Bill Text: TX HB1203 | 2013-2014 | 83rd Legislature | Comm Sub
Bill Title: Relating to expedited credentialing for certain podiatrists and therapeutic optometrists providing services under a managed care plan.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2013-05-02 - Laid on the table subject to call [HB1203 Detail]
Download: Texas-2013-HB1203-Comm_Sub.html
83R19535 SCL-F | |||
By: Parker | H.B. No. 1203 | ||
Substitute the following for H.B. No. 1203: | |||
By: Sheets | C.S.H.B. No. 1203 |
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relating to expedited credentialing for certain podiatrists and | ||
therapeutic optometrists 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 Subchapters D and E to read as follows: | ||
SUBCHAPTER D. EXPEDITED CREDENTIALING PROCESS | ||
FOR CERTAIN PODIATRISTS | ||
Sec. 1452.151. DEFINITIONS. In this subchapter: | ||
(1) "Applicant podiatrist" means a podiatrist | ||
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) "Participating provider" means a health care | ||
provider who has contracted with a health benefit plan issuer to | ||
provide services to enrollees. | ||
(6) "Professional practice" means a business entity | ||
that is owned by one or more podiatrists or physicians. | ||
Sec. 1452.152. APPLICABILITY. This subchapter applies only | ||
to a podiatrist who joins an established professional practice that | ||
has a current contract in force with a managed care plan. | ||
Sec. 1452.153. ELIGIBILITY REQUIREMENTS. To qualify for | ||
expedited credentialing under this subchapter and payment under | ||
Section 1452.154, an applicant podiatrist must: | ||
(1) be licensed in this state by, and in good standing | ||
with, the Texas State Board of Podiatric Medical Examiners; | ||
(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 podiatrist 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 podiatrist's established professional practice. | ||
Sec. 1452.154. PAYMENT OF APPLICANT PODIATRIST DURING | ||
CREDENTIALING PROCESS. On submission by the applicant podiatrist | ||
of the information required by the managed care plan issuer under | ||
Section 1452.153(2), and for payment purposes only, the issuer | ||
shall treat the applicant podiatrist as if the podiatrist were a | ||
participating provider in the health benefit plan network when the | ||
applicant podiatrist provides services to the managed care plan's | ||
enrollees, including: | ||
(1) authorizing the applicant podiatrist to collect | ||
copayments from the enrollees; and | ||
(2) making payments to the applicant podiatrist. | ||
Sec. 1452.155. DIRECTORY ENTRIES. Pending the approval of | ||
an application submitted under Section 1452.154, the managed care | ||
plan may exclude the applicant podiatrist from the managed care | ||
plan's directory of participating podiatrists, the managed care | ||
plan's website listing of participating podiatrists, or any other | ||
listing of participating podiatrists. | ||
Sec. 1452.156. EFFECT OF FAILURE TO MEET CREDENTIALING | ||
REQUIREMENTS. If, on completion of the credentialing process, the | ||
managed care plan issuer determines that the applicant podiatrist | ||
does not meet the issuer's credentialing requirements: | ||
(1) the managed care plan issuer may recover from the | ||
applicant podiatrist or the podiatrist's professional practice an | ||
amount equal to the difference between payments for in-network | ||
benefits and out-of-network benefits; and | ||
(2) the applicant podiatrist or the podiatrist's | ||
professional practice may retain any copayments collected or in the | ||
process of being collected as of the date of the issuer's | ||
determination. | ||
Sec. 1452.157. 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 podiatrist who is determined to be ineligible under Section | ||
1452.156 and the managed care plan's charges for out-of-network | ||
services. The podiatrist and the podiatrist's professional | ||
practice may not charge the enrollee for any portion of the | ||
podiatrist's fee that is not paid or reimbursed by the enrollee's | ||
managed care plan. | ||
Sec. 1452.158. 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 podiatrist as if the podiatrist were a | ||
participating provider in the health benefit plan network. | ||
SUBCHAPTER E. EXPEDITED CREDENTIALING PROCESS | ||
