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�	H.B.�No.�1594

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�	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.
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�	______________________________	______________________________
�	���President of the Senate	Speaker of the House�����
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�	�������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.
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�	______________________________
�	Chief Clerk of the House���
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�	�������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.
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�	______________________________
�	Secretary of the Senate���
�	APPROVED: __________________
�	����������������Date�������
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�	�������� __________________
�	��������������Governor�������