Texas 2019 - 86th Regular

Texas House Bill HB4178 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	~~86R27018~~ JG-D
	1	+	86R10228 JG-D
2	2		By: Frank H.B. No. 4178
3		-	Substitute the following for H.B. No. 4178:
4		-	By: Klick C.S.H.B. No. 4178
5	3
6	4
7	5		A BILL TO BE ENTITLED
8	6		AN ACT
9	7		relating to the operation and administration of certain health and
10	8		human services programs, including the Medicaid managed care
11	9		program.
12	10		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	11		SECTION 1. Section 531.001, Government Code, is amended by
14	12		adding Subdivision (4-c) to read as follows:
15	13		(4-c) "Medicaid managed care organization" means a
16	14		managed care organization as defined by Section 533.001 that
17	15		contracts with the commission under Chapter 533 to provide health
18	16		care services to Medicaid recipients.
19	17		SECTION 2. Subchapter B, Chapter 531, Government Code, is
20	18		amended by adding Section 531.02112 to read as follows:
21		-	Sec. 531.02112. POLICIES FOR IMPLEMENTING CHANGES TO
22		-	PAYMENT RATES UNDER MEDICAID AND CHILD HEALTH PLAN PROGRAM. (a)
23		-	The commission shall adopt policies related to the determination of
24		-	fees, charges, and rates for payments under Medicaid and the child
25		-	health plan program to ensure, to the greatest extent possible,
26		-	that changes to a fee schedule are implemented in a way that
27		-	minimizes administrative complexity, financial uncertainty, and
28		-	retroactive adjustments for providers.
29		-	(b) In adopting policies under Subsection (a), the
30		-	commission shall:
31		-	(1) develop a process for individuals and entities
32		-	that deliver services under the Medicaid managed care program to
33		-	provide oral or written input on the proposed policies; and
34		-	(2) ensure that managed care organizations and the
35		-	entity serving as the state's Medicaid claims administrator under
36		-	the Medicaid fee-for-service delivery model are provided a period
37		-	of not less than 45 days before the effective date of a final fee
38		-	schedule change to make any necessary administrative or systems
39		-	adjustments to implement the change.
40		-	(c) This section does not apply to changes to the fees,
41		-	charges, or rates for payments made to a nursing facility or to
42		-	capitation rates paid to a Medicaid managed care organization.
	19	+	Sec. 531.02112. PROCEDURE FOR IMPLEMENTING CHANGES TO
	20	+	PAYMENT RATES UNDER MEDICAID AND CHILD HEALTH PLAN PROGRAM. (a) In
	21	+	adopting rules and standards related to the determination of fees,
	22	+	charges, and rates for payments under Medicaid and the child health
	23	+	plan program, the executive commissioner, in consultation with the
	24	+	advisory committee established under Subsection (b), shall adopt
	25	+	rules to ensure that changes to the fees, charges, and rates are
	26	+	implemented in accordance with this section and in a way that
	27	+	minimizes administrative complexity and financial uncertainty.
	28	+	(b) The executive commissioner shall establish an advisory
	29	+	committee to provide input for the adoption of rules and standards
	30	+	that comply with this section. The advisory committee is composed
	31	+	of representatives of managed care organizations and providers
	32	+	under Medicaid and the child health plan program. The advisory
	33	+	committee is abolished on the date the rules that comply with this
	34	+	section are adopted. This subsection expires September 1, 2021.
	35	+	(c) Before implementing a change to the fees, charges, and
	36	+	rates for payments under Medicaid or the child health plan program,
	37	+	the commission shall:
	38	+	(1) before or at the time notice of the proposed change
	39	+	is published under Subdivision (2), notify managed care
	40	+	organizations and the entity serving as the state's Medicaid claims
	41	+	administrator under the Medicaid fee-for-service delivery model of
	42	+	the proposed change;
	43	+	(2) publish notice of the proposed change:
	44	+	(A) for public comment in the Texas Register for
	45	+	a period of not less than 60 days; and
	46	+	(B) on the commission's and state Medicaid claims
	47	+	administrator's Internet websites during the period specified
	48	+	under Paragraph (A);
	49	+	(3) publish notice of a final determination to make
	50	+	the proposed change:
	51	+	(A) in the Texas Register for a period of not less
	52	+	than 30 days before the change becomes effective; and
	53	+	(B) on the commission's and state Medicaid claims
	54	+	administrator's Internet websites during the period specified
	55	+	under Paragraph (A); and
	56	+	(4) provide managed care organizations and the entity
	57	+	serving as the state's Medicaid claims administrator under the
	58	+	Medicaid fee-for-service delivery model with a period of not less
	59	+	than 30 days before the effective date of the final change to make
	60	+	any necessary administrative or systems adjustments to implement
	61	+	the change.
	62	+	(d) If changes to the fees, charges, or rates for payments
	63	+	under Medicaid or the child health plan program are mandated by the
	64	+	legislature or federal government on a date that does not fall
	65	+	within the time frame for the implementation of those changes
	66	+	described by this section, the commission shall:
	67	+	(1) prorate the amount of the change over the fee,
	68	+	charge, or rate period; and
	69	+	(2) publish the proration schedule described by
	70	+	Subdivision (1) in the Texas Register along with the notice
	71	+	provided under Subsection (c)(3).
	72	+	(e) This section does not apply to changes to the fees,
	73	+	charges, or rates for payments made to a nursing facility.
43	74		SECTION 3. Section 531.02118, Government Code, is amended
44	75		by amending Subsection (c) and adding Subsections (e) and (f) to
45	76		read as follows:
46	77		(c) In streamlining the Medicaid provider credentialing
47	78		process under this section, the commission may designate a
48	79		centralized credentialing entity and, if a centralized
49	80		credentialing entity is designated, shall [may]:
50	81		(1) share information in the database established
51	82		under Subchapter C, Chapter 32, Human Resources Code, with the
52	83		centralized credentialing entity to reduce the submission of
53	84		duplicative information or documents necessary for both Medicaid
54	85		enrollment and credentialing; and
55	86		(2) require all Medicaid managed care organizations
56	87		[contracting with the commission to provide health care services to
57	88		Medicaid recipients under a managed care plan issued by the
58	89		organization] to use the centralized credentialing entity as a hub
59	90		for the collection and sharing of information.
60	91		(e) To the extent permitted by federal law, the commission
61	92		shall use available Medicare data to streamline the enrollment and
62	93		credentialing of Medicaid providers by reducing the submission of
63	94		duplicative information or documents.
64	95		(f) The commission shall develop and implement a process to
65	96		expedite the Medicaid provider enrollment process for a health care
66	97		provider who is providing health care services through a single
67	98		case agreement to a Medicaid recipient with primary insurance
68	99		coverage. The commission shall use a provider's national provider
69	100		identifier number to enroll a provider under this subsection. In
70	101		this subsection, "national provider identifier number" has the
71	102		meaning assigned by Section 531.021182.
