By: Kolkhorst, Hinojosa, Lucio S.B. No. 1105
A BILL TO BE ENTITLED
AN ACT
relating to the administration and operation of Medicaid, including
Medicaid managed care.
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 Sections 531.021182, 531.02131, 531.02142,
531.024162, and 531.0511 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.
Sec. 531.02131. GRIEVANCES RELATED TO MEDICAID. (a) The
commission shall adopt a definition of "grievance" related to
Medicaid and ensure the definition is consistent among divisions
within the commission to ensure all grievances are managed
consistently.
(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
Medicaid managed care organization.
(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 in
consultation and collaboration with the appropriate advisory
committees related to Medicaid shall make available to the public
on the commission's 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. 531.024162. NOTICE REQUIREMENTS REGARDING DENIAL OF
COVERAGE OR PRIOR AUTHORIZATION. (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 law;
(2) a clear and easy-to-understand explanation of the
reason for the denial for the recipient; and
(3) a clinical explanation of the reason for the
denial for the provider.
(b) To ensure cost-effectiveness, the commission may
implement the notice requirements described by Subsection (a) at
the same time as other required or scheduled notice changes.
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 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 4. Section 533.00253, Government Code, is amended
by amending Subsection (c) and adding Subsections (c-1), (c-2),
(f), (g), and (h) 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) To improve the care needs assessment tool used for
purposes of a care needs assessment provided as a component of care
management services and to improve the initial assessment and
reassessment processes, the commission in consultation and
collaboration with the STAR Kids Managed Care Advisory Committee
shall consider changes that will:
(1) reduce the amount of time needed to complete the
care needs assessment initially and at reassessment; and
(2) improve training and consistency in the completion
of the care needs assessment using the tool and in the initial
assessment and reassessment processes across different Medicaid
managed care organizations and different service coordinators
within the same Medicaid managed care organization.
(c-2) To the extent feasible and allowed by federal law, the
commission shall streamline the STAR Kids managed care program
annual care needs reassessment process for a child who has not had a
significant change in function that may affect medical necessity.
(f) Using existing resources, the executive commissioner in
consultation and collaboration with the STAR Kids Managed Care
Advisory Committee shall determine the feasibility of providing
Medicaid benefits to children enrolled in the STAR Kids managed
care program under:
(1) an accountable care organization model in
accordance with guidelines established by the Centers for Medicare
and Medicaid Services; or
(2) an alternative model developed by or in
collaboration with the Centers for Medicare and Medicaid Services
Innovation Center.
(g) Not later than December 1, 2022, the commission shall
prepare and submit a written report to the legislature of the
executive commissioner's determination under Subsection (f).
(h) Subsections (f) and (g) and this subsection expire
September 1, 2023.
SECTION 5. Subchapter A, Chapter 533, Government Code, is
amended by adding Sections 533.00254 and 533.0031 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 December 31, 2023:
(1) the advisory committee is abolished; and
(2) this section expires.
Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION.
(a) A managed care plan offered by a Medicaid managed care
organization must be accredited by a nationally recognized
accreditation organization. The commission may choose whether to
require all managed care plans offered by Medicaid managed care
organizations to be accredited by the same organization or to allow
for accreditation by different organizations.
(b) The commission may use the data, scoring, and other
information provided to or received from an accreditation
organization in the commission's contract oversight processes.
SECTION 6. The Health and Human Services Commission shall
issue a request for information to seek information and comments
regarding contracting with a managed care organization to arrange
for or provide a managed care plan under the STAR Kids managed care
program established under Section 533.00253, Government Code, as
amended by this Act, throughout the state instead of on a regional
basis.
SECTION 7. (a) Using available resources, the Health and
Human Services Commission shall report available data on 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. To the extent data is available on the subject, the commission
shall also report on:
(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 the report containing the data
described by 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 8. 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 9. Not later than March 1, 2020, the Health and
Human Services Commission shall:
(1) develop a plan to improve the care needs
assessment tool and the initial assessment and reassessment
processes as required by Sections 533.00253(c-1) and (c-2),
Government Code, as added by this Act; and
(2) post the plan on the commission's Internet
website.
SECTION 10. The Health and Human Services Commission shall
require that a managed care plan offered by a managed care
organization with which the commission enters into or renews a
contract under Chapter 533, Government Code, on or after the
effective date of this Act comply with Section 533.0031, Government
Code, as added by this Act, not later than September 1, 2022.
SECTION 11. 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 12. The Health and Human Services Commission is
required to implement a provision of this Act only if the
legislature appropriates money specifically for that purpose. If
the legislature does not appropriate money specifically for that
purpose, the commission may, but is not required to, implement a
provision of this Act using other appropriations available for that
purpose.
SECTION 13. This Act takes effect September 1, 2019.