Texas 2019 - 86th Regular

Texas House Bill HB2222 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	86R7658 MM-D
2	2	By: Raymond H.B. No. 2222
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the administration and oversight of the Medicaid and
8	8	child health plan programs.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subchapter C, Chapter 531, Government Code, is
11	11	amended by adding Section 531.1133 to read as follows:
12	12	Sec. 531.1133. PROVIDER NOT LIABLE FOR MANAGED CARE
13	13	ORGANIZATION OVERPAYMENT OR DEBT. (a) If the commission's office
14	14	of inspector general makes a determination to recoup an overpayment
15	15	or debt from a managed care organization that contracts with the
16	16	commission to provide health care services to Medicaid recipients,
17	17	a provider that contracts with the managed care organization may
18	18	not be held liable for the good faith provision of services under
19	19	the provider's contract with the managed care organization that
20	20	were provided with prior authorization.
21	21	(b) This section does not:
22	22	(1) limit the office of inspector general's authority
23	23	to recoup an overpayment or debt from a provider that is owed by the
24	24	provider as a result of the provider's failure to comply with
25	25	applicable law or a contract provision, notwithstanding any prior
26	26	authorization for a service provided; or
27	27	(2) apply to an action brought under Chapter 36, Human
28	28	Resources Code.
29	29	SECTION 2. Section 533.00281, Government Code, is
30	30	redesignated as Section 533.0121, Government Code, and amended to
31	31	read as follows:
32	32	Sec. 533.0121 [533.00281]. UTILIZATION REVIEW AND
33	33	FINANCIAL AUDIT PROCESS FOR [STAR + PLUS] MEDICAID MANAGED CARE
34	34	ORGANIZATIONS. (a) The commission's office responsible for [of]
35	35	contract management shall establish an annual utilization review
36	36	and financial audit process for managed care organizations
37	37	participating in the [STAR + PLUS] Medicaid managed care program.
38	38	The commission shall determine the topics to be examined in a [the]
39	39	review [process], except that with respect to a managed care
40	40	organization participating in the STAR+PLUS Medicaid managed care
41	41	program, the review [process] must include a thorough investigation
42	42	of the [each managed care] organization's procedures for
43	43	determining whether a recipient should be enrolled in the STAR+PLUS
44	44	[STAR + PLUS] home and community-based services and supports (HCBS)
45	45	program, including the conduct of functional assessments for that
46	46	purpose and records relating to those assessments.
47	47	(b) The commission's office responsible for [of] contract
48	48	management shall use the utilization review and financial audit
49	49	process established under this section to review each fiscal year:
50	50	(1) each managed care organization [every managed care
51	51	organization] participating in the [STAR + PLUS] Medicaid managed
52	52	care program in this state for that organization's first five years
53	53	of participation; [or]
54	54	(2) each managed care organization providing health
55	55	care services to a population of recipients new to receiving those
56	56	services through a Medicaid [only the] managed care delivery model
57	57	for the first three years that the organization provides those
58	58	services to that population; or
59	59	(3) managed care organizations that, using a
60	60	risk-based assessment process and evaluation of prior history, the
61	61	office determines have a higher likelihood of contract or financial
62	62	noncompliance [inappropriate client placement in the STAR + PLUS
63	63	home and community-based services and supports (HCBS) program].
64	64	(c) In addition to the reviews required by Subsection (b),
65	65	the commission's office responsible for contract management shall
66	66	use the utilization review and financial audit process established
67	67	under this section to review each managed care organization
68	68	participating in the Medicaid managed care program at least once
69	69	every five years.
70	70	(d) In conjunction with the commission's office responsible
71	71	for [of] contract management, the commission shall provide a report
72	72	to the standing committees of the senate and house of
73	73	representatives with jurisdiction over Medicaid not later than
74	74	December 1 of each year. The report must:
75	75	(1) summarize the results of the [utilization] reviews
76	76	conducted under this section during the preceding fiscal year;
77	77	(2) provide analysis of errors committed by each
78	78	reviewed managed care organization; and
79	79	(3) extrapolate those findings and make
80	80	recommendations for improving the efficiency of the Medicaid
81	81	managed care program.
