86R27018 JG-D
By: Frank H.B. No. 4178
Substitute the following for H.B. No. 4178:
By: Klick C.S.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. POLICIES FOR IMPLEMENTING CHANGES TO
PAYMENT RATES UNDER MEDICAID AND CHILD HEALTH PLAN PROGRAM. (a)
The commission shall adopt policies related to the determination of
fees, charges, and rates for payments under Medicaid and the child
health plan program to ensure, to the greatest extent possible,
that changes to a fee schedule are implemented in a way that
minimizes administrative complexity, financial uncertainty, and
retroactive adjustments for providers.
(b) In adopting policies under Subsection (a), the
commission shall:
(1) develop a process for individuals and entities
that deliver services under the Medicaid managed care program to
provide oral or written input on the proposed policies; and
(2) ensure that managed care organizations and the
entity serving as the state's Medicaid claims administrator under
the Medicaid fee-for-service delivery model are provided a period
of not less than 45 days before the effective date of a final fee
schedule change to make any necessary administrative or systems
adjustments to implement the change.
(c) This section does not apply to changes to the fees,
charges, or rates for payments made to a nursing facility or to
capitation rates paid to a Medicaid managed care organization.
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) The commission shall transition from using a
state-issued provider identifier number to using only a national
provider identifier number in accordance with this section.
(c) The commission shall implement a Medicaid provider
management and enrollment system and, following that
implementation, use only a national provider identifier number to
enroll a provider in Medicaid.
(d) The commission shall implement a modernized claims
processing system and, following that implementation, use only a
national provider identifier number to process claims for and
authorize Medicaid services.
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, 531.024163, and 531.024164
to read as follows:
Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID
COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
(a) 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 and state law and
applicable regulations;
(2) for the recipient, a clear and easy-to-understand
explanation of the reason for the denial; and
(3) for the provider, a thorough and detailed clinical
explanation of the reason for the denial, including, as applicable,
information required under Subsection (b).
(b) The commission or a Medicaid managed care organization
that receives from a provider a coverage or prior authorization
request that contains insufficient or inadequate documentation to
approve the request shall issue a notice to the provider and the
Medicaid recipient on whose behalf the request was submitted. The
notice issued under this subsection must:
(1) include a section specifically for the provider
that contains:
(A) a clear and specific list and description of
the documentation necessary for the commission or organization to
make a final determination on the request;
(B) the applicable timeline, based on the
requested service, for the provider to submit the documentation and
a description of the reconsideration process described by Section
533.00284, if applicable; and
(C) information on the manner through which a
provider may contact a Medicaid managed care organization or other
entity as required by Section 531.024163; and
(2) be sent to the provider:
(A) using the provider's preferred method of
contact most recently provided to the commission or the Medicaid
managed care organization and using any alternative and known
methods of contact; and
(B) as applicable, through an electronic
notification on an Internet portal.
Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING
MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) 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 the
organization or entity maintains on the organization's or entity's
Internet website in an easily searchable and accessible format:
(1) the applicable timelines for prior authorization
requirements, including:
(A) the time within which the organization or
entity must make a determination on a prior authorization request;
(B) a description of the notice the organization
or entity provides to a provider and Medicaid recipient regarding
the documentation required to complete a determination on a prior
authorization request; and
(C) the deadline by which the organization or
entity is required to submit the notice described by Paragraph (B);
and
(2) an accurate and up-to-date catalogue of coverage
criteria and prior authorization requirements, including:
(A) for a prior authorization requirement first
imposed on or after September 1, 2019, the effective date of the
requirement;
(B) a list or description of any necessary or
supporting documentation necessary to obtain prior authorization
for a specified service; and
(C) the date and results of each review of the
prior authorization requirement conducted under Section 533.00283,
if applicable.
(b) 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:
(1) adopt and maintain a process for a provider or
Medicaid recipient to contact the organization or entity to clarify
prior authorization requirements or assist the provider or
recipient in submitting a prior authorization request; and
(2) ensure that the process described by Subdivision
(1) is not arduous or overly burdensome to a provider or recipient.
Sec. 531.024164. INDEPENDENT REVIEW ORGANIZATIONS. (a) In
this section, "independent review organization" means an
organization certified under Chapter 4202, Insurance Code.
