BILL ANALYSIS

H.B. 1266

By: Guillen

Insurance

Committee Report (Unamended)

BACKGROUND AND PURPOSE

When a physician assistant (PA) or advanced practice registered nurse (APRN) is hired by a medical group, current law provides for a credentialing process to gain in-network status under the practice's existing contract with a health benefit plan issuer. The bill author has informed the committee that, while health benefit plan issuers ultimately credential the vast majority of providers that apply, the process is often long and burdensome and that during that time, the PA or APRN whose credentials are pending review is considered out-of-network, meaning the medical group cannot bill for their services. H.B. 1266 seeks to address this issue by creating an expedited credentialing process for certain PAs and APRNs and by requiring certain health benefit plan issuers to treat, for payment purposes, a PA or APRN who is eligible for expedited credentialing as a network provider when providing services to enrollees under an existing contract between the medical group and the health benefit plan issuer. The bill also adds safeguards that seek to protect patients from extra costs if an applicant ultimately does not meet credentialing requirements.

CRIMINAL JUSTICE IMPACT

It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.

ANALYSIS

H.B. 1266 amends the Insurance Code to provide for an expedited credentialing process for a licensed physician assistant or a registered nurse licensed by the Texas Board of Nursing to practice as an 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.

H.B. 1266 requires a physician assistant or advanced practice nurse to satisfy the following eligibility requirements in order to qualify for the expedited credentialing process and payment for services during the credentialing process:

· be licensed in Texas by, and in good standing with, the Texas Physician Assistant Board or the Texas Board of Nursing;

· 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;

· 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

· have received express written consent from the physician assistant's or advanced practice nurse's established medical group to apply for expedited credentialing under the bill's provisions.

After a physician assistant or advanced practice nurse applicant has met such eligibility requirements, the managed care plan issuer must, 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 authorizing the applicant's medical group to collect copayments from the enrollees for the applicant's services and making payments to the applicant's medical group for the applicant's services.

H.B. 1266 prohibits the bill from being construed as requiring the managed care plan issuer to include an applicant in the plan's directory, website listing, or other listing of participating providers.

H.B. 1266 provides that, if the issuer determines that the applicant does not meet the issuer's credentialing requirements on completion of the credentialing process:

· the issuer may recover from the applicant's medical group that was paid for the applicant's services an amount equal to the difference between payments for in-network benefits and out-of-network benefits; and

· 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.

H.B. 1266 establishes that a managed care plan enrollee is not responsible and is to be held harmless for the difference between the following:

· in-network copayments paid 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 the bill's provisions for a failure to meet the issuer's credentialing requirements; and

· the enrollee's managed care plan's charges for out-of-network services.

Moreover, 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.

H.B. 1266 establishes that a managed care plan issuer in compliance with the bill's provisions 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 the expedited credentialing process established by the bill.

H.B. 1266 defines the following terms:

· "advanced practice nurse" as an advanced practice registered nursed as defined by the Nursing Practice Act;

· "enrollee" as an individual who is eligible to receive health care services under a managed care plan;

· "health care provider" as an individual who is licensed, certified, or otherwise authorized to provide health care services in Texas or a hospital, emergency clinic, outpatient clinic, or other facility providing health care services;

· "managed care plan" as a health benefit plan, including a plan issued by a health maintenance organization, a preferred provider benefit plan issuer, or any other entity that issues a health benefit plan, including an insurance company, 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;

· "medical group" as a professional association composed solely of licensed physicians or a single legal entity authorized to practice medicine in Texas that is owned by two or more licensed physicians;

· "participating provider" as a health care provider who has contracted with a health benefit plan issuer to provide services to enrollees;

· "physician" as an individual licensed to practice medicine in Texas; and

· "physician assistant" as an individual who holds a license issued under the Physician Assistant Licensing Act.

EFFECTIVE DATE

September 1, 2025.