86R11465 SCL-D
By: Zaffirini S.B. No. 1796
A BILL TO BE ENTITLED
AN ACT
relating to physician and health care practitioner credentialing by
managed care plan issuers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1452, Insurance Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. CREDENTIALING OF PHYSICIANS AND PROVIDERS BY MANAGED
CARE PLAN ISSUER
Sec. 1452.251. DEFINITIONS. In this subchapter:
(1) "Enrollee" means an individual who is eligible to
receive health care services under a managed care plan.
(2) "Health benefit plan" means a plan that provides
benefits for medical, surgical, or other treatment expenses
incurred as a result of a health condition, a mental health
condition, an accident, sickness, or substance abuse, including:
(A) an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or similar
coverage document that is issued by:
(i) an insurance company;
(ii) a group hospital service corporation
operating under Chapter 842;
(iii) a health maintenance organization
operating under Chapter 843;
(iv) an approved nonprofit health
corporation that holds a certificate of authority under Chapter
844;
(v) a multiple employer welfare arrangement
that holds a certificate of authority under Chapter 846;
(vi) a stipulated premium company operating
under Chapter 884;
(vii) a fraternal benefit society operating
under Chapter 885;
(viii) a Lloyd's plan operating under
Chapter 941; or
(ix) an exchange operating under Chapter
942;
(B) a small employer health benefit plan written
under Chapter 1501;
(C) a health benefit plan issued under Chapter
1551, 1575, 1579, or 1601; or
(D) a health benefit plan issued under the
Medicaid managed care program under Chapter 533, Government Code.
(3) "Health care practitioner" means an individual,
other than a physician, who is licensed to provide and provides
health care services.
(4) "Managed care plan" means a health benefit plan
under which health care services are provided to enrollees through
contracts with physicians or health care practitioners and that
requires enrollees to use participating providers or that provides
a different level of coverage for enrollees who use participating
providers.
(5) "Participating provider" means a physician or
health care practitioner who has contracted with a managed care
plan issuer to provide services to enrollees.
(6) "Physician" means an individual licensed to
practice medicine in this state.
Sec. 1452.252. PROMPT CREDENTIALING REQUIRED. A managed
care plan issuer shall determine in a reasonable time in accordance
with commissioner rule whether to credential a physician or health
care practitioner who is not eligible for expedited credentialing
under Subchapter C.
Sec. 1452.253. ELIGIBILITY REQUIREMENTS. To qualify for
credentialing under this subchapter and payment under Section
1452.254, an applicant must:
(1) be licensed in this state by, and in good standing
with, the Texas Medical Board or other appropriate licensing
authority;
(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 the applicant in the issuer's managed care
plan network; and
(3) agree to comply with the terms of the applicable
managed care plan's participating provider contract.
Sec. 1452.254. PAYMENT OF APPLICANT DURING CREDENTIALING
PROCESS. On agreement to participating provider contract terms by
an applicant and managed care plan issuer, and for payment purposes
only, the issuer shall treat the applicant as if the applicant is a
participating provider in the managed care plan network when the
applicant provides services to the managed care plan's enrollees,
including:
(1) authorizing the applicant to collect copayments
from the enrollees; and
(2) making payments to the applicant.
Sec. 1452.255. EFFECT OF FAILURE TO MEET CREDENTIALING
REQUIREMENTS. If, on completion of the credentialing process, the
managed care plan issuer determines that the applicant does not
meet the issuer's credentialing requirements:
(1) the managed care plan issuer may recover from the
applicant an amount equal to the difference between payments for
in-network benefits and out-of-network benefits; and
(2) the applicant may retain any copayments collected
or in the process of being collected as of the date of the issuer's
determination.
Sec. 1452.256. 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 an applicant who is determined to be ineligible under Section
1452.255 and the managed care plan's charges for out-of-network
services. The applicant may not charge the enrollee for any portion
of the amount that is not paid or reimbursed by the enrollee's
managed care plan.
Sec. 1452.257. LIMITATION ON MANAGED CARE PLAN 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 as if the applicant were a participating
provider in the managed care plan network.
Sec. 1452.258. DEPARTMENT AUDIT. A managed care plan
issuer shall make available all relevant information to the
department to allow the department to audit the credentialing
process to determine compliance with this subchapter.
Sec. 1452.259. PUBLIC INSURANCE COUNSEL REPORT. The Office
of Public Insurance Counsel shall create and publish an annual
report on the counsel's Internet website of the largest managed
care plan issuers in this state and include information for each
issuer on:
(1) the issuer's network adequacy;
(2) the percentage of enrollees receiving a bill from
an out-of-network provider due to provider charges unpaid by the
issuer and the enrollee's responsibility under the managed care
plan; and
(3) the impact of managed care plan issuer
credentialing policies on network adequacy and enrollee payment of
out-of-network charges.
SECTION 2. This Act takes effect September 1, 2019.