86R3261 LED-D
By: Kolkhorst S.B. No. 1105
A BILL TO BE ENTITLED
AN ACT
relating to administration and operation of Medicaid, including
Medicaid managed care.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.02118, Government Code, is amended
by adding Subsections (e) and (f) to read as follows:
(e) The commission shall enroll a provider as a Medicaid
provider, without requiring the provider to separately apply for
enrollment through the entity serving as the state's Medicaid
claims administrator, if the provider is:
(1) credentialed by a managed care organization that
contracts with the commission under Chapter 533; or
(2) enrolled as a Medicare provider.
(f) The commission and the entity serving as the state's
Medicaid claims administrator shall use a provider's national
provider identifier number issued by the Centers for Medicare and
Medicaid Services to identify an enrolled provider and may not
issue a separate state provider identifier number.
SECTION 2. Subchapter B, Chapter 531, Government Code, is
amended by adding Sections 531.02131, 531.02142, and 531.0511 to
read as follows:
Sec. 531.02131. GRIEVANCES RELATED TO MEDICAID. (a) To
ensure all grievances are managed consistently, the commission
shall ensure the definition of a grievance related to Medicaid is
consistent among divisions within the commission.
(b) The commission shall standardize Medicaid grievance
data reporting and tracking among divisions within the commission.
(c) The commission shall implement a no-wrong-door system
for Medicaid grievances reported to the commission.
(d) The commission shall establish a procedure for
expedited resolution of a grievance related to Medicaid that allows
the commission to:
(1) identify a grievance related to a Medicaid access
to care issue that is urgent and requires an expedited resolution;
and
(2) resolve the grievance within a specified period.
(e) The commission shall verify grievance data reported by a
managed care organization that contracts with the commission under
Chapter 533 to provide health care services to Medicaid recipients.
(f) The commission shall:
(1) aggregate Medicaid recipient and provider
grievance data to provide a comprehensive data set of grievances;
and
(2) make the aggregated data available to the
legislature and the public in a manner that does not allow for the
identification of a particular recipient or provider.
Sec. 531.02142. PUBLIC ACCESS TO CERTAIN MEDICAID DATA.
(a) To the extent permitted by federal law, the commission shall
make available to the public on its Internet website in an
easy-to-read format data relating to the quality of health care
received by Medicaid recipients and the health outcomes of those
recipients. Data made available to the public under this section
must be made available in a manner that does not identify or allow
for the identification of individual recipients.
(b) In performing its duties under this section, the
commission may collaborate with an institution of higher education
or another state agency with experience in analyzing and producing
public use data.
Sec. 531.0511. MEDICALLY DEPENDENT CHILDREN WAIVER
PROGRAM: CONSUMER DIRECTION OF SERVICES. Notwithstanding Sections
531.051(c)(1) and (d), a consumer direction model implemented under
Section 531.051, including the consumer-directed service option,
for the delivery of services under the medically dependent children
(MDCP) waiver program must allow for the delivery of all services
and supports available under that program through consumer
direction.
SECTION 3. Section 531.073, Government Code, is amended by
adding Subsection (i) to read as follows:
(i) Notwithstanding Subsection (a), prior authorization may
not be required under the Medicaid vendor drug program for low-cost
generic drugs. The executive commissioner shall adopt rules
defining "low-cost" for purposes of this subsection.
SECTION 4. Section 533.00253, Government Code, is amended
by amending Subsection (c) and adding Subsections (c-1), (f), (g),
(h), and (i) to read as follows:
(c) The commission may require that care management
services made available as provided by Subsection (b)(7):
(1) incorporate best practices, as determined by the
commission;
(2) integrate with a nurse advice line to ensure
appropriate redirection rates;
(3) use an identification and stratification
methodology that identifies recipients who have the greatest need
for services;
(4) provide a care needs assessment for a recipient
[that is comprehensive, holistic, consumer-directed,
evidence-based, and takes into consideration social and medical
issues, for purposes of prioritizing the recipient's needs that
threaten independent living];
(5) are delivered through multidisciplinary care
teams located in different geographic areas of this state that use
in-person contact with recipients and their caregivers;
(6) identify immediate interventions for transition
of care;
(7) include monitoring and reporting outcomes that, at
a minimum, include:
(A) recipient quality of life;
(B) recipient satisfaction; and
(C) other financial and clinical metrics
determined appropriate by the commission; and
(8) use innovations in the provision of services.
(c-1) A care needs assessment provided as a component of
care management services made available as provided by Subsection
(b)(7) may be conducted using any nationally recognized screening
tool the assessor chooses to use.
