88R10354 CJD-F
	By: Guillen	H.B. No. 4300

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