80R8331 PB-D
 
  By: Zerwas H.B. No. 1594
 
Substitute the following for H.B. No. 1594:
 
  By:  Thompson C.S.H.B. No. 1594
 
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.