86R24397 SCL-D
 
  By: J. Johnson of Dallas, Oliverson, Moody, H.B. No. 2631
      et al.
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to physician and health care practitioner credentialing by
  managed care plan issuers.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1452, Insurance Code, is amended by
  adding Subchapter F to read as follows:
  SUBCHAPTER F. CREDENTIALING OF PHYSICIANS AND PROVIDERS BY MANAGED
  CARE PLAN ISSUER
         Sec. 1452.251.  DEFINITIONS. In this subchapter:
               (1)  "Enrollee" means an individual who is eligible to
  receive health care services under a managed care plan.
               (2)  "Health benefit plan" means a plan that provides
  benefits for medical, surgical, or other treatment expenses
  incurred as a result of a health condition, a mental health
  condition, an accident, sickness, or substance abuse, including:
                     (A)  an individual, group, blanket, or franchise
  insurance policy or insurance agreement, a group hospital service
  contract, or an individual or group evidence of coverage or similar
  coverage document that is issued by:
                           (i)  an insurance company;
                           (ii)  a group hospital service corporation
  operating under Chapter 842;
                           (iii)  a health maintenance organization
  operating under Chapter 843;
                           (iv)  an approved nonprofit health
  corporation that holds a certificate of authority under Chapter
  844;
                           (v)  a multiple employer welfare arrangement
  that holds a certificate of authority under Chapter 846;
                           (vi)  a stipulated premium company operating
  under Chapter 884;
                           (vii)  a fraternal benefit society operating
  under Chapter 885;
                           (viii)  a Lloyd's plan operating under
  Chapter 941; or
                           (ix)  an exchange operating under Chapter
  942;
                     (B)  a small employer health benefit plan written
  under Chapter 1501;
                     (C)  a health benefit plan issued under Chapter
  1551, 1575, 1579, or 1601; or
                     (D)  a health benefit plan issued under the
  Medicaid managed care program under Chapter 533, Government Code.
               (3)  "Health care practitioner" means an individual,
  other than a physician, who is licensed to provide and provides
  health care services.
               (4)  "Managed care plan" means a health benefit plan
  under which health care services are provided to enrollees through
  contracts with physicians or health care practitioners and that
  requires enrollees to use participating providers or that provides
  a different level of coverage for enrollees who use participating
  providers.
               (5)  "Participating provider" means a physician or
  health care practitioner who has contracted with a managed care
  plan issuer to provide services to enrollees.
               (6)  "Physician" means an individual licensed to
  practice medicine in this state.
         Sec. 1452.252.  PROMPT CREDENTIALING REQUIRED. A managed
  care plan issuer shall determine in a reasonable time in accordance
  with commissioner rule whether to credential a physician or health
  care practitioner who is not eligible for expedited credentialing
  under Subchapter C.
         Sec. 1452.253.  ELIGIBILITY REQUIREMENTS. To qualify for
  credentialing under this subchapter and payment under Section
  1452.254, an applicant must:
               (1)  be licensed in this state by, and in good standing
  with, the Texas Medical Board or other appropriate licensing
  authority;
               (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 the applicant in the issuer's managed care
  plan network; and
               (3)  agree to comply with the terms of the applicable
  managed care plan's participating provider contract.
         Sec. 1452.254.  PAYMENT OF APPLICANT DURING CREDENTIALING
  PROCESS. (a)  On election by the applicant after receiving notice
  under Subsection (b) and on agreement to participating provider
  contract terms by the applicant and managed care plan issuer, and
  for payment purposes only, the issuer shall treat the applicant as
  if the applicant is a participating provider in the managed care
  plan network when the applicant provides services to the managed
  care plan's enrollees, including:
               (1)  authorizing the applicant to collect copayments
  from the enrollees; and
               (2)  making payments to the applicant.
         (b)  On receipt of a credentialing application, a managed
  care plan issuer shall provide notice to the applicant of the effect
  of failure to meet the issuer's credentialing requirements under
  Section 1452.255 if the applicant elects to be considered a  
  participating provider under Subsection (a).
         Sec. 1452.255.  EFFECT OF FAILURE TO MEET CREDENTIALING
  REQUIREMENTS. If, on completion of the credentialing process, the
  managed care plan issuer determines that an applicant who made an
  election under Section 1452.254 does not meet the issuer's
  credentialing requirements:
               (1)  the managed care plan issuer may recover from the
  applicant an amount equal to the difference between payments for
  in-network benefits and out-of-network benefits; and
               (2)  the applicant may retain any copayments collected
  or in the process of being collected as of the date of the issuer's
  determination.
         Sec. 1452.256.  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 an applicant who is determined to be ineligible under Section
  1452.255 and the managed care plan's charges for out-of-network
  services.  The applicant may not charge the enrollee for any portion
  of the amount that is not paid or reimbursed by the enrollee's
  managed care plan.
         Sec.  1452.257.  LIMITATION ON MANAGED CARE PLAN 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 as if the applicant were a participating
  provider in the managed care plan network.
         Sec. 1452.258.  DEPARTMENT AUDIT. A managed care plan
  issuer shall make available all relevant information to the
  department to allow the department to audit the credentialing
  process to determine compliance with this subchapter.
         Sec. 1452.259.  PUBLIC INSURANCE COUNSEL REPORT. Using
  existing resources, the office of public insurance counsel shall
  create and publish an annual report on the counsel's Internet
  website of the largest managed care plan issuers in this state and
  include information for each issuer on:
               (1)  the issuer's network adequacy;
               (2)  the percentage of enrollees receiving a bill from
  an out-of-network provider due to provider charges unpaid by the
  issuer and the enrollee's responsibility under the managed care
  plan; and
               (3)  the impact of managed care plan issuer
  credentialing policies on network adequacy and enrollee payment of
  out-of-network charges.
         SECTION 2.  This Act takes effect September 1, 2019.