72	103		SECTION 4. Subchapter B, Chapter 531, Government Code, is
73	104		amended by adding Section 531.021182 to read as follows:
74	105		Sec. 531.021182. USE OF NATIONAL PROVIDER IDENTIFIER
75	106		NUMBER. (a) In this section, "national provider identifier
76	107		number" means the national provider identifier number required
77	108		under Section 1128J(e), Social Security Act (42 U.S.C. Section
78	109		1320a-7k(e)).
79		-	(b) The commission shall transition from using a
80		-	state-issued provider identifier number to using only a national
81		-	provider identifier number in accordance with this section.
82		-	(c) The commission shall implement a Medicaid provider
83		-	management and enrollment system and, following that
84		-	implementation, use only a national provider identifier number to
85		-	enroll a provider in Medicaid.
86		-	(d) The commission shall implement a modernized claims
87		-	processing system and, following that implementation, use only a
88		-	national provider identifier number to process claims for and
89		-	authorize Medicaid services.
	110	+	(b) Beginning September 1, 2020, the commission:
	111	+	(1) may not use a state-issued provider identifier
	112	+	number to identify a Medicaid provider;
	113	+	(2) shall use only a national provider identifier
	114	+	number to identify a Medicaid provider; and
	115	+	(3) must allow a Medicaid provider to bill for
	116	+	Medicaid services using the provider's national provider
	117	+	identifier number.
90	118		SECTION 5. Section 531.024(b), Government Code, is amended
91	119		to read as follows:
92	120		(b) The rules promulgated under Subsection (a)(7) must
93	121		provide due process to an applicant for Medicaid services or
94	122		programs and to a Medicaid recipient who seeks a Medicaid service,
95	123		including a service that requires prior authorization. The rules
96	124		must provide the protections for applicants and recipients required
97	125		by 42 C.F.R. Part 431, Subpart E, including requiring that:
98	126		(1) the written notice to an individual of the
99	127		individual's right to a hearing must:
100	128		(A) contain a clear [an] explanation of:
101	129		(i) the adverse determination and the
102	130		circumstances under which Medicaid is continued if a hearing is
103	131		requested; and
104	132		(ii) the fair hearing process, including
105	133		the individual's ability to use an independent review process; and
106	134		(B) be mailed at least 10 days before the date the
107	135		individual's Medicaid eligibility or service is scheduled to be
108	136		terminated, suspended, or reduced, except as provided by 42 C.F.R.
109	137		Section 431.213 or 431.214; and
110	138		(2) if a hearing is requested before the date a
111	139		Medicaid recipient's service, including a service that requires
112	140		prior authorization, is scheduled to be terminated, suspended, or
113	141		reduced, the agency may not take that proposed action before a
114	142		decision is rendered after the hearing unless:
115	143		(A) it is determined at the hearing that the sole
116	144		issue is one of federal or state law or policy; and
117	145		(B) the agency promptly informs the recipient in
118	146		writing that services are to be terminated, suspended, or reduced
119	147		pending the hearing decision.
120	148		SECTION 6. Subchapter B, Chapter 531, Government Code, is
121		-	amended by adding Sections 531.024162, 531.024163, and 531.024164
122		-	to read as follows:
123		-	Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID
124		-	COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
125		-	(a) The commission shall ensure that notice sent by the commission
126		-	or a Medicaid managed care organization to a Medicaid recipient or
127		-	provider regarding the denial of coverage or prior authorization
128		-	for a service includes:
129		-	(1) information required by federal and state law and
130		-	applicable regulations;
131		-	(2) for the recipient, a clear and easy-to-understand
132		-	explanation of the reason for the denial; and
133		-	(3) for the provider, a thorough and detailed clinical
134		-	explanation of the reason for the denial, including, as applicable,
135		-	information required under Subsection (b).
136		-	(b) The commission or a Medicaid managed care organization
137		-	that receives from a provider a coverage or prior authorization
138		-	request that contains insufficient or inadequate documentation to
139		-	approve the request shall issue a notice to the provider and the
140		-	Medicaid recipient on whose behalf the request was submitted. The
141		-	notice issued under this subsection must:
142		-	(1) include a section specifically for the provider
143		-	that contains:
144		-	(A) a clear and specific list and description of
145		-	the documentation necessary for the commission or organization to
146		-	make a final determination on the request;
147		-	(B) the applicable timeline, based on the
148		-	requested service, for the provider to submit the documentation and
149		-	a description of the reconsideration process described by Section
150		-	533.00284, if applicable; and
151		-	(C) information on the manner through which a
152		-	provider may contact a Medicaid managed care organization or other
153		-	entity as required by Section 531.024163; and
154		-	(2) be sent to the provider:
155		-	(A) using the provider's preferred method of
156		-	contact most recently provided to the commission or the Medicaid
157		-	managed care organization and using any alternative and known
158		-	methods of contact; and
159		-	(B) as applicable, through an electronic
160		-	notification on an Internet portal.
161		-	Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING
162		-	MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive
163		-	commissioner by rule shall require each Medicaid managed care
164		-	organization or other entity responsible for authorizing coverage
165		-	for health care services under Medicaid to ensure that the
166		-	organization or entity maintains on the organization's or entity's
167		-	Internet website in an easily searchable and accessible format:
168		-	(1) the applicable timelines for prior authorization
169		-	requirements, including:
170		-	(A) the time within which the organization or
171		-	entity must make a determination on a prior authorization request;
172		-	(B) a description of the notice the organization
173		-	or entity provides to a provider and Medicaid recipient regarding
174		-	the documentation required to complete a determination on a prior
175		-	authorization request; and
176		-	(C) the deadline by which the organization or
177		-	entity is required to submit the notice described by Paragraph (B);
178		-	and
179		-	(2) an accurate and up-to-date catalogue of coverage
180		-	criteria and prior authorization requirements, including:
181		-	(A) for a prior authorization requirement first
182		-	imposed on or after September 1, 2019, the effective date of the
183		-	requirement;
184		-	(B) a list or description of any necessary or
185		-	supporting documentation necessary to obtain prior authorization
186		-	for a specified service; and
187		-	(C) the date and results of each review of the
188		-	prior authorization requirement conducted under Section 533.00283,
189		-	if applicable.
190		-	(b) The executive commissioner by rule shall require each
191		-	Medicaid managed care organization or other entity responsible for
192		-	authorizing coverage for health care services under Medicaid to:
193		-	(1) adopt and maintain a process for a provider or
194		-	Medicaid recipient to contact the organization or entity to clarify
195		-	prior authorization requirements or assist the provider or
196		-	recipient in submitting a prior authorization request; and
197		-	(2) ensure that the process described by Subdivision
198		-	(1) is not arduous or overly burdensome to a provider or recipient.
