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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 advanced practice nurses by managed care plan |
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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 ADVANCED PRACTICE NURSES |
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Sec. 1452.251. DEFINITIONS. In this subchapter: |
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(1) "Advanced practice nurse" means an advanced |
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practice registered nurse as defined by Section 301.152, |
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Occupations Code. |
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(2) "Applicant" means a physician assistant or |
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advanced practice nurse applying for expedited credentialing under |
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this subchapter. |
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(3) "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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(4) "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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(5) "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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(6) "Medical group" means: |
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(A) a single legal entity authorized to practice |
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medicine in this state that is owned by two or more physicians; or |
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(B) a professional association composed solely |
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of physicians. |
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(7) "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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(8) "Physician" means an individual licensed to |
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practice medicine in this state. |
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(9) "Physician assistant" means an individual who |
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holds a license issued under Chapter 204, Occupations Code. |
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Sec. 1452.252. APPLICABILITY. This subchapter applies only |
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to a physician assistant or advanced practice nurse who joins, as an |
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employee, an established medical group that has a contract with a |
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managed care plan that already includes contracted rates for |
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physician assistants or advanced practice nurses employed by the |
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medical group. |
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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 advanced practice nurse |
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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 Board of |
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Nursing; |
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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 advanced practice nurse in the plan's network; |
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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 advanced practice nurse's established medical group, |
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including the rates applicable to other physician assistants or |
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advanced practice nurses under the contract; and |
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(4) have received express written consent from the |
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physician assistant's or advanced practice nurse's established |
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medical group to apply for expedited credentialing under this |
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subchapter. |
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Sec. 1452.254. PAYMENT FOR SERVICES OF PHYSICIAN ASSISTANT |
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OR ADVANCED PRACTICE NURSE DURING CREDENTIALING PROCESS. After an |
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applicant has met the eligibility requirements under Section |
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1452.253, the issuer shall, for payment purposes only, treat the |
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applicant as if the applicant is a participating provider in the |
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plan's network when the applicant provides services to the plan's |
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enrollees as an employee of the applicant's established medical |
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group, including: |
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(1) authorizing the applicant's medical group to |
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collect copayments from the enrollees for the applicant's services; |
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and |
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(2) making payments to the applicant's medical group |
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for the applicant's services. |
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Sec. 1452.255. DIRECTORY ENTRIES. Nothing in this |
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subchapter may be construed as requiring the managed care plan |
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issuer to include the applicant in the plan's directory, Internet |
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website listing, or other listing of participating 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's |
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medical group that was paid under Section 1452.254 an amount equal |
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to the difference between payments for in-network benefits and |
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out-of-network benefits; and |
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(2) the applicant's medical group may retain any |
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copayments collected or in the process of being collected as of the |
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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 under Section 1452.254 by the enrollee |
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to an applicant's medical group for services provided by an |
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employee applicant physician assistant or advanced practice nurse |
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who is determined to be ineligible under Section 1452.256 and the |
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enrollee's managed care plan's charges for out-of-network services. |
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The physician assistant's or advanced practice nurse's medical |
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group may not charge the enrollee for any portion of the physician |
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assistant's or advanced practice nurse's fee that is not paid or |
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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's or advanced practice nurse's medical group |
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for services provided by the medical group's employed physician |
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assistant or advanced practice nurse treated as if the physician |
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assistant or advanced practice nurse is a participating provider in |
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the plan's network under this subchapter. |
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SECTION 2. This Act takes effect September 1, 2023. |