(b) The commission shall contract with an independent
review organization to make review determinations with respect to:
(1) a Medicaid managed care organization's resolution
of an internal appeal challenging a medical necessity
determination;
(2) a denial by the commission of eligibility for a
Medicaid program on the basis of the Medicaid recipient's or
applicant's medical and functional needs; and
(3) an action, as defined by 42 C.F.R. Section
431.201, by the commission based on the recipient's medical and
functional needs.
(c) The executive commissioner by rule shall determine:
(1) the manner in which an independent review
organization is to settle the disputes;
(2) when, in the appeals process, an organization may
be accessed; and
(3) the recourse available after the organization
makes a review determination.
(d) The commission shall ensure that a contract entered into
under Subsection (b):
(1) requires an independent review organization to
make a review determination in a timely manner;
(2) provides procedures to protect the
confidentiality of medical records transmitted to the organization
for use in conducting an independent review;
(3) sets minimum qualifications for and requires the
independence of each physician or other health care provider making
a review determination on behalf of the organization;
(4) specifies the procedures to be used by the
organization in making review determinations;
(5) requires the timely notice to a Medicaid recipient
of the results of an independent review, including the clinical
basis for the review determination;
(6) requires that the organization report the
following aggregate information to the commission in the form and
manner and at the times prescribed by the commission:
(A) the number of requests for independent
reviews received by the independent review organization;
(B) the number of independent reviews conducted;
(C) the number of review determinations made:
(i) in favor of a Medicaid managed care
organization; and
(ii) in favor of a Medicaid recipient;
(D) the number of review determinations that
resulted in a Medicaid managed care organization deciding to cover
the service at issue;
(E) a summary of the disputes at issue in
independent reviews;
(F) a summary of the services that were the
subject of independent reviews; and
(G) the average time the organization took to
complete an independent review and make a review determination; and
(7) requires that, in addition to the aggregate
information required by Subdivision (6), the organization include
in the report the information required by that subdivision
categorized by Medicaid managed care organization.
(e) An independent review organization with which the
commission contracts under this section shall:
(1) obtain all information relating to the internal
appeal at issue, as applicable, from the Medicaid managed care
organization and the provider in accordance with time frames
prescribed by the commission;
(2) obtain all information relating to the denial or
action at issue, as applicable, from the commission and provider in
accordance with time frames prescribed by the commission;
(3) assign a physician or other health care provider
with appropriate expertise as a reviewer to make a review
determination;
(4) for each review, perform a check to ensure that the
organization and the physician or other health care provider
assigned to make a review determination do not have a conflict of
interest, as defined in the contract entered into between the
commission and the organization;
(5) communicate procedural rules, approved by the
commission, and other information regarding the appeals process to
all parties; and
(6) render a timely review determination, as
determined by the commission.
(f) The commission shall ensure that the commission, the
Medicaid managed care organization, the provider, and the Medicaid
recipient involved in a dispute, as applicable, do not have a choice
in the reviewer who is assigned to perform the review.
(g) In selecting an independent review organization with
which to contract, the commission shall avoid conflicts of interest
by considering and monitoring existing relationships between
independent review organizations and Medicaid managed care
organizations.
(h) The executive commissioner shall adopt rules necessary
to implement this section.
SECTION 7. Section 531.02444, Government Code, is amended
by amending Subsection (a) and adding Subsection (a-1) to read as
follows:
(a) The executive commissioner shall develop and implement:
(1) to the extent permitted by a waiver sought by the
commission under Section 1115 of the federal Social Security Act
(42 U.S.C. Section 1315), a Medicaid buy-in program for persons
with disabilities as authorized by the Ticket to Work and Work
Incentives Improvement Act of 1999 (Pub. L. No. 106-170) or the
Balanced Budget Act of 1997 (Pub. L. No. 105-33); and
(2) subject to Subsection (a-1) as authorized by the
Deficit Reduction Act of 2005 (Pub. L. No. 109-171), a Medicaid
buy-in program for children with disabilities that is described by
42 U.S.C. Section 1396a(cc)(1) whose family incomes do not exceed
300 percent of the applicable federal poverty level.
