86R10228 JG-D
By: Frank H.B. No. 4178
A BILL TO BE ENTITLED
AN ACT
relating to the operation and administration of certain health and
human services programs, including the Medicaid managed care
program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.001, Government Code, is amended by
adding Subdivision (4-c) to read as follows:
(4-c) "Medicaid managed care organization" means a
managed care organization as defined by Section 533.001 that
contracts with the commission under Chapter 533 to provide health
care services to Medicaid recipients.
SECTION 2. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.02112 to read as follows:
Sec. 531.02112. PROCEDURE FOR IMPLEMENTING CHANGES TO
PAYMENT RATES UNDER MEDICAID AND CHILD HEALTH PLAN PROGRAM. (a) In
adopting rules and standards related to the determination of fees,
charges, and rates for payments under Medicaid and the child health
plan program, the executive commissioner, in consultation with the
advisory committee established under Subsection (b), shall adopt
rules to ensure that changes to the fees, charges, and rates are
implemented in accordance with this section and in a way that
minimizes administrative complexity and financial uncertainty.
(b) The executive commissioner shall establish an advisory
committee to provide input for the adoption of rules and standards
that comply with this section. The advisory committee is composed
of representatives of managed care organizations and providers
under Medicaid and the child health plan program. The advisory
committee is abolished on the date the rules that comply with this
section are adopted. This subsection expires September 1, 2021.
(c) Before implementing a change to the fees, charges, and
rates for payments under Medicaid or the child health plan program,
the commission shall:
(1) before or at the time notice of the proposed change
is published under Subdivision (2), notify managed care
organizations and the entity serving as the state's Medicaid claims
administrator under the Medicaid fee-for-service delivery model of
the proposed change;
(2) publish notice of the proposed change:
(A) for public comment in the Texas Register for
a period of not less than 60 days; and
(B) on the commission's and state Medicaid claims
administrator's Internet websites during the period specified
under Paragraph (A);
(3) publish notice of a final determination to make
the proposed change:
(A) in the Texas Register for a period of not less
than 30 days before the change becomes effective; and
(B) on the commission's and state Medicaid claims
administrator's Internet websites during the period specified
under Paragraph (A); and
(4) provide managed care organizations and the entity
serving as the state's Medicaid claims administrator under the
Medicaid fee-for-service delivery model with a period of not less
than 30 days before the effective date of the final change to make
any necessary administrative or systems adjustments to implement
the change.
(d) If changes to the fees, charges, or rates for payments
under Medicaid or the child health plan program are mandated by the
legislature or federal government on a date that does not fall
within the time frame for the implementation of those changes
described by this section, the commission shall:
(1) prorate the amount of the change over the fee,
charge, or rate period; and
(2) publish the proration schedule described by
Subdivision (1) in the Texas Register along with the notice
provided under Subsection (c)(3).
(e) This section does not apply to changes to the fees,
charges, or rates for payments made to a nursing facility.
SECTION 3. Section 531.02118, Government Code, is amended
by amending Subsection (c) and adding Subsections (e) and (f) to
read as follows:
(c) In streamlining the Medicaid provider credentialing
process under this section, the commission may designate a
centralized credentialing entity and, if a centralized
credentialing entity is designated, shall [may]:
(1) share information in the database established
under Subchapter C, Chapter 32, Human Resources Code, with the
centralized credentialing entity to reduce the submission of
duplicative information or documents necessary for both Medicaid
enrollment and credentialing; and
(2) require all Medicaid managed care organizations
[contracting with the commission to provide health care services to
Medicaid recipients under a managed care plan issued by the
organization] to use the centralized credentialing entity as a hub
for the collection and sharing of information.
(e) To the extent permitted by federal law, the commission
shall use available Medicare data to streamline the enrollment and
credentialing of Medicaid providers by reducing the submission of
duplicative information or documents.
(f) The commission shall develop and implement a process to
expedite the Medicaid provider enrollment process for a health care
provider who is providing health care services through a single
case agreement to a Medicaid recipient with primary insurance
coverage. The commission shall use a provider's national provider
identifier number to enroll a provider under this subsection. In
this subsection, "national provider identifier number" has the
meaning assigned by Section 531.021182.
