Texas 2019 - 86th Regular

Texas House Bill HB2631 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		86R24397 SCL-D
2	2		By: J. Johnson of Dallas, Oliverson, Moody, H.B. No. 2631
3	3		et al.
	4	+	Substitute the following for H.B. No. 2631:
	5	+	By: Lucio III C.S.H.B. No. 2631
4	6
5	7
6	8		A BILL TO BE ENTITLED
7	9		AN ACT
8	10		relating to physician and health care practitioner credentialing by
9	11		managed care plan issuers.
10	12		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	13		SECTION 1. Chapter 1452, Insurance Code, is amended by
12	14		adding Subchapter F to read as follows:
13	15		SUBCHAPTER F. CREDENTIALING OF PHYSICIANS AND PROVIDERS BY MANAGED
14	16		CARE PLAN ISSUER
15	17		Sec. 1452.251. DEFINITIONS. In this subchapter:
16	18		(1) "Enrollee" means an individual who is eligible to
17	19		receive health care services under a managed care plan.
18	20		(2) "Health benefit plan" means a plan that provides
19	21		benefits for medical, surgical, or other treatment expenses
20	22		incurred as a result of a health condition, a mental health
21	23		condition, an accident, sickness, or substance abuse, including:
22	24		(A) an individual, group, blanket, or franchise
23	25		insurance policy or insurance agreement, a group hospital service
24	26		contract, or an individual or group evidence of coverage or similar
25	27		coverage document that is issued by:
26	28		(i) an insurance company;
27	29		(ii) a group hospital service corporation
28	30		operating under Chapter 842;
29	31		(iii) a health maintenance organization
30	32		operating under Chapter 843;
31	33		(iv) an approved nonprofit health
32	34		corporation that holds a certificate of authority under Chapter
33	35		844;
34	36		(v) a multiple employer welfare arrangement
35	37		that holds a certificate of authority under Chapter 846;
36	38		(vi) a stipulated premium company operating
37	39		under Chapter 884;
38	40		(vii) a fraternal benefit society operating
39	41		under Chapter 885;
40	42		(viii) a Lloyd's plan operating under
41	43		Chapter 941; or
42	44		(ix) an exchange operating under Chapter
43	45		942;
44	46		(B) a small employer health benefit plan written
45	47		under Chapter 1501;
46	48		(C) a health benefit plan issued under Chapter
47	49		1551, 1575, 1579, or 1601; or
48	50		(D) a health benefit plan issued under the
49	51		Medicaid managed care program under Chapter 533, Government Code.
50	52		(3) "Health care practitioner" means an individual,
51	53		other than a physician, who is licensed to provide and provides
52	54		health care services.
53	55		(4) "Managed care plan" means a health benefit plan
54	56		under which health care services are provided to enrollees through
55	57		contracts with physicians or health care practitioners and that
56	58		requires enrollees to use participating providers or that provides
57	59		a different level of coverage for enrollees who use participating
58	60		providers.
59	61		(5) "Participating provider" means a physician or
60	62		health care practitioner who has contracted with a managed care
61	63		plan issuer to provide services to enrollees.
62	64		(6) "Physician" means an individual licensed to
63	65		practice medicine in this state.
64	66		Sec. 1452.252. PROMPT CREDENTIALING REQUIRED. A managed
65	67		care plan issuer shall determine in a reasonable time in accordance
66	68		with commissioner rule whether to credential a physician or health
67	69		care practitioner who is not eligible for expedited credentialing
68	70		under Subchapter C.
69	71		Sec. 1452.253. ELIGIBILITY REQUIREMENTS. To qualify for
70	72		credentialing under this subchapter and payment under Section
71	73		1452.254, an applicant must:
72	74		(1) be licensed in this state by, and in good standing
73	75		with, the Texas Medical Board or other appropriate licensing
74	76		authority;
75	77		(2) submit all documentation and other information
76	78		required by the issuer of the managed care plan as necessary to
77	79		enable the issuer to begin the credentialing process required by
78	80		the issuer to include the applicant in the issuer's managed care
79	81		plan network; and
80	82		(3) agree to comply with the terms of the applicable
81	83		managed care plan's participating provider contract.
82	84		Sec. 1452.254. PAYMENT OF APPLICANT DURING CREDENTIALING
83	85		PROCESS. (a) On election by the applicant after receiving notice
84	86		under Subsection (b) and on agreement to participating provider
85	87		contract terms by the applicant and managed care plan issuer, and
86	88		for payment purposes only, the issuer shall treat the applicant as
87	89		if the applicant is a participating provider in the managed care
88	90		plan network when the applicant provides services to the managed
89	91		care plan's enrollees, including:
90	92		(1) authorizing the applicant to collect copayments
91	93		from the enrollees; and
92	94		(2) making payments to the applicant.
93	95		(b) On receipt of a credentialing application, a managed
94	96		care plan issuer shall provide notice to the applicant of the effect
95	97		of failure to meet the issuer's credentialing requirements under
96	98		Section 1452.255 if the applicant elects to be considered a
97	99		participating provider under Subsection (a).
98	100		Sec. 1452.255. EFFECT OF FAILURE TO MEET CREDENTIALING
99	101		REQUIREMENTS. If, on completion of the credentialing process, the
100	102		managed care plan issuer determines that an applicant who made an
101	103		election under Section 1452.254 does not meet the issuer's
102	104		credentialing requirements:
103	105		(1) the managed care plan issuer may recover from the
104	106		applicant an amount equal to the difference between payments for
105	107		in-network benefits and out-of-network benefits; and
106	108		(2) the applicant may retain any copayments collected
107	109		or in the process of being collected as of the date of the issuer's
108	110		determination.
109	111		Sec. 1452.256. ENROLLEE HELD HARMLESS. An enrollee in the
110	112		managed care plan is not responsible and shall be held harmless for
111	113		the difference between in-network copayments paid by the enrollee
112	114		to an applicant who is determined to be ineligible under Section
113	115		1452.255 and the managed care plan's charges for out-of-network
114	116		services. The applicant may not charge the enrollee for any portion
115	117		of the amount that is not paid or reimbursed by the enrollee's
116	118		managed care plan.
117	119		Sec. 1452.257. LIMITATION ON MANAGED CARE PLAN ISSUER
118	120		LIABILITY. A managed care plan issuer that complies with this
119	121		subchapter is not subject to liability for damages arising out of or
120	122		in connection with, directly or indirectly, the payment by the
121	123		issuer of an applicant as if the applicant were a participating
122	124		provider in the managed care plan network.
123	125		Sec. 1452.258. DEPARTMENT AUDIT. A managed care plan
124	126		issuer shall make available all relevant information to the
125	127		department to allow the department to audit the credentialing
126	128		process to determine compliance with this subchapter.
127	129		Sec. 1452.259. PUBLIC INSURANCE COUNSEL REPORT. Using
128	130		existing resources, the office of public insurance counsel shall
129	131		create and publish an annual report on the counsel's Internet
130	132		website of the largest managed care plan issuers in this state and
131	133		include information for each issuer on:
132	134		(1) the issuer's network adequacy;
133	135		(2) the percentage of enrollees receiving a bill from
134	136		an out-of-network provider due to provider charges unpaid by the
135	137		issuer and the enrollee's responsibility under the managed care
136	138		plan; and
137	139		(3) the impact of managed care plan issuer
138	140		credentialing policies on network adequacy and enrollee payment of
139	141		out-of-network charges.
140	142		SECTION 2. This Act takes effect September 1, 2019.