(a-1) The executive commissioner by rule shall increase the
maximum family income prescribed by Subsection (a)(2) for
determining eligibility for the buy-in program under that
subdivision of a child who is eligible for the medically dependent
children (MDCP) waiver program and is on the interest list for that
program to the maximum family income amount allowable, considering
available appropriations for that purpose.
SECTION 8. Subchapter B, Chapter 531, Government Code, is
amended by adding Sections 531.024441, 531.0319, 531.03191, and
531.0602 to read as follows:
Sec. 531.024441. MEDICAID BUY-IN FOR CHILDREN PROGRAM
DISABILITY DETERMINATION ASSESSMENT. (a) The commission shall, at
the request of a child's legally authorized representative, conduct
a disability determination assessment of the child to determine the
child's eligibility for the Medicaid buy-in for children program
implemented under Section 531.02444.
(b) The commission may seek a waiver to the state Medicaid
plan under Section 1115 of the federal Social Security Act (42
U.S.C. Section 1315) to implement this section.
Sec. 531.0319. PROCESS FOR ADOPTING AND AMENDING POLICIES
APPLICABLE TO MEDICAID MEDICAL BENEFITS. The commission shall
develop and implement a process for adopting and amending policies
applicable to Medicaid medical benefits under the Medicaid managed
care delivery model. The commission shall seek input from the state
Medicaid managed care advisory committee in developing and
implementing the process.
Sec. 531.03191. MEDICAID MEDICAL BENEFITS POLICY MANUAL.
(a) To the greatest extent possible, the commission shall
consolidate policy manuals, handbooks, and other informational
documents into one Medicaid medical benefits policy manual to
clarify and provide guidance on the policies under the Medicaid
managed care delivery model.
(b) The commission shall periodically update the Medicaid
medical benefits policy manual described by this section to reflect
policies adopted or amended using the process under Section
531.0319.
Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
PROGRAM REASSESSMENTS. (a) To the extent allowed by federal law,
the commission shall streamline the annual reassessment for making
a medical necessity determination for a recipient participating in
the medically dependent children (MDCP) waiver program. The annual
reassessment should focus on significant changes in function that
may affect medical necessity.
(b) The commission shall ensure that the care coordinator
for a Medicaid managed care organization under the STAR Kids
managed care program provides the results of the reassessment to
the parent or legally authorized representative of a recipient
described by Subsection (a) for review. The commission shall
ensure the provision of the results does not delay the
determination of the services to be provided to the recipient or the
ability to authorize and initiate services.
(c) The commission shall require the parent's or
representative's signature to verify the parent or representative
received the results of the reassessment from the care coordinator
under Subsection (b). A Medicaid managed care organization may not
delay the delivery of care pending the signature.
(d) The commission shall provide a parent or representative
who disagrees with the results of the reassessment an opportunity
to dispute the reassessment with the commission through a
peer-to-peer review with the treating physician of choice.
(e) This section does not affect any rights of a recipient
to appeal a reassessment determination through the Medicaid managed
care organization's internal appeal process or through the Medicaid
fair hearing process.
SECTION 9. 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 10. 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, no more than
two of whom are voting members and at least [as nonvoting members,]
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 not less than two [a] consumer advocates
[advocate] who represent [represents] Medicaid recipients, at
least one of whom is a nonvoting member.
SECTION 11. Section 531.0737, Government Code, is amended
to read as follows:
Sec. 531.0737. DRUG UTILIZATION REVIEW BOARD: CONFLICTS OF
INTEREST. (a) A voting member of the Drug Utilization Review
Board must disclose any [may not have a] contractual relationship,
ownership interest, or other conflict of interest with a pharmacy
benefit manager, Medicaid managed care organization, or
pharmaceutical manufacturer or labeler or with an entity engaged by
the commission to assist in the development of the preferred drug
lists or in the administration of the Medicaid Drug Utilization
Review Program.
(b) The executive commissioner may adopt [implement this
section by adopting] rules that identify prohibited relationships
and conflicts or require [requiring] the board to develop a
conflict-of-interest policy that applies to the board.
SECTION 12. Section 533.00253(a)(1), Government Code, is
amended to read as follows:
(1) "Advisory committee" means the STAR Kids Managed
Care Advisory Committee described by [established under] Section
533.00254.
