Texas 2019 - 86th Regular

Texas Senate Bill SB1139 Compare Versions

Only one version of the bill is available at this time.

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1	1	86R6908 LED-D
2	2	By: Watson S.B. No. 1139
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the operation and administration of Medicaid, including
8	8	the Medicaid managed care program.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 531.001, Government Code, is amended by
11	11	adding Subdivision (4-c) to read as follows:
12	12	(4-c) "Medicaid managed care organization" means a
13	13	managed care organization as defined by Section 533.001 that
14	14	contracts with the commission under Chapter 533 to provide health
15	15	care services to Medicaid recipients.
16	16	SECTION 2. Subchapter A, Chapter 531, Government Code, is
17	17	amended by adding Section 531.0172 to read as follows:
18	18	Sec. 531.0172. OMBUDSMAN FOR MEDICAID PROVIDERS. (a) In
19	19	this section, "office" means the office of ombudsman for Medicaid
20	20	providers.
21	21	(b) The office of ombudsman for Medicaid providers is
22	22	established within the commission's office of inspector general to
23	23	support Medicaid providers in resolving disputes, complaints, or
24	24	other issues between the provider and the commission or a Medicaid
25	25	managed care organization under a Medicaid managed care or
26	26	fee-for-service delivery model.
27	27	(c) The staff of the office shall work in conjunction with
28	28	the other staff of the office of inspector general to ensure that,
29	29	in assessing administrative penalties otherwise authorized by law
30	30	on behalf of the commission or a health and human services agency,
31	31	the office of inspector general assesses penalties against a
32	32	Medicaid managed care organization for a rule violation that
33	33	results in a provider dispute or complaint in an amount that is
34	34	sufficient to deter future violations.
35	35	(d) The office shall report issues regarding the Medicaid
36	36	managed care program to the Medicaid director with timely
37	37	information.
38	38	(e) The office shall provide feedback to a person who files
39	39	a grievance with the office, such as feedback concerning any
40	40	investigation resulting from and the outcome of the grievance, in
41	41	accordance with the no-wrong-door system established under Section
42	42	533.027.
43	43	(f) Data collected by the office must be collected and
44	44	reported by provider type and population served. The office shall
45	45	use the data to develop and make to the commission's Medicaid and
46	46	CHIP services division recommendations for reforming providers'
47	47	experiences with Medicaid, including Medicaid managed care.
48	48	(g) The executive commissioner shall adopt rules as
49	49	necessary to implement this section.
50	50	SECTION 3. Subchapter B, Chapter 531, Government Code, is
51	51	amended by adding Section 531.02133 to read as follows:
52	52	Sec. 531.02133. REQUESTING INFORMATION IN STAR HEALTH
53	53	PROGRAM. The commission shall provide clear guidance on the
54	54	process for requesting and responding to requests for documents
55	55	relating to and medical records of a recipient under the STAR Health
56	56	program to:
57	57	(1) a Medicaid managed care organization that provides
58	58	health care services under that program; and
59	59	(2) attorneys ad litem representing recipients under
60	60	that program.
61	61	SECTION 4. Section 531.02141, Government Code, is amended
62	62	by adding Subsection (f) to read as follows:
63	63	(f) For each hearing officer that conducts Medicaid fair
64	64	hearings, the commission or the third-party arbiter described by
65	65	Section 533.00715 annually shall collect data regarding the
66	66	officer's decisions and rate of upholding or reversing decisions on
67	67	appeal. The commission or third-party arbiter shall analyze the
68	68	data to identify outliers. The third-party arbiter shall provide
69	69	corrective education to hearing officers whose decisions or rates
70	70	are outliers.
71	71	SECTION 5. Section 531.024, Government Code, is amended by
72	72	adding Subsection (c) to read as follows:
73	73	(c) The rules promulgated under Subsection (a)(7) must
74	74	provide a Medicaid recipient the right to an in-person hearing,
75	75	regardless of whether the recipient demonstrates good cause.