199		-	Sec. 531.024164. INDEPENDENT REVIEW ORGANIZATIONS. (a) In
200		-	this section, "independent review organization" means an
201		-	organization certified under Chapter 4202, Insurance Code.
202		-	(b) The commission shall contract with an independent
203		-	review organization to make review determinations with respect to:
204		-	(1) a Medicaid managed care organization's resolution
205		-	of an internal appeal challenging a medical necessity
206		-	determination;
207		-	(2) a denial by the commission of eligibility for a
208		-	Medicaid program on the basis of the Medicaid recipient's or
209		-	applicant's medical and functional needs; and
210		-	(3) an action, as defined by 42 C.F.R. Section
211		-	431.201, by the commission based on the recipient's medical and
212		-	functional needs.
213		-	(c) The executive commissioner by rule shall determine:
214		-	(1) the manner in which an independent review
215		-	organization is to settle the disputes;
216		-	(2) when, in the appeals process, an organization may
217		-	be accessed; and
218		-	(3) the recourse available after the organization
219		-	makes a review determination.
220		-	(d) The commission shall ensure that a contract entered into
221		-	under Subsection (b):
222		-	(1) requires an independent review organization to
223		-	make a review determination in a timely manner;
224		-	(2) provides procedures to protect the
225		-	confidentiality of medical records transmitted to the organization
226		-	for use in conducting an independent review;
227		-	(3) sets minimum qualifications for and requires the
228		-	independence of each physician or other health care provider making
229		-	a review determination on behalf of the organization;
230		-	(4) specifies the procedures to be used by the
231		-	organization in making review determinations;
232		-	(5) requires the timely notice to a Medicaid recipient
233		-	of the results of an independent review, including the clinical
234		-	basis for the review determination;
235		-	(6) requires that the organization report the
236		-	following aggregate information to the commission in the form and
237		-	manner and at the times prescribed by the commission:
238		-	(A) the number of requests for independent
239		-	reviews received by the independent review organization;
240		-	(B) the number of independent reviews conducted;
241		-	(C) the number of review determinations made:
242		-	(i) in favor of a Medicaid managed care
243		-	organization; and
244		-	(ii) in favor of a Medicaid recipient;
245		-	(D) the number of review determinations that
246		-	resulted in a Medicaid managed care organization deciding to cover
247		-	the service at issue;
248		-	(E) a summary of the disputes at issue in
249		-	independent reviews;
250		-	(F) a summary of the services that were the
251		-	subject of independent reviews; and
252		-	(G) the average time the organization took to
253		-	complete an independent review and make a review determination; and
254		-	(7) requires that, in addition to the aggregate
255		-	information required by Subdivision (6), the organization include
256		-	in the report the information required by that subdivision
257		-	categorized by Medicaid managed care organization.
258		-	(e) An independent review organization with which the
259		-	commission contracts under this section shall:
260		-	(1) obtain all information relating to the internal
261		-	appeal at issue, as applicable, from the Medicaid managed care
262		-	organization and the provider in accordance with time frames
263		-	prescribed by the commission;
264		-	(2) obtain all information relating to the denial or
265		-	action at issue, as applicable, from the commission and provider in
266		-	accordance with time frames prescribed by the commission;
267		-	(3) assign a physician or other health care provider
268		-	with appropriate expertise as a reviewer to make a review
269		-	determination;
270		-	(4) for each review, perform a check to ensure that the
271		-	organization and the physician or other health care provider
272		-	assigned to make a review determination do not have a conflict of
273		-	interest, as defined in the contract entered into between the
274		-	commission and the organization;
275		-	(5) communicate procedural rules, approved by the
276		-	commission, and other information regarding the appeals process to
277		-	all parties; and
278		-	(6) render a timely review determination, as
279		-	determined by the commission.
280		-	(f) The commission shall ensure that the commission, the
281		-	Medicaid managed care organization, the provider, and the Medicaid
282		-	recipient involved in a dispute, as applicable, do not have a choice
283		-	in the reviewer who is assigned to perform the review.
284		-	(g) In selecting an independent review organization with
285		-	which to contract, the commission shall avoid conflicts of interest
286		-	by considering and monitoring existing relationships between
287		-	independent review organizations and Medicaid managed care
288		-	organizations.
289		-	(h) The executive commissioner shall adopt rules necessary
290		-	to implement this section.
291		-	SECTION 7. Section 531.02444, Government Code, is amended
292		-	by amending Subsection (a) and adding Subsection (a-1) to read as
293		-	follows:
294		-	(a) The executive commissioner shall develop and implement:
295		-	(1) to the extent permitted by a waiver sought by the
296		-	commission under Section 1115 of the federal Social Security Act
297		-	(42 U.S.C. Section 1315), a Medicaid buy-in program for persons
298		-	with disabilities as authorized by the Ticket to Work and Work
299		-	Incentives Improvement Act of 1999 (Pub. L. No. 106-170) or the
300		-	Balanced Budget Act of 1997 (Pub. L. No. 105-33); and
301		-	(2) subject to Subsection (a-1) as authorized by the
302		-	Deficit Reduction Act of 2005 (Pub. L. No. 109-171), a Medicaid
303		-	buy-in program for children with disabilities that is described by
304		-	42 U.S.C. Section 1396a(cc)(1) whose family incomes do not exceed
305		-	300 percent of the applicable federal poverty level.
306		-	(a-1) The executive commissioner by rule shall increase the
307		-	maximum family income prescribed by Subsection (a)(2) for
308		-	determining eligibility for the buy-in program under that
309		-	subdivision of a child who is eligible for the medically dependent
310		-	children (MDCP) waiver program and is on the interest list for that
311		-	program to the maximum family income amount allowable, considering
312		-	available appropriations for that purpose.
313		-	SECTION 8. Subchapter B, Chapter 531, Government Code, is
314		-	amended by adding Sections 531.024441, 531.0319, 531.03191, and
315		-	531.0602 to read as follows:
316		-	Sec. 531.024441. MEDICAID BUY-IN FOR CHILDREN PROGRAM
317		-	DISABILITY DETERMINATION ASSESSMENT. (a) The commission shall, at
318		-	the request of a child's legally authorized representative, conduct
319		-	a disability determination assessment of the child to determine the
320		-	child's eligibility for the Medicaid buy-in for children program
321		-	implemented under Section 531.02444.
322		-	(b) The commission may seek a waiver to the state Medicaid
323		-	plan under Section 1115 of the federal Social Security Act (42
324		-	U.S.C. Section 1315) to implement this section.
325		-	Sec. 531.0319. PROCESS FOR ADOPTING AND AMENDING POLICIES
326		-	APPLICABLE TO MEDICAID MEDICAL BENEFITS. The commission shall
327		-	develop and implement a process for adopting and amending policies
328		-	applicable to Medicaid medical benefits under the Medicaid managed
329		-	care delivery model. The commission shall seek input from the state
330		-	Medicaid managed care advisory committee in developing and
331		-	implementing the process.
