89R4132 SCF-F
By: Hull H.B. No. 3151
A BILL TO BE ENTITLED
AN ACT
relating to expedited credentialing of certain federally qualified
health center providers by managed care plan issuers and Medicaid
managed care organizations.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 540.0656(d), Government Code, as
effective April 1, 2025, is amended to read as follows:
(d) To qualify for expedited credentialing and payment
under Subsection (e), an applicant provider must:
(1) be a member of one of the following that has a
current contract with a Medicaid managed care organization:
(A) an established health care provider group;
(B) a federally qualified health center as
defined by 42 U.S.C. Section 1396d(l)(2)(B); or
(C) an established medical group or professional
practice that is designated by the United States Department of
Health and Human Services Health Resources and Services
Administration as a federally qualified health center [an
established health care provider group that has a current contract
with a Medicaid managed care organization];
(2) be a Medicaid-enrolled provider;
(3) agree to comply with the terms of the contract
described by Subdivision (1); and
(4) submit all documentation and other information the
Medicaid managed care organization requires as necessary to enable
the organization to begin the credentialing process the
organization requires to include a provider in the organization's
provider network.
SECTION 2. Chapter 1452, Insurance Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. EXPEDITED CREDENTIALING PROCESS FOR FEDERALLY
QUALIFIED HEALTH CENTER PROVIDERS
Sec. 1452.251. DEFINITIONS. In this subchapter:
(1) "Applicant" means a health care provider 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) "Federally qualified health center" has the
meaning assigned by 42 U.S.C. Section 1396d(l)(2)(B).
(4) "Health care provider" means an individual who is
licensed, certified, or otherwise authorized to provide health care
services in this state.
(5) "Managed care plan" has the meaning assigned by
Section 1452.151.
(6) "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, medical and dental unit, or
teaching hospital, as defined or described by Section 61.003,
61.501, or 74.601, Education Code.
(7) "Participating provider" means a health care
provider or health care entity that has contracted with a health
benefit plan issuer to provide services to enrollees.
(8) "Professional practice" means a business entity
that is owned by one or more health care providers.
Sec. 1452.252. APPLICABILITY. This subchapter applies only
to:
(1) a health care provider who joins an established
federally qualified health center that has a contract with a
managed care plan; or
(2) a medical group or professional practice that has
a contract with a managed care plan and becomes a federally
qualified health center.
Sec. 1452.253. ELIGIBILITY REQUIREMENTS. (a) To qualify
for expedited credentialing under this subchapter and payment under
Section 1452.255, a health care provider must:
(1) be licensed, certified, or otherwise authorized to
provide health care services in this state by, and be in good
standing with, the applicable state 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 health care provider
in the plan's network; and
(3) agree to comply with the terms of the managed care
plan's participating provider contract with the applicant's
federally qualified health center.
(b) Not later than the fifth business day after an applicant
submits the information required under Subsection (a), the managed
care plan issuer shall:
(1) confirm that the applicant's application is
complete; or
(2) request from the applicant any missing information
required by the managed care plan issuer.
(c) Regardless of whether an applicant specifically
requests expedited credentialing, a managed care plan issuer shall
use an expedited credentialing process for an applicant that has
met the eligibility requirements under Subsection (a).
Sec. 1452.254. EXPEDITED CREDENTIALING DECISION. Not later
than the 10th business day after the receipt of an applicant's
completed application under Section 1452.253, a managed care plan
issuer shall render a decision regarding the expedited
credentialing of the applicant's application.
Sec. 1452.255. PAYMENT FOR SERVICES OF APPLICANT DURING
CREDENTIALING PROCESS. (a) After an applicant has submitted the
information required by the managed care plan issuer 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, including by:
(1) authorizing the applicant's federally qualified
health center to collect copayments from the enrollees for the
applicant's services; and
(2) making payments, including payments for
in-network benefits for services provided by the applicant during
the credentialing process, to the applicant's federally qualified
health center for the applicant's services.
(b) A managed care plan issuer must ensure that the issuer's
claims processing system is able to process claims from an
applicant not later than the 30th day after receipt of the
applicant's completed application under Section 1452.253.
Sec. 1452.256. 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. 1452.257. 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 federally qualified health center 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 federally
qualified health center may retain any copayments collected or in
the process of being collected as of the date of the issuer's
determination.
Sec. 1452.258. 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 health care
provider who is determined to be ineligible under Section 1452.257
and the enrollee's managed care plan's charges for out-of-network
services. The health care provider and the health care provider's
federally qualified health center may not charge the enrollee for
any portion of the health care provider's fee that is not paid or
reimbursed by the plan.
Sec. 1452.259. 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 is a participating
provider in the plan's network.
SECTION 3. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4. This Act takes effect September 1, 2025.