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