332		-	Sec. 531.03191. MEDICAID MEDICAL BENEFITS POLICY MANUAL.
333		-	(a) To the greatest extent possible, the commission shall
334		-	consolidate policy manuals, handbooks, and other informational
335		-	documents into one Medicaid medical benefits policy manual to
336		-	clarify and provide guidance on the policies under the Medicaid
337		-	managed care delivery model.
338		-	(b) The commission shall periodically update the Medicaid
339		-	medical benefits policy manual described by this section to reflect
340		-	policies adopted or amended using the process under Section
341		-	531.0319.
	149	+	amended by adding Sections 531.024162, 531.0319, and 531.0602 to
	150	+	read as follows:
	151	+	Sec. 531.024162. NOTICE REQUIREMENTS REGARDING DENIAL OF
	152	+	COVERAGE OR PRIOR AUTHORIZATION. The commission shall ensure that
	153	+	notice sent by the commission or a Medicaid managed care
	154	+	organization to a Medicaid recipient or provider regarding the
	155	+	denial of coverage or prior authorization for a service includes:
	156	+	(1) information required by federal law;
	157	+	(2) a clear and easy-to-understand explanation of the
	158	+	reason for the denial for the recipient; and
	159	+	(3) a clinical explanation of the reason for the
	160	+	denial for the provider.
	161	+	Sec. 531.0319. MEDICAID MEDICAL POLICY MANUAL. (a) The
	162	+	commission shall develop and publish on the commission's Internet
	163	+	website a Medicaid medical policy manual. The manual must:
	164	+	(1) be updated monthly, as necessary;
	165	+	(2) primarily address the managed care delivery model
	166	+	for Medicaid benefits;
	167	+	(3) include a description of each service covered
	168	+	under Medicaid, including the scope, duration, and amount of
	169	+	coverage; and
	170	+	(4) direct Medicaid providers to the Medicaid managed
	171	+	care manual that applies to the provider for specific prior
	172	+	authorization and billing policies.
	173	+	(b) The commission shall publish the Medicaid medical
	174	+	policy manual not later than January 1, 2020. Beginning on that
	175	+	date, the commission may not use any prior Medicaid procedures
	176	+	manual for providers. This subsection expires September 1, 2021.
342	177		Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
343		-	PROGRAM REASSESSMENTS. (a) To the extent allowed by federal law,
344		-	the commission shall streamline the annual reassessment for making
345		-	a medical necessity determination for a recipient participating in
346		-	the medically dependent children (MDCP) waiver program. The annual
347		-	reassessment should focus on significant changes in function that
348		-	may affect medical necessity.
349		-	(b) The commission shall ensure that the care coordinator
350		-	for a Medicaid managed care organization under the STAR Kids
351		-	managed care program provides the results of the reassessment to
352		-	the parent or legally authorized representative of a recipient
353		-	described by Subsection (a) for review. The commission shall
354		-	ensure the provision of the results does not delay the
355		-	determination of the services to be provided to the recipient or the
356		-	ability to authorize and initiate services.
357		-	(c) The commission shall require the parent's or
358		-	representative's signature to verify the parent or representative
359		-	received the results of the reassessment from the care coordinator
360		-	under Subsection (b). A Medicaid managed care organization may not
361		-	delay the delivery of care pending the signature.
362		-	(d) The commission shall provide a parent or representative
363		-	who disagrees with the results of the reassessment an opportunity
364		-	to dispute the reassessment with the commission through a
365		-	peer-to-peer review with the treating physician of choice.
366		-	(e) This section does not affect any rights of a recipient
367		-	to appeal a reassessment determination through the Medicaid managed
368		-	care organization's internal appeal process or through the Medicaid
369		-	fair hearing process.
370		-	SECTION 9. Section 531.072(c), Government Code, is amended
	178	+	PROGRAM REASSESSMENTS. To the extent allowed by federal law, the
	179	+	commission shall require that a child participating in the
	180	+	medically dependent children (MDCP) waiver program be reassessed to
	181	+	determine whether the child meets the level of care criteria for
	182	+	medical necessity for nursing facility care only if the child has a
	183	+	significant change in function that may affect the medical
	184	+	necessity for that level of care instead of requiring that the
	185	+	reassessment be made annually.
	186	+	SECTION 7. Section 531.072(c), Government Code, is amended
371	187		to read as follows:
372	188		(c) In making a decision regarding the placement of a drug
373	189		on each of the preferred drug lists, the commission shall consider:
374	190		(1) the recommendations of the Drug Utilization Review
375	191		Board under Section 531.0736;
376	192		(2) the clinical efficacy of the drug;
377	193		(3) the price of competing drugs after deducting any
378	194		federal and state rebate amounts; [and]
379	195		(4) the impact on recipient health outcomes and
380	196		continuity of care; and
381	197		(5) program benefit offerings solely or in conjunction
382	198		with rebates and other pricing information.
383		-	SECTION 10. Section 531.0736(c), Government Code, is
384		-	~~amended~~ to read as follows:
	199	+	SECTION 8. Section 531.0736(c), Government Code, is amended
	200	+	to read as follows:
385	201		(c) The executive commissioner shall determine the
386	202		composition of the board, which must:
387	203		(1) comply with applicable federal law, including 42
388	204		C.F.R. Section 456.716;
389	205		(2) include five [two] representatives of managed care
390		-	organizations to represent each managed care product~~, no more than~~
391		-	~~two~~ of whom ~~are voting members~~ and ~~at least [as nonvoting members,]~~
392		-	~~one of whom must be a physician and one of whom~~ must be a pharmacist;
	206	+	organizations to represent each managed care product [as nonvoting
	207	+	members], at least one of whom must be a physician and one of whom
	208	+	must be a pharmacist;
393	209		(3) include at least 17 physicians and pharmacists
394	210		who:
395	211		(A) provide services across the entire
396	212		population of Medicaid recipients and represent different
397	213		specialties, including at least one of each of the following types
398	214		of physicians:
399	215		(i) a pediatrician;
400	216		(ii) a primary care physician;
401	217		(iii) an obstetrician and gynecologist;
402	218		(iv) a child and adolescent psychiatrist;
403	219		and
404	220		(v) an adult psychiatrist; and
405	221		(B) have experience in either developing or
406	222		practicing under a preferred drug list; and
407		-	(4) include not less than two [a] consumer advocates
408		-	[advocate] who represent [represents] Medicaid recipients, at
409		-	least one of whom is a nonvoting member.