FOR CERTAIN THERAPEUTIC OPTOMETRISTS | ||
Sec. 1452.201. DEFINITIONS. In this subchapter: | ||
(1) "Applicant therapeutic optometrist" means a | ||
therapeutic optometrist 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" has the meaning assigned by | ||
Section 1452.151. | ||
(4) "Managed care plan" has the meaning assigned by | ||
Section 1452.151. | ||
(5) "Participating provider" means a health care | ||
provider who has contracted with a health benefit plan issuer to | ||
provide services to enrollees. | ||
(6) "Professional practice" means a business entity | ||
that is owned by one or more therapeutic optometrists or | ||
physicians. | ||
Sec. 1452.202. APPLICABILITY. This subchapter applies only | ||
to a therapeutic optometrist who joins an established professional | ||
practice that has a current contract in force with a managed care | ||
plan. | ||
Sec. 1452.203. ELIGIBILITY REQUIREMENTS. To qualify for | ||
expedited credentialing under this subchapter and payment under | ||
Section 1452.204, an applicant therapeutic optometrist must: | ||
(1) be licensed in this state by, and in good standing | ||
with, the Texas Optometry 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 therapeutic optometrist 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 therapeutic optometrist's established professional | ||
practice. | ||
Sec. 1452.204. PAYMENT OF APPLICANT THERAPEUTIC | ||
OPTOMETRIST DURING CREDENTIALING PROCESS. On submission by the | ||
applicant therapeutic optometrist of the information required by | ||
the managed care plan issuer under Section 1452.203(2), and for | ||
payment purposes only, the issuer shall treat the applicant | ||
therapeutic optometrist as if the therapeutic optometrist were a | ||
participating provider in the health benefit plan network when the | ||
applicant therapeutic optometrist provides services to the managed | ||
care plan's enrollees, including: | ||
(1) authorizing the applicant therapeutic optometrist | ||
to collect copayments from the enrollees; and | ||
(2) making payments to the applicant therapeutic | ||
optometrist. | ||
Sec. 1452.205. DIRECTORY ENTRIES. Pending the approval of | ||
an application submitted under Section 1452.204, the managed care | ||
plan may exclude the applicant therapeutic optometrist from the | ||
managed care plan's directory of participating therapeutic | ||
optometrists, the managed care plan's website listing of | ||
participating therapeutic optometrists, or any other listing of | ||
participating therapeutic optometrists. | ||
Sec. 1452.206. EFFECT OF FAILURE TO MEET CREDENTIALING | ||
REQUIREMENTS. If, on completion of the credentialing process, the | ||
managed care plan issuer determines that the applicant therapeutic | ||
optometrist does not meet the issuer's credentialing requirements: | ||
(1) the managed care plan issuer may recover from the | ||
applicant therapeutic optometrist or the therapeutic optometrist's | ||
professional practice an amount equal to the difference between | ||
payments for in-network benefits and out-of-network benefits; and | ||
(2) the applicant therapeutic optometrist or the | ||
therapeutic optometrist's professional practice may retain any | ||
copayments collected or in the process of being collected as of the | ||
date of the issuer's determination. | ||
Sec. 1452.207. 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 therapeutic optometrist who is determined to be ineligible | ||
under Section 1452.206 and the managed care plan's charges for | ||
out-of-network services. The therapeutic optometrist and the | ||
therapeutic optometrist's professional practice may not charge the | ||
enrollee for any portion of the therapeutic optometrist's fee that | ||
is not paid or reimbursed by the enrollee's managed care plan. | ||
Sec. 1452.208. 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 therapeutic optometrist as if the | ||
therapeutic optometrist were a participating provider in the health | ||
benefit plan network. | ||
SECTION 2. The change in law made by this Act applies only | ||
to credentialing of a podiatrist or a therapeutic optometrist under | ||
a contract entered into or renewed by a professional practice 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 3. This Act takes effect September 1, 2013. |