the
health benefit plan network when the applicant health care provider
provides services to the managed care plan's enrollees, including:
(1) authorizing the applicant health care provider to
collect copayments from the enrollees; and
(2) making payments to the applicant health care
provider.
Sec. 1452.155. DIRECTORY ENTRIES. Pending the approval of
an application submitted under Section 1452.154, the managed care
plan may exclude the applicant health care provider from the
managed care plan's directory of participating health care
providers, the managed care plan's website listing of participating
health care providers, or any other listing of participating health
care providers.
Sec. 1452.156. EFFECT OF FAILURE TO MEET CREDENTIALING
REQUIREMENTS. If, on completion of the credentialing process, the
managed care plan issuer determines that the applicant health care
provider does not meet the issuer's credentialing requirements:
(1) the managed care plan issuer may recover from the
applicant health care provider or the applicant's established
professional group an amount equal to the difference between
payments for in-network benefits and out-of-network benefits; and
(2) the applicant health care provider or the
applicant's established professional group may retain any
copayments collected or in the process of being collected as of the
date of the issuer's determination.
Sec. 1452.157. ENROLLEE HELD HARMLESS. An enrollee in the
managed care plan is not responsible and shall be held harmless for
the difference between in-network copayments paid by the enrollee
to a health care provider who is determined to be ineligible under
Section 1452.156 and the managed care plan's charges for
out-of-network services. The health care provider and the
provider's established professional group may not charge the
enrollee for any portion of the provider's fee that is not paid or
reimbursed by the enrollee's managed care plan.
Sec. 1452.158. LIMITATION ON MANAGED CARE ISSUER LIABILITY.
A managed care plan issuer that complies with this subchapter is not
subject to liability for damages arising out of or in connection
with, directly or indirectly, the payment by the issuer of an
applicant health care provider as if the applicant were a
participating provider in the health benefit plan network.
SECTION 2. Section 843.203(c), Insurance Code, is amended
to read as follows:
(c) For purposes of this subchapter, an applicant
physician, as defined by Subchapter C, Chapter 1452, or an
applicant health care provider, as defined by Subchapter D, Chapter
1452, may not be considered to be an available primary care
physician or primary care provider within the health maintenance
organization delivery network for selection by an enrollee.
SECTION 3. Section 843.304, Insurance Code, is amended by
adding Subsection (f) to read as follows:
(f) Subchapter D, Chapter 1452, does not affect the
authority of a health maintenance organization under Subsection
(c), (d), or (e).
SECTION 4. Section 1301.051, Insurance Code, is amended by
adding Subsection (f) to read as follows:
(f) Subchapter D, Chapter 1452, does not affect the
authority of an insurer under Subsection (d).
SECTION 5. The change in law made by this Act applies only
to credentialing of an individual health care provider under a
contract entered into or renewed by an established professional
group and an issuer of a managed care plan on or after the effective
date of this Act. A contract entered into or renewed before the
effective date of this Act is governed by the law in effect
immediately before that date, and that law is continued in effect
for that purpose.
SECTION 6. This Act takes effect September 1, 2009.