Cook Bill Gives Plans 10 Business Days To Credential Clinic Doctors

The text as introduced · 1,221 words

89R4132 SCF-F

By: Cook
S.B. No. 2093

A BILL TO BE ENTITLED

AN ACT

relating to expedited credentialing of certain federally qualified

health center providers by managed care plan issuers and Medicaid

managed care organizations.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 540.0656(d), Government Code, as

effective April 1, 2025, is amended to read as follows:

(d) To qualify for expedited credentialing and payment

under Subsection (e), an applicant provider must:

(1) be a member of one of the following that has a

current contract with a Medicaid managed care organization:

(A) an established health care provider group;

(B) a federally qualified health center as

defined by 42 U.S.C. Section 1396d(l)(2)(B); or

(C) an established medical group or professional

practice that is designated by the United States Department of

Health and Human Services Health Resources and Services

Administration as a federally qualified health center [ an

established health care provider group that has a current contract

with a Medicaid managed care organization ];

(2) be a Medicaid-enrolled provider;

(3) agree to comply with the terms of the contract

described by Subdivision (1); and

(4) submit all documentation and other information the

Medicaid managed care organization requires as necessary to enable

the organization to begin the credentialing process the

organization requires to include a provider in the organization's

provider network.

SECTION 2. Chapter 1452, Insurance Code, is amended by

adding Subchapter F to read as follows:

SUBCHAPTER F. EXPEDITED CREDENTIALING PROCESS FOR FEDERALLY

QUALIFIED HEALTH CENTER PROVIDERS

Sec. 1452.251. DEFINITIONS. In this subchapter:

(1) "Applicant" means a health care provider 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) "Federally qualified health center" has the

meaning assigned by 42 U.S.C. Section 1396d(l)(2)(B).

(4) "Health care provider" means an individual who is

licensed, certified, or otherwise authorized to provide health care

services in this state.

(5) "Managed care plan" has the meaning assigned by

Section 1452.151.

(6) "Medical group" means:

(A) a single legal entity owned by two or more

physicians;

(B) a professional association composed of

licensed physicians;

(C) any other business entity composed of

licensed physicians as permitted under Subchapter B, Chapter 162,

Occupations Code; or

(D) two or more physicians on the medical staff

of, or teaching at, a medical school, medical and dental unit, or

teaching hospital, as defined or described by Section 61.003,

61.501, or 74.601, Education Code.

(7) "Participating provider" means a health care

provider or health care entity that has contracted with a health

benefit plan issuer to provide services to enrollees.

(8) "Professional practice" means a business entity

that is owned by one or more health care providers.

Sec. 1452.252. APPLICABILITY. This subchapter applies only

to:

(1) a health care provider who joins an established

federally qualified health center that has a contract with a

managed care plan; or

(2) a medical group or professional practice that has

a contract with a managed care plan and becomes a federally

qualified health center.

Sec. 1452.253. ELIGIBILITY REQUIREMENTS. (a) To qualify

for expedited credentialing under this subchapter and payment under

Section 1452.255, a health care provider must:

(1) be licensed, certified, or otherwise authorized to

provide health care services in this state by, and be in good

standing with, the applicable state board;

(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 health care provider

in the plan's network; and

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

plan's participating provider contract with the applicant's

federally qualified health center.

(b) Not later than the fifth business day after an applicant

submits the information required under Subsection (a), the managed

care plan issuer shall:

(1) confirm that the applicant's application is

complete; or

(2) request from the applicant any missing information

required by the managed care plan issuer.

(c) Regardless of whether an applicant specifically

requests expedited credentialing, a managed care plan issuer shall

use an expedited credentialing process for an applicant that has

met the eligibility requirements under Subsection (a).

Sec. 1452.254. EXPEDITED CREDENTIALING DECISION. Not later

than the 10th business day after the receipt of an applicant's

completed application under Section 1452.253, a managed care plan

issuer shall render a decision regarding the expedited

credentialing of the applicant's application.

Sec. 1452.255. PAYMENT FOR SERVICES OF APPLICANT DURING

CREDENTIALING PROCESS. (a) After an applicant has submitted the

information required by the managed care plan issuer under Section

1452.253, the managed care plan 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 by:

(1) authorizing the applicant's federally qualified

health center to collect copayments from the enrollees for the

applicant's services; and

(2) making payments, including payments for

in-network benefits for services provided by the applicant during

the credentialing process, to the applicant's federally qualified

health center for the applicant's services.

(b) A managed care plan issuer must ensure that the issuer's

claims processing system is able to process claims from an

applicant not later than the 30th day after receipt of the

applicant's completed application under Section 1452.253.

Sec. 1452.256. 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. 1452.257. 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 federally qualified health center 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 federally

qualified health center may retain any copayments collected or in

the process of being collected as of the date of the issuer's

determination.

Sec. 1452.258. 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 health care

provider who is determined to be ineligible under Section 1452.257

and the enrollee's managed care plan's charges for out-of-network

services. The health care provider and the health care provider's

federally qualified health center may not charge the enrollee for

any portion of the health care provider's fee that is not paid or

reimbursed by the plan.

Sec. 1452.259. LIMITATION ON MANAGED CARE PLAN 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 as if the applicant is a participating

provider in the plan's network.

SECTION 3. If before implementing any provision of this Act

a state agency determines that a waiver or authorization from a

federal agency is necessary for implementation of that provision,

the agency affected by the provision shall request the waiver or

authorization and may delay implementing that provision until the

waiver or authorization is granted.

SECTION 4. This Act takes effect September 1, 2025.