SECTION 4. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.021182 to read as follows:
Sec. 531.021182. USE OF NATIONAL PROVIDER IDENTIFIER
NUMBER. (a) In this section, "national provider identifier
number" means the national provider identifier number required
under Section 1128J(e), Social Security Act (42 U.S.C. Section
1320a-7k(e)).
(b) Beginning September 1, 2020, the commission:
(1) may not use a state-issued provider identifier
number to identify a Medicaid provider;
(2) shall use only a national provider identifier
number to identify a Medicaid provider; and
(3) must allow a Medicaid provider to bill for
Medicaid services using the provider's national provider
identifier number.
SECTION 5. Section 531.024(b), Government Code, is amended
to read as follows:
(b) The rules promulgated under Subsection (a)(7) must
provide due process to an applicant for Medicaid services or
programs and to a Medicaid recipient who seeks a Medicaid service,
including a service that requires prior authorization. The rules
must provide the protections for applicants and recipients required
by 42 C.F.R. Part 431, Subpart E, including requiring that:
(1) the written notice to an individual of the
individual's right to a hearing must:
(A) contain a clear [an] explanation of:
(i) the adverse determination and the
circumstances under which Medicaid is continued if a hearing is
requested; and
(ii) the fair hearing process, including
the individual's ability to use an independent review process; and
(B) be mailed at least 10 days before the date the
individual's Medicaid eligibility or service is scheduled to be
terminated, suspended, or reduced, except as provided by 42 C.F.R.
Section 431.213 or 431.214; and
(2) if a hearing is requested before the date a
Medicaid recipient's service, including a service that requires
prior authorization, is scheduled to be terminated, suspended, or
reduced, the agency may not take that proposed action before a
decision is rendered after the hearing unless:
(A) it is determined at the hearing that the sole
issue is one of federal or state law or policy; and
(B) the agency promptly informs the recipient in
writing that services are to be terminated, suspended, or reduced
pending the hearing decision.
SECTION 6. Subchapter B, Chapter 531, Government Code, is
amended by adding Sections 531.024162, 531.0319, and 531.0602 to
read as follows:
Sec. 531.024162. NOTICE REQUIREMENTS REGARDING DENIAL OF
COVERAGE OR PRIOR AUTHORIZATION. The commission shall ensure that
notice sent by the commission or a Medicaid managed care
organization to a Medicaid recipient or provider regarding the
denial of coverage or prior authorization for a service includes:
(1) information required by federal law;
(2) a clear and easy-to-understand explanation of the
reason for the denial for the recipient; and
(3) a clinical explanation of the reason for the
denial for the provider.
Sec. 531.0319. MEDICAID MEDICAL POLICY MANUAL. (a) The
commission shall develop and publish on the commission's Internet
website a Medicaid medical policy manual. The manual must:
(1) be updated monthly, as necessary;
(2) primarily address the managed care delivery model
for Medicaid benefits;
(3) include a description of each service covered
under Medicaid, including the scope, duration, and amount of
coverage; and
(4) direct Medicaid providers to the Medicaid managed
care manual that applies to the provider for specific prior
authorization and billing policies.
(b) The commission shall publish the Medicaid medical
policy manual not later than January 1, 2020. Beginning on that
date, the commission may not use any prior Medicaid procedures
manual for providers. This subsection expires September 1, 2021.
Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
PROGRAM REASSESSMENTS. To the extent allowed by federal law, the
commission shall require that a child participating in the
medically dependent children (MDCP) waiver program be reassessed to
determine whether the child meets the level of care criteria for
medical necessity for nursing facility care only if the child has a
significant change in function that may affect the medical
necessity for that level of care instead of requiring that the
reassessment be made annually.
SECTION 7. Section 531.072(c), Government Code, is amended
to read as follows:
(c) In making a decision regarding the placement of a drug
on each of the preferred drug lists, the commission shall consider:
(1) the recommendations of the Drug Utilization Review
Board under Section 531.0736;
(2) the clinical efficacy of the drug;
(3) the price of competing drugs after deducting any
federal and state rebate amounts; [and]
(4) the impact on recipient health outcomes and
continuity of care; and
(5) program benefit offerings solely or in conjunction
with rebates and other pricing information.
