| |
|
|
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. |