76	76	SECTION 6. Section 531.02411, Government Code, is amended
77	77	to read as follows:
78	78	Sec. 531.02411. STREAMLINING ADMINISTRATIVE PROCESSES.
79	79	(a) The commission shall make every effort using the commission's
80	80	existing resources to reduce the paperwork and other administrative
81	81	burdens placed on Medicaid recipients and providers and other
82	82	participants in Medicaid and shall use technology and efficient
83	83	business practices to decrease those burdens. In addition, the
84	84	commission shall make every effort to improve the business
85	85	practices associated with the administration of Medicaid by any
86	86	method the commission determines is cost-effective, including:
87	87	(1) expanding the utilization of the electronic claims
88	88	payment system;
89	89	(2) developing an Internet portal system for prior
90	90	authorization requests;
91	91	(3) encouraging Medicaid providers to submit their
92	92	program participation applications electronically;
93	93	(4) ensuring that the Medicaid provider application is
94	94	easy to locate on the Internet so that providers may conveniently
95	95	apply to the program;
96	96	(5) working with federal partners to take advantage of
97	97	every opportunity to maximize additional federal funding for
98	98	technology in Medicaid; and
99	99	(6) encouraging the increased use of medical
100	100	technology by providers, including increasing their use of:
101	101	(A) electronic communications between patients
102	102	and their physicians or other health care providers;
103	103	(B) electronic prescribing tools that provide
104	104	up-to-date payer formulary information at the time a physician or
105	105	other health care practitioner writes a prescription and that
106	106	support the electronic transmission of a prescription;
107	107	(C) ambulatory computerized order entry systems
108	108	that facilitate physician and other health care practitioner orders
109	109	at the point of care for medications and laboratory and
110	110	radiological tests;
111	111	(D) inpatient computerized order entry systems
112	112	to reduce errors, improve health care quality, and lower costs in a
113	113	hospital setting;
114	114	(E) regional data-sharing to coordinate patient
115	115	care across a community for patients who are treated by multiple
116	116	providers; and
117	117	(F) electronic intensive care unit technology to
118	118	allow physicians to fully monitor hospital patients remotely.
119	119	(b) The commission shall adopt and implement policies that
120	120	encourage the use of electronic transactions in Medicaid. The
121	121	policies must:
122	122	(1) promote electronic payment systems for Medicaid
123	123	providers, including electronic funds transfer or other electronic
124	124	payment remittance and electronic payment status reports; and
125	125	(2) encourage providers through the use of incentives
126	126	to submit claims and prior authorization requests electronically to
127	127	help promote faster response times and reduce the administrative
128	128	costs related to paper claims processing.
129	129	SECTION 7. Section 531.0317, Government Code, is amended by
130	130	adding Subsections (c-1) and (c-2) to read as follows:
131	131	(c-1) For the portion of the Internet site relating to
132	132	Medicaid, the commission shall:
133	133	(1) ensure the information is accessible and usable;
134	134	(2) publish Medicaid managed care organization
135	135	performance measures; and
136	136	(3) organize and maintain that portion of the Internet
137	137	site in a manner that serves Medicaid recipients, providers, and
138	138	managed care organizations, stakeholders, and the public.
139	139	(c-2) The commission shall establish and maintain an
140	140	interactive, public portal on the Internet site that incorporates
141	141	data collected under Section 533.026 to allow Medicaid recipients
142	142	to compare Medicaid managed care organizations within a service
143	143	region.
144	144	SECTION 8. Section 531.073, Government Code, is amended by
145	145	adding Subsection (k) to read as follows:
146	146	(k) The commission annually shall review prior
147	147	authorization requirements in the Medicaid vendor drug program and
148	148	determine whether to change, update, or delete any of the
149	149	requirements.