82	82	(e) If a [utilization] review conducted under this section
83	83	results in a determination to recoup money from a managed care
84	84	organization, the provider protections from liability under
85	85	Section 531.1133 apply [a service provider who contracts with the
86	86	managed care organization may not be held liable for the good faith
87	87	provision of services based on an authorization from the managed
88	88	care organization].
89	89	SECTION 3. Subchapter A, Chapter 533, Government Code, is
90	90	amended by adding Section 533.0031 to read as follows:
91	91	Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION.
92	92	(a) Notwithstanding Section 533.004 or any other law requiring the
93	93	commission to contract with a managed care organization to provide
94	94	health care services to recipients, the commission may contract
95	95	with a managed care organization to provide those services only if
96	96	the managed care plan offered by the organization is accredited by a
97	97	nationally recognized accrediting entity.
98	98	(b) This section does not apply to a managed care
99	99	organization that contracts with the commission to provide only
100	100	dental or medical transportation services.
101	101	SECTION 4. Subchapter A, Chapter 533, Government Code, is
102	102	amended by adding Section 533.00611 to read as follows:
103	103	Sec. 533.00611. STANDARDS FOR DETERMINING MEDICAL
104	104	NECESSITY. (a) Except as provided by Subsection (b), the
105	105	commission shall establish standards that govern the processes,
106	106	criteria, and guidelines under which managed care organizations
107	107	determine the medical necessity of a health care service covered by
108	108	Medicaid. In establishing standards under this section, the
109	109	commission shall:
110	110	(1) ensure that each recipient has equal access in
111	111	scope and duration to the same covered health care services for
112	112	which the recipient is eligible, regardless of the managed care
113	113	organization with which the recipient is enrolled;
114	114	(2) provide managed care organizations with
115	115	flexibility to approve covered medically necessary services for
116	116	recipients that may not be within prescribed criteria and
117	117	guidelines;
118	118	(3) require managed care organizations to make
119	119	available to providers all criteria and guidelines used to
120	120	determine medical necessity through an Internet portal accessible
121	121	by the providers;
122	122	(4) ensure that managed care organizations
123	123	consistently apply the same medical necessity criteria and
124	124	guidelines for the approval of services and in retrospective
125	125	utilization reviews; and
126	126	(5) ensure that managed care organizations include in
127	127	any service or prior authorization denial specific information
128	128	about the medical necessity criteria or guidelines that were not
129	129	met.
130	130	(b) This section does not apply to or affect the
131	131	commission's authority to:
132	132	(1) determine medical necessity for home and
133	133	community-based services provided under the STAR+PLUS Medicaid
134	134	managed care program; or
135	135	(2) conduct utilization reviews of those services.
136	136	SECTION 5. Section 533.0076, Government Code, is amended by
137	137	amending Subsection (c) and adding Subsection (d) to read as
138	138	follows:
139	139	(c) The commission shall allow a recipient who is enrolled
140	140	in a managed care plan under this chapter to disenroll from that
141	141	plan and enroll in another managed care plan[:
142	142	[(1)] at any time for cause in accordance with federal
143	143	law, including because:
144	144	(1) the recipient moves out of the managed care
145	145	organization's service area;
146	146	(2) the plan does not, on the basis of moral or
147	147	religious objections, cover the service the recipient seeks;
148	148	(3) the recipient needs related services to be
149	149	performed at the same time, not all related services are available
150	150	within the organization's provider network, and the recipient's
151	151	primary care provider or another provider determines that receiving
152	152	the services separately would subject the recipient to unnecessary
153	153	risk;
154	154	(4) for recipients of long-term services or supports,
155	155	the recipient would have to change the recipient's residential,
156	156	institutional, or employment supports provider based on that
157	157	provider's change in status from an in-network to an out-of-network
158	158	provider with the managed care organization and, as a result, would
159	159	experience a disruption in the recipient's residence or employment;
160	160	or
161	161	(5) of another reason permitted under federal law,
162	162	including poor quality of care, lack of access to services covered
163	163	under the contract, or lack of access to providers experienced in
164	164	dealing with the recipient's care needs[; and
165	165	[(2) once for any reason after the periods described
166	166	by Subsections (a) and (b)].
