By: Schwertner, et al. S.B. No. 348
(Kolkhorst)
A BILL TO BE ENTITLED
AN ACT
relating to a utilization review process for managed care
organizations participating in the STAR + PLUS Medicaid managed
care program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.00281 to read as follows:
Sec. 533.00281. UTILIZATION REVIEW FOR STAR + PLUS MEDICAID
MANAGED CARE ORGANIZATIONS. (a) The commission's office of
contract management shall establish an annual utilization review
process for managed care organizations participating in the STAR +
PLUS Medicaid managed care program. The commission shall determine
the topics to be examined in the review process, except that the
review process must include a thorough investigation of each
managed care organization's procedures for determining whether a
recipient should be enrolled in the STAR + PLUS home and
community-based services and supports (HCBS) program, including
the conduct of functional assessments for that purpose and records
relating to those assessments.
(b) The office of contract management shall use the
utilization review process to review each fiscal year:
(1) every managed care organization participating in
the STAR + PLUS Medicaid managed care program; or
(2) only the managed care organizations that, using a
risk-based assessment process, the office determines have a higher
likelihood of inappropriate client placement in the STAR + PLUS
home and community-based services and supports (HCBS) program.
(c) Notwithstanding Subsection (b), during the state fiscal
biennium ending August 31, 2015, the office of contract management
shall use the utilization review process to review every managed
care organization participating in the STAR + PLUS Medicaid managed
care program. This subsection expires September 1, 2016.
(d) In conjunction with the commission's office of contract
management, the commission shall provide a report to the standing
committees of the senate and house of representatives with
jurisdiction over the Medicaid program not later than December 1 of
each year. The report must:
(1) summarize the results of the utilization reviews
conducted under this section during the preceding fiscal year;
(2) provide analysis of errors committed by each
reviewed managed care organization; and
(3) extrapolate those findings and make
recommendations for improving the efficiency of the program.
(e) If a utilization review conducted under this section
results in a determination to recoup money from a managed care
organization, a service provider who contracts with the managed
care organization may not be held liable for the good faith
provision of services based on an authorization from the managed
care organization.
SECTION 2. The Health and Human Services Commission shall
provide the first report required by Subsection (d), Section
533.00281, Government Code, as added by this Act, not later than
December 1, 2014.
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 immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2013.