88R10354 CJD-F
By: Guillen H.B. No. 4300
A BILL TO BE ENTITLED
AN ACT
relating to expedited credentialing of certain physician
assistants and nurse practitioners 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. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN
PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS
Sec. 1452.251. DEFINITIONS. In this subchapter:
(1) "Applicant" means a physician assistant or nurse
practitioner 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) "Medical group" means:
(A) a single legal entity owned by two or more
physicians;
(B) a professional association composed of
licensed physicians;
(C) any other business entity composed of
licensed physicians as permitted under Subchapter B, Chapter 162,
Occupations Code; or
(D) two or more physicians on the medical staff
of, or teaching at, a medical school, as defined by Section 61.501,
Education Code, or medical and dental unit, as defined by Section
61.003, Education Code.
(6) "Participating provider" means a health care
provider who has contracted with a health benefit plan issuer to
provide services to enrollees.
Sec. 1452.252. APPLICABILITY. This subchapter applies only
to a physician assistant or nurse practitioner who joins an
established medical group that has a contract with a managed care
plan.
Sec. 1452.253. ELIGIBILITY REQUIREMENTS. To qualify for
expedited credentialing under this subchapter and payment under
Section 1452.254, a physician assistant or nurse practitioner must:
(1) be licensed in this state by, and in good standing
with, the Texas Physician Assistant Board or Texas Nursing Board;
(2) submit all documentation and other information
required by the managed care plan issuer to begin the credentialing
process required for the issuer to include the physician assistant
or nurse practitioner in the plan's network; and
(3) agree to comply with the terms of the managed care
plan's participating provider contract with the physician
assistant's or nurse practitioner's established medical group.
Sec. 1452.254. PAYMENT OF PHYSICIAN ASSISTANT OR NURSE
PRACTITIONER DURING CREDENTIALING PROCESS. After an applicant has
submitted the information required by the managed care plan issuer
under Section 1452.253, the issuer shall, for payment purposes
only, treat the applicant as if the applicant is a participating
provider in the plan's network when the applicant provides services
to the plan's enrollees, including:
(1) authorizing the applicant to collect copayments
from the enrollees; and
(2) making payments to the applicant.
Sec. 1452.255. DIRECTORY ENTRIES. Pending the approval of
an application submitted under Section 1452.253, the managed care
plan issuer may exclude the applicant from the plan's directory,
Internet website listing, or other listing of participating
providers.
Sec. 1452.256. 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 issuer may recover from the applicant or the
applicant's medical group an amount equal to the difference between
payments for in-network benefits and out-of-network benefits; and
(2) the applicant or the applicant's medical group may
retain any copayments collected or in the process of being
collected as of the date of the issuer's determination.
Sec. 1452.257. ENROLLEE HELD HARMLESS. An enrollee is not
responsible and shall be held harmless for the difference between
in-network copayments paid by the enrollee to a physician assistant
or nurse practitioner who is determined to be ineligible under
Section 1452.256 and the enrollee's managed care plan's charges for
out-of-network services. The physician assistant or nurse
practitioner and the physician assistant's or nurse practitioner's
medical group may not charge the enrollee for any portion of the
physician assistant's or nurse practitioner's fee that is not paid
or reimbursed by the plan.
Sec. 1452.258. 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 a
physician assistant or nurse practitioner treated as if the
physician assistant or nurse practitioner is a participating
provider in the plan's network.
SECTION 2. This Act takes effect September 1, 2023.