Sec. 533.006. PROVIDER NETWORKS. (a) The commission shall require that each managed care organization that contracts with the commission to provide health care services to recipients in a region:
(1) seek participation in the organization's provider network from:
(A) each health care provider in the region who has traditionally provided care to recipients;
(B) each hospital in the region that has been designated as a disproportionate share hospital under Medicaid; and
(C) each specialized pediatric laboratory in the region, including those laboratories located in children's hospitals; and
(2) include in its provider network for not less than three years:
(A) each health care provider in the region who:
(i) previously provided care to Medicaid and charity care recipients at a significant level as prescribed by the commission;
(ii) agrees to accept the prevailing provider contract rate of the managed care organization; and
(iii) has the credentials required by the managed care organization, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network;
(B) each accredited primary care residency program in the region; and
(C) each disproportionate share hospital designated by the commission as a statewide significant traditional provider.
(b) A contract between a managed care organization and the commission for the organization to provide health care services to recipients in a health care service region that includes a rural area must require that the organization include in its provider network rural hospitals, physicians, home and community support services agencies, and other rural health care providers who:
(1) are sole community providers;
(2) provide care to Medicaid and charity care recipients at a significant level as prescribed by the commission;
(3) agree to accept the prevailing provider contract rate of the managed care organization; and
(4) have the credentials required by the managed care organization, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997. Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 5, eff. June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.05, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.225, eff. April 2, 2015.
Text of section as added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.21
For text of section as added by Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 5, see other Sec. 533.0061.
Last modified: September 28, 2016