Texas 2019 - 86th Regular

Texas House Bill HB3721 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	By: Deshotel, Raymond, Zedler H.B. No. 3721
	1	+	86R24052 KFF-D
	2	+	By: Deshotel H.B. No. 3721
	3	+	Substitute the following for H.B. No. 3721:
	4	+	By: Hinojosa C.S.H.B. No. 3721
2	5
3	6
4	7		A BILL TO BE ENTITLED
5	8		AN ACT
6	9		relating to an independent review organization to conduct reviews
7	10		of certain medical necessity determinations under the Medicaid
8	11		managed care program.
9	12		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	13		SECTION 1. Subchapter A, Chapter 533, Government Code, is
11	14		amended by adding Section 533.039 to read as follows:
12	15		Sec. 533.039. INDEPENDENT REVIEW ORGANIZATIONS. (a) In
13	16		this section, "independent review organization" means an
14	17		organization certified under Chapter 4202, Insurance Code.
15	18		(b) The commission shall contract with an independent
16	19		review organization to make review determinations with respect to
17	20		disputes at issue in requests for appeal submitted to the
18	21		commission challenging a medical necessity determination of a
19	22		managed care organization that contracts with the commission under
20		-	this chapter, except as provided by Subsection (~~b-1) or (~~g). The
21		-	~~executive~~ commissioner by rule shall determine:
	23	+	this chapter, except as provided by Subsection (g). The executive
	24	+	commissioner by rule shall determine:
22	25		(1) the manner in which an independent review
23	26		organization is to settle the disputes;
24		-	(2) when, ~~subject to Subsection (b-1),~~ in the appeals
25		-	~~process, an organization may~~ be accessed; and
	27	+	(2) when, in the appeals process, an organization may
	28	+	be accessed; and
26	29		(3) the recourse available after the organization
27	30		makes a review determination.
28		-	(b-1) With regard to a recipient dispute related to a
29		-	reduction in or denial of services on the basis of medical
30		-	necessity, the commission shall ensure that an independent review
31		-	conducted by an independent review organization under this section
32		-	occurs after the managed care organization has conducted an
33		-	internal appeal and before the Medicaid fair hearing is granted. A
34		-	recipient, or the recipient's parent or legally authorized
35		-	representative, described by this subsection may opt out of being
36		-	subject to an independent review determination under this section
37		-	and instead opt to proceed directly to a Medicaid fair hearing.
38	31		(c) The commission shall ensure that a contract entered into
39	32		under Subsection (b):
40	33		(1) requires an independent review organization to
41		-	make a review determination in a timely manner as determined by the
42		-	commission;
	34	+	make a review determination in a timely manner;
43	35		(2) provides procedures to protect the
44	36		confidentiality of medical records transmitted to the organization
45	37		for use in conducting an independent review;
46	38		(3) sets minimum qualifications for and requires the
47	39		independence of each physician or other health care provider making
48	40		a review determination on behalf of the organization;
49		-	(4) subject to Subsection (c-1), specifies the
50		-	procedures to be used by the organization in making review
51		-	determinations;
	41	+	(4) specifies the procedures to be used by the
	42	+	organization in making review determinations;
52	43		(5) requires the timely notice to a recipient of the
53	44		results of an independent review, including the clinical basis for
54	45		the review determination;
55	46		(6) requires that the organization report the
56	47		following aggregate information to the commission in the form and
57	48		manner and at the times prescribed by the commission:
58	49		(A) the number of requests for independent
59	50		reviews received by the independent review organization;
60	51		(B) the number of independent reviews conducted;
61	52		(C) the number of review determinations made:
62	53		(i) in favor of a managed care
63	54		organization; and
64	55		(ii) in favor of a recipient;
65	56		(D) the number of review determinations that
66	57		resulted in a managed care organization deciding to cover the
67	58		service at issue;
68	59		(E) a summary of the disputes at issue in
69	60		independent reviews;
70	61		(F) a summary of the services that were the
71	62		subject of independent reviews; and
72	63		(G) the average time the organization took to
73	64		complete an independent review and make a review determination; and
74	65		(7) requires that, in addition to the aggregate
75	66		information required by Subdivision (6), the organization include
76	67		in the report the information required by that subdivision
77	68		categorized by managed care organization.
78		-	(c-1) The commission shall establish a common procedure for
79		-	independent reviews conducted under this section. The procedure
80		-	must provide that a service ordered by a health care provider is
81		-	presumed medically necessary and the managed care organization
82		-	bears the burden of proof to show the service is not medically
83		-	necessary. Medical necessity must be based on publicly available,
84		-	up-to-date, evidence-based, and peer-reviewed clinical criteria.
85		-	The commission shall also establish a procedure for expedited
86		-	reviews that allows the reviewer to identify an appeal that
87		-	requires an expedited resolution.
88	69		(d) An independent review organization with which the
89	70		commission contracts under this section shall:
90	71		(1) obtain all information relating to the dispute at
91	72		issue from the managed care organization and the provider in
92	73		accordance with time frames prescribed by the commission;
93	74		(2) assign a physician or other health care provider
94	75		with appropriate expertise as a reviewer to make a review
95	76		determination;
96	77		(3) for each review, perform a check to ensure that the
97	78		organization and the physician or other health care provider
98	79		assigned to make a review determination do not have a conflict of
99	80		interest, as defined in the contract entered into between the
100	81		commission and the organization;
101	82		(4) communicate procedural rules, approved by the
102	83		commission, and other information regarding the appeals process to
103	84		all parties; and
104	85		(5) render a timely review determination, as
105	86		determined by the commission.
106	87		(e) The commission shall ensure that the managed care
107	88		organization, the provider, and the recipient involved in a dispute
108	89		do not have a choice in the reviewer who is assigned to perform the
109	90		review.
110		-	(e-1) An independent review organization's review
111		-	determination of medical necessity establishes the minimum level of
112		-	services a recipient must receive.
113		-	(f) A managed care organization described by Subsection (b)
114		-	may not have a financial relationship with or ownership interest in
115		-	an independent review organization with which the commission
116		-	contracts. In selecting an independent review organization with
	91	+	(f) In selecting an independent review organization with
117	92		which to contract, the commission shall avoid conflicts of interest
118	93		by considering and monitoring existing relationships between
119	94		independent review organizations and managed care organizations.
120		-	An independent review organization with which the commission
121		-	contracts must:
122		-	(1) be overseen by a medical director who is a
123		-	physician licensed in this state; and
124		-	(2) employ or be able to consult with staff with
125		-	experience in providing private duty nursing services and long-term
126		-	services and supports.
127	95		(g) This section does not apply to, and an independent
128	96		review organization may not make a review determination with
129	97		respect to, a dispute involving the commission's office of
130	98		inspector general or an action taken at the direction of that
131	99		office, including a dispute relating to:
132	100		(1) an action taken by a managed care organization at
133	101		the direction of the office under the lock-in program established
134	102		in accordance with 42 C.F.R. Part 431.54(e); or
135	103		(2) the termination or potential termination of a
136	104		provider's enrollment in a managed care organization's provider
137	105		network at the direction of the office.
138	106		(h) The executive commissioner shall adopt rules necessary
139	107		to implement this section.
140	108		SECTION 2. If before implementing any provision of this Act
141	109		a state agency determines that a waiver or authorization from a
142	110		federal agency is necessary for implementation of that provision,
143	111		the agency affected by the provision shall request the waiver or
144	112		authorization and may delay implementing that provision until the
145	113		waiver or authorization is granted.
146	114		SECTION 3. This Act takes effect September 1, 2019.