Texas 2019 - 86th Regular

Texas Senate Bill SB1105 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	86R33484 LED-D
2		-	By: Kolkhorst, et al. S.B. No. 1105
3		-	(Frank, Klick)
4		-	Substitute the following for S.B. No. 1105: No.
	1	+	By: Kolkhorst, Hinojosa, Lucio S.B. No. 1105
5	2
6	3
7	4		A BILL TO BE ENTITLED
8	5		AN ACT
9	6		relating to the administration and operation of Medicaid, including
10	7		Medicaid managed care.
11	8		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	9		SECTION 1. Section 531.001, Government Code, is amended by
13	10		adding Subdivision (4-c) to read as follows:
14	11		(4-c) "Medicaid managed care organization" means a
15	12		managed care organization as defined by Section 533.001 that
16	13		contracts with the commission under Chapter 533 to provide health
17	14		care services to Medicaid recipients.
18	15		SECTION 2. Subchapter B, Chapter 531, Government Code, is
19		-	amended by adding Sections 531.02112, 531.021182, 531.02131,
20		-	531.02142, 531.024162, 531.024163, 531.0319, and 531.0511 to read
21		-	as follows:
22		-	Sec. 531.02112. POLICIES FOR IMPLEMENTING CHANGES TO
23		-	PAYMENT RATES UNDER MEDICAID. (a) The commission shall adopt
24		-	policies related to the determination of fees, charges, and rates
25		-	for payments under Medicaid to ensure, to the greatest extent
26		-	possible, that changes to a fee schedule are implemented in a way
27		-	that minimizes administrative complexity, financial uncertainty,
28		-	and 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.
	16	+	amended by adding Sections 531.021182, 531.02131, 531.02142,
	17	+	531.024162, and 531.0511 to read as follows:
43	18		Sec. 531.021182. USE OF NATIONAL PROVIDER IDENTIFIER
44	19		NUMBER. (a) In this section, "national provider identifier
45	20		number" means the national provider identifier number required
46	21		under Section 1128J(e), Social Security Act (42 U.S.C. Section
47	22		1320a-7k(e)).
48	23		(b) The commission shall transition from using a
49	24		state-issued provider identifier number to using only a national
50	25		provider identifier number in accordance with this section.
51	26		(c) The commission shall implement a Medicaid provider
52	27		management and enrollment system and, following that
53	28		implementation, use only a national provider identifier number to
54	29		enroll a provider in Medicaid.
55	30		(d) The commission shall implement a modernized claims
56	31		processing system and, following that implementation, use only a
57	32		national provider identifier number to process claims for and
58	33		authorize Medicaid services.
59	34		Sec. 531.02131. GRIEVANCES RELATED TO MEDICAID. (a) The
60	35		commission shall adopt a definition of "grievance" related to
61	36		Medicaid and ensure the definition is consistent among divisions
62	37		within the commission to ensure all grievances are managed
63	38		consistently.
64	39		(b) The commission shall standardize Medicaid grievance
65	40		data reporting and tracking among divisions within the commission.
66	41		(c) The commission shall implement a no-wrong-door system
67	42		for Medicaid grievances reported to the commission.
68	43		(d) The commission shall establish a procedure for
69	44		expedited resolution of a grievance related to Medicaid that allows
70	45		the commission to:
71	46		(1) identify a grievance related to a Medicaid access
72	47		to care issue that is urgent and requires an expedited resolution;
73	48		and
74	49		(2) resolve the grievance within a specified period.
75	50		(e) The commission shall verify grievance data reported by a
76	51		Medicaid managed care organization.
77	52		(f) The commission shall:
78	53		(1) aggregate Medicaid recipient and provider
79	54		grievance data to provide a comprehensive data set of grievances;
80	55		and
81	56		(2) make the aggregated data available to the
82	57		legislature and the public in a manner that does not allow for the
83	58		identification of a particular recipient or provider.