SECTION 8. Section 531.0736(c), Government Code, is amended
to read as follows:
(c) The executive commissioner shall determine the
composition of the board, which must:
(1) comply with applicable federal law, including 42
C.F.R. Section 456.716;
(2) include five [two] representatives of managed care
organizations to represent each managed care product [as nonvoting
members], at least one of whom must be a physician and one of whom
must be a pharmacist;
(3) include at least 17 physicians and pharmacists
who:
(A) provide services across the entire
population of Medicaid recipients and represent different
specialties, including at least one of each of the following types
of physicians:
(i) a pediatrician;
(ii) a primary care physician;
(iii) an obstetrician and gynecologist;
(iv) a child and adolescent psychiatrist;
and
(v) an adult psychiatrist; and
(B) have experience in either developing or
practicing under a preferred drug list; and
(4) include a consumer advocate who represents
Medicaid recipients.
SECTION 9. Subchapter A, Chapter 533, Government Code, is
amended by adding Sections 533.00284 and 533.00285 to read as
follows:
Sec. 533.00284. ADOPTION OF PRIOR AUTHORIZATION PRACTICE
GUIDELINES; ACCESSIBILITY. (a) In developing medical policies and
standards for making medical necessity determinations for prior
authorizations, each Medicaid managed care organization shall:
(1) in consultation with health care providers in the
organization's provider network, adopt practice guidelines that:
(A) are based on valid and reliable clinical
evidence or the medical consensus among health care professionals
who practice in the applicable field; and
(B) take into consideration the health care needs
of the recipients enrolled in a managed care plan offered by the
organization; and
(2) develop a written process describing the method
for periodically reviewing and amending utilization management
clinical review criteria.
(b) A Medicaid managed care organization shall annually
review and, as necessary, update the practice guidelines adopted
under Subsection (a)(1).
(c) The executive commissioner by rule shall require each
Medicaid managed care organization or other entity responsible for
authorizing coverage for health care services under Medicaid to
ensure that:
(1) coverage criteria and prior authorization
requirements are:
(A) made available to recipients and providers on
the organization's or entity's Internet website; and
(B) communicated in a clear, concise, and easily
understandable manner;
(2) any necessary or supporting documents needed to
obtain prior authorization are made available on a web page of the
organization's or entity's Internet website accessible through a
clearly marked link to the web page; and
(3) the process for contacting the organization or
entity for clarification or assistance in obtaining prior
authorization is not arduous or overly burdensome to a recipient or
provider.
Sec. 533.00285. PRIOR AUTHORIZATION PROCEDURES. In
addition to the requirements of Section 533.005, a contract between
a Medicaid managed care organization and the commission described
by that section must include:
(1) time frames for the prior authorization of health
care services that enable Medicaid providers to:
(A) deliver those services in a timely manner;
and
(B) request a peer review regarding the prior
authorization before the organization makes a final decision on the
prior authorization; and
(2) a requirement that the organization:
(A) has appropriate personnel reasonably
available at a toll-free telephone number to receive prior
authorization requests between 6 a.m. and 6 p.m. central time
Monday through Friday on each day that is not a legal holiday and
between 9 a.m. and noon central time on Saturday and Sunday; and
(B) has a telephone system capable of receiving
and recording incoming telephone calls for prior authorization
requests after 6 p.m. central time Monday through Friday and after
noon central time on Saturday and Sunday.
