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  H.B. No. 1594
 
 
 
 
AN ACT
  relating to expedited credentialing for certain physicians
  providing services under a managed care plan.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1452, Insurance Code, is amended by
  adding Subchapter C to read as follows:
  SUBCHAPTER C. EXPEDITED CREDENTIALING PROCESS
  FOR CERTAIN PHYSICIANS
         Sec. 1452.101.  DEFINITIONS. In this subchapter:
               (1)  "Applicant physician" means a physician 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 professional corporation
  or other business entity composed of licensed physicians as
  permitted under Subchapter B, Chapter 162, Occupations Code.
               (6)  "Participating provider" means a health care
  provider who has contracted with a health benefit plan issuer to
  provide services to enrollees.
         Sec. 1452.102.  APPLICABILITY. This subchapter applies only
  to a physician who joins an established medical group that has a
  current contract in force with a managed care plan.
         Sec. 1452.103.  ELIGIBILITY REQUIREMENTS. To qualify for
  expedited credentialing under this subchapter and payment under
  Section 1452.104, an applicant physician must:
               (1)  be licensed in this state by, and in good standing
  with, the Texas Medical Board;
               (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 a physician in the issuer's health benefit
  plan network; and
               (3)  agree to comply with the terms of the managed care
  plan's participating provider contract currently in force with the
  applicant physician's established medical group.
         Sec. 1452.104.  PAYMENT OF APPLICANT PHYSICIAN DURING
  CREDENTIALING PROCESS. On submission by the applicant physician of
  the information required by the managed care plan issuer under
  Section 1452.103(2), and for payment purposes only, the issuer
  shall treat the applicant physician as if the physician were a
  participating provider in the health benefit plan network when the
  applicant physician provides services to the managed care plan's
  enrollees, including:
               (1)  authorizing the applicant physician to collect
  copayments from the enrollees; and
               (2)  making payments to the applicant physician.
         Sec. 1452.105.  DIRECTORY ENTRIES.  Pending the approval of
  an application submitted under Section 1452.104, the managed care
  plan may exclude the applicant physician from the managed care
  plan's directory of participating physicians, the managed care
  plan's website listing of participating physicians, or any other
  listing of participating physicians.
         Sec. 1452.106.  EFFECT OF FAILURE TO MEET CREDENTIALING
  REQUIREMENTS. If, on completion of the credentialing process, the
  managed care plan issuer determines that the applicant physician
  does not meet the issuer's credentialing requirements:
               (1)  the managed care plan issuer may recover from the
  applicant physician or the physician's medical group an amount
  equal to the difference between payments for in-network benefits
  and out-of-network benefits; and
               (2)  the applicant physician or the physician'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. 1452.107.  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 a physician who is determined to be ineligible under Section
  1452.106 and the managed care plan's charges for out-of-network
  services. The physician and the physician's medical group may not
  charge the enrollee for any portion of the physician's fee that is
  not paid or reimbursed by the enrollee's managed care plan.
         Sec.  1452.108.  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 an applicant physician as if the physician were a
  participating provider in the health benefit plan network.
         SECTION 2.  Section 843.203, Insurance Code, is amended by
  adding Subsection (c) to read as follows:
         (c)  For purposes of this subchapter, an applicant
  physician, as defined by Chapter 1452, may not be considered to be
  an available primary care physician or primary care provider within
  the  health maintenance organization delivery network for selection
  by an enrollee.
         SECTION 3.  The change in law made by this Act applies only
  to credentialing of a physician under a contract entered into or
  renewed by a medical group and an issuer of a managed care plan on or
  after the effective date of this Act. A contract entered into or
  renewed before the effective date of this Act is governed by the law
  in effect immediately before that date, and that law is continued in
  effect for that purpose.
         SECTION 4.  This Act takes effect September 1, 2007.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 1594 was passed by the House on April
  4, 2007, by the following vote:  Yeas 142, Nays 0, 2 present, not
  voting; that the House refused to concur in Senate amendments to
  H.B. No. 1594 on May 17, 2007, and requested the appointment of a
  conference committee to consider the differences between the two
  houses; and that the House adopted the conference committee report
  on H.B. No. 1594 on May 26, 2007, by the following vote:  Yeas 144,
  Nays 0, 2 present, not voting.
 
  ______________________________
  Chief Clerk of the House   
 
         I certify that H.B. No. 1594 was passed by the Senate, with
  amendments, on May 15, 2007, by the following vote:  Yeas 31, Nays
  0; at the request of the House, the Senate appointed a conference
  committee to consider the differences between the two houses; and
  that the Senate adopted the conference committee report on H.B. No.
  1594 on May 26, 2007, by the following vote:  Yeas 30, Nays 0.
 
  ______________________________
  Secretary of the Senate   
  APPROVED: __________________
                  Date       
   
           __________________
                Governor