86R7658 MM-D
By: Raymond H.B. No. 2222
A BILL TO BE ENTITLED
AN ACT
relating to the administration and oversight of the Medicaid and
child health plan programs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter C, Chapter 531, Government Code, is
amended by adding Section 531.1133 to read as follows:
Sec. 531.1133. PROVIDER NOT LIABLE FOR MANAGED CARE
ORGANIZATION OVERPAYMENT OR DEBT. (a) If the commission's office
of inspector general makes a determination to recoup an overpayment
or debt from a managed care organization that contracts with the
commission to provide health care services to Medicaid recipients,
a provider that contracts with the managed care organization may
not be held liable for the good faith provision of services under
the provider's contract with the managed care organization that
were provided with prior authorization.
(b) This section does not:
(1) limit the office of inspector general's authority
to recoup an overpayment or debt from a provider that is owed by the
provider as a result of the provider's failure to comply with
applicable law or a contract provision, notwithstanding any prior
authorization for a service provided; or
(2) apply to an action brought under Chapter 36, Human
Resources Code.
SECTION 2. Section 533.00281, Government Code, is
redesignated as Section 533.0121, Government Code, and amended to
read as follows:
Sec. 533.0121 [533.00281]. UTILIZATION REVIEW AND
FINANCIAL AUDIT PROCESS FOR [STAR + PLUS] MEDICAID MANAGED CARE
ORGANIZATIONS. (a) The commission's office responsible for [of]
contract management shall establish an annual utilization review
and financial audit process for managed care organizations
participating in the [STAR + PLUS] Medicaid managed care program.
The commission shall determine the topics to be examined in a [the]
review [process], except that with respect to a managed care
organization participating in the STAR+PLUS Medicaid managed care
program, the review [process] must include a thorough investigation
of the [each managed care] organization's procedures for
determining whether a recipient should be enrolled in the STAR+PLUS
[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 commission's office responsible for [of] contract
management shall use the utilization review and financial audit
process established under this section to review each fiscal year:
(1) each managed care organization [every managed care
organization] participating in the [STAR + PLUS] Medicaid managed
care program in this state for that organization's first five years
of participation; [or]
(2) each managed care organization providing health
care services to a population of recipients new to receiving those
services through a Medicaid [only the] managed care delivery model
for the first three years that the organization provides those
services to that population; or
(3) managed care organizations that, using a
risk-based assessment process and evaluation of prior history, the
office determines have a higher likelihood of contract or financial
noncompliance [inappropriate client placement in the STAR + PLUS
home and community-based services and supports (HCBS) program].
(c) In addition to the reviews required by Subsection (b),
the commission's office responsible for contract management shall
use the utilization review and financial audit process established
under this section to review each managed care organization
participating in the Medicaid managed care program at least once
every five years.
(d) In conjunction with the commission's office responsible
for [of] contract management, the commission shall provide a report
to the standing committees of the senate and house of
representatives with jurisdiction over Medicaid 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 Medicaid
managed care program.
(e) If a [utilization] review conducted under this section
results in a determination to recoup money from a managed care
organization, the provider protections from liability under
Section 531.1133 apply [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 3. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.0031 to read as follows:
Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION.
(a) Notwithstanding Section 533.004 or any other law requiring the
commission to contract with a managed care organization to provide
health care services to recipients, the commission may contract
with a managed care organization to provide those services only if
the managed care plan offered by the organization is accredited by a
nationally recognized accrediting entity.
(b) This section does not apply to a managed care
organization that contracts with the commission to provide only
dental or medical transportation services.
SECTION 4. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.00611 to read as follows:
Sec. 533.00611. STANDARDS FOR DETERMINING MEDICAL
NECESSITY. (a) Except as provided by Subsection (b), the
commission shall establish standards that govern the processes,
criteria, and guidelines under which managed care organizations
determine the medical necessity of a health care service covered by
Medicaid. In establishing standards under this section, the
commission shall:
(1) ensure that each recipient has equal access in
scope and duration to the same covered health care services for
which the recipient is eligible, regardless of the managed care
organization with which the recipient is enrolled;
(2) provide managed care organizations with
flexibility to approve covered medically necessary services for
recipients that may not be within prescribed criteria and
guidelines;
(3) require managed care organizations to make
available to providers all criteria and guidelines used to
determine medical necessity through an Internet portal accessible
by the providers;
(4) ensure that managed care organizations
consistently apply the same medical necessity criteria and
guidelines for the approval of services and in retrospective
utilization reviews; and
(5) ensure that managed care organizations include in
any service or prior authorization denial specific information
about the medical necessity criteria or guidelines that were not
met.