410		-	SECTION 11. Section 531.0737, Government Code, is amended
411		-	to read as follows:
412		-	Sec. 531.0737. DRUG UTILIZATION REVIEW BOARD: CONFLICTS OF
413		-	INTEREST. (a) A voting member of the Drug Utilization Review
414		-	Board must disclose any [may not have a] contractual relationship,
415		-	ownership interest, or other conflict of interest with a pharmacy
416		-	benefit manager, Medicaid managed care organization, or
417		-	pharmaceutical manufacturer or labeler or with an entity engaged by
418		-	the commission to assist in the development of the preferred drug
419		-	lists or in the administration of the Medicaid Drug Utilization
420		-	Review Program.
421		-	(b) The executive commissioner may adopt [implement this
422		-	section by adopting] rules that identify prohibited relationships
423		-	and conflicts or require [requiring] the board to develop a
424		-	conflict-of-interest policy that applies to the board.
425		-	SECTION 12. Section 533.00253(a)(1), Government Code, is
426		-	amended to read as follows:
427		-	(1) "Advisory committee" means the STAR Kids Managed
428		-	Care Advisory Committee described by [established under] Section
429		-	533.00254.
430		-	SECTION 13. Subchapter A, Chapter 533, Government Code, is
431		-	amended by adding Sections 533.00254, 533.00282, 533.00283, and
432		-	533.00284 to read as follows:
433		-	Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
434		-	(a) The STAR Kids Managed Care Advisory Committee established by
435		-	the executive commissioner under Section 531.012 shall:
436		-	(1) advise the commission on the operation of the STAR
437		-	Kids managed care program under Section 533.00253; and
438		-	(2) make recommendations for improvements to that
439		-	program.
440		-	(b) On September 1, 2023:
441		-	(1) the advisory committee is abolished; and
442		-	(2) this section expires.
443		-	Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION
444		-	PROCEDURES. (a) Section 4201.304, Insurance Code, does not apply
445		-	to a Medicaid managed care organization or a utilization review
446		-	agent who conducts utilization reviews for a Medicaid managed care
447		-	organization.
448		-	(b) In addition to the requirements of Section 533.005, a
449		-	contract between a Medicaid managed care organization and the
450		-	commission must require that:
451		-	(1) before issuing an adverse determination on a prior
452		-	authorization request, the organization provide the physician
453		-	requesting the prior authorization with a reasonable opportunity to
454		-	discuss the request with another physician who practices in the
455		-	same or a similar specialty, but not necessarily the same
456		-	subspecialty, and has experience in treating the same category of
457		-	population as the recipient on whose behalf the request is
458		-	submitted;
459		-	(2) the organization review and issue determinations
460		-	on prior authorization requests according to the following time
461		-	frames:
462		-	(A) with respect to a recipient who is
463		-	hospitalized at the time of the request:
464		-	(i) within one business day after receiving
465		-	the request, except as provided by Subparagraphs (ii) and (iii);
466		-	(ii) within 72 hours after receiving the
467		-	request if the request is submitted by a provider of acute care
468		-	inpatient services for services or equipment necessary to discharge
469		-	the recipient from an inpatient facility; or
470		-	(iii) within one hour after receiving the
471		-	request if the request is related to poststabilization care or a
472		-	life-threatening condition; or
473		-	(B) with respect to a recipient who is not
474		-	hospitalized at the time of the request:
475		-	(i) within three business days after
476		-	receiving the request; or
477		-	(ii) if the period prescribed by
478		-	Subparagraph (i) is not appropriate, within the time appropriate to
479		-	the circumstances relating to the delivery of the services to the
480		-	recipient and to the recipient's condition, provided that, when
481		-	issuing a determination related to poststabilization care after
482		-	emergency treatment as requested by a treating physician or other
483		-	health care provider, the agent shall issue the determination to
484		-	the treating physician or other health care provider not later than
485		-	one hour after the time of the request; and
486		-	(3) the organization:
487		-	(A) have appropriate personnel reasonably
488		-	available at a toll-free telephone number to respond to a prior
489		-	authorization request between 6 a.m. and 6 p.m. central time Monday
490		-	through Friday on each day that is not a legal holiday and between 9
491		-	a.m. and noon central time on Saturday, Sunday, and legal holidays;
492		-	(B) have a telephone system capable of receiving
	223	+	(4) include a consumer advocate who represents
	224	+	Medicaid recipients.
	225	+	SECTION 9. Subchapter A, Chapter 533, Government Code, is
	226	+	amended by adding Sections 533.00284 and 533.00285 to read as
	227	+	follows:
	228	+	Sec. 533.00284. ADOPTION OF PRIOR AUTHORIZATION PRACTICE
	229	+	GUIDELINES; ACCESSIBILITY. (a) In developing medical policies and
	230	+	standards for making medical necessity determinations for prior
	231	+	authorizations, each Medicaid managed care organization shall:
	232	+	(1) in consultation with health care providers in the
	233	+	organization's provider network, adopt practice guidelines that:
	234	+	(A) are based on valid and reliable clinical
	235	+	evidence or the medical consensus among health care professionals
	236	+	who practice in the applicable field; and
	237	+	(B) take into consideration the health care needs
	238	+	of the recipients enrolled in a managed care plan offered by the
	239	+	organization; and
	240	+	(2) develop a written process describing the method
	241	+	for periodically reviewing and amending utilization management
	242	+	clinical review criteria.
	243	+	(b) A Medicaid managed care organization shall annually
	244	+	review and, as necessary, update the practice guidelines adopted
	245	+	under Subsection (a)(1).
	246	+	(c) The executive commissioner by rule shall require each
	247	+	Medicaid managed care organization or other entity responsible for
	248	+	authorizing coverage for health care services under Medicaid to
	249	+	ensure that:
	250	+	(1) coverage criteria and prior authorization
	251	+	requirements are:
	252	+	(A) made available to recipients and providers on
	253	+	the organization's or entity's Internet website; and
	254	+	(B) communicated in a clear, concise, and easily
	255	+	understandable manner;
	256	+	(2) any necessary or supporting documents needed to
	257	+	obtain prior authorization are made available on a web page of the
	258	+	organization's or entity's Internet website accessible through a
	259	+	clearly marked link to the web page; and
	260	+	(3) the process for contacting the organization or
	261	+	entity for clarification or assistance in obtaining prior
	262	+	authorization is not arduous or overly burdensome to a recipient or
	263	+	provider.
