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AN ACT
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relating to expedited credentialing for certain physicians |
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providing services under a managed care plan. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1452, Insurance Code, is amended by |
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adding Subchapter C to read as follows: |
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SUBCHAPTER C. EXPEDITED CREDENTIALING PROCESS |
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FOR CERTAIN PHYSICIANS |
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Sec. 1452.101. DEFINITIONS. In this subchapter: |
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(1) "Applicant physician" means a physician applying |
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for expedited credentialing under this subchapter. |
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(2) "Enrollee" means an individual who is eligible to |
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receive health care services under a managed care plan. |
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(3) "Health care provider" means: |
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(A) an individual who is licensed, certified, or |
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otherwise authorized to provide health care services in this state; |
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or |
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(B) a hospital, emergency clinic, outpatient |
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clinic, or other facility providing health care services. |
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(4) "Managed care plan" means a health benefit plan |
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under which health care services are provided to enrollees through |
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contracts with health care providers and that requires enrollees to |
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use participating providers or that provides a different level of |
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coverage for enrollees who use participating providers. The term |
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includes a health benefit plan issued by: |
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(A) a health maintenance organization; |
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(B) a preferred provider benefit plan issuer; or |
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(C) any other entity that issues a health benefit |
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plan, including an insurance company. |
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(5) "Medical group" means a professional corporation |
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or other business entity composed of licensed physicians as |
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permitted under Subchapter B, Chapter 162, Occupations Code. |
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(6) "Participating provider" means a health care |
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provider who has contracted with a health benefit plan issuer to |
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provide services to enrollees. |
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Sec. 1452.102. APPLICABILITY. This subchapter applies only |
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to a physician who joins an established medical group that has a |
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current contract in force with a managed care plan. |
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Sec. 1452.103. ELIGIBILITY REQUIREMENTS. To qualify for |
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expedited credentialing under this subchapter and payment under |
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Section 1452.104, an applicant physician must: |
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(1) be licensed in this state by, and in good standing |
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with, the Texas Medical Board; |
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(2) submit all documentation and other information |
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required by the issuer of the managed care plan as necessary to |
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enable the issuer to begin the credentialing process required by |
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the issuer to include a physician in the issuer's health benefit |
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plan network; and |
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(3) agree to comply with the terms of the managed care |
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plan's participating provider contract currently in force with the |
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applicant physician's established medical group. |
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Sec. 1452.104. PAYMENT OF APPLICANT PHYSICIAN DURING |
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CREDENTIALING PROCESS. On submission by the applicant physician of |
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the information required by the managed care plan issuer under |
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Section 1452.103(2), and for payment purposes only, the issuer |
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shall treat the applicant physician as if the physician were a |
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participating provider in the health benefit plan network when the |
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applicant physician provides services to the managed care plan's |
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enrollees, including: |
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(1) authorizing the applicant physician to collect |
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copayments from the enrollees; and |
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(2) making payments to the applicant physician. |
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Sec. 1452.105. DIRECTORY ENTRIES. Pending the approval of |
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an application submitted under Section 1452.104, the managed care |
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plan may exclude the applicant physician from the managed care |
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plan's directory of participating physicians, the managed care |
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plan's website listing of participating physicians, or any other |
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listing of participating physicians. |
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Sec. 1452.106. EFFECT OF FAILURE TO MEET CREDENTIALING |
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REQUIREMENTS. If, on completion of the credentialing process, the |
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managed care plan issuer determines that the applicant physician |
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does not meet the issuer's credentialing requirements: |
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(1) the managed care plan issuer may recover from the |
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applicant physician or the physician's medical group an amount |
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equal to the difference between payments for in-network benefits |
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and out-of-network benefits; and |
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(2) the applicant physician or the physician's medical |
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group may retain any copayments collected or in the process of being |
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collected as of the date of the issuer's determination. |
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Sec. 1452.107. ENROLLEE HELD HARMLESS. An enrollee in the |
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managed care plan is not responsible and shall be held harmless for |
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the difference between in-network copayments paid by the enrollee |
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to a physician who is determined to be ineligible under Section |
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1452.106 and the managed care plan's charges for out-of-network |
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services. The physician and the physician's medical group may not |
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charge the enrollee for any portion of the physician's fee that is |
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not paid or reimbursed by the enrollee's managed care plan. |
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Sec. 1452.108. LIMITATION ON MANAGED CARE ISSUER |
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LIABILITY. A managed care plan issuer that complies with this |
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subchapter is not subject to liability for damages arising out of or |
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in connection with, directly or indirectly, the payment by the |
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issuer of an applicant physician as if the physician were a |
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participating provider in the health benefit plan network. |
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SECTION 2. Section 843.203, Insurance Code, is amended by |
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adding Subsection (c) to read as follows: |
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(c) For purposes of this subchapter, an applicant |
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physician, as defined by Chapter 1452, may not be considered to be |
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an available primary care physician or primary care provider within |
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the health maintenance organization delivery network for selection |
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by an enrollee. |
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SECTION 3. The change in law made by this Act applies only |
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to credentialing of a physician under a contract entered into or |
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renewed by a medical group and an issuer of a managed care plan on or |
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after the effective date of this Act. A contract entered into or |
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renewed before the effective date of this Act is governed by the law |
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in effect immediately before that date, and that law is continued in |
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effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2007. |
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______________________________ |
______________________________ |
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President of the Senate |
Speaker of the House |
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I certify that H.B. No. 1594 was passed by the House on April |
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4, 2007, by the following vote: Yeas 142, Nays 0, 2 present, not |
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voting; that the House refused to concur in Senate amendments to |
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H.B. No. 1594 on May 17, 2007, and requested the appointment of a |
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conference committee to consider the differences between the two |
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houses; and that the House adopted the conference committee report |
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on H.B. No. 1594 on May 26, 2007, by the following vote: Yeas 144, |
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Nays 0, 2 present, not voting. |
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______________________________ |
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Chief Clerk of the House |
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I certify that H.B. No. 1594 was passed by the Senate, with |
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amendments, on May 15, 2007, by the following vote: Yeas 31, Nays |
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0; at the request of the House, the Senate appointed a conference |
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committee to consider the differences between the two houses; and |
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that the Senate adopted the conference committee report on H.B. No. |
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1594 on May 26, 2007, by the following vote: Yeas 30, Nays 0. |
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______________________________ |
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Secretary of the Senate |
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APPROVED: __________________ |
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Date |
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__________________ |
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Governor |