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A BILL TO BE ENTITLED
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AN ACT
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relating to expedited credentialing of certain physician |
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assistants and nurse practitioners by 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. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN |
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PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS |
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Sec. 1452.251. DEFINITIONS. In this subchapter: |
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(1) "Applicant" means a physician assistant or nurse |
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practitioner applying for expedited credentialing under this |
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subchapter. |
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(2) "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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(3) "Health care provider" means: |
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(A) an individual who is licensed, certified, or |
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otherwise authorized to provide health care services in this state; |
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or |
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(B) a hospital, emergency clinic, outpatient |
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clinic, or other facility providing 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 health care providers and that requires enrollees to |
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use participating providers or that provides a different level of |
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coverage for enrollees who use participating providers. The term |
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includes a health benefit plan issued by: |
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(A) a health maintenance organization; |
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(B) a preferred provider benefit plan issuer; or |
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(C) any other entity that issues a health benefit |
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plan, including an insurance company. |
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(5) "Medical group" means: |
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(A) a single legal entity owned by two or more |
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physicians; |
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(B) a professional association composed of |
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licensed physicians; |
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(C) any other business entity composed of |
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licensed physicians as permitted under Subchapter B, Chapter 162, |
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Occupations Code; or |
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(D) two or more physicians on the medical staff |
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of, or teaching at, a medical school, as defined by Section 61.501, |
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Education Code, or medical and dental unit, as defined by Section |
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61.003, Education Code. |
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(6) "Participating provider" means a health care |
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provider who has contracted with a health benefit plan issuer to |
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provide services to enrollees. |
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Sec. 1452.252. APPLICABILITY. This subchapter applies only |
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to a physician assistant or nurse practitioner who joins an |
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established medical group that has a contract with a managed care |
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plan. |
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Sec. 1452.253. ELIGIBILITY REQUIREMENTS. To qualify for |
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expedited credentialing under this subchapter and payment under |
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Section 1452.254, a physician assistant or nurse practitioner must: |
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(1) be licensed in this state by, and in good standing |
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with, the Texas Physician Assistant Board or Texas Nursing Board; |
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(2) submit all documentation and other information |
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required by the managed care plan issuer to begin the credentialing |
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process required for the issuer to include the physician assistant |
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or nurse practitioner in the plan's network; and |
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(3) agree to comply with the terms of the managed care |
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plan's participating provider contract with the physician |
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assistant's or nurse practitioner's established medical group. |
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Sec. 1452.254. PAYMENT OF PHYSICIAN ASSISTANT OR NURSE |
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PRACTITIONER DURING CREDENTIALING PROCESS. After an applicant has |
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submitted the information required by the managed care plan issuer |
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under Section 1452.253, the issuer shall, for payment purposes |
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only, treat the applicant as if the applicant is a participating |
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provider in the plan's network when the applicant provides services |
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to the 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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Sec. 1452.255. DIRECTORY ENTRIES. Pending the approval of |
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an application submitted under Section 1452.253, the managed care |
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plan issuer may exclude the applicant from the plan's directory, |
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Internet website listing, or other listing of participating |
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providers. |
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Sec. 1452.256. 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 the applicant does not |
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meet the issuer's credentialing requirements: |
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(1) the issuer may recover from the applicant or the |
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applicant's medical group an amount equal to the difference between |
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payments for in-network benefits and out-of-network benefits; and |
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(2) the applicant or the applicant's medical group may |
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retain any copayments collected or in the process of being |
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collected as of the date of the issuer's determination. |
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Sec. 1452.257. ENROLLEE HELD HARMLESS. An enrollee is not |
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responsible and shall be held harmless for the difference between |
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in-network copayments paid by the enrollee to a physician assistant |
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or nurse practitioner who is determined to be ineligible under |
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Section 1452.256 and the enrollee's managed care plan's charges for |
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out-of-network services. The physician assistant or nurse |
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practitioner and the physician assistant's or nurse practitioner's |
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medical group may not charge the enrollee for any portion of the |
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physician assistant's or nurse practitioner's fee that is not paid |
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or reimbursed by the plan. |
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Sec. 1452.258. LIMITATION ON MANAGED CARE ISSUER LIABILITY. |
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A managed care plan issuer that complies with this subchapter is not |
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subject to liability for damages arising out of or in connection |
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with, directly or indirectly, the payment by the issuer of a |
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physician assistant or nurse practitioner treated as if the |
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physician assistant or nurse practitioner is a participating |
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provider in the plan's network. |
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SECTION 2. This Act takes effect September 1, 2023. |