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.