Texas 2019 - 86th Regular

Texas House Bill HB3478 Compare Versions

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

Old	New	Differences
1	1	86R10759 LED-D
2	2	By: Davis of Harris H.B. No. 3478
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to an independent medical review of certain determinations
8	8	by the Health and Human Services Commission or a Medicaid managed
9	9	care organization.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Subchapter A, Chapter 533, Government Code, is
12	12	amended by adding Section 533.00715 to read as follows:
13	13	Sec. 533.00715. INDEPENDENT APPEALS PROCEDURE. (a) In
14	14	this section, "third-party arbiter" means a third-party medical
15	15	review organization that provides objective, unbiased medical
16	16	necessity determinations conducted by clinical staff with
17	17	education and practice in the same or similar practice area as the
18	18	procedure for which an independent determination of medical
19	19	necessity is sought.
20	20	(b) The commission shall contract with at least three
21	21	independent, third-party arbiters to resolve recipient appeals of
22	22	any commission or a Medicaid managed care organization adverse
23	23	benefit determination or reduction in or denial of health care
24	24	services on the basis of medical necessity.
25	25	(c) The commission shall establish a common procedure for
26	26	appeals. The procedure must provide that a health care service
27	27	ordered by a health care provider is presumed medically necessary
28	28	and the commission or Medicaid managed care organization bears the
29	29	burden of proof to show the health care service is not medically
30	30	necessary. The commission shall also establish a procedure for
31	31	expedited appeals that allows a third-party arbiter to:
32	32	(1) identify an appeal that requires an expedited
33	33	resolution; and
34	34	(2) resolve the appeal within a specified period.
35	35	(d) Subject to Subsection (e), the commission shall ensure
36	36	an appeal is randomly assigned to a third-party arbiter.
37	37	(e) The commission shall ensure each third-party arbiter
38	38	has the necessary medical expertise to resolve an appeal.
39	39	(f) A third-party arbiter shall establish and maintain an
40	40	Internet portal through which a recipient may track the status and
41	41	final disposition of an appeal.
42	42	(g) A third-party arbiter shall educate recipients and
43	43	employees of Medicaid managed care organizations regarding appeals
44	44	processes, options, and proper and improper denials of health care
45	45	services on the basis of medical necessity.
46	46	(h) A third-party arbiter shall review aggregate denial
47	47	data categorized by Medicaid managed care plan to identify trends
48	48	and determine whether a Medicaid managed care organization is
49	49	disproportionately denying prior authorization requests from a
50	50	single provider or set of providers.
51	51	SECTION 2. As soon as practicable after the effective date
52	52	of this Act, the executive commissioner of the Health and Human
53	53	Services Commission shall adopt the rules necessary to implement
54	54	this Act.
55	55	SECTION 3. If before implementing any provision of this Act
56	56	a state agency determines that a waiver or authorization from a
57	57	federal agency is necessary for implementation of that provision,
58	58	the agency affected by the provision shall request the waiver or
59	59	authorization and may delay implementing that provision until the
60	60	waiver or authorization is granted.
61	61	SECTION 4. This Act takes effect September 1, 2019.