SRC-CTC C.S.S.B. 1143 77(R)BILL ANALYSIS


Senate Research CenterC.S.S.B. 1143
77R9923 AJA-FBy: Carona
Business & Commerce
3/28/2001
Committee Report (Substituted)


DIGEST AND PURPOSE 

Currently, all contracts between health maintenance organizations and
physicians or other providers require credentialing.  The initial
credentialing process includes an application, verification of information,
and a site visit.  Texas has not updated the standards on credentialing
health maintenance organizations to stay in line with the National
Committee for Quality Assurance (NCQA).  Medicaid and Medicare
credentialing standards are based on NCQA standards.  C.S.S.B. 1143 applies
NCQA standards for health maintenance organizations to move Texas
requirements in line with national standards. 

RULEMAKING AUTHORITY

This bill does not expressly grant any additional rulemaking authority to a
state officer, institution, or agency. 

SECTION BY SECTION ANALYSIS

SECTION 1. Amends Chapter 20A, Insurance Code, by adding Section 39, as
follows: 

Sec. 39.  CREDENTIALING OF PHYSICIANS AND PROVIDERS.  (a) Requires rules
adopted by the commissioner of insurance (commissioner) under Section 37 of
this Act that relate to implementation and maintenance by a health
maintenance organization (HMO) of a process for selecting and retaining
affiliated physicians and providers to comply with this section and
standards promulgated by the National Committee for Quality Assurance, to
the extent those standards do not conflict with other laws of this state. 

(b) Requires the commissioner to require an HMO to verify that a
physician's license to practice medicine and any other certificate the
physician is required to hold, including a certificate issued by the Texas
Department of Public Safety, the federal Drug Enforcement Agency, or a
certificate issued under the Medicare program, is valid as of the date of
initial credentialing and on the date of each recredentialing. 

(c) Requires the commissioner to require an HMO that conducts a site visit
for the purpose of initial credentialing to evaluate during the visit a
site's accessibility, appearance, space, medical or dental recordkeeping
practices, availability of appointments, and confidentiality procedures.
Prohibits the commissioner from requiring the HMO to evaluate the
appropriateness of equipment during the site visit. 

  (d) Prohibits the commissioner from requiring certain actions from an HMO.

(e) Provides that this section does not preclude an HMO from performing a
site visit of a physician or provider at any time for cause, including a
complaint made by a member or another external complaint made to the HMO. 

SECTION 2.  Effective date: September 1, 2001.
 
SUMMARY OF COMMITTEE CHANGES

SECTION 1.  Amends As Filed S.B. 1143 by requiring rules adopted by the
commissioner of insurance (commissioner) under Section 37 of this Act that
relate to the implementation and maintenance by a health maintenance
organization (HMO) of a process for selecting and retaining affiliated
physicians and providers to comply with this section.  Requires certain
actions to be and prohibits certain actions from being performed by the
commissioner, rather than the Texas Department of Insurance.  Prohibits the
commissioner from requiring that an HMO verify the validity of a license or
certificate held by a physician other than as of the date of initial
credentialing or recredentialing of the physician.  Reformats proposed text
to create Section 39, Chapter 20A, Insurance Code, rather than Section
20A.37(h), Insurance Code.   

SECTION 2.  No change.