|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to expedited credentialing for certain physicians |
|
|
providing services under a managed care plan. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Chapter 1452, Insurance Code, is amended by |
|
|
adding Subchapter C to read as follows: |
|
|
SUBCHAPTER C. EXPEDITED CREDENTIALING PROCESS |
|
|
FOR CERTAIN PHYSICIANS |
|
|
Sec. 1452.101. DEFINITIONS. In this subchapter: |
|
|
(1) "Applicant physician" means a physician applying |
|
|
for expedited credentialing under this subchapter. |
|
|
(2) "Enrollee" means an individual who is eligible to |
|
|
receive health care services under a managed care plan. |
|
|
(3) "Health care provider" means: |
|
|
(A) an individual who is licensed, certified, or |
|
|
otherwise authorized to provide health care services in this state; |
|
|
or |
|
|
(B) a hospital, emergency clinic, outpatient |
|
|
clinic, or other facility providing health care services. |
|
|
(4) "Managed care plan" means a health benefit plan |
|
|
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. The term |
|
|
includes a health benefit plan issued by: |
|
|
(A) a health maintenance organization; |
|
|
(B) a preferred provider benefit plan issuer; or |
|
|
(C) any other entity that issues a health benefit |
|
|
plan, including an insurance company. |
|
|
(5) "Medical group" means a professional corporation |
|
|
or other business entity composed of licensed physicians as |
|
|
permitted under Subchapter B, Chapter 162, Occupations Code. |
|
|
(6) "Participating provider" means a health care |
|
|
provider who has contracted with a health benefit plan issuer to |
|
|
provide services to enrollees. |
|
|
Sec. 1452.102. APPLICABILITY. This subchapter applies only |
|
|
to a physician who joins an established medical group that has a |
|
|
current contract in force with a managed care plan. |
|
|
Sec. 1452.103. ELIGIBILITY REQUIREMENTS. To qualify for |
|
|
expedited credentialing under this subchapter, an applicant |
|
|
physician must: |
|
|
(1) be licensed in this state by, and in good standing |
|
|
with, the Texas Medical Board; and |
|
|
(2) submit all documentation and other information |
|
|
required by the issuer of the managed care plan as necessary to |
|
|
enable the issuer to begin the credentialing process required by |
|
|
the issuer to include a physician in the issuer's health benefit |
|
|
plan network. |
|
|
Sec. 1452.104. PAYMENT OF APPLICANT PHYSICIAN DURING |
|
|
CREDENTIALING PROCESS. On submission by the applicant physician of |
|
|
the information required by the managed care plan issuer under |
|
|
Section 1452.103(2), the issuer shall treat the applicant physician |
|
|
as if the physician were a participating provider in the health |
|
|
benefit plan network when the applicant physician provides services |
|
|
to the managed care plan's enrollees, including: |
|
|
(1) authorizing the applicant physician to collect |
|
|
copayments from the enrollees; and |
|
|
(2) making payments to the applicant physician. |
|
|
Sec. 1452.105. EFFECT OF FAILURE TO MEET CREDENTIALING |
|
|
REQUIREMENTS. If, on completion of the credentialing process, the |
|
|
managed care plan issuer determines that the applicant physician |
|
|
does not meet the issuer's credentialing requirements: |
|
|
(1) the managed care plan issuer may recover from the |
|
|
applicant physician or the physician's medical group an amount |
|
|
equal to the difference between payments for in-network benefits |
|
|
and out-of-network benefits; and |
|
|
(2) the applicant physician or the physician's medical |
|
|
group may retain any copayments collected or in the process of being |
|
|
collected as of the date of the issuer's determination. |
|
|
Sec. 1452.106. ENROLLEE HELD HARMLESS. An enrollee in the |
|
|
managed care plan is not responsible and shall be held harmless for |
|
|
the difference between in-network copayments paid by the enrollee |
|
|
to a physician who is determined to be ineligible under Section |
|
|
1452.105 and the managed care plan's total payments for |
|
|
out-of-network services. The physician and the physician's medical |
|
|
group may not charge the enrollee for any portion of the physician's |
|
|
fee that is not paid or reimbursed by the enrollee's managed care |
|
|
plan. |
|
|
SECTION 2. The change in law made by this Act applies only |
|
|
to credentialing of a physician under a contract entered into or |
|
|
renewed by a medical group and an issuer of a managed care plan on or |
|
|
after the effective date of this Act. A contract entered into or |
|
|
renewed before the effective date of this Act is governed by the law |
|
|
in effect immediately before that date, and that law is continued in |
|
|
effect for that purpose. |
|
|
SECTION 3. This Act takes effect September 1, 2007. |