	264	+	Sec. 533.00285. PRIOR AUTHORIZATION PROCEDURES. In
	265	+	addition to the requirements of Section 533.005, a contract between
	266	+	a Medicaid managed care organization and the commission described
	267	+	by that section must include:
	268	+	(1) time frames for the prior authorization of health
	269	+	care services that enable Medicaid providers to:
	270	+	(A) deliver those services in a timely manner;
	271	+	and
	272	+	(B) request a peer review regarding the prior
	273	+	authorization before the organization makes a final decision on the
	274	+	prior authorization; and
	275	+	(2) a requirement that the organization:
	276	+	(A) has appropriate personnel reasonably
	277	+	available at a toll-free telephone number to receive prior
	278	+	authorization requests between 6 a.m. and 6 p.m. central time
	279	+	Monday through Friday on each day that is not a legal holiday and
	280	+	between 9 a.m. and noon central time on Saturday and Sunday; and
	281	+	(B) has a telephone system capable of receiving
493	282		and recording incoming telephone calls for prior authorization
494	283		requests after 6 p.m. central time Monday through Friday and after
495		-	noon central time on Saturday, Sunday, and legal holidays; and
496		-	(C) have appropriate personnel to respond to each
497		-	call described by Paragraph (B) not later than 24 hours after
498		-	receiving the call.
499		-	Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION
500		-	REQUIREMENTS. (a) Each Medicaid managed care organization shall
501		-	develop and implement a process to conduct an annual review of the
502		-	organization's prior authorization requirements, other than a
503		-	prior authorization requirement prescribed by or implemented under
504		-	Section 531.073 for the vendor drug program. In conducting a
505		-	review, the organization must:
506		-	(1) solicit, receive, and consider input from
507		-	providers in the organization's provider network; and
508		-	(2) ensure that each prior authorization requirement
509		-	is based on accurate, up-to-date, evidence-based, and
510		-	peer-reviewed clinical criteria that distinguish, as appropriate,
511		-	between categories, including age, of recipients for whom prior
512		-	authorization requests are submitted.
513		-	(b) A Medicaid managed care organization may not impose a
514		-	prior authorization requirement, other than a prior authorization
515		-	requirement prescribed by or implemented under Section 531.073 for
516		-	the vendor drug program, unless the organization has reviewed the
517		-	requirement during the most recent annual review required under
518		-	this section.
519		-	Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE
520		-	DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In
521		-	addition to the requirements of Section 533.005, a contract between
522		-	a Medicaid managed care organization and the commission must
523		-	include a requirement that the organization establish a process for
524		-	reconsidering an adverse determination on a prior authorization
525		-	request that resulted solely from the submission of insufficient or
526		-	inadequate documentation.
527		-	(b) The process for reconsidering an adverse determination
528		-	on a prior authorization request under this section must:
529		-	(1) allow a provider to, not later than the seventh
530		-	business day following the date of the determination, submit any
531		-	documentation that was identified as insufficient or inadequate in
532		-	the notice provided under Section 531.024162;
533		-	(2) allow the provider requesting the prior
534		-	authorization to discuss the request with another provider who
535		-	practices in the same or a similar specialty, but not necessarily
536		-	the same subspecialty, and has experience in treating the same
537		-	category of population as the recipient on whose behalf the request
538		-	is submitted; and
539		-	(3) require the Medicaid managed care organization to,
540		-	not later than the first business day following the date the
541		-	provider submits sufficient and adequate documentation under
542		-	Subdivision (1), amend the determination to approve the prior
543		-	authorization request.
544		-	(c) An adverse determination on a prior authorization
545		-	request is considered a denial of services in an evaluation of the
546		-	Medicaid managed care organization only if the determination is not
547		-	amended under Subsection (b)(3).
548		-	(d) The process for reconsidering an adverse determination
549		-	on a prior authorization request under this section does not
550		-	affect:
551		-	(1) any related timelines, including the timeline for
552		-	an internal appeal, a Medicaid fair hearing, or a review conducted
553		-	by an independent review organization; or
554		-	(2) any rights of a recipient to appeal a
555		-	determination on a prior authorization request.
556		-	SECTION 14. Section 533.0071, Government Code, is amended
	284	+	noon central time on Saturday and Sunday.
	285	+	SECTION 10. Section 533.0071, Government Code, is amended
557	286		to read as follows:
558	287		Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission
559	288		shall make every effort to improve the administration of contracts
560	289		with Medicaid managed care organizations. To improve the
561	290		administration of these contracts, the commission shall:
562	291		(1) ensure that the commission has appropriate
563	292		expertise and qualified staff to effectively manage contracts with
564	293		managed care organizations under the Medicaid managed care program;
565	294		(2) evaluate options for Medicaid payment recovery
566	295		from managed care organizations if the enrollee dies or is
567	296		incarcerated or if an enrollee is enrolled in more than one state
568	297		program or is covered by another liable third party insurer;
569	298		(3) maximize Medicaid payment recovery options by
570	299		contracting with private vendors to assist in the recovery of
571	300		capitation payments, payments from other liable third parties, and
572	301		other payments made to managed care organizations with respect to
573	302		enrollees who leave the managed care program;
574	303		(4) decrease the administrative burdens of managed
575	304		care for the state, the managed care organizations, and the
576	305		providers under managed care networks to the extent that those
577	306		changes are compatible with state law and existing Medicaid managed
578	307		care contracts, including decreasing those burdens by:
579	308		(A) where possible, decreasing the duplication
580	309		of administrative reporting and process requirements for the
581	310		managed care organizations and providers, such as requirements for
582	311		the submission of encounter data, quality reports, historically
583	312		underutilized business reports, and claims payment summary
584	313		reports;
585	314		(B) allowing managed care organizations to
586	315		provide updated address information directly to the commission for
587	316		correction in the state system;
588	317		(C) promoting consistency and uniformity among
589	318		managed care organization policies, including policies relating to
590	319		the preauthorization process, lengths of hospital stays, filing
591	320		deadlines, levels of care, and case management services;
592	321		(D) reviewing the appropriateness of primary
593	322		care case management requirements in the admission and clinical
594	323		criteria process, such as requirements relating to including a
595	324		separate cover sheet for all communications, submitting
596	325		handwritten communications instead of electronic or typed review
597	326		processes, and admitting patients listed on separate
598	327		notifications; and
599	328		(E) providing a portal through which providers in
600	329		any managed care organization's provider network may submit acute
601	330		care services and long-term services and supports claims; and
602	331		(5) ensure that the commission's fair hearing process
603	332		and [reserve the right to amend] the managed care organization's
604	333		process for resolving recipient and provider appeals of denials
605	334		based on medical necessity [to] include an independent review
606	335		process established by the commission for final determination of
607	336		these disputes.
608		-	SECTION 15. Subchapter A, Chapter 533, Government Code, is
	337	+	SECTION 11. Section 533.0076(c), Government Code, is
	338	+	amended to read as follows:
	339	+	(c) The commission shall allow a recipient who is enrolled
	340	+	in a managed care plan under this chapter to disenroll from that
	341	+	plan and enroll in another managed care plan[:
	342	+	[(1)] at any time for cause in accordance with federal
	343	+	law[; and
	344	+	[(2) once for any reason after the periods described
	345	+	by Subsections (a) and (b)].
