Texas 2025 - 89th Regular

Texas Senate Bill SB2093 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	89R4132 SCF-F
2	2	By: Cook S.B. No. 2093
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to expedited credentialing of certain federally qualified
10	10	health center providers by managed care plan issuers and Medicaid
11	11	managed care organizations.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Section 540.0656(d), Government Code, as
14	14	effective April 1, 2025, is amended to read as follows:
15	15	(d) To qualify for expedited credentialing and payment
16	16	under Subsection (e), an applicant provider must:
17	17	(1) be a member of one of the following that has a
18	18	current contract with a Medicaid managed care organization:
19	19	(A) an established health care provider group;
20	20	(B) a federally qualified health center as
21	21	defined by 42 U.S.C. Section 1396d(l)(2)(B); or
22	22	(C) an established medical group or professional
23	23	practice that is designated by the United States Department of
24	24	Health and Human Services Health Resources and Services
25	25	Administration as a federally qualified health center [an
26	26	established health care provider group that has a current contract
27	27	with a Medicaid managed care organization];
28	28	(2) be a Medicaid-enrolled provider;
29	29	(3) agree to comply with the terms of the contract
30	30	described by Subdivision (1); and
31	31	(4) submit all documentation and other information the
32	32	Medicaid managed care organization requires as necessary to enable
33	33	the organization to begin the credentialing process the
34	34	organization requires to include a provider in the organization's
35	35	provider network.
36	36	SECTION 2. Chapter 1452, Insurance Code, is amended by
37	37	adding Subchapter F to read as follows:
38	38	SUBCHAPTER F. EXPEDITED CREDENTIALING PROCESS FOR FEDERALLY
39	39	QUALIFIED HEALTH CENTER PROVIDERS
40	40	Sec. 1452.251. DEFINITIONS. In this subchapter:
41	41	(1) "Applicant" means a health care provider applying
42	42	for expedited credentialing under this subchapter.
43	43	(2) "Enrollee" means an individual who is eligible to
44	44	receive health care services under a managed care plan.
45	45	(3) "Federally qualified health center" has the
46	46	meaning assigned by 42 U.S.C. Section 1396d(l)(2)(B).
47	47	(4) "Health care provider" means an individual who is
48	48	licensed, certified, or otherwise authorized to provide health care
49	49	services in this state.
50	50	(5) "Managed care plan" has the meaning assigned by
51	51	Section 1452.151.
52	52	(6) "Medical group" means:
53	53	(A) a single legal entity owned by two or more
54	54	physicians;
55	55	(B) a professional association composed of
56	56	licensed physicians;
57	57	(C) any other business entity composed of
58	58	licensed physicians as permitted under Subchapter B, Chapter 162,
59	59	Occupations Code; or
60	60	(D) two or more physicians on the medical staff
61	61	of, or teaching at, a medical school, medical and dental unit, or
62	62	teaching hospital, as defined or described by Section 61.003,
63	63	61.501, or 74.601, Education Code.
64	64	(7) "Participating provider" means a health care
65	65	provider or health care entity that has contracted with a health
66	66	benefit plan issuer to provide services to enrollees.
67	67	(8) "Professional practice" means a business entity
68	68	that is owned by one or more health care providers.
69	69	Sec. 1452.252. APPLICABILITY. This subchapter applies only
70	70	to:
71	71	(1) a health care provider who joins an established
72	72	federally qualified health center that has a contract with a
73	73	managed care plan; or
74	74	(2) a medical group or professional practice that has
75	75	a contract with a managed care plan and becomes a federally
76	76	qualified health center.
77	77	Sec. 1452.253. ELIGIBILITY REQUIREMENTS. (a) To qualify
78	78	for expedited credentialing under this subchapter and payment under
79	79	Section 1452.255, a health care provider must:
80	80	(1) be licensed, certified, or otherwise authorized to
81	81	provide health care services in this state by, and be in good
82	82	standing with, the applicable state board;
83	83	(2) submit all documentation and other information
84	84	required by the managed care plan issuer to begin the credentialing
85	85	process required for the issuer to include the health care provider
86	86	in the plan's network; and
87	87	(3) agree to comply with the terms of the managed care
88	88	plan's participating provider contract with the applicant's
89	89	federally qualified health center.