167	167	(d) The commission shall implement a process by which the
168	168	commission verifies that a recipient is permitted to disenroll from
169	169	one managed care plan offered by a managed care organization and
170	170	enroll in another managed care plan, including a plan offered by
171	171	another managed care organization, before the disenrollment
172	172	occurs.
173	173	SECTION 6. Subchapter A, Chapter 533, Government Code, is
174	174	amended by adding Section 533.0091 to read as follows:
175	175	Sec. 533.0091. CARE COORDINATION SERVICES. A managed care
176	176	organization that contracts with the commission to provide health
177	177	care services to recipients shall ensure that persons providing
178	178	care coordination services through the organization coordinate
179	179	with hospital discharge planners, who must notify the organization
180	180	of an inpatient admission of a recipient, to facilitate the timely
181	181	discharge of the recipient to the appropriate level of care and
182	182	minimize potentially preventable readmissions, as defined by
183	183	Section 536.001.
184	184	SECTION 7. Subchapter D, Chapter 62, Health and Safety
185	185	Code, is amended by adding Section 62.1552 to read as follows:
186	186	Sec. 62.1552. MANAGED CARE PLAN ACCREDITATION. (a)
187	187	Notwithstanding any other law requiring the commission to contract
188	188	with a managed care organization to provide health benefits under
189	189	the child health plan, the commission may contract with a managed
190	190	care organization to provide those benefits only if the managed
191	191	care plan offered by the organization is accredited by a nationally
192	192	recognized accrediting entity.
193	193	(b) This section does not apply to a managed care
194	194	organization that contracts with the commission to provide only
195	195	dental benefits.
196	196	SECTION 8. (a) The Health and Human Services Commission
197	197	shall require that a managed care plan offered by a managed care
198	198	organization with which the commission enters into or renews a
199	199	contract under Chapter 533, Government Code, or Chapter 62, Health
200	200	and Safety Code, as applicable, on or after the effective date of
201	201	this Act complies with Section 533.0031, Government Code, as added
202	202	by this Act, or Section 62.1552, Health and Safety Code, as added by
203	203	this Act, as applicable, not later than September 1, 2022.
204	204	(b) Notwithstanding Section 533.0031, Government Code, as
205	205	added by this Act, or Section 62.1552, Health and Safety Code, as
206	206	added by this Act, a managed care organization may continue
207	207	providing health care services or health benefits under a contract
208	208	with the Health and Human Services Commission entered into under
209	209	Chapter 533, Government Code, or Chapter 62, Health and Safety
210	210	Code, as applicable, before the effective date of this Act, until
211	211	the earlier of:
212	212	(1) the termination of the contract; or
213	213	(2) the third anniversary of the effective date of a
214	214	contract amendment requiring accreditation of the managed care plan
215	215	offered by the managed care organization.
216	216	(c) Not later than March 31, 2020, the Health and Human
217	217	Services Commission shall seek to amend contracts described by
218	218	Subsection (b) of this section to ensure those contracts comply
219	219	with Section 533.0031, Government Code, as added by this Act, or
220	220	Section 62.1552, Health and Safety Code, as added by this Act, as
221	221	applicable. To the extent of a conflict between Section 533.0031,
222	222	Government Code, as added by this Act, or Section 62.1552, Health
223	223	and Safety Code, as added by this Act, and a provision of a contract
224	224	with a managed care organization entered into before the effective
225	225	date of this Act, the contract provision prevails.
226	226	SECTION 9. If before implementing any provision of this Act
227	227	a state agency determines that a waiver or authorization from a
228	228	federal agency is necessary for implementation of that provision,
229	229	the agency affected by the provision shall request the waiver or
230	230	authorization and may delay implementing that provision until the
231	231	waiver or authorization is granted.
232	232	SECTION 10. This Act takes effect September 1, 2019.