SECTION 13. Subchapter A, Chapter 533, Government Code, is
amended by adding Sections 533.00254, 533.00282, 533.00283, and
533.00284 to read as follows:
Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
(a) The STAR Kids Managed Care Advisory Committee established by
the executive commissioner under Section 531.012 shall:
(1) advise the commission on the operation of the STAR
Kids managed care program under Section 533.00253; and
(2) make recommendations for improvements to that
program.
(b) On September 1, 2023:
(1) the advisory committee is abolished; and
(2) this section expires.
Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION
PROCEDURES. (a) Section 4201.304, Insurance Code, does not apply
to a Medicaid managed care organization or a utilization review
agent who conducts utilization reviews for a Medicaid managed care
organization.
(b) In addition to the requirements of Section 533.005, a
contract between a Medicaid managed care organization and the
commission must require that:
(1) before issuing an adverse determination on a prior
authorization request, the organization provide the physician
requesting the prior authorization with a reasonable opportunity to
discuss the request with another physician who practices in the
same or a similar specialty, but not necessarily the same
subspecialty, and has experience in treating the same category of
population as the recipient on whose behalf the request is
submitted;
(2) the organization review and issue determinations
on prior authorization requests according to the following time
frames:
(A) with respect to a recipient who is
hospitalized at the time of the request:
(i) within one business day after receiving
the request, except as provided by Subparagraphs (ii) and (iii);
(ii) within 72 hours after receiving the
request if the request is submitted by a provider of acute care
inpatient services for services or equipment necessary to discharge
the recipient from an inpatient facility; or
(iii) within one hour after receiving the
request if the request is related to poststabilization care or a
life-threatening condition; or
(B) with respect to a recipient who is not
hospitalized at the time of the request:
(i) within three business days after
receiving the request; or
(ii) if the period prescribed by
Subparagraph (i) is not appropriate, within the time appropriate to
the circumstances relating to the delivery of the services to the
recipient and to the recipient's condition, provided that, when
issuing a determination related to poststabilization care after
emergency treatment as requested by a treating physician or other
health care provider, the agent shall issue the determination to
the treating physician or other health care provider not later than
one hour after the time of the request; and
(3) the organization:
(A) have appropriate personnel reasonably
available at a toll-free telephone number to respond to a prior
authorization request 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, Sunday, and legal holidays;
(B) have 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, Sunday, and legal holidays; and
(C) have appropriate personnel to respond to each
call described by Paragraph (B) not later than 24 hours after
receiving the call.
Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION
REQUIREMENTS. (a) Each Medicaid managed care organization shall
develop and implement a process to conduct an annual review of the
organization's prior authorization requirements, other than a
prior authorization requirement prescribed by or implemented under
Section 531.073 for the vendor drug program. In conducting a
review, the organization must:
(1) solicit, receive, and consider input from
providers in the organization's provider network; and
(2) ensure that each prior authorization requirement
is based on accurate, up-to-date, evidence-based, and
peer-reviewed clinical criteria that distinguish, as appropriate,
between categories, including age, of recipients for whom prior
authorization requests are submitted.
(b) A Medicaid managed care organization may not impose a
prior authorization requirement, other than a prior authorization
requirement prescribed by or implemented under Section 531.073 for
the vendor drug program, unless the organization has reviewed the
requirement during the most recent annual review required under
this section.
Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE
DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In
addition to the requirements of Section 533.005, a contract between
a Medicaid managed care organization and the commission must
include a requirement that the organization establish a process for
reconsidering an adverse determination on a prior authorization
request that resulted solely from the submission of insufficient or
inadequate documentation.
(b) The process for reconsidering an adverse determination
on a prior authorization request under this section must:
(1) allow a provider to, not later than the seventh
business day following the date of the determination, submit any
documentation that was identified as insufficient or inadequate in
the notice provided under Section 531.024162;
(2) allow the provider requesting the prior
authorization to discuss the request with another provider who
practices in the same or a similar specialty, but not necessarily
the same subspecialty, and has experience in treating the same
category of population as the recipient on whose behalf the request
is submitted; and
(3) require the Medicaid managed care organization to,
not later than the first business day following the date the
provider submits sufficient and adequate documentation under
Subdivision (1), amend the determination to approve the prior
authorization request.