84	59		Sec. 531.02142. PUBLIC ACCESS TO CERTAIN MEDICAID DATA.
85	60		(a) To the extent permitted by federal law, the commission in
86	61		consultation and collaboration with the appropriate advisory
87	62		committees related to Medicaid shall make available to the public
88	63		on the commission's Internet website in an easy-to-read format data
89	64		relating to the quality of health care received by Medicaid
90	65		recipients and the health outcomes of those recipients. Data made
91	66		available to the public under this section must be made available in
92	67		a manner that does not identify or allow for the identification of
93	68		individual recipients.
94	69		(b) In performing its duties under this section, the
95	70		commission may collaborate with an institution of higher education
96	71		or another state agency with experience in analyzing and producing
97	72		public use data.
98		-	Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID
99		-	COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
100		-	(a) The commission shall ensure that notice sent by the commission
101		-	or a Medicaid managed care organization to a Medicaid recipient or
102		-	provider regarding the denial of coverage or prior authorization
103		-	for a service includes:
104		-	(1) information required by federal and state law and
105		-	applicable regulations;
106		-	(2) for the recipient, a clear and easy-to-understand
107		-	explanation of the reason for the denial; and
108		-	(3) for the provider, a thorough and detailed clinical
109		-	explanation of the reason for the denial, including, as applicable,
110		-	information required under Subsection (b).
111		-	(b) The commission or a Medicaid managed care organization
112		-	that receives from a provider a coverage or prior authorization
113		-	request that contains insufficient or inadequate documentation to
114		-	approve the request shall issue a notice to the provider and the
115		-	Medicaid recipient on whose behalf the request was submitted. The
116		-	notice issued under this subsection must:
117		-	(1) include a section specifically for the provider
118		-	that contains:
119		-	(A) a clear and specific list and description of
120		-	the documentation necessary for the commission or organization to
121		-	make a final determination on the request;
122		-	(B) the applicable timeline, based on the
123		-	requested service, for the provider to submit the documentation and
124		-	a description of the reconsideration process described by Section
125		-	533.00284, if applicable; and
126		-	(C) information on the manner through which a
127		-	provider may contact a Medicaid managed care organization or other
128		-	entity as required by Section 531.024163; and
129		-	(2) be sent to the provider:
130		-	(A) using the provider's preferred method of
131		-	contact most recently provided to the commission or the Medicaid
132		-	managed care organization and using any alternative and known
133		-	methods of contact; and
134		-	(B) as applicable, through an electronic
135		-	notification on an Internet portal.
136		-	Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING
137		-	MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive
138		-	commissioner by rule shall require each Medicaid managed care
139		-	organization or other entity responsible for authorizing coverage
140		-	for health care services under Medicaid to ensure that the
141		-	organization or entity maintains on the organization's or entity's
142		-	Internet website in an easily searchable and accessible format:
143		-	(1) the applicable timelines for prior authorization
144		-	requirements, including:
145		-	(A) the time within which the organization or
146		-	entity must make a determination on a prior authorization request;
147		-	(B) a description of the notice the organization
148		-	or entity provides to a provider and Medicaid recipient on whose
149		-	behalf the request was submitted regarding the documentation
150		-	required to complete a determination on a prior authorization
151		-	request; and
152		-	(C) the deadline by which the organization or
153		-	entity is required to submit the notice described by Paragraph (B);
154		-	and
155		-	(2) an accurate and up-to-date catalogue of coverage
156		-	criteria and prior authorization requirements, including:
157		-	(A) for a prior authorization requirement first
158		-	imposed on or after September 1, 2019, the effective date of the
159		-	requirement;
160		-	(B) a list or description of any necessary or
161		-	supporting documentation necessary to obtain prior authorization
162		-	for a specified service; and
163		-	(C) the date and results of each review of the
164		-	prior authorization requirement conducted under Section 533.00283,
165		-	if applicable.
