HB1266 - Relating to expedited credentialing of certain physician assistants and advanced practice nurses by managed care plan issuers.

  89R37 CJD-F     By: Guillen H.B. No. 1266       A BILL TO BE ENTITLED   AN ACT   relating to expedited credentialing of certain physician   assistants and advanced practice nurses by managed care plan   issuers.          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   PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE NURSES           Sec. 1452.251.  DEFINITIONS. In this subchapter:                 (1)     "Advanced practice nurse"   means an advanced   practice registered nurse as defined by Section 301.152,   Occupations Code.                 (2)     "Applicant" means a physician assistant or   advanced practice nurse applying for expedited credentialing under   this subchapter.                 (3)     "Enrollee" means an individual who is eligible to   receive health care services under a managed care plan.                 (4)  "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.                 (5)     "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.                 (6)  "Medical group" means:                       (A)     a single legal entity authorized to practice   medicine in this state that is owned by two or more physicians; or                       (B)     a professional association composed solely   of physicians.                 (7)     "Participating provider" means a health care   provider who has contracted with a health benefit plan issuer to   provide services to enrollees.                 (8)     "Physician"   means an individual licensed to   practice medicine in this state.                 (9)     "Physician assistant"   means an individual who   holds a license issued under Chapter 204, Occupations Code.           Sec.   1452.252.     APPLICABILITY. This subchapter applies only   to a physician assistant or advanced practice nurse who joins, as an   employee, an established medical group that has a contract with a   managed care plan that already includes contracted rates for   physician assistants or advanced practice nurses employed by the   medical group.           Sec.   1452.253.     ELIGIBILITY REQUIREMENTS. To qualify for   expedited credentialing under this subchapter and payment under   Section 1452.254, a physician assistant or advanced practice nurse   must:                 (1)     be licensed in this state by, and in good standing   with, the Texas Physician Assistant Board or Texas Board of   Nursing;                 (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 physician assistant   or advanced practice nurse in the plan's network;                 (3)     agree to comply with the terms of the managed care   plan's participating provider contract with the physician   assistant's or advanced practice nurse's established medical group,   including the rates applicable to other physician assistants or   advanced practice nurses under the contract; and                 (4)     have received express written consent from the   physician assistant's or advanced practice nurse's established   medical group to apply for expedited credentialing under this   subchapter.           Sec.   1452.254.     PAYMENT FOR SERVICES OF PHYSICIAN ASSISTANT   OR ADVANCED PRACTICE NURSE DURING CREDENTIALING PROCESS. After an   applicant has met the eligibility requirements 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 as an employee of the applicant's   established medical group, including:                 (1)     authorizing the applicant's medical group to   collect copayments from the enrollees for the applicant's services;   and                 (2)     making payments to the applicant's medical group   for the applicant's services.           Sec.   1452.255.     DIRECTORY ENTRIES. Nothing in this   subchapter may be construed as requiring the managed care plan   issuer to include the applicant in 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's   medical group that was paid under Section 1452.254 an amount equal   to the difference between payments for in-network benefits and   out-of-network benefits; and                 (2)     the applicant'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.   1452.257.     ENROLLEE HELD HARMLESS. An enrollee is not   responsible and shall be held harmless for the difference between   in-network copayments paid under Section 1452.254 by the enrollee   to an applicant's medical group for services provided by an   employee applicant physician assistant or advanced practice nurse   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 applicant's medical group may not charge the enrollee for any   portion of the applicant's fee that is not paid or reimbursed by the   plan.           Sec.   1452.258.     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 a physician assistant's or advanced practice nurse's   medical group for services provided by the medical group's employed   physician assistant or advanced practice nurse treated as if the   physician assistant or advanced practice nurse is a participating   provider in the plan's network under this subchapter.          SECTION 2.  This Act takes effect September 1, 2025.