	346	+	SECTION 12. Subchapter A, Chapter 533, Government Code, is
609	347		amended by adding Sections 533.038 and 533.039 to read as follows:
610	348		Sec. 533.038. COORDINATION OF BENEFITS. (a) In this
611	349		section, "Medicaid wrap-around benefit" means a Medicaid-covered
612	350		service, including a pharmacy or medical benefit, that is provided
613	351		to a recipient with both Medicaid and primary health benefit plan
614	352		coverage when the recipient has exceeded the primary health benefit
615	353		plan coverage limit or when the service is not covered by the
616	354		primary health benefit plan issuer.
617		-	(b) The commission, in consultation with Medicaid managed
618		-	care organizations and the state Medicaid managed care advisory
619		-	committee, shall develop and implement a policy that ensures the
620		-	coordinated and timely delivery of Medicaid wrap-around benefits to
621		-	recipients. In developing and implementing the policy under this
622		-	subsection, the commission shall consider:
623		-	(1) streamlining a Medicaid managed care
624		-	organization's prior approval of services that are not
625		-	traditionally covered by primary health benefit plan coverage;
626		-	(2) including the cost of providing a Medicaid
627		-	wrap-around benefit in a Medicaid managed care organization's
628		-	financial reports and in computing capitation rates, if the
629		-	Medicaid managed care organization provides the wrap-around
630		-	benefit in good faith and follows commission policies;
631		-	(3) reducing health care provider and recipient
632		-	abrasion resulting from the recovery process when a recipient's
633		-	primary health benefit plan issuer should have been the primary
634		-	payor of a claim;
635		-	(4) efficiently providing Medicaid reimbursement for
636		-	services ordered, referred, prescribed, or delivered by a health
637		-	care provider who is primarily providing services to a recipient
638		-	through primary health benefit plan coverage;
639		-	(5) allowing a recipient with complex medical needs
640		-	who has established a relationship with a specialty provider in an
641		-	area outside of the recipient's Medicaid managed care
642		-	organization's service delivery area to continue receiving care
643		-	from that provider; and
644		-	(6) allowing a recipient using a prescription drug
645		-	previously paid for under the recipient's primary health benefit
646		-	plan coverage to continue receiving the prescription drug without
647		-	requiring additional prior authorization.
648		-	(c) The executive commissioner may seek a waiver from the
	355	+	(b) The commission, in coordination with Medicaid managed
	356	+	care organizations, shall develop and adopt a clear policy for a
	357	+	Medicaid managed care organization to ensure the coordination and
	358	+	timely delivery of Medicaid wrap-around benefits for recipients
	359	+	with both primary health benefit plan coverage and Medicaid
	360	+	coverage.
	361	+	(c) To further assist with the coordination of benefits, the
	362	+	commission, in coordination with Medicaid managed care
	363	+	organizations, shall develop and maintain a list of services that
	364	+	are not traditionally covered by primary health benefit plan
	365	+	coverage that a Medicaid managed care organization may approve
	366	+	without having to coordinate with the primary health benefit plan
	367	+	issuer and that can be resolved through third-party liability
	368	+	resolution processes. The commission shall review and update the
	369	+	list quarterly.
	370	+	(d) A Medicaid managed care organization that in good faith
	371	+	and following commission policies provides coverage for a Medicaid
	372	+	wrap-around benefit shall include the cost of providing the benefit
	373	+	in the organization's financial reports. The commission shall
	374	+	include the reported costs in computing capitation rates for the
	375	+	managed care organization.
	376	+	(e) If the commission determines that a recipient's primary
	377	+	health benefit plan issuer should have been the primary payor of a
	378	+	claim, the Medicaid managed care organization that paid the claim
	379	+	shall work with the commission on the recovery process and make
	380	+	every attempt to reduce health care provider and recipient
	381	+	abrasion.
	382	+	(f) The executive commissioner may seek a waiver from the
649	383		federal government as needed to:
650	384		(1) address federal policies related to coordination
651		-	of benefits, third-party liability, and provider enrollment
652		-	relating to Medicaid wrap-around benefits; and
	385	+	of benefits and third-party liability; and
653	386		(2) maximize federal financial participation for
654	387		recipients with both primary health benefit plan coverage and
655	388		Medicaid coverage.
656		-	(d) The commission shall ensure that the Medicaid managed
657		-	care eligibility files indicate whether a recipient has primary
658		-	health benefit plan coverage or health insurance premium payment
659		-	coverage. For a recipient who has that coverage, the files may
660		-	include the following up-to-date, accurate information related to
661		-	primary health benefit plan coverage to the extent the information
662		-	has been made available to the commission by the primary health
663		-	benefit plan issuer:
	389	+	(g) Notwithstanding Sections 531.073 and 533.005(a)(23) or
	390	+	any other law, the commission shall ensure that a prescription drug
	391	+	that is covered under the Medicaid vendor drug program or other
	392	+	applicable formulary and is prescribed to a recipient with primary
	393	+	health benefit plan coverage is not subject to any prior
	394	+	authorization requirement if the primary health benefit plan issuer
	395	+	will pay at least $0.01 on the prescription drug claim. If the
	396	+	primary insurer will pay nothing on a prescription drug claim, the
	397	+	prescription drug is subject to any applicable Medicaid clinical or
	398	+	nonpreferred prior authorization requirement.
	399	+	(h) The commission shall ensure that the daily Medicaid
	400	+	managed care eligibility files indicate whether a recipient has
	401	+	primary health benefit plan coverage or health insurance premium
	402	+	payment coverage. For a recipient who has that coverage, the files
	403	+	must include the following up-to-date, accurate information
	404	+	related to primary health benefit plan coverage:
664	405		(1) the health benefit plan issuer's name and address
665	406		and the recipient's policy number;
666	407		(2) the primary health benefit plan coverage start and
667	408		end dates;
668	409		(3) the primary health benefit plan coverage benefits,
669	410		limits, copayment, and coinsurance information; and
670	411		(4) any additional information that would be useful to
671	412		ensure the coordination of benefits.
	413	+	(i) The commission shall develop and implement processes
	414	+	and policies to allow a health care provider who is primarily
	415	+	providing services to a recipient through primary health benefit
	416	+	plan coverage to receive Medicaid reimbursement for services
	417	+	ordered, referred, prescribed, or delivered, regardless of whether
	418	+	the provider is enrolled as a Medicaid provider. The commission
	419	+	shall allow a provider who is not enrolled as a Medicaid provider to
	420	+	order, refer, prescribe, or deliver services to a recipient based
	421	+	on the provider's national provider identifier number and may not
	422	+	require an additional state provider identifier number to receive
	423	+	reimbursement for the services. The commission may seek a waiver of
	424	+	Medicaid provider enrollment requirements for providers of
	425	+	recipients with primary health benefit plan coverage to implement
	426	+	this subsection.