166		-	(b) The executive commissioner by rule shall require each
167		-	Medicaid managed care organization or other entity responsible for
168		-	authorizing coverage for health care services under Medicaid to:
169		-	(1) adopt and maintain a process for a provider or
170		-	Medicaid recipient to contact the organization or entity to clarify
171		-	prior authorization requirements or assist the provider or
172		-	recipient in submitting a prior authorization request; and
173		-	(2) ensure that the process described by Subdivision
174		-	(1) is not arduous or overly burdensome to a provider or recipient.
175		-	Sec. 531.0319. MEDICAID MEDICAL BENEFITS POLICY MANUAL.
176		-	(a) To the greatest extent possible, the commission shall
177		-	consolidate policy manuals, handbooks, and other informational
178		-	documents into one Medicaid medical benefits policy manual to
179		-	clarify and provide guidance on the policies under the Medicaid
180		-	managed care delivery model.
181		-	(b) The commission shall periodically update the Medicaid
182		-	medical benefits policy manual described by this section to reflect
183		-	policies adopted or amended by the commission.
	73	+	Sec. 531.024162. NOTICE REQUIREMENTS REGARDING DENIAL OF
	74	+	COVERAGE OR PRIOR AUTHORIZATION. (a) The commission shall ensure
	75	+	that notice sent by the commission or a Medicaid managed care
	76	+	organization to a Medicaid recipient or provider regarding the
	77	+	denial of coverage or prior authorization for a service includes:
	78	+	(1) information required by federal law;
	79	+	(2) a clear and easy-to-understand explanation of the
	80	+	reason for the denial for the recipient; and
	81	+	(3) a clinical explanation of the reason for the
	82	+	denial for the provider.
	83	+	(b) To ensure cost-effectiveness, the commission may
	84	+	implement the notice requirements described by Subsection (a) at
	85	+	the same time as other required or scheduled notice changes.
184	86		Sec. 531.0511. MEDICALLY DEPENDENT CHILDREN WAIVER
185	87		PROGRAM: CONSUMER DIRECTION OF SERVICES. Notwithstanding Sections
186	88		531.051(c)(1) and (d), a consumer direction model implemented under
187	89		Section 531.051, including the consumer-directed service option,
188	90		for the delivery of services under the medically dependent children
189	91		(MDCP) waiver program must allow for the delivery of all services
190	92		and supports available under that program through consumer
191	93		direction.
192	94		SECTION 3. Section 533.00253(a)(1), Government Code, is
193	95		amended to read as follows:
194	96		(1) "Advisory committee" means the STAR Kids Managed
195		-	Care Advisory Committee ~~established~~ by ~~the executive commissioner~~
196		-	~~under Section 531.012 [~~533.00254].
	97	+	Care Advisory Committee described by [established under] Section
	98	+	533.00254.
197	99		SECTION 4. Section 533.00253, Government Code, is amended
198		-	by adding Subsections (f), (g), and (h) to read as follows:
	100	+	by amending Subsection (c) and adding Subsections (c-1), (c-2),
	101	+	(f), (g), and (h) to read as follows:
	102	+	(c) The commission may require that care management
	103	+	services made available as provided by Subsection (b)(7):
	104	+	(1) incorporate best practices, as determined by the
	105	+	commission;
	106	+	(2) integrate with a nurse advice line to ensure
	107	+	appropriate redirection rates;
	108	+	(3) use an identification and stratification
	109	+	methodology that identifies recipients who have the greatest need
	110	+	for services;
	111	+	(4) provide a care needs assessment for a recipient
	112	+	[that is comprehensive, holistic, consumer-directed,
	113	+	evidence-based, and takes into consideration social and medical
	114	+	issues, for purposes of prioritizing the recipient's needs that
	115	+	threaten independent living];
	116	+	(5) are delivered through multidisciplinary care
	117	+	teams located in different geographic areas of this state that use
	118	+	in-person contact with recipients and their caregivers;
	119	+	(6) identify immediate interventions for transition
	120	+	of care;
	121	+	(7) include monitoring and reporting outcomes that, at
	122	+	a minimum, include:
	123	+	(A) recipient quality of life;
	124	+	(B) recipient satisfaction; and
	125	+	(C) other financial and clinical metrics
	126	+	determined appropriate by the commission; and
	127	+	(8) use innovations in the provision of services.
