Texas 2009 - 81st Regular

Texas Senate Bill SB779 Compare Versions

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1	1	By: Watson S.B. No. 779
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to expedited credentialing for certain individual health
7	7	care providers providing services under a managed care plan.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Chapter 1452, Insurance Code, is amended by
10	10	adding Subchapter D to read as follows:
11	11	SUBCHAPTER D. EXPEDITED CREDENTIALING PROCESS FOR INDIVIDUAL
12	12	HEALTH CARE PROVIDERS WHO ARE NOT PHYSICIANS
13	13	Sec. 1452.151. DEFINITIONS. (a) In this subchapter:
14	14	(1) "Applicant health care provider" means an
15	15	individual who:
16	16	(A) is a health care provider described by
17	17	Section 1452.101(3)(A); and
18	18	(B) is applying for expedited credentialing
19	19	under this subchapter.
20	20	(2) "Established professional group" means:
21	21	(A) a single legal entity owned by two or more
22	22	health care providers;
23	23	(B) a professional association composed of
24	24	licensed health care providers; or
25	25	(C) any other business entity composed of
26	26	licensed health care providers permitted under the Occupations
27	27	Code.
28	28	(b) "Enrollee," "health care provider," "managed care
29	29	plan," and "participating provider" have the meanings assigned by
30	30	Section 1452.101.
31	31	Sec. 1452.152. APPLICABILITY. This subchapter applies only
32	32	to an individual health care provider who:
33	33	(1) is not a physician; and
34	34	(2) joins an established professional group of health
35	35	care providers that has a contract in force with a managed care plan
36	36	on the date the health care provider joins the group.
37	37	Sec. 1452.153. ELIGIBILITY REQUIREMENTS. To qualify for
38	38	expedited credentialing under this subchapter and payment under
39	39	Section 1452.154, an applicant health care provider must:
40	40	(1) be licensed, certified, or otherwise authorized in
41	41	this state by, and in good standing with, the agency of this state
42	42	that issues the license, certification, or other authorization
43	43	appropriate to the profession of the applicant health care
44	44	provider;
45	45	(2) submit all documentation and other information
46	46	required by the issuer of the managed care plan as necessary to
47	47	enable the issuer to begin the credentialing process required by
48	48	the issuer to include that type of health care provider in the
49	49	issuer's health benefit plan network; and
50	50	(3) agree to comply with the terms of the managed care
51	51	plan's participating provider contract currently in force with the
52	52	applicant health care provider's established professional group.
53	53	Sec. 1452.154. PAYMENT OF APPLICANT HEALTH CARE PROVIDER
54	54	DURING CREDENTIALING PROCESS. On submission by the applicant
55	55	health care provider of the information required by the managed
56	56	care plan issuer under Section 1452.153(2), and for payment
57	57	purposes only, the issuer shall treat the applicant health care
58	58	provider as if the applicant were a participating provider in the
59	59	health benefit plan network when the applicant health care provider
60	60	provides services to the managed care plan's enrollees, including:
61	61	(1) authorizing the applicant health care provider to
62	62	collect copayments from the enrollees; and
63	63	(2) making payments to the applicant health care
64	64	provider.
65	65	Sec. 1452.155. DIRECTORY ENTRIES. Pending the approval of
66	66	an application submitted under Section 1452.154, the managed care
67	67	plan may exclude the applicant health care provider from the
68	68	managed care plan's directory of participating health care
69	69	providers, the managed care plan's website listing of participating
70	70	health care providers, or any other listing of participating health
71	71	care providers.
72	72	Sec. 1452.156. EFFECT OF FAILURE TO MEET CREDENTIALING
73	73	REQUIREMENTS. If, on completion of the credentialing process, the
74	74	managed care plan issuer determines that the applicant health care
75	75	provider does not meet the issuer's credentialing requirements:
76	76	(1) the managed care plan issuer may recover from the
77	77	applicant health care provider or the applicant's established
78	78	professional group an amount equal to the difference between
79	79	payments for in-network benefits and out-of-network benefits; and
80	80	(2) the applicant health care provider or the
81	81	applicant's established professional group may retain any
82	82	copayments collected or in the process of being collected as of the
83	83	date of the issuer's determination.
84	84	Sec. 1452.157. ENROLLEE HELD HARMLESS. An enrollee in the
85	85	managed care plan is not responsible and shall be held harmless for
86	86	the difference between in-network copayments paid by the enrollee
87	87	to a health care provider who is determined to be ineligible under
88	88	Section 1452.156 and the managed care plan's charges for
89	89	out-of-network services. The health care provider and the
90	90	provider's established professional group may not charge the
91	91	enrollee for any portion of the provider's fee that is not paid or
92	92	reimbursed by the enrollee's managed care plan.
93	93	Sec. 1452.158. LIMITATION ON MANAGED CARE ISSUER LIABILITY.
94	94	A managed care plan issuer that complies with this subchapter is not
95	95	subject to liability for damages arising out of or in connection
96	96	with, directly or indirectly, the payment by the issuer of an
97	97	applicant health care provider as if the applicant were a
98	98	participating provider in the health benefit plan network.
99	99	SECTION 2. Subsection (c), Section 843.203, Insurance Code,
100	100	is amended to read as follows:
101	101	(c) For purposes of this subchapter, an applicant
102	102	physician, as defined by Subchapter C, Chapter 1452, or an
103	103	applicant health care provider, as defined by Subchapter D, Chapter
104	104	1452, may not be considered to be an available primary care
105	105	physician or primary care provider within the health maintenance
106	106	organization delivery network for selection by an enrollee.
107	107	SECTION 3. Section 843.304, Insurance Code, is amended by
108	108	adding Subsection (f) to read as follows:
109	109	(f) Subchapter D, Chapter 1452, does not affect the
110	110	authority of a health maintenance organization under Subsection
111	111	(c), (d), or (e).
112	112	SECTION 4. Section 1301.051, Insurance Code, is amended by
113	113	adding Subsection (f) to read as follows:
114	114	(f) Subchapter D, Chapter 1452, does not affect the
115	115	authority of an insurer under Subsection (d).
116	116	SECTION 5. The change in law made by this Act applies only
117	117	to credentialing of an individual health care provider under a
118	118	contract entered into or renewed by an established professional
119	119	group and an issuer of a managed care plan on or after the effective
120	120	date of this Act. A contract entered into or renewed before the
121	121	effective date of this Act is governed by the law in effect
122	122	immediately before that date, and that law is continued in effect
123	123	for that purpose.
124	124	SECTION 6. This Act takes effect September 1, 2009.