	427	+	(j) The commission shall develop and implement a clear and
	428	+	easy process to allow a recipient with complex medical needs who has
	429	+	established a relationship with a specialty provider in an area
	430	+	outside of the recipient's Medicaid managed care organization's
	431	+	service delivery area to continue receiving care from that provider
	432	+	if the provider will enter into a single-case agreement with the
	433	+	Medicaid managed care organization. A single-case agreement with a
	434	+	provider outside of the organization's service delivery area in
	435	+	accordance with this subsection is not considered an
	436	+	out-of-network agreement and must be included in the organization's
	437	+	network adequacy determination.
	438	+	(k) The commission shall develop and implement processes
	439	+	to:
	440	+	(1) reimburse a recipient with primary health benefit
	441	+	plan coverage who pays a copayment, coinsurance, or other
	442	+	cost-sharing amount out of pocket because the primary health
	443	+	benefit plan issuer refuses to enroll in Medicaid, enter into a
	444	+	single-case agreement, or bill the recipient's Medicaid managed
	445	+	care organization; and
	446	+	(2) capture encounter data for the Medicaid
	447	+	wrap-around benefits provided by the Medicaid managed care
	448	+	organization under this subsection.
672	449		Sec. 533.039. COORDINATION OF BENEFITS FOR PERSONS DUALLY
673	450		ELIGIBLE UNDER MEDICAID AND MEDICARE. (a) In this section,
674	451		"Medicaid wrap-around benefit" means a Medicaid-covered service,
675	452		including a pharmacy or medical benefit, that is provided to a
676	453		recipient with both Medicaid and Medicare coverage when the
677	454		recipient has exceeded the Medicare coverage limit or when the
678	455		service is not covered by Medicare.
679		-	(b) The commission, in consultation with Medicaid managed
680		-	care organizations and the state Medicaid managed care advisory
681		-	committee, shall implement a policy that ensures the coordinated
682		-	and timely delivery of Medicaid wrap-around benefits. The policy
683		-	must:
	456	+	(b) The executive commissioner, in consultation with
	457	+	Medicaid managed care organizations, by rule shall develop and
	458	+	implement a policy that ensures the coordinated and timely delivery
	459	+	of Medicaid wrap-around benefits. The policy must:
684	460		(1) include a benefits equivalency crosswalk or other
685	461		method for mapping equivalent benefits under Medicaid and Medicare;
686	462		and
687	463		(2) in a manner that is consistent with federal and
688	464		state law, require sharing of information concerning third-party
689	465		sources of coverage and reimbursement.
690		-	SECTION 16. Section 62.152, Health and Safety Code, is
691		-	amended to read as follows:
692		-	Sec. 62.152. APPLICATION OF INSURANCE LAW. (a) To provide
693		-	the flexibility necessary to satisfy the requirements of Title XXI
694		-	of the Social Security Act (42 U.S.C. Section 1397aa et seq.), as
695		-	amended, and any other applicable law or regulations, the child
696		-	health plan is not subject to a law that requires:
697		-	(1) coverage or the offer of coverage of a health care
698		-	service or benefit;
699		-	(2) coverage or the offer of coverage for the
700		-	provision of services by a particular health care services
701		-	provider, except as provided by Section 62.155(b); or
702		-	(3) the use of a particular policy or contract form or
703		-	of particular language in a policy or contract form.
704		-	(b) Section 4201.304, Insurance Code, does not apply to a
705		-	health plan provider or the provider's utilization review agent.
706		-	SECTION 17. The policies for implementing changes to
707		-	payment rates required by Section 531.02112, Government Code, as
708		-	added by this Act, apply only to a change to a fee, charge, or rate
709		-	that takes effect on or after January 1, 2021.
710		-	SECTION 18. The Health and Human Services Commission shall
711		-	implement:
712		-	(1) the Medicaid provider management and enrollment
713		-	system required by Section 531.021182(c), Government Code, as added
714		-	by this Act, not later than September 1, 2020; and
715		-	(2) the modernized claims processing system required
716		-	by Section 531.021182(d), Government Code, as added by this Act,
717		-	not later than September 1, 2023.
718		-	SECTION 19. Not later than December 31, 2019, the Health and
719		-	Human Services Commission shall develop, implement, and publish on
720		-	the commission's Internet website the process required under
721		-	Section 531.0319, Government Code, as added by this Act.
722		-	SECTION 20. Section 531.0602, Government Code, as added by
	466	+	SECTION 13. (a) Not later than December 31, 2019, the
	467	+	executive commissioner of the Health and Human Services Commission
	468	+	shall establish the advisory committee as required by Section
	469	+	531.02112(b), Government Code, as added by this Act.
	470	+	(b) The procedure for implementing changes to payment rates
	471	+	required by Section 531.02112, Government Code, as added by this
	472	+	Act, applies only to a change to a fee, charge, or rate that takes
	473	+	effect on or after January 1, 2021.
	474	+	SECTION 14. Section 531.0602, Government Code, as added by
723	475		this Act, applies only to a reassessment of a child's eligibility
724	476		for the medically dependent children (MDCP) waiver program made on
725	477		or after December 1, 2019.
726		-	SECTION 21. As soon as practicable after the effective date
	478	+	SECTION 15. As soon as practicable after the effective date
727	479		of this Act, the executive commissioner of the Health and Human
728	480		Services Commission shall adopt rules necessary to implement the
729	481		changes in law made by this Act.
730		-	SECTION 22. (a) Sections 533.00282 and 533.00284,
731		-	Government Code, as added by this Act, apply only to a contract
732		-	between the Health and Human Services Commission and a Medicaid
733		-	managed care organization under Chapter 533, Government Code, that
734		-	is entered into or renewed on or after the effective date of this
735		-	Act.
	482	+	SECTION 16. (a) Section 533.00285, Government Code, as
	483	+	added by this Act, applies only to a contract between the Health and
	484	+	Human Services Commission and a Medicaid managed care organization
	485	+	under Chapter 533, Government Code, that is entered into or renewed
	486	+	on or after the effective date of this Act.
736	487		(b) The Health and Human Services Commission shall seek to
737	488		amend contracts entered into with Medicaid managed care
738	489		organizations under Chapter 533, Government Code, before the
739	490		effective date of this Act to include the provisions required by
740		-	Sections 533.00282 and 533.00284, Government Code, as added by this
741		-	Act.
742		-	SECTION 23. If before implementing any provision of this
	491	+	Section 533.00285, Government Code, as added by this Act.
	492	+	SECTION 17. If before implementing any provision of this
743	493		Act a state agency determines that a waiver or authorization from a
744	494		federal agency is necessary for implementation of that provision,
745	495		the agency affected by the provision shall request the waiver or
746	496		authorization and may delay implementing that provision until the
747	497		waiver or authorization is granted.
748		-	SECTION 24. This Act takes effect September 1, 2019.
	498	+	SECTION 18. This Act takes effect September 1, 2019.