Texas 2013 - 83rd Regular

Texas Senate Bill SB365 Compare Versions

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1	1	83R19535 SCL-F
2	2	By: Carona S.B. No. 365
3	3	(Parker)
4	4	Substitute the following for S.B. No. 365: No.
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to expedited credentialing for certain podiatrists and
10	10	therapeutic optometrists providing services under a managed care
11	11	plan.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Chapter 1452, Insurance Code, is amended by
14	14	adding Subchapters D and E to read as follows:
15	15	SUBCHAPTER D. EXPEDITED CREDENTIALING PROCESS
16	16	FOR CERTAIN PODIATRISTS
17	17	Sec. 1452.151. DEFINITIONS. In this subchapter:
18	18	(1) "Applicant podiatrist" means a podiatrist
19	19	applying for expedited credentialing under this subchapter.
20	20	(2) "Enrollee" means an individual who is eligible to
21	21	receive health care services under a managed care plan.
22	22	(3) "Health care provider" means:
23	23	(A) an individual who is licensed, certified, or
24	24	otherwise authorized to provide health care services in this state;
25	25	or
26	26	(B) a hospital, emergency clinic, outpatient
27	27	clinic, or other facility providing health care services.
28	28	(4) "Managed care plan" means a health benefit plan
29	29	under which health care services are provided to enrollees through
30	30	contracts with health care providers and that requires enrollees to
31	31	use participating providers or that provides a different level of
32	32	coverage for enrollees who use participating providers. The term
33	33	includes a health benefit plan issued by:
34	34	(A) a health maintenance organization;
35	35	(B) a preferred provider benefit plan issuer; or
36	36	(C) any other entity that issues a health benefit
37	37	plan, including an insurance company.
38	38	(5) "Participating provider" means a health care
39	39	provider who has contracted with a health benefit plan issuer to
40	40	provide services to enrollees.
41	41	(6) "Professional practice" means a business entity
42	42	that is owned by one or more podiatrists or physicians.
43	43	Sec. 1452.152. APPLICABILITY. This subchapter applies only
44	44	to a podiatrist who joins an established professional practice that
45	45	has a current contract in force with a managed care plan.
46	46	Sec. 1452.153. ELIGIBILITY REQUIREMENTS. To qualify for
47	47	expedited credentialing under this subchapter and payment under
48	48	Section 1452.154, an applicant podiatrist must:
49	49	(1) be licensed in this state by, and in good standing
50	50	with, the Texas State Board of Podiatric Medical Examiners;
51	51	(2) submit all documentation and other information
52	52	required by the issuer of the managed care plan as necessary to
53	53	enable the issuer to begin the credentialing process required by
54	54	the issuer to include a podiatrist in the issuer's health benefit
55	55	plan network; and
56	56	(3) agree to comply with the terms of the managed care
57	57	plan's participating provider contract currently in force with the
58	58	applicant podiatrist's established professional practice.
59	59	Sec. 1452.154. PAYMENT OF APPLICANT PODIATRIST DURING
60	60	CREDENTIALING PROCESS. On submission by the applicant podiatrist
61	61	of the information required by the managed care plan issuer under
62	62	Section 1452.153(2), and for payment purposes only, the issuer
63	63	shall treat the applicant podiatrist as if the podiatrist were a
64	64	participating provider in the health benefit plan network when the
65	65	applicant podiatrist provides services to the managed care plan's
66	66	enrollees, including:
67	67	(1) authorizing the applicant podiatrist to collect
68	68	copayments from the enrollees; and
69	69	(2) making payments to the applicant podiatrist.
70	70	Sec. 1452.155. DIRECTORY ENTRIES. Pending the approval of
71	71	an application submitted under Section 1452.154, the managed care
72	72	plan may exclude the applicant podiatrist from the managed care
73	73	plan's directory of participating podiatrists, the managed care
74	74	plan's website listing of participating podiatrists, or any other
75	75	listing of participating podiatrists.
76	76	Sec. 1452.156. EFFECT OF FAILURE TO MEET CREDENTIALING
77	77	REQUIREMENTS. If, on completion of the credentialing process, the
78	78	managed care plan issuer determines that the applicant podiatrist
79	79	does not meet the issuer's credentialing requirements:
80	80	(1) the managed care plan issuer may recover from the
81	81	applicant podiatrist or the podiatrist's professional practice an
82	82	amount equal to the difference between payments for in-network
83	83	benefits and out-of-network benefits; and
84	84	(2) the applicant podiatrist or the podiatrist's
85	85	professional practice may retain any copayments collected or in the
86	86	process of being collected as of the date of the issuer's
87	87	determination.
88	88	Sec. 1452.157. ENROLLEE HELD HARMLESS. An enrollee in the
89	89	managed care plan is not responsible and shall be held harmless for
90	90	the difference between in-network copayments paid by the enrollee
91	91	to a podiatrist who is determined to be ineligible under Section
92	92	1452.156 and the managed care plan's charges for out-of-network
93	93	services. The podiatrist and the podiatrist's professional
94	94	practice may not charge the enrollee for any portion of the
95	95	podiatrist's fee that is not paid or reimbursed by the enrollee's
96	96	managed care plan.
97	97	Sec. 1452.158. LIMITATION ON MANAGED CARE ISSUER
98	98	LIABILITY. A managed care plan issuer that complies with this
99	99	subchapter is not subject to liability for damages arising out of or
100	100	in connection with, directly or indirectly, the payment by the
101	101	issuer of an applicant podiatrist as if the podiatrist were a
102	102	participating provider in the health benefit plan network.
