81R2255 PB-D

By: Watson S.B. No. 779

A BILL TO BE ENTITLED

AN ACT

relating to expedited credentialing for certain individual health care providers 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 D to read as follows:

SUBCHAPTER D. EXPEDITED CREDENTIALING PROCESS FOR INDIVIDUAL

HEALTH CARE PROVIDERS WHO ARE NOT PHYSICIANS

Sec. 1452.151. DEFINITIONS. (a) In this subchapter:

(1) "Applicant health care provider" means an individual who:

(A) is a health care provider described by Section 1452.101(3)(A); and

(B) is applying for expedited credentialing under this subchapter.

(2) "Established professional group" means a legal entity organized, jointly owned, and managed by individual health care providers to deliver health care services.

(b) "Enrollee," "health care provider," "managed care plan," and "participating provider" have the meanings assigned by Section 1452.101.

Sec. 1452.152. APPLICABILITY. This subchapter applies only to an individual health care provider who:

(1) is not a physician; and

(2) joins an established professional group of health care providers that has a contract in force with a managed care plan on the date the health care provider joins the group.

Sec. 1452.153. ELIGIBILITY REQUIREMENTS. To qualify for expedited credentialing under this subchapter and payment under Section 1452.154, an applicant health care provider must:

(1) be licensed, certified, or otherwise authorized in this state by, and in good standing with, the agency of this state that issues the license, certification, or other authorization appropriate to the profession of the applicant health care provider;

(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 that type of health care provider in the issuer's health benefit plan network; and

(3) agree to comply with the terms of the managed care plan's participating provider contract currently in force with the applicant health care provider's established professional group.

Sec. 1452.154. PAYMENT OF APPLICANT HEALTH CARE PROVIDER DURING CREDENTIALING PROCESS. On submission by the applicant health care provider of the information required by the managed care plan issuer under Section 1452.153(2), and for payment purposes only, the issuer shall treat the applicant health care provider as if the applicant were a participating provider in the health benefit plan network when the applicant health care provider provides services to the managed care plan's enrollees, including:

(1) authorizing the applicant health care provider to collect copayments from the enrollees; and

(2) making payments to the applicant health care provider.

Sec. 1452.155. DIRECTORY ENTRIES. Pending the approval of an application submitted under Section 1452.154, the managed care plan may exclude the applicant health care provider from the managed care plan's directory of participating health care providers, the managed care plan's website listing of participating health care providers, or any other listing of participating health care providers.

Sec. 1452.156. EFFECT OF FAILURE TO MEET CREDENTIALING REQUIREMENTS. If, on completion of the credentialing process, the managed care plan issuer determines that the applicant health care provider does not meet the issuer's credentialing requirements:

(1) the managed care plan issuer may recover from the applicant health care provider or the applicant's established professional group an amount equal to the difference between payments for in-network benefits and out-of-network benefits; and

(2) the applicant health care provider or the applicant's established professional group may retain any copayments collected or in the process of being collected as of the date of the issuer's determination.

Sec. 1452.157. 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 health care provider who is determined to be ineligible under Section 1452.156 and the managed care plan's charges for out-of-network services. The health care provider and the provider's established professional group may not charge the enrollee for any portion of the provider's fee that is not paid or reimbursed by the enrollee's managed care plan.

Sec. 1452.158. LIMITATION ON MANAGED CARE ISSUER LIABILITY. A managed care plan issuer that complies with this subchapter is not subject to liability for damages arising out of or in connection with, directly or indirectly, the payment by the issuer of an applicant health care provider as if the applicant were a participating provider in the health benefit plan network.

SECTION 2. Section 843.203(c), Insurance Code, is amended to read as follows:

(c) For purposes of this subchapter, an applicant physician, as defined by Subchapter C, Chapter 1452, or an applicant health care provider, as defined by Subchapter D, Chapter 1452, may not be considered to be an available primary care physician or primary care provider within the health maintenance organization delivery network for selection by an enrollee.

SECTION 3. Section 843.304, Insurance Code, is amended by adding Subsection (f) to read as follows:

(f) Subchapter D, Chapter 1452, does not affect the authority of a health maintenance organization under Subsection (c), (d), or (e).

SECTION 4. Section 1301.051, Insurance Code, is amended by adding Subsection (f) to read as follows:

(f) Subchapter D, Chapter 1452, does not affect the authority of an insurer under Subsection (d).

SECTION 5. The change in law made by this Act applies only to credentialing of an individual health care provider under a contract entered into or renewed by an established professional 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 6. This Act takes effect September 1, 2009.