SECTION 10. Section 533.0071, Government Code, is amended
to read as follows:
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission
shall make every effort to improve the administration of contracts
with Medicaid managed care organizations. To improve the
administration of these contracts, the commission shall:
(1) ensure that the commission has appropriate
expertise and qualified staff to effectively manage contracts with
managed care organizations under the Medicaid managed care program;
(2) evaluate options for Medicaid payment recovery
from managed care organizations if the enrollee dies or is
incarcerated or if an enrollee is enrolled in more than one state
program or is covered by another liable third party insurer;
(3) maximize Medicaid payment recovery options by
contracting with private vendors to assist in the recovery of
capitation payments, payments from other liable third parties, and
other payments made to managed care organizations with respect to
enrollees who leave the managed care program;
(4) decrease the administrative burdens of managed
care for the state, the managed care organizations, and the
providers under managed care networks to the extent that those
changes are compatible with state law and existing Medicaid managed
care contracts, including decreasing those burdens by:
(A) where possible, decreasing the duplication
of administrative reporting and process requirements for the
managed care organizations and providers, such as requirements for
the submission of encounter data, quality reports, historically
underutilized business reports, and claims payment summary
reports;
(B) allowing managed care organizations to
provide updated address information directly to the commission for
correction in the state system;
(C) promoting consistency and uniformity among
managed care organization policies, including policies relating to
the preauthorization process, lengths of hospital stays, filing
deadlines, levels of care, and case management services;
(D) reviewing the appropriateness of primary
care case management requirements in the admission and clinical
criteria process, such as requirements relating to including a
separate cover sheet for all communications, submitting
handwritten communications instead of electronic or typed review
processes, and admitting patients listed on separate
notifications; and
(E) providing a portal through which providers in
any managed care organization's provider network may submit acute
care services and long-term services and supports claims; and
(5) ensure that the commission's fair hearing process
and [reserve the right to amend] the managed care organization's
process for resolving recipient and provider appeals of denials
based on medical necessity [to] include an independent review
process established by the commission for final determination of
these disputes.
SECTION 11. Section 533.0076(c), Government Code, is
amended 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[; and
[(2) once for any reason after the periods described
by Subsections (a) and (b)].
SECTION 12. Subchapter A, Chapter 533, Government Code, is
amended by adding Sections 533.038 and 533.039 to read as follows:
Sec. 533.038. COORDINATION OF BENEFITS. (a) In this
section, "Medicaid wrap-around benefit" means a Medicaid-covered
service, including a pharmacy or medical benefit, that is provided
to a recipient with both Medicaid and primary health benefit plan
coverage when the recipient has exceeded the primary health benefit
plan coverage limit or when the service is not covered by the
primary health benefit plan issuer.
(b) The commission, in coordination with Medicaid managed
care organizations, shall develop and adopt a clear policy for a
Medicaid managed care organization to ensure the coordination and
timely delivery of Medicaid wrap-around benefits for recipients
with both primary health benefit plan coverage and Medicaid
coverage.
(c) To further assist with the coordination of benefits, the
commission, in coordination with Medicaid managed care
organizations, shall develop and maintain a list of services that
are not traditionally covered by primary health benefit plan
coverage that a Medicaid managed care organization may approve
without having to coordinate with the primary health benefit plan
issuer and that can be resolved through third-party liability
resolution processes. The commission shall review and update the
list quarterly.
(d) A Medicaid managed care organization that in good faith
and following commission policies provides coverage for a Medicaid
wrap-around benefit shall include the cost of providing the benefit
in the organization's financial reports. The commission shall
include the reported costs in computing capitation rates for the
managed care organization.
(e) If the commission determines that a recipient's primary
health benefit plan issuer should have been the primary payor of a
claim, the Medicaid managed care organization that paid the claim
shall work with the commission on the recovery process and make
every attempt to reduce health care provider and recipient
abrasion.
(f) The executive commissioner may seek a waiver from the
federal government as needed to:
(1) address federal policies related to coordination
of benefits and third-party liability; and
(2) maximize federal financial participation for
recipients with both primary health benefit plan coverage and
Medicaid coverage.
(g) Notwithstanding Sections 531.073 and 533.005(a)(23) or
any other law, the commission shall ensure that a prescription drug
that is covered under the Medicaid vendor drug program or other
applicable formulary and is prescribed to a recipient with primary
health benefit plan coverage is not subject to any prior
authorization requirement if the primary health benefit plan issuer
will pay at least $0.01 on the prescription drug claim. If the
primary insurer will pay nothing on a prescription drug claim, the
prescription drug is subject to any applicable Medicaid clinical or
nonpreferred prior authorization requirement.
