86R33484 LED-D
By: Kolkhorst, et al. S.B. No. 1105
(Frank, Klick)
Substitute the following for S.B. No. 1105: No.
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 531.02112, 531.021182, 531.02131,
531.02142, 531.024162, 531.024163, 531.0319, and 531.0511 to read
as follows:
Sec. 531.02112. POLICIES FOR IMPLEMENTING CHANGES TO
PAYMENT RATES UNDER MEDICAID. (a) The commission shall adopt
policies related to the determination of fees, charges, and rates
for payments under Medicaid 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.
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 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 on whose
behalf the request was submitted 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. 531.0319. 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 by the commission.
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 established by the executive commissioner
under Section 531.012 [533.00254].
SECTION 4. Section 533.00253, Government Code, is amended
by adding Subsections (f), (g), and (h) to read as follows:
(f) Using existing resources, the executive commissioner in
consultation and collaboration with the 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 533.00282, 533.00283, 533.00284, and
533.0031 to read as follows:
Sec. 533.00282. UTILIZATION REVIEW PROCEDURES. 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.
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;
(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 on the prior authorization
request, as necessary, considering the additional documentation;
and
(4) comply with 42 C.F.R. Section 438.210.
(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 or a Medicaid fair hearing; or
(2) any rights of a recipient to appeal a
determination on a prior authorization request.
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,
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 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 9. 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 10. 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 11. (a) Section 533.00284, Government Code, as
added by this Act, applies only to a contract between the Health and
Human Services Commission and a Medicaid managed care organization
under Chapter 533, Government Code, that is entered into or renewed
on or after the effective date of this Act.
(b) The Health and Human Services Commission shall seek to
amend contracts entered into with Medicaid managed care
organizations under Chapter 533, Government Code, before the
effective date of this Act to include the provisions required by
Section 533.00284, Government Code, as added by this Act.
SECTION 12. 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 13. 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 14. 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 15. This Act takes effect September 1, 2019.