By: Rodriguez S.B. No. 1193
(In the Senate - Filed March 4, 2011; March 16, 2011, read
first time and referred to Committee on Health and Human Services;
May 17, 2011, reported adversely, with favorable Committee
Substitute by the following vote: Yeas 9, Nays 0; May 17, 2011,
sent to printer.)
COMMITTEE SUBSTITUTE FOR S.B. No. 1193 By: Nichols
A BILL TO BE ENTITLED
AN ACT
relating to coordination of services provided by Medicaid managed
care organizations and certain community centers and local mental
health or mental retardation authorities.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subsection (a), Section 533.005, Government
Code, is amended to read as follows:
(a) A contract between a managed care organization and the
commission for the organization to provide health care services to
recipients must contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation rates that ensure the cost-effective
provision of quality health care;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than the
45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to exceed
60 days, specified by a written agreement between the physician or
provider and the managed care organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the managed
care organization, inform the organization of the recipient's
Medicaid certification date;
(9) a requirement that the managed care organization
comply with Section 533.006 as a condition of contract retention
and renewal;
(10) a requirement that the managed care organization
provide the information required by Section 533.012 and otherwise
comply and cooperate with the commission's office of inspector
general;
(11) a requirement that the managed care
organization's usages of out-of-network providers or groups of
out-of-network providers may not exceed limits for those usages
relating to total inpatient admissions, total outpatient services,
and emergency room admissions determined by the commission;
(12) if the commission finds that a managed care
organization has violated Subdivision (11), a requirement that the
managed care organization reimburse an out-of-network provider for
health care services at a rate that is equal to the allowable rate
for those services, as determined under Sections 32.028 and
32.0281, Human Resources Code;
(13) a requirement that the organization use advanced
practice nurses in addition to physicians as primary care providers
to increase the availability of primary care providers in the
organization's provider network;
(14) a requirement that the managed care organization
reimburse a federally qualified health center or rural health
clinic for health care services provided to a recipient outside of
regular business hours, including on a weekend day or holiday, at a
rate that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician; [and]
(15) a requirement that the managed care organization
develop, implement, and maintain a system for tracking and
resolving all provider appeals related to claims payment, including
a process that will require:
(A) a tracking mechanism to document the status
and final disposition of each provider's claims payment appeal;
(B) the contracting with physicians who are not
network providers and who are of the same or related specialty as
the appealing physician to resolve claims disputes related to
denial on the basis of medical necessity that remain unresolved
subsequent to a provider appeal; and
(C) the determination of the physician resolving
the dispute to be binding on the managed care organization and
provider; and
(16) a requirement that the managed care organization
coordinate the care of each recipient who is receiving services
through the managed care organization and through a community
center created under Subchapter A, Chapter 534, Health and Safety
Code, or local mental health or mental retardation authority with
the community center or authority, as applicable.
SECTION 2. Subsection (d), Section 533.0352, Health and
Safety Code, is amended to read as follows:
(d) In developing the local service area plan, the local
mental health or mental retardation authority shall:
(1) solicit information regarding community needs
from:
(A) representatives of the local community;
(B) consumers of community-based mental health
and mental retardation services and members of the families of
those consumers;
(C) consumers of services of state schools for
persons with mental retardation, members of families of those
consumers, and members of state school volunteer services councils,
if a state school is located in the local service area of the local
authority; and
(D) other interested persons; [and]
(2) consider:
(A) criteria for assuring accountability for,
cost-effectiveness of, and relative value of service delivery
options;
(B) goals to minimize the need for state hospital
and community hospital care;
(C) goals to ensure a client with mental
retardation is placed in the least restrictive environment
appropriate to the person's care;
(D) opportunities for innovation to ensure that
the local authority is communicating to all potential and incoming
consumers about the availability of services of state schools for
persons with mental retardation in the local service area of the
local authority;
(E) goals to divert consumers of services from
the criminal justice system;
(F) goals to ensure that a child with mental
illness remains with the child's parent or guardian as appropriate
to the child's care; and
(G) opportunities for innovation in services and
service delivery; and
(3) include strategies in the plan that are designed
to coordinate the care of each consumer who is receiving services
through the local mental health or mental retardation authority and
through a Medicaid managed care organization with the managed care
organization.
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, 2011.
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