Texas 2019 - 86th Regular

Texas Senate Bill SB1796 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	86R11465 SCL-D
2	2	By: Zaffirini S.B. No. 1796
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to physician and health care practitioner credentialing by
8	8	managed care plan issuers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1452, Insurance Code, is amended by
11	11	adding Subchapter F to read as follows:
12	12	SUBCHAPTER F. CREDENTIALING OF PHYSICIANS AND PROVIDERS BY MANAGED
13	13	CARE PLAN ISSUER
14	14	Sec. 1452.251. DEFINITIONS. In this subchapter:
15	15	(1) "Enrollee" means an individual who is eligible to
16	16	receive health care services under a managed care plan.
17	17	(2) "Health benefit plan" means a plan that provides
18	18	benefits for medical, surgical, or other treatment expenses
19	19	incurred as a result of a health condition, a mental health
20	20	condition, an accident, sickness, or substance abuse, including:
21	21	(A) an individual, group, blanket, or franchise
22	22	insurance policy or insurance agreement, a group hospital service
23	23	contract, or an individual or group evidence of coverage or similar
24	24	coverage document that is issued by:
25	25	(i) an insurance company;
26	26	(ii) a group hospital service corporation
27	27	operating under Chapter 842;
28	28	(iii) a health maintenance organization
29	29	operating under Chapter 843;
30	30	(iv) an approved nonprofit health
31	31	corporation that holds a certificate of authority under Chapter
32	32	844;
33	33	(v) a multiple employer welfare arrangement
34	34	that holds a certificate of authority under Chapter 846;
35	35	(vi) a stipulated premium company operating
36	36	under Chapter 884;
37	37	(vii) a fraternal benefit society operating
38	38	under Chapter 885;
39	39	(viii) a Lloyd's plan operating under
40	40	Chapter 941; or
41	41	(ix) an exchange operating under Chapter
42	42	942;
43	43	(B) a small employer health benefit plan written
44	44	under Chapter 1501;
45	45	(C) a health benefit plan issued under Chapter
46	46	1551, 1575, 1579, or 1601; or
47	47	(D) a health benefit plan issued under the
48	48	Medicaid managed care program under Chapter 533, Government Code.
49	49	(3) "Health care practitioner" means an individual,
50	50	other than a physician, who is licensed to provide and provides
51	51	health care services.
52	52	(4) "Managed care plan" means a health benefit plan
53	53	under which health care services are provided to enrollees through
54	54	contracts with physicians or health care practitioners and that
55	55	requires enrollees to use participating providers or that provides
56	56	a different level of coverage for enrollees who use participating
57	57	providers.
58	58	(5) "Participating provider" means a physician or
59	59	health care practitioner who has contracted with a managed care
60	60	plan issuer to provide services to enrollees.
61	61	(6) "Physician" means an individual licensed to
62	62	practice medicine in this state.
63	63	Sec. 1452.252. PROMPT CREDENTIALING REQUIRED. A managed
64	64	care plan issuer shall determine in a reasonable time in accordance
65	65	with commissioner rule whether to credential a physician or health
66	66	care practitioner who is not eligible for expedited credentialing
67	67	under Subchapter C.
68	68	Sec. 1452.253. ELIGIBILITY REQUIREMENTS. To qualify for
69	69	credentialing under this subchapter and payment under Section
70	70	1452.254, an applicant must:
71	71	(1) be licensed in this state by, and in good standing
72	72	with, the Texas Medical Board or other appropriate licensing
73	73	authority;
74	74	(2) submit all documentation and other information
75	75	required by the issuer of the managed care plan as necessary to
76	76	enable the issuer to begin the credentialing process required by
77	77	the issuer to include the applicant in the issuer's managed care
78	78	plan network; and
79	79	(3) agree to comply with the terms of the applicable
80	80	managed care plan's participating provider contract.
81	81	Sec. 1452.254. PAYMENT OF APPLICANT DURING CREDENTIALING
82	82	PROCESS. On agreement to participating provider contract terms by
83	83	an applicant and managed care plan issuer, and for payment purposes
84	84	only, the issuer shall treat the applicant as if the applicant is a
85	85	participating provider in the managed care plan network when the
86	86	applicant provides services to the managed care plan's enrollees,
87	87	including:
88	88	(1) authorizing the applicant to collect copayments
89	89	from the enrollees; and
90	90	(2) making payments to the applicant.
91	91	Sec. 1452.255. EFFECT OF FAILURE TO MEET CREDENTIALING
92	92	REQUIREMENTS. If, on completion of the credentialing process, the
93	93	managed care plan issuer determines that the applicant does not
94	94	meet the issuer's credentialing requirements:
95	95	(1) the managed care plan issuer may recover from the
96	96	applicant an amount equal to the difference between payments for
97	97	in-network benefits and out-of-network benefits; and
98	98	(2) the applicant may retain any copayments collected
99	99	or in the process of being collected as of the date of the issuer's
100	100	determination.
101	101	Sec. 1452.256. ENROLLEE HELD HARMLESS. An enrollee in the
102	102	managed care plan is not responsible and shall be held harmless for
103	103	the difference between in-network copayments paid by the enrollee
104	104	to an applicant who is determined to be ineligible under Section
105	105	1452.255 and the managed care plan's charges for out-of-network
106	106	services. The applicant may not charge the enrollee for any portion
107	107	of the amount that is not paid or reimbursed by the enrollee's
108	108	managed care plan.
109	109	Sec. 1452.257. LIMITATION ON MANAGED CARE PLAN ISSUER
110	110	LIABILITY. A managed care plan issuer that complies with this
111	111	subchapter is not subject to liability for damages arising out of or
112	112	in connection with, directly or indirectly, the payment by the
113	113	issuer of an applicant as if the applicant were a participating
114	114	provider in the managed care plan network.
115	115	Sec. 1452.258. DEPARTMENT AUDIT. A managed care plan
116	116	issuer shall make available all relevant information to the
117	117	department to allow the department to audit the credentialing
118	118	process to determine compliance with this subchapter.
119	119	Sec. 1452.259. PUBLIC INSURANCE COUNSEL REPORT. The Office
120	120	of Public Insurance Counsel shall create and publish an annual
121	121	report on the counsel's Internet website of the largest managed
122	122	care plan issuers in this state and include information for each
123	123	issuer on:
124	124	(1) the issuer's network adequacy;
125	125	(2) the percentage of enrollees receiving a bill from
126	126	an out-of-network provider due to provider charges unpaid by the
127	127	issuer and the enrollee's responsibility under the managed care
128	128	plan; and
129	129	(3) the impact of managed care plan issuer
130	130	credentialing policies on network adequacy and enrollee payment of
131	131	out-of-network charges.
132	132	SECTION 2. This Act takes effect September 1, 2019.