83R19535 SCL-F
By: Carona S.B. No. 365
(Parker)
Substitute the following for S.B. No. 365: No.
A BILL TO BE ENTITLED
AN ACT
relating to expedited credentialing for certain podiatrists and
therapeutic optometrists 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 Subchapters D and E to read as follows:
SUBCHAPTER D. EXPEDITED CREDENTIALING PROCESS
FOR CERTAIN PODIATRISTS
Sec. 1452.151. DEFINITIONS. In this subchapter:
(1) "Applicant podiatrist" means a podiatrist
applying for expedited credentialing under this subchapter.
(2) "Enrollee" means an individual who is eligible to
receive health care services under a managed care plan.
(3) "Health care provider" means:
(A) an individual who is licensed, certified, or
otherwise authorized to provide health care services in this state;
or
(B) a hospital, emergency clinic, outpatient
clinic, or other facility providing health care services.
(4) "Managed care plan" means a health benefit plan
under which health care services are provided to enrollees through
contracts with health care providers and that requires enrollees to
use participating providers or that provides a different level of
coverage for enrollees who use participating providers. The term
includes a health benefit plan issued by:
(A) a health maintenance organization;
(B) a preferred provider benefit plan issuer; or
(C) any other entity that issues a health benefit
plan, including an insurance company.
(5) "Participating provider" means a health care
provider who has contracted with a health benefit plan issuer to
provide services to enrollees.
(6) "Professional practice" means a business entity
that is owned by one or more podiatrists or physicians.
Sec. 1452.152. APPLICABILITY. This subchapter applies only
to a podiatrist who joins an established professional practice that
has a current contract in force with a managed care plan.
Sec. 1452.153. ELIGIBILITY REQUIREMENTS. To qualify for
expedited credentialing under this subchapter and payment under
Section 1452.154, an applicant podiatrist must:
(1) be licensed in this state by, and in good standing
with, the Texas State Board of Podiatric Medical Examiners;
(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 a podiatrist 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 podiatrist's established professional practice.
Sec. 1452.154. PAYMENT OF APPLICANT PODIATRIST DURING
CREDENTIALING PROCESS. On submission by the applicant podiatrist
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 podiatrist as if the podiatrist were a
participating provider in the health benefit plan network when the
applicant podiatrist provides services to the managed care plan's
enrollees, including:
(1) authorizing the applicant podiatrist to collect
copayments from the enrollees; and
(2) making payments to the applicant podiatrist.
Sec. 1452.155. DIRECTORY ENTRIES. Pending the approval of
an application submitted under Section 1452.154, the managed care
plan may exclude the applicant podiatrist from the managed care
plan's directory of participating podiatrists, the managed care
plan's website listing of participating podiatrists, or any other
listing of participating podiatrists.
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 podiatrist
does not meet the issuer's credentialing requirements:
(1) the managed care plan issuer may recover from the
applicant podiatrist or the podiatrist's professional practice an
amount equal to the difference between payments for in-network
benefits and out-of-network benefits; and
(2) the applicant podiatrist or the podiatrist's
professional practice 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 podiatrist who is determined to be ineligible under Section
1452.156 and the managed care plan's charges for out-of-network
services. The podiatrist and the podiatrist's professional
practice may not charge the enrollee for any portion of the
podiatrist'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 podiatrist as if the podiatrist were a
participating provider in the health benefit plan network.
SUBCHAPTER E. EXPEDITED CREDENTIALING PROCESS
FOR CERTAIN THERAPEUTIC OPTOMETRISTS
Sec. 1452.201. DEFINITIONS. In this subchapter:
(1) "Applicant therapeutic optometrist" means a
therapeutic optometrist applying for expedited credentialing under
this subchapter.
(2) "Enrollee" means an individual who is eligible to
receive health care services under a managed care plan.
(3) "Health care provider" has the meaning assigned by
Section 1452.151.
(4) "Managed care plan" has the meaning assigned by
Section 1452.151.
(5) "Participating provider" means a health care
provider who has contracted with a health benefit plan issuer to
provide services to enrollees.
(6) "Professional practice" means a business entity
that is owned by one or more therapeutic optometrists or
physicians.
Sec. 1452.202. APPLICABILITY. This subchapter applies only
to a therapeutic optometrist who joins an established professional
practice that has a current contract in force with a managed care
plan.
Sec. 1452.203. ELIGIBILITY REQUIREMENTS. To qualify for
expedited credentialing under this subchapter and payment under
Section 1452.204, an applicant therapeutic optometrist must:
(1) be licensed in this state by, and in good standing
with, the Texas Optometry Board;
(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 a therapeutic optometrist 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 therapeutic optometrist's established professional
practice.
Sec. 1452.204. PAYMENT OF APPLICANT THERAPEUTIC
OPTOMETRIST DURING CREDENTIALING PROCESS. On submission by the
applicant therapeutic optometrist of the information required by
the managed care plan issuer under Section 1452.203(2), and for
payment purposes only, the issuer shall treat the applicant
therapeutic optometrist as if the therapeutic optometrist were a
participating provider in the health benefit plan network when the
applicant therapeutic optometrist provides services to the managed
care plan's enrollees, including:
(1) authorizing the applicant therapeutic optometrist
to collect copayments from the enrollees; and
(2) making payments to the applicant therapeutic
optometrist.
Sec. 1452.205. DIRECTORY ENTRIES. Pending the approval of
an application submitted under Section 1452.204, the managed care
plan may exclude the applicant therapeutic optometrist from the
managed care plan's directory of participating therapeutic
optometrists, the managed care plan's website listing of
participating therapeutic optometrists, or any other listing of
participating therapeutic optometrists.
Sec. 1452.206. EFFECT OF FAILURE TO MEET CREDENTIALING
REQUIREMENTS. If, on completion of the credentialing process, the
managed care plan issuer determines that the applicant therapeutic
optometrist does not meet the issuer's credentialing requirements:
(1) the managed care plan issuer may recover from the
applicant therapeutic optometrist or the therapeutic optometrist's
professional practice an amount equal to the difference between
payments for in-network benefits and out-of-network benefits; and
(2) the applicant therapeutic optometrist or the
therapeutic optometrist's professional practice may retain any
copayments collected or in the process of being collected as of the
date of the issuer's determination.
Sec. 1452.207. 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 therapeutic optometrist who is determined to be ineligible
under Section 1452.206 and the managed care plan's charges for
out-of-network services. The therapeutic optometrist and the
therapeutic optometrist's professional practice may not charge the
enrollee for any portion of the therapeutic optometrist's fee that
is not paid or reimbursed by the enrollee's managed care plan.
Sec. 1452.208. 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 therapeutic optometrist as if the
therapeutic optometrist were a participating provider in the health
benefit plan network.
SECTION 2. The change in law made by this Act applies only
to credentialing of a podiatrist or a therapeutic optometrist under
a contract entered into or renewed by a professional practice 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 3. This Act takes effect September 1, 2013.