	128	+	(c-1) To improve the care needs assessment tool used for
	129	+	purposes of a care needs assessment provided as a component of care
	130	+	management services and to improve the initial assessment and
	131	+	reassessment processes, the commission in consultation and
	132	+	collaboration with the STAR Kids Managed Care Advisory Committee
	133	+	shall consider changes that will:
	134	+	(1) reduce the amount of time needed to complete the
	135	+	care needs assessment initially and at reassessment; and
	136	+	(2) improve training and consistency in the completion
	137	+	of the care needs assessment using the tool and in the initial
	138	+	assessment and reassessment processes across different Medicaid
	139	+	managed care organizations and different service coordinators
	140	+	within the same Medicaid managed care organization.
	141	+	(c-2) To the extent feasible and allowed by federal law, the
	142	+	commission shall streamline the STAR Kids managed care program
	143	+	annual care needs reassessment process for a child who has not had a
	144	+	significant change in function that may affect medical necessity.
199	145		(f) Using existing resources, the executive commissioner in
200		-	consultation and collaboration with the advisory committee shall
201		-	determine the feasibility of providing Medicaid benefits to
202		-	children enrolled in the STAR Kids managed care program under:
	146	+	consultation and collaboration with the STAR Kids Managed Care
	147	+	Advisory Committee shall determine the feasibility of providing
	148	+	Medicaid benefits to children enrolled in the STAR Kids managed
	149	+	care program under:
203	150		(1) an accountable care organization model in
204	151		accordance with guidelines established by the Centers for Medicare
205	152		and Medicaid Services; or
206	153		(2) an alternative model developed by or in
207	154		collaboration with the Centers for Medicare and Medicaid Services
208	155		Innovation Center.
209	156		(g) Not later than December 1, 2022, the commission shall
210	157		prepare and submit a written report to the legislature of the
211	158		executive commissioner's determination under Subsection (f).
212	159		(h) Subsections (f) and (g) and this subsection expire
213	160		September 1, 2023.
214	161		SECTION 5. Subchapter A, Chapter 533, Government Code, is
215		-	amended by adding Sections 533.00282, 533.00283, 533.00284, and
216		-	533.0031 to read as follows:
217		-	Sec. 533.00282. UTILIZATION REVIEW PROCEDURES. Section
218		-	4201.304, Insurance Code, does not apply to a Medicaid managed care
219		-	organization or a utilization review agent who conducts utilization
220		-	reviews for a Medicaid managed care organization.
221		-	Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION
222		-	REQUIREMENTS. (a) Each Medicaid managed care organization shall
223		-	develop and implement a process to conduct an annual review of the
224		-	organization's prior authorization requirements, other than a
225		-	prior authorization requirement prescribed by or implemented under
226		-	Section 531.073 for the vendor drug program. In conducting a
227		-	review, the organization must:
228		-	(1) solicit, receive, and consider input from
229		-	providers in the organization's provider network; and
230		-	(2) ensure that each prior authorization requirement
231		-	is based on accurate, up-to-date, evidence-based, and
232		-	peer-reviewed clinical criteria that distinguish, as appropriate,
233		-	between categories, including age, of recipients for whom prior
234		-	authorization requests are submitted.
235		-	(b) A Medicaid managed care organization may not impose a
236		-	prior authorization requirement, other than a prior authorization
237		-	requirement prescribed by or implemented under Section 531.073 for
238		-	the vendor drug program, unless the organization has reviewed the
239		-	requirement during the most recent annual review required under
240		-	this section.
