in-network pay for behavior analysts before the paperwork clears

The text as introduced · 751 words

89R4864 SCR-F

By: Bucy
H.B. No. 586

A BILL TO BE ENTITLED

AN ACT

relating to expedited credentialing for licensed behavior analysts

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 F to read as follows:

SUBCHAPTER F. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN BEHAVIOR

ANALYSTS

Sec. 1452.251. DEFINITIONS. In this subchapter:

(1) "Applicant" means a behavior analyst 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 an individual who is

licensed, certified, or otherwise authorized to provide health care

services in this state.

(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 behavior analysts.

Sec. 1452.252. APPLICABILITY. This subchapter applies only

to a behavior analyst who joins an established professional

practice 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 behavior analyst must:

(1) be licensed in this state by, and in good standing

with, the Texas Department of Licensing and Regulation;

(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 behavior analyst in

the plan's network; and

(3) agree to comply with the terms of the managed care

plan's participating provider contract with the behavior analyst's

established professional practice.

Sec. 1452.254. PAYMENT OF BEHAVIOR ANALYST 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 professional practice 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 professional

practice may retain any copayments collected or in the process of

being collected as of the date of the issuer's determination.

Sec. 1452.257. 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 behavior analyst

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 behavior analyst and the behavior analyst's professional

practice may not charge the enrollee for any portion of the behavior

analyst'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

behavior analyst treated as if the behavior analyst is a

participating provider in the plan's network.

SECTION 2. This Act takes effect immediately if it receives

a vote of two-thirds of all the members elected to each house, as

provided by Section 39, Article III, Texas Constitution. If this

Act does not receive the vote necessary for immediate effect, this

Act takes effect September 1, 2025.