1-1 AN ACT 1-2 relating to requiring the provision of periodic health evaluations 1-3 and credentialing of physicians and health care providers by health 1-4 maintenance organizations and to the verification of physician 1-5 credentials. 1-6 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-7 SECTION 1. The Texas Health Maintenance Organization Act 1-8 (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding 1-9 Section 9B to read as follows: 1-10 Sec. 9B. PERIODIC HEALTH EVALUATIONS REQUIRED. (a) The 1-11 basic health care services provided under an evidence of coverage 1-12 must include periodic health evaluations for each adult enrollee. 1-13 (b) The services provided under this section must include a 1-14 health risk assessment at least once every three years and, for a 1-15 female enrollee, an annual well-woman examination provided in 1-16 accordance with Article 21.53D of this code, as added by Chapter 1-17 912, Acts of the 75th Legislature, Regular Session, 1997. 1-18 (c) This section does not apply to an evidence of coverage 1-19 for a limited health care service plan or a single health care 1-20 service plan. 1-21 SECTION 2. The Texas Health Maintenance Organization Act 1-22 (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding 1-23 Section 39 to read as follows: 1-24 Sec. 39. CREDENTIALING OF PHYSICIANS AND PROVIDERS. 1-25 (a) Rules adopted by the commissioner under Section 37 of this Act 2-1 that relate to implementation and maintenance by a health 2-2 maintenance organization of a process for selecting and retaining 2-3 affiliated physicians and providers must comply with: 2-4 (1) this section; and 2-5 (2) standards promulgated by the National Committee 2-6 for Quality Assurance, to the extent those standards do not 2-7 conflict with other laws of this state. 2-8 (b) The commissioner shall require a health maintenance 2-9 organization to verify that a physician's license to practice 2-10 medicine and any other certificate the physician is required to 2-11 hold, including a certificate issued by the Department of Public 2-12 Safety of the State of Texas or the federal Drug Enforcement Agency 2-13 or a certificate issued under the Medicare program, is valid as of 2-14 the date of initial credentialing and on the date of each 2-15 recredentialing. 2-16 (c) The commissioner shall require a health maintenance 2-17 organization that conducts a site visit for the purpose of initial 2-18 credentialing to evaluate during the visit a site's accessibility, 2-19 appearance, space, medical or dental recordkeeping practices, 2-20 availability of appointments, and confidentiality procedures. The 2-21 commissioner may not require the health maintenance organization to 2-22 evaluate the appropriateness of equipment during the site visit. 2-23 (d) The commissioner may not require that a health 2-24 maintenance organization: 2-25 (1) formally recredential physicians or providers more 2-26 frequently than once in any three-year period; 3-1 (2) verify the validity of a license or certificate 3-2 held by a physician other than as of the date of initial 3-3 credentialing or recredentialing of the physician; 3-4 (3) use clinical personnel to perform a site visit for 3-5 initial credentialing of a physician or provider unless clinical 3-6 review is needed during the site visit; or 3-7 (4) require a site visit be performed for 3-8 recredentialing of a physician or provider. 3-9 (e) This section does not preclude a health maintenance 3-10 organization from performing a site visit of a physician or 3-11 provider at any time for cause, including a complaint made by a 3-12 member or another external complaint made to the health maintenance 3-13 organization. 3-14 SECTION 3. Subchapter E, Chapter 21, Insurance Code, is 3-15 amended by adding Article 21.58D to read as follows: 3-16 Art. 21.58D. STANDARDIZED FORM FOR VERIFICATION OF PHYSICIAN 3-17 CREDENTIALS 3-18 Sec. 1. DEFINITION. In this article, "physician" means an 3-19 individual licensed to practice medicine in this state. 3-20 Sec. 2. STANDARDIZED FORM. (a) The commissioner by rule 3-21 shall: 3-22 (1) adopt a standardized form for the verification of 3-23 the credentials of a physician; and 3-24 (2) require that a public or private hospital, a 3-25 health maintenance organization operating under the Texas Health 3-26 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance 4-1 Code), or a preferred provider organization operating under Article 4-2 3.70-3C, Insurance Code, as added by Chapter 1024, Acts of the 75th 4-3 Legislature, Regular Session, 1997, use the form for verification 4-4 of credentials. 4-5 (b) In adopting a form under Subsection (a) of this section, 4-6 the commissioner shall consider any credentialing application form 4-7 that is widely used in this state. 4-8 SECTION 4. (a) The Texas State Board of Medical Examiners 4-9 shall study the establishment of a program for standardized 4-10 credentials verification through using a credentialing information 4-11 system. 4-12 (b) Not later than January 1, 2003, the Texas State Board of 4-13 Medical Examiners shall report on its recommendations for proposed 4-14 legislation, based on the study conducted under Subsection (a) of 4-15 this section, to: 4-16 (1) the governor; 4-17 (2) the lieutenant governor; and 4-18 (3) the speaker of the house of representatives. 4-19 SECTION 5. Sections 2, 3, and 4 of this Act take effect 4-20 September 1, 2001. Section 1 of this Act takes effect September 1, 4-21 2001, and applies only to an evidence of coverage that is 4-22 delivered, issued for delivery, or renewed on or after January 1, 4-23 2002. An evidence of coverage that is delivered, issued for 4-24 delivery, or renewed before January 1, 2002, is governed by the law 4-25 as it existed immediately before the effective date of this Act, 4-26 and that law is continued in effect for that purpose. _______________________________ _______________________________ President of the Senate Speaker of the House I hereby certify that S.B. No. 544 passed the Senate on April 5, 2001, by the following vote: Yeas 30, Nays 0, one present not voting; and that the Senate concurred in House amendment on May 26, 2001, by a viva-voce vote. _______________________________ Secretary of the Senate I hereby certify that S.B. No. 544 passed the House, with amendment, on May 23, 2001, by a non-record vote. _______________________________ Chief Clerk of the House Approved: _______________________________ Date _______________________________ Governor