241		-	Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE
242		-	DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In
243		-	addition to the requirements of Section 533.005, a contract between
244		-	a Medicaid managed care organization and the commission must
245		-	include a requirement that the organization establish a process for
246		-	reconsidering an adverse determination on a prior authorization
247		-	request that resulted solely from the submission of insufficient or
248		-	inadequate documentation.
249		-	(b) The process for reconsidering an adverse determination
250		-	on a prior authorization request under this section must:
251		-	(1) allow a provider to, not later than the seventh
252		-	business day following the date of the determination, submit any
253		-	documentation that was identified as insufficient or inadequate in
254		-	the notice provided under Section 531.024162;
255		-	(2) allow the provider requesting the prior
256		-	authorization to discuss the request with another provider who
257		-	practices in the same or a similar specialty, but not necessarily
258		-	the same subspecialty, and has experience in treating the same
259		-	category of population as the recipient on whose behalf the request
260		-	is submitted;
261		-	(3) require the Medicaid managed care organization to,
262		-	not later than the first business day following the date the
263		-	provider submits sufficient and adequate documentation under
264		-	Subdivision (1), amend the determination on the prior authorization
265		-	request, as necessary, considering the additional documentation;
266		-	and
267		-	(4) comply with 42 C.F.R. Section 438.210.
268		-	(c) An adverse determination on a prior authorization
269		-	request is considered a denial of services in an evaluation of the
270		-	Medicaid managed care organization only if the determination is not
271		-	amended under Subsection (b)(3).
272		-	(d) The process for reconsidering an adverse determination
273		-	on a prior authorization request under this section does not
274		-	affect:
275		-	(1) any related timelines, including the timeline for
276		-	an internal appeal or a Medicaid fair hearing; or
277		-	(2) any rights of a recipient to appeal a
278		-	determination on a prior authorization request.
	162	+	amended by adding Sections 533.00254 and 533.0031 to read as
	163	+	follows:
	164	+	Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
	165	+	(a) The STAR Kids Managed Care Advisory Committee established by
	166	+	the executive commissioner under Section 531.012 shall:
	167	+	(1) advise the commission on the operation of the STAR
	168	+	Kids managed care program under Section 533.00253; and
	169	+	(2) make recommendations for improvements to that
	170	+	program.
	171	+	(b) On December 31, 2023:
	172	+	(1) the advisory committee is abolished; and
	173	+	(2) this section expires.
279	174		Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION.
280	175		(a) A managed care plan offered by a Medicaid managed care
281	176		organization must be accredited by a nationally recognized
282	177		accreditation organization. The commission may choose whether to
283	178		require all managed care plans offered by Medicaid managed care
284	179		organizations to be accredited by the same organization or to allow
285	180		for accreditation by different organizations.
286	181		(b) The commission may use the data, scoring, and other
287	182		information provided to or received from an accreditation
288	183		organization in the commission's contract oversight processes.
289	184		SECTION 6. The Health and Human Services Commission shall
290	185		issue a request for information to seek information and comments
291	186		regarding contracting with a managed care organization to arrange
292	187		for or provide a managed care plan under the STAR Kids managed care
293		-	program established under Section 533.00253, Government Code,
294		-	throughout the state instead of on a regional basis.
	188	+	program established under Section 533.00253, Government Code, as
	189	+	amended by this Act, throughout the state instead of on a regional
	190	+	basis.
295	191		SECTION 7. (a) Using available resources, the Health and
296	192		Human Services Commission shall report available data on the 30-day
297	193		limitation on reimbursement for inpatient hospital care provided to
298	194		Medicaid recipients enrolled in the STAR+PLUS Medicaid managed care
299	195		program under 1 T.A.C. Section 354.1072(a)(1) and other applicable
300	196		law. To the extent data is available on the subject, the commission
301	197		shall also report on:
302	198		(1) the number of Medicaid recipients affected by the
303	199		limitation and their clinical outcomes; and
304	200		(2) the impact of the limitation on reducing
305	201		unnecessary Medicaid inpatient hospital days and any cost savings
306	202		achieved by the limitation under Medicaid.