(c) An adverse determination on a prior authorization
request is considered a denial of services in an evaluation of the
Medicaid managed care organization only if the determination is not
amended under Subsection (b)(3).
(d) The process for reconsidering an adverse determination
on a prior authorization request under this section does not
affect:
(1) any related timelines, including the timeline for
an internal appeal, a Medicaid fair hearing, or a review conducted
by an independent review organization; or
(2) any rights of a recipient to appeal a
determination on a prior authorization request.
SECTION 14. 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 15. 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 consultation with Medicaid managed
care organizations and the state Medicaid managed care advisory
committee, shall develop and implement a policy that ensures the
coordinated and timely delivery of Medicaid wrap-around benefits to
recipients. In developing and implementing the policy under this
subsection, the commission shall consider:
(1) streamlining a Medicaid managed care
organization's prior approval of services that are not
traditionally covered by primary health benefit plan coverage;
(2) including the cost of providing a Medicaid
wrap-around benefit in a Medicaid managed care organization's
financial reports and in computing capitation rates, if the
Medicaid managed care organization provides the wrap-around
benefit in good faith and follows commission policies;
(3) reducing health care provider and recipient
abrasion resulting from the recovery process when a recipient's
primary health benefit plan issuer should have been the primary
payor of a claim;
(4) efficiently providing Medicaid reimbursement for
services ordered, referred, prescribed, or delivered by a health
care provider who is primarily providing services to a recipient
through primary health benefit plan coverage;
(5) allowing 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; and
(6) allowing a recipient using a prescription drug
previously paid for under the recipient's primary health benefit
plan coverage to continue receiving the prescription drug without
requiring additional prior authorization.
(c) The executive commissioner may seek a waiver from the
federal government as needed to:
(1) address federal policies related to coordination
of benefits, third-party liability, and provider enrollment
relating to Medicaid wrap-around benefits; and
(2) maximize federal financial participation for
recipients with both primary health benefit plan coverage and
Medicaid coverage.
(d) The commission shall ensure that the 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 may
include the following up-to-date, accurate information related to
primary health benefit plan coverage to the extent the information
has been made available to the commission by the primary health
benefit plan issuer:
(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.
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 commission, in consultation with Medicaid managed
care organizations and the state Medicaid managed care advisory
committee, shall 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 16. Section 62.152, Health and Safety Code, is
amended to read as follows:
Sec. 62.152. APPLICATION OF INSURANCE LAW. (a) To provide
the flexibility necessary to satisfy the requirements of Title XXI
of the Social Security Act (42 U.S.C. Section 1397aa et seq.), as
amended, and any other applicable law or regulations, the child
health plan is not subject to a law that requires:
(1) coverage or the offer of coverage of a health care
service or benefit;
(2) coverage or the offer of coverage for the
provision of services by a particular health care services
provider, except as provided by Section 62.155(b); or
(3) the use of a particular policy or contract form or
of particular language in a policy or contract form.
(b) Section 4201.304, Insurance Code, does not apply to a
health plan provider or the provider's utilization review agent.
SECTION 17. The policies for implementing changes to
payment rates required by Section 531.02112, Government Code, as
added by this Act, apply only to a change to a fee, charge, or rate
that takes effect on or after January 1, 2021.
SECTION 18. The Health and Human Services Commission shall
implement:
(1) the Medicaid provider management and enrollment
system required by Section 531.021182(c), Government Code, as added
by this Act, not later than September 1, 2020; and
(2) the modernized claims processing system required
by Section 531.021182(d), Government Code, as added by this Act,
not later than September 1, 2023.
SECTION 19. Not later than December 31, 2019, the Health and
Human Services Commission shall develop, implement, and publish on
the commission's Internet website the process required under
Section 531.0319, Government Code, as added by this Act.
SECTION 20. 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 21. 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 22. (a) Sections 533.00282 and 533.00284,
Government Code, as added by this Act, apply 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
Sections 533.00282 and 533.00284, Government Code, as added by this
Act.
SECTION 23. 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 24. This Act takes effect September 1, 2019.