103	103	SUBCHAPTER E. EXPEDITED CREDENTIALING PROCESS
104	104	FOR CERTAIN THERAPEUTIC OPTOMETRISTS
105	105	Sec. 1452.201. DEFINITIONS. In this subchapter:
106	106	(1) "Applicant therapeutic optometrist" means a
107	107	therapeutic optometrist applying for expedited credentialing under
108	108	this subchapter.
109	109	(2) "Enrollee" means an individual who is eligible to
110	110	receive health care services under a managed care plan.
111	111	(3) "Health care provider" has the meaning assigned by
112	112	Section 1452.151.
113	113	(4) "Managed care plan" has the meaning assigned by
114	114	Section 1452.151.
115	115	(5) "Participating provider" means a health care
116	116	provider who has contracted with a health benefit plan issuer to
117	117	provide services to enrollees.
118	118	(6) "Professional practice" means a business entity
119	119	that is owned by one or more therapeutic optometrists or
120	120	physicians.
121	121	Sec. 1452.202. APPLICABILITY. This subchapter applies only
122	122	to a therapeutic optometrist who joins an established professional
123	123	practice that has a current contract in force with a managed care
124	124	plan.
125	125	Sec. 1452.203. ELIGIBILITY REQUIREMENTS. To qualify for
126	126	expedited credentialing under this subchapter and payment under
127	127	Section 1452.204, an applicant therapeutic optometrist must:
128	128	(1) be licensed in this state by, and in good standing
129	129	with, the Texas Optometry Board;
130	130	(2) submit all documentation and other information
131	131	required by the issuer of the managed care plan as necessary to
132	132	enable the issuer to begin the credentialing process required by
133	133	the issuer to include a therapeutic optometrist in the issuer's
134	134	health benefit plan network; and
135	135	(3) agree to comply with the terms of the managed care
136	136	plan's participating provider contract currently in force with the
137	137	applicant therapeutic optometrist's established professional
138	138	practice.
139	139	Sec. 1452.204. PAYMENT OF APPLICANT THERAPEUTIC
140	140	OPTOMETRIST DURING CREDENTIALING PROCESS. On submission by the
141	141	applicant therapeutic optometrist of the information required by
142	142	the managed care plan issuer under Section 1452.203(2), and for
143	143	payment purposes only, the issuer shall treat the applicant
144	144	therapeutic optometrist as if the therapeutic optometrist were a
145	145	participating provider in the health benefit plan network when the
146	146	applicant therapeutic optometrist provides services to the managed
147	147	care plan's enrollees, including:
148	148	(1) authorizing the applicant therapeutic optometrist
149	149	to collect copayments from the enrollees; and
150	150	(2) making payments to the applicant therapeutic
151	151	optometrist.
152	152	Sec. 1452.205. DIRECTORY ENTRIES. Pending the approval of
153	153	an application submitted under Section 1452.204, the managed care
154	154	plan may exclude the applicant therapeutic optometrist from the
155	155	managed care plan's directory of participating therapeutic
156	156	optometrists, the managed care plan's website listing of
157	157	participating therapeutic optometrists, or any other listing of
158	158	participating therapeutic optometrists.
159	159	Sec. 1452.206. EFFECT OF FAILURE TO MEET CREDENTIALING
160	160	REQUIREMENTS. If, on completion of the credentialing process, the
161	161	managed care plan issuer determines that the applicant therapeutic
162	162	optometrist does not meet the issuer's credentialing requirements:
163	163	(1) the managed care plan issuer may recover from the
164	164	applicant therapeutic optometrist or the therapeutic optometrist's
165	165	professional practice an amount equal to the difference between
166	166	payments for in-network benefits and out-of-network benefits; and
167	167	(2) the applicant therapeutic optometrist or the
168	168	therapeutic optometrist's professional practice may retain any
169	169	copayments collected or in the process of being collected as of the
170	170	date of the issuer's determination.
171	171	Sec. 1452.207. ENROLLEE HELD HARMLESS. An enrollee in the
172	172	managed care plan is not responsible and shall be held harmless for
173	173	the difference between in-network copayments paid by the enrollee
174	174	to a therapeutic optometrist who is determined to be ineligible
175	175	under Section 1452.206 and the managed care plan's charges for
176	176	out-of-network services. The therapeutic optometrist and the
177	177	therapeutic optometrist's professional practice may not charge the
178	178	enrollee for any portion of the therapeutic optometrist's fee that
179	179	is not paid or reimbursed by the enrollee's managed care plan.
180	180	Sec. 1452.208. LIMITATION ON MANAGED CARE ISSUER
181	181	LIABILITY. A managed care plan issuer that complies with this
182	182	subchapter is not subject to liability for damages arising out of or
183	183	in connection with, directly or indirectly, the payment by the
184	184	issuer of an applicant therapeutic optometrist as if the
185	185	therapeutic optometrist were a participating provider in the health
186	186	benefit plan network.
187	187	SECTION 2. The change in law made by this Act applies only
188	188	to credentialing of a podiatrist or a therapeutic optometrist under
189	189	a contract entered into or renewed by a professional practice and an
190	190	issuer of a managed care plan on or after the effective date of this
191	191	Act. A contract entered into or renewed before the effective date
192	192	of this Act is governed by the law in effect immediately before that
193	193	date, and that law is continued in effect for that purpose.
194	194	SECTION 3. This Act takes effect September 1, 2013.