307	203		(b) Not later than December 1, 2020, the Health and Human
308	204		Services Commission shall submit the report containing the data
309	205		described by Subsection (a) of this section to the governor, the
310	206		legislature, and the Legislative Budget Board. The report required
311	207		under this subsection may be combined with any other report
312	208		required by this Act or other law.
313		-	SECTION 8. The policies for implementing changes to payment
314		-	rates required by Section 531.02112, Government Code, as added by
315		-	this Act, apply only to a change to a fee, charge, or rate that takes
316		-	effect on or after January 1, 2021.
317		-	SECTION 9. The Health and Human Services Commission shall
	209	+	SECTION 8. The Health and Human Services Commission shall
318	210		implement:
319	211		(1) the Medicaid provider management and enrollment
320	212		system required by Section 531.021182(c), Government Code, as added
321	213		by this Act, not later than September 1, 2020; and
322	214		(2) the modernized claims processing system required
323	215		by Section 531.021182(d), Government Code, as added by this Act,
324	216		not later than September 1, 2023.
325		-	SECTION 10. As soon as practicable after the effective date
326		-	of this Act, the executive commissioner of the Health and Human
327		-	Services Commission shall adopt rules necessary to implement the
328		-	changes in law made by this Act.
329		-	SECTION 11. (a) Section 533.00284, Government Code, as
330		-	added by this Act, applies only to a contract between the Health and
331		-	Human Services Commission and a Medicaid managed care organization
332		-	under Chapter 533, Government Code, that is entered into or renewed
333		-	on or after the effective date of this Act.
334		-	(b) The Health and Human Services Commission shall seek to
335		-	amend contracts entered into with Medicaid managed care
336		-	organizations under Chapter 533, Government Code, before the
337		-	effective date of this Act to include the provisions required by
338		-	Section 533.00284, Government Code, as added by this Act.
339		-	SECTION 12. The Health and Human Services Commission shall
	217	+	SECTION 9. Not later than March 1, 2020, the Health and
	218	+	Human Services Commission shall:
	219	+	(1) develop a plan to improve the care needs
	220	+	assessment tool and the initial assessment and reassessment
	221	+	processes as required by Sections 533.00253(c-1) and (c-2),
	222	+	Government Code, as added by this Act; and
	223	+	(2) post the plan on the commission's Internet
	224	+	website.
	225	+	SECTION 10. The Health and Human Services Commission shall
340	226		require that a managed care plan offered by a managed care
341	227		organization with which the commission enters into or renews a
342	228		contract under Chapter 533, Government Code, on or after the
343	229		effective date of this Act comply with Section 533.0031, Government
344	230		Code, as added by this Act, not later than September 1, 2022.
345		-	SECTION 13. If before implementing any provision of this
	231	+	SECTION 11. If before implementing any provision of this
346	232		Act a state agency determines that a waiver or authorization from a
347	233		federal agency is necessary for implementation of that provision,
348	234		the agency affected by the provision shall request the waiver or
349	235		authorization and may delay implementing that provision until the
350	236		waiver or authorization is granted.
351		-	SECTION 14. The Health and Human Services Commission is
	237	+	SECTION 12. The Health and Human Services Commission is
352	238		required to implement a provision of this Act only if the
353	239		legislature appropriates money specifically for that purpose. If
354	240		the legislature does not appropriate money specifically for that
355	241		purpose, the commission may, but is not required to, implement a
356	242		provision of this Act using other appropriations available for that
357	243		purpose.
358		-	SECTION 15. This Act takes effect September 1, 2019.
	244	+	SECTION 13. This Act takes effect September 1, 2019.