88R8764 CJD-F
By: Bucy H.B. No. 5233
A BILL TO BE ENTITLED
AN ACT
relating to expedited credentialing for licensed behavior analysts
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 Subchapter F to read as follows:
SUBCHAPTER F. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN BEHAVIOR
ANALYSTS
Sec. 1452.251. DEFINITIONS. In this subchapter:
(1) "Applicant" means a behavior analyst 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 an individual who is
licensed, certified, or otherwise authorized to provide health care
services in this state.
(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 behavior analysts.
Sec. 1452.252. APPLICABILITY. This subchapter applies only
to a behavior analyst who joins an established professional
practice 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 behavior analyst must:
(1) be licensed in this state by, and in good standing
with, the Texas Department of Licensing and Regulation;
(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 behavior analyst in
the plan's network; and
(3) agree to comply with the terms of the managed care
plan's participating provider contract with the behavior analyst's
established professional practice.
Sec. 1452.254. PAYMENT OF BEHAVIOR ANALYST 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 professional practice 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 professional
practice may retain any copayments collected or in the process of
being collected as of the date of the issuer's determination.
Sec. 1452.257. 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 behavior analyst
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 behavior analyst and the behavior analyst's professional
practice may not charge the enrollee for any portion of the behavior
analyst'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
behavior analyst treated as if the behavior analyst is a
participating provider in the plan's network.
SECTION 2. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2023.