90	90	(b) Not later than the fifth business day after an applicant
91	91	submits the information required under Subsection (a), the managed
92	92	care plan issuer shall:
93	93	(1) confirm that the applicant's application is
94	94	complete; or
95	95	(2) request from the applicant any missing information
96	96	required by the managed care plan issuer.
97	97	(c) Regardless of whether an applicant specifically
98	98	requests expedited credentialing, a managed care plan issuer shall
99	99	use an expedited credentialing process for an applicant that has
100	100	met the eligibility requirements under Subsection (a).
101	101	Sec. 1452.254. EXPEDITED CREDENTIALING DECISION. Not later
102	102	than the 10th business day after the receipt of an applicant's
103	103	completed application under Section 1452.253, a managed care plan
104	104	issuer shall render a decision regarding the expedited
105	105	credentialing of the applicant's application.
106	106	Sec. 1452.255. PAYMENT FOR SERVICES OF APPLICANT DURING
107	107	CREDENTIALING PROCESS. (a) After an applicant has submitted the
108	108	information required by the managed care plan issuer under Section
109	109	1452.253, the managed care plan issuer shall, for payment purposes
110	110	only, treat the applicant as if the applicant is a participating
111	111	provider in the plan's network when the applicant provides services
112	112	to the plan's enrollees, including by:
113	113	(1) authorizing the applicant's federally qualified
114	114	health center to collect copayments from the enrollees for the
115	115	applicant's services; and
116	116	(2) making payments, including payments for
117	117	in-network benefits for services provided by the applicant during
118	118	the credentialing process, to the applicant's federally qualified
119	119	health center for the applicant's services.
120	120	(b) A managed care plan issuer must ensure that the issuer's
121	121	claims processing system is able to process claims from an
122	122	applicant not later than the 30th day after receipt of the
123	123	applicant's completed application under Section 1452.253.
124	124	Sec. 1452.256. DIRECTORY ENTRIES. Pending the approval of
125	125	an application submitted under Section 1452.253, the managed care
126	126	plan issuer may exclude the applicant from the plan's directory,
127	127	Internet website listing, or other listing of participating
128	128	providers.
129	129	Sec. 1452.257. EFFECT OF FAILURE TO MEET CREDENTIALING
130	130	REQUIREMENTS. If, on completion of the credentialing process, the
131	131	managed care plan issuer determines that the applicant does not
132	132	meet the issuer's credentialing requirements:
133	133	(1) the issuer may recover from the applicant or the
134	134	applicant's federally qualified health center an amount equal to
135	135	the difference between payments for in-network benefits and
136	136	out-of-network benefits; and
137	137	(2) the applicant or the applicant's federally
138	138	qualified health center may retain any copayments collected or in
139	139	the process of being collected as of the date of the issuer's
140	140	determination.
141	141	Sec. 1452.258. ENROLLEE HELD HARMLESS. An enrollee is not
142	142	responsible and shall be held harmless for the difference between
143	143	in-network copayments paid by the enrollee to a health care
144	144	provider who is determined to be ineligible under Section 1452.257
145	145	and the enrollee's managed care plan's charges for out-of-network
146	146	services. The health care provider and the health care provider's
147	147	federally qualified health center may not charge the enrollee for
148	148	any portion of the health care provider's fee that is not paid or
149	149	reimbursed by the plan.
150	150	Sec. 1452.259. LIMITATION ON MANAGED CARE PLAN ISSUER
151	151	LIABILITY. A managed care plan issuer that complies with this
152	152	subchapter is not subject to liability for damages arising out of or
153	153	in connection with, directly or indirectly, the payment by the
154	154	issuer of an applicant as if the applicant is a participating
155	155	provider in the plan's network.
156	156	SECTION 3. If before implementing any provision of this Act
157	157	a state agency determines that a waiver or authorization from a
158	158	federal agency is necessary for implementation of that provision,
159	159	the agency affected by the provision shall request the waiver or
160	160	authorization and may delay implementing that provision until the
161	161	waiver or authorization is granted.
162	162	SECTION 4. This Act takes effect September 1, 2025.