89R37 CJD-F
By: Guillen H.B. No. 1266
A BILL TO BE ENTITLED
AN ACT
relating to expedited credentialing of certain physician
assistants and advanced practice nurses 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 ADVANCED PRACTICE NURSES
Sec. 1452.251. DEFINITIONS. In this subchapter:
(1) "Advanced practice nurse" means an advanced
practice registered nurse as defined by Section 301.152,
Occupations Code.
(2) "Applicant" means a physician assistant or
advanced practice nurse applying for expedited credentialing under
this subchapter.
(3) "Enrollee" means an individual who is eligible to
receive health care services under a managed care plan.
(4) "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.
(5) "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.
(6) "Medical group" means:
(A) a single legal entity authorized to practice
medicine in this state that is owned by two or more physicians; or
(B) a professional association composed solely
of physicians.
(7) "Participating provider" means a health care
provider who has contracted with a health benefit plan issuer to
provide services to enrollees.
(8) "Physician" means an individual licensed to
practice medicine in this state.
(9) "Physician assistant" means an individual who
holds a license issued under Chapter 204, Occupations Code.
Sec. 1452.252. APPLICABILITY. This subchapter applies only
to a physician assistant or advanced practice nurse who joins, as an
employee, an established medical group that has a contract with a
managed care plan that already includes contracted rates for
physician assistants or advanced practice nurses employed by the
medical group.
Sec. 1452.253. ELIGIBILITY REQUIREMENTS. To qualify for
expedited credentialing under this subchapter and payment under
Section 1452.254, a physician assistant or advanced practice nurse
must:
(1) be licensed in this state by, and in good standing
with, the Texas Physician Assistant Board or Texas Board of
Nursing;
(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 advanced practice nurse in the plan's network;
(3) agree to comply with the terms of the managed care
plan's participating provider contract with the physician
assistant's or advanced practice nurse's established medical group,
including the rates applicable to other physician assistants or
advanced practice nurses under the contract; and
(4) have received express written consent from the
physician assistant's or advanced practice nurse's established
medical group to apply for expedited credentialing under this
subchapter.
Sec. 1452.254. PAYMENT FOR SERVICES OF PHYSICIAN ASSISTANT
OR ADVANCED PRACTICE NURSE DURING CREDENTIALING PROCESS. After an
applicant has met the eligibility requirements under Section
1452.253, the managed care plan 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 as an employee of the applicant's
established medical group, including:
(1) authorizing the applicant's medical group to
collect copayments from the enrollees for the applicant's services;
and
(2) making payments to the applicant's medical group
for the applicant's services.
Sec. 1452.255. DIRECTORY ENTRIES. Nothing in this
subchapter may be construed as requiring the managed care plan
issuer to include the applicant in 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's
medical group that was paid under Section 1452.254 an amount equal
to the difference between payments for in-network benefits and
out-of-network benefits; and
(2) 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 under Section 1452.254 by the enrollee
to an applicant's medical group for services provided by an
employee applicant physician assistant or advanced practice nurse
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 applicant's medical group may not charge the enrollee for any
portion of the applicant's fee that is not paid or reimbursed by the
plan.
Sec. 1452.258. 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 a physician assistant's or advanced practice nurse's
medical group for services provided by the medical group's employed
physician assistant or advanced practice nurse treated as if the
physician assistant or advanced practice nurse is a participating
provider in the plan's network under this subchapter.
SECTION 2. This Act takes effect September 1, 2025.