(b) This section does not apply to or affect the
commission's authority to:
(1) determine medical necessity for home and
community-based services provided under the STAR+PLUS Medicaid
managed care program; or
(2) conduct utilization reviews of those services.
SECTION 5. Section 533.0076, Government Code, is amended by
amending Subsection (c) and adding Subsection (d) to read as
follows:
(c) The commission shall allow a recipient who is enrolled
in a managed care plan under this chapter to disenroll from that
plan and enroll in another managed care plan[:
[(1)] at any time for cause in accordance with federal
law, including because:
(1) the recipient moves out of the managed care
organization's service area;
(2) the plan does not, on the basis of moral or
religious objections, cover the service the recipient seeks;
(3) the recipient needs related services to be
performed at the same time, not all related services are available
within the organization's provider network, and the recipient's
primary care provider or another provider determines that receiving
the services separately would subject the recipient to unnecessary
risk;
(4) for recipients of long-term services or supports,
the recipient would have to change the recipient's residential,
institutional, or employment supports provider based on that
provider's change in status from an in-network to an out-of-network
provider with the managed care organization and, as a result, would
experience a disruption in the recipient's residence or employment;
or
(5) of another reason permitted under federal law,
including poor quality of care, lack of access to services covered
under the contract, or lack of access to providers experienced in
dealing with the recipient's care needs[; and
[(2) once for any reason after the periods described
by Subsections (a) and (b)].
(d) The commission shall implement a process by which the
commission verifies that a recipient is permitted to disenroll from
one managed care plan offered by a managed care organization and
enroll in another managed care plan, including a plan offered by
another managed care organization, before the disenrollment
occurs.
SECTION 6. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.0091 to read as follows:
Sec. 533.0091. CARE COORDINATION SERVICES. A managed care
organization that contracts with the commission to provide health
care services to recipients shall ensure that persons providing
care coordination services through the organization coordinate
with hospital discharge planners, who must notify the organization
of an inpatient admission of a recipient, to facilitate the timely
discharge of the recipient to the appropriate level of care and
minimize potentially preventable readmissions, as defined by
Section 536.001.
SECTION 7. Subchapter D, Chapter 62, Health and Safety
Code, is amended by adding Section 62.1552 to read as follows:
Sec. 62.1552. MANAGED CARE PLAN ACCREDITATION. (a)
Notwithstanding any other law requiring the commission to contract
with a managed care organization to provide health benefits under
the child health plan, the commission may contract with a managed
care organization to provide those benefits only if the managed
care plan offered by the organization is accredited by a nationally
recognized accrediting entity.
(b) This section does not apply to a managed care
organization that contracts with the commission to provide only
dental benefits.
SECTION 8. (a) The Health and Human Services Commission
shall require that a managed care plan offered by a managed care
organization with which the commission enters into or renews a
contract under Chapter 533, Government Code, or Chapter 62, Health
and Safety Code, as applicable, on or after the effective date of
this Act complies with Section 533.0031, Government Code, as added
by this Act, or Section 62.1552, Health and Safety Code, as added by
this Act, as applicable, not later than September 1, 2022.
(b) Notwithstanding Section 533.0031, Government Code, as
added by this Act, or Section 62.1552, Health and Safety Code, as
added by this Act, a managed care organization may continue
providing health care services or health benefits under a contract
with the Health and Human Services Commission entered into under
Chapter 533, Government Code, or Chapter 62, Health and Safety
Code, as applicable, before the effective date of this Act, until
the earlier of:
(1) the termination of the contract; or
(2) the third anniversary of the effective date of a
contract amendment requiring accreditation of the managed care plan
offered by the managed care organization.
(c) Not later than March 31, 2020, the Health and Human
Services Commission shall seek to amend contracts described by
Subsection (b) of this section to ensure those contracts comply
with Section 533.0031, Government Code, as added by this Act, or
Section 62.1552, Health and Safety Code, as added by this Act, as
applicable. To the extent of a conflict between Section 533.0031,
Government Code, as added by this Act, or Section 62.1552, Health
and Safety Code, as added by this Act, and a provision of a contract
with a managed care organization entered into before the effective
date of this Act, the contract provision prevails.
SECTION 9. 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 10. This Act takes effect September 1, 2019.