84R11113 KFF-F
By: Garcia S.B. No. 1475
A BILL TO BE ENTITLED
AN ACT
relating to establishing an enhanced Medicaid managed care consumer
support system.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.02132 to read as follows:
Sec. 531.02132. MEDICAID MANAGED CARE CONSUMER SUPPORT
SYSTEM. (a) In this section, "enhanced system" means the Medicaid
managed care consumer support system established by this section.
(b) The commission shall develop and establish an enhanced
Medicaid managed care consumer support system consisting of a
connected network of Medicaid managed care consumer support staff
that is organized for the purpose of:
(1) educating Medicaid managed care recipients
regarding:
(A) the concept of managed care;
(B) their rights under the Medicaid program,
including grievance and appeal procedures; and
(C) how to advocate for themselves; and
(2) ultimately reducing the need for the internal
appeals process of managed care organizations under the Medicaid
program and for the Medicaid fair hearing process.
(c) The enhanced system must be designed to:
(1) be fully integrated with:
(A) the unit of the commission's office of the
ombudsman responsible for providing the Medicaid Managed Care
Helpline; and
(B) the office of the state long-term care
ombudsman established under Chapter 101, Human Resources Code;
(2) include specialized capacity to meet the needs of
all current and future Medicaid managed care recipients, including
children receiving dental benefits and other recipients receiving
benefits, under the:
(A) STAR Medicaid managed care program;
(B) STAR + PLUS Medicaid managed care program,
including the Texas Dual Eligibles Integrated Care Demonstration
Project provided under that program;
(C) STAR Kids managed care program established
under Section 533.00253;
(D) STAR Health program; and
(E) child health plan established under Chapter
62, Health and Safety Code;
(3) include adequate staffing to support timely access
to the enhanced system by all Medicaid managed care recipients in
this state;
(4) ensure that the enhanced system staff:
(A) receives sufficient training, including
training in the Medicare program for the purpose of assisting
recipients who are dually eligible for Medicare and Medicaid, and
has sufficient authority to resolve barriers experienced by
recipients to health care and long-term services and supports;
(B) has the capacity to actively refer recipients
to community-based organizations that can assist the recipients
with the appeals process, including preparation for appeals and
representation, as needed, whether the appeal is an internal
appeal provided by a managed care organization or an appeal under
the Medicaid fair hearing process;
(C) is locally accessible through satellite
offices in a network of regional hub sites with at least one office
in each Medicaid managed care service area, patterned after similar
satellite offices operated by:
(i) the following partners in the Health
Information, Counseling, and Advocacy Program:
(a) area agencies on aging; and
(b) aging and disability resource
centers established under the Aging and Disability Resource Center
initiative funded in part by the federal Administration on Aging
and the Centers for Medicare and Medicaid Services; and
(ii) the office of the state long-term care
ombudsman; and
(D) has ready access to the upper management of
the commission and managed care organizations participating in the
Medicaid program that will enable staff to promptly identify and
resolve both recipient-specific and systemic issues; and
(5) include an advisory interface with nonprofit,
community-based organizations that routinely assist recipients in
resolving Medicaid managed care issues, for purposes of timely
identifying recurring, systemic issues.
(d) Enhanced system staff may include the employees of
appropriate health and human services agencies and the staff of
appropriate community partners under contract with the state.
(e) The commission's office of the ombudsman, or other
division of the commission in which the enhanced system is
established, must be:
(1) sufficiently independent from other aspects of the
Medicaid managed care system and have no financial interest in the
outcome of recipient grievances; and
(2) empowered to represent the best interests of
recipients in problem resolution.
(f) The enhanced system staff shall collect and maintain
statistical information on a Medicaid managed care service area
basis and publish quarterly reports that:
(1) track the incidence of complaints and barriers
identified by the enhanced system;
(2) identify trends and recurring barriers in delivery
and access to Medicaid managed care in this state; and
(3) identify other problems occurring in the Medicaid
managed care system.
SECTION 2. Not later than January 1, 2016, the Health and
Human Services Commission shall establish the Medicaid managed care
consumer support system required under Section 531.02132,
Government Code, as added by this Act.
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, 2015.