(h) The commission shall ensure that the daily Medicaid
managed care eligibility files indicate whether a recipient has
primary health benefit plan coverage or health insurance premium
payment coverage. For a recipient who has that coverage, the files
must include the following up-to-date, accurate information
related to primary health benefit plan coverage:
(1) the health benefit plan issuer's name and address
and the recipient's policy number;
(2) the primary health benefit plan coverage start and
end dates;
(3) the primary health benefit plan coverage benefits,
limits, copayment, and coinsurance information; and
(4) any additional information that would be useful to
ensure the coordination of benefits.
(i) The commission shall develop and implement processes
and policies to allow a health care provider who is primarily
providing services to a recipient through primary health benefit
plan coverage to receive Medicaid reimbursement for services
ordered, referred, prescribed, or delivered, regardless of whether
the provider is enrolled as a Medicaid provider. The commission
shall allow a provider who is not enrolled as a Medicaid provider to
order, refer, prescribe, or deliver services to a recipient based
on the provider's national provider identifier number and may not
require an additional state provider identifier number to receive
reimbursement for the services. The commission may seek a waiver of
Medicaid provider enrollment requirements for providers of
recipients with primary health benefit plan coverage to implement
this subsection.
(j) The commission shall develop and implement a clear and
easy process to allow a recipient with complex medical needs who has
established a relationship with a specialty provider in an area
outside of the recipient's Medicaid managed care organization's
service delivery area to continue receiving care from that provider
if the provider will enter into a single-case agreement with the
Medicaid managed care organization. A single-case agreement with a
provider outside of the organization's service delivery area in
accordance with this subsection is not considered an
out-of-network agreement and must be included in the organization's
network adequacy determination.
(k) The commission shall develop and implement processes
to:
(1) reimburse a recipient with primary health benefit
plan coverage who pays a copayment, coinsurance, or other
cost-sharing amount out of pocket because the primary health
benefit plan issuer refuses to enroll in Medicaid, enter into a
single-case agreement, or bill the recipient's Medicaid managed
care organization; and
(2) capture encounter data for the Medicaid
wrap-around benefits provided by the Medicaid managed care
organization under this subsection.
Sec. 533.039. COORDINATION OF BENEFITS FOR PERSONS DUALLY
ELIGIBLE UNDER MEDICAID AND MEDICARE. (a) In this section,
"Medicaid wrap-around benefit" means a Medicaid-covered service,
including a pharmacy or medical benefit, that is provided to a
recipient with both Medicaid and Medicare coverage when the
recipient has exceeded the Medicare coverage limit or when the
service is not covered by Medicare.
(b) The executive commissioner, in consultation with
Medicaid managed care organizations, by rule shall develop and
implement a policy that ensures the coordinated and timely delivery
of Medicaid wrap-around benefits. The policy must:
(1) include a benefits equivalency crosswalk or other
method for mapping equivalent benefits under Medicaid and Medicare;
and
(2) in a manner that is consistent with federal and
state law, require sharing of information concerning third-party
sources of coverage and reimbursement.
SECTION 13. (a) Not later than December 31, 2019, the
executive commissioner of the Health and Human Services Commission
shall establish the advisory committee as required by Section
531.02112(b), Government Code, as added by this Act.
(b) The procedure for implementing changes to payment rates
required by Section 531.02112, Government Code, as added by this
Act, applies only to a change to a fee, charge, or rate that takes
effect on or after January 1, 2021.
SECTION 14. Section 531.0602, Government Code, as added by
this Act, applies only to a reassessment of a child's eligibility
for the medically dependent children (MDCP) waiver program made on
or after December 1, 2019.
SECTION 15. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall adopt rules necessary to implement the
changes in law made by this Act.
SECTION 16. (a) Section 533.00285, Government Code, as
added by this Act, applies only to a contract between the Health and
Human Services Commission and a Medicaid managed care organization
under Chapter 533, Government Code, that is entered into or renewed
on or after the effective date of this Act.
(b) The Health and Human Services Commission shall seek to
amend contracts entered into with Medicaid managed care
organizations under Chapter 533, Government Code, before the
effective date of this Act to include the provisions required by
Section 533.00285, Government Code, as added by this Act.
SECTION 17. 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 18. This Act takes effect September 1, 2019.