86R13476 KLA-D
By: Muñoz, Jr. H.B. No. 2357
A BILL TO BE ENTITLED
AN ACT
relating to utilization reviews and care coordination under the
Medicaid managed care program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 533.00281, Government Code, is amended
by adding Subsection (f) to read as follows:
(f) Nothing in this section precludes the commission from
conducting a utilization review for managed care organizations
participating in another Medicaid managed care program or with
respect to other service types within a Medicaid managed care
program.
SECTION 2. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.00294 to read as follows:
Sec. 533.00294. CARE COORDINATION BENEFITS. (a) In this
section:
(1) "Care coordination" means assisting recipients to
develop a plan of care, including a service plan, that meets the
recipient's needs and coordinating the provision of Medicaid
benefits in a manner that is consistent with the plan of care. The
term is synonymous with "case management," "service coordination,"
and "service management."
(2) "Medicaid managed care organization" means a
managed care organization that contracts with the commission under
this chapter to provide health care services to recipients.
(b) The commission shall streamline and clarify the
provision of care coordination benefits across Medicaid programs
and services for recipients receiving benefits under a managed care
delivery model. In streamlining and clarifying the provision of
care coordination benefits, the commission shall, at a minimum,
include requirements in Medicaid managed care contracts that are
designed to:
(1) subject to Subsection (c), establish a process for
determining and designating a single person as the primary person
responsible for a recipient's care coordination;
(2) evaluate and eliminate duplicative services
intended to achieve recipient care coordination, including care
coordination or related benefits provided:
(A) by a Medicaid managed care organization;
(B) by a recipient's medical or health home;
(C) through a disease management program
provided by a Medicaid managed care organization;
(D) by a provider of targeted case management and
psychiatric rehabilitation services; or
(E) through a program of case management for
high-risk pregnant women and high-risk children established under
Section 22.0031, Human Resources Code;
(3) evaluate and, if the commission determines it
appropriate, modify the capitation rate paid to Medicaid managed
care organizations to account for the provision of care
coordination benefits by a person not affiliated with the
organization; and
(4) establish and use a consistent set of terms for
care coordination provided under a managed care delivery model.
(c) In establishing a process under Subsection (b)(1), the
commission shall ensure that:
(1) for a recipient who receives targeted case
management and psychiatric rehabilitation services through a local
mental health authority, the default entity to act as the primary
entity responsible for the recipient's care coordination under
Subsection (b)(1) is the local mental health authority;
(2) for a recipient who receives targeted case
management and psychiatric rehabilitation services through a
Medicaid managed care organization network provider, the default
person to act as the primary person responsible for the recipient's
care coordination under Subsection (b)(1) is the network provider;
and
(3) for recipients other than those described by
Subdivision (1) or (2), the process includes an evaluation designed
to identify the provider that would best and most cost-effectively
meet the care coordination needs of a recipient.
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, 2019.