(f) A STAR Kids managed care organization shall, after
conducting a care needs assessment for a recipient, report to the
commission any significant change in condition the recipient
experiences, including a change in condition resulting in the
recipient no longer meeting an institutional level of care
requirement. After receiving the report, the commission shall
redetermine the recipient's eligibility for the STAR Kids managed
care program.
(g) The executive commissioner shall develop and implement
a pilot program through which Medicaid benefits are provided to
children enrolled in the STAR Kids managed care program under an
accountable care organization model in accordance with guidelines
established by the Centers for Medicare and Medicaid Services. A
child's participation in the pilot program is optional.
(h) Not later than December 1, 2022, the commission shall
prepare and submit a written report to the legislature evaluating
the outcomes of the pilot program and recommending whether the
pilot program should be continued, expanded, or terminated.
(i) Subsections (g) and (h) and this subsection expire
September 1, 2023.
SECTION 5. Subchapter A, Chapter 533, Government Code, is
amended by adding Sections 533.0031, 533.029, and 533.030 to read
as follows:
Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION.
(a) Notwithstanding Section 533.004 or any other law requiring the
commission to contract with a managed care organization to provide
health care services to recipients, the commission may contract
with a managed care organization to provide those services only if
the managed care plan offered by the organization is accredited by a
nationally recognized accrediting entity.
(b) As required by 42 C.F.R. Section 438.360, the commission
shall provide information from the accrediting entity's review of a
managed care plan offered by a managed care organization that
contracts with the commission under this chapter to the external
quality review organization, as defined by Section 533.051.
Sec. 533.029. HEALTH INSURANCE PREMIUM PAYMENT
REIMBURSEMENT PROGRAM PROCEDURES. (a) The commission shall adopt
uniform policies and procedures applicable to a managed care
organization that contracts with the commission to provide health
care services to a recipient who is also enrolled in a group health
benefit plan as provided by Section 32.0422, Human Resources Code,
that require the managed care organization to pay any deductible,
copayment, coinsurance, or other cost-sharing obligation imposed
on the recipient for a benefit covered under the group health
benefit plan without requiring prior authorization.
(b) The policies and procedures must also include a process
to streamline the Medicaid enrollment of a provider who:
(1) treats a recipient described by Subsection (a);
and
(2) is enrolled as a provider in the group health
benefit plan in which the recipient is enrolled as provided by
Section 32.0422, Human Resources Code.
Sec. 533.030. STATEWIDE MANAGED CARE PLANS. (a) The
commission shall contract with a managed care organization to
arrange for or provide managed care plans to recipients in certain
Medicaid managed care programs throughout the state instead of on a
regional basis. The executive commissioner shall determine the
managed care programs or categories of recipients for which to
arrange for or provide statewide managed care plans. In
contracting with a managed care organization under this section,
the commission shall consider:
(1) regional variations in the cost of and access to
health care services;
(2) recipient access to and choice of providers;
(3) the potential impact on providers, including
safety net providers; and
(4) public input.
(b) Not later than December 1, 2022, the commission shall
prepare and submit a written report to the legislature evaluating
the outcomes of the statewide managed care plans and recommending
whether offering the plans on a statewide basis should be
continued, expanded, or terminated.
(c) Subsection (b) and this subsection expire September 1,
2023.
SECTION 6. (a) Using available resources, the Health and
Human Services Commission shall conduct a study to evaluate the
30-day limitation on reimbursement for inpatient hospital care
provided to Medicaid recipients enrolled in the STAR+PLUS Medicaid
managed care program under 1 T.A.C. Section 354.1072(a)(1) and
other applicable law. In evaluating the limitation and to the
extent data is available on the subject, the commission shall
consider:
(1) the number of Medicaid recipients affected by the
limitation and their clinical outcomes; and
(2) the impact of the limitation on reducing
unnecessary Medicaid inpatient hospital days and any cost savings
achieved by the limitation under Medicaid.
(b) Not later than December 1, 2020, the Health and Human
Services Commission shall submit a report containing the results of
the study conducted under Subsection (a) of this section to the
governor, the legislature, and the Legislative Budget Board. The
report required under this subsection may be combined with any
other report required by this Act or other law.
SECTION 7. Section 533.0031, Government Code, as added by
this Act, applies to a contract entered into or renewed on or after
the effective date of this Act. A contract entered into or renewed
before that date is governed by the law in effect immediately before
the effective date of this Act, and that law is continued in effect
for that purpose.
SECTION 8. 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 9. This Act takes effect September 1, 2019.