150	150	SECTION 9. Section 531.076, Government Code, is amended by
151	151	amending Subsection (b) and adding Subsections (c), (d), (e), (f),
152	152	(g), and (h) to read as follows:
153	153	(b) The commission shall monitor Medicaid managed care
154	154	organizations to ensure that the organizations:
155	155	(1) are using prior authorization and utilization
156	156	review processes to reduce authorizations of unnecessary services
157	157	and inappropriate use of services; and
158	158	(2) are not using prior authorization to negatively
159	159	impact recipients' access to care.
160	160	(c) The commission annually shall review a Medicaid managed
161	161	care organization's prior authorization requirements and determine
162	162	whether the organization should change, update, or delete any of
163	163	those requirements.
164	164	(d) To enable the commission to increase the commission's
165	165	utilization review resources with respect to Medicaid managed care
166	166	organization performance, the commission shall:
167	167	(1) increase the sample size and types of services
168	168	subject to utilization review to ensure an adequate and
169	169	representative sample;
170	170	(2) use a data-driven approach to efficiently select
171	171	cases for utilization review that aligns with the commission's
172	172	priorities for improved outcomes; and
173	173	(3) use additional measures the commission considers
174	174	appropriate.
175	175	(e) The commission shall request information regarding and
176	176	review the outcomes and timeliness of a Medicaid managed care
177	177	organization's prior authorizations to determine for particular
178	178	service requests:
179	179	(1) the number of service hours and units requested,
180	180	delivered, and billed;
181	181	(2) the period the prior authorization request was
182	182	pending;
183	183	(3) whether the organization denied, approved, or
184	184	amended the prior authorization request; and
185	185	(4) whether a denied prior authorization request
186	186	resulted in an internal appeal or an appeal to the third-party
187	187	arbiter described by Section 533.00715.
188	188	(f) The commission may:
189	189	(1) require an assessment of a Medicaid managed care
190	190	organization's employee who conducts utilization review to ensure
191	191	the employee's decisions and assessments are consistent with those
192	192	of other employees, clinical criteria, and guidelines;
193	193	(2) require the organization to provide a sample case
194	194	to:
195	195	(A) test how the organization conducts service
196	196	planning and utilization review; and
197	197	(B) determine whether the organization is
198	198	following the organization's utilization management policies and
199	199	procedures as expressed in the contract between the organization
200	200	and the commission, the organization's patient handbook, and other
201	201	publicly available written documents; and
202	202	(3) randomly select an employee to test how the
203	203	organization conducts service planning and utilization review,
204	204	particularly in the:
205	205	(A) STAR+PLUS Medicaid managed care program;
206	206	(B) STAR Kids managed care program; and
207	207	(C) STAR Health program.
208	208	(g) To the extent feasible, the commission shall align
209	209	treatments and conditions subject to prior authorization to create
210	210	uniformity among Medicaid managed care plans. The commission by
211	211	rule shall require each Medicaid managed care organization to
212	212	submit to the commission at least every two years a list of the
213	213	conditions and treatments subject to prior authorization under the
214	214	managed care plan offered by the organization. The commission
215	215	shall designate a single, searchable, public-facing Internet
216	216	website that contains prior authorization lists categorized by
217	217	Medicaid managed care program and subcategorized by Medicaid
218	218	managed care organization.
219	219	(h) The commission's and each Medicaid managed care
220	220	organization's prior authorization requirements, including prior
221	221	authorization requirements applicable in the Medicaid vendor drug
222	222	program, must be based on publicly available clinical criteria and
223	223	posted in an easily searchable format on their respective Internet
224	224	websites. Information posted under this subsection must include
225	225	the date of last review.
226	226	SECTION 10. Section 533.00253, Government Code, is amended
227	227	by adding Subsections (f) and (g) to read as follows:
228	228	(f) The commission shall ensure that the care coordinator
229	229	for a Medicaid managed care organization under the STAR Kids
230	230	managed care program offers a recipient's parent or legally
231	231	authorized representative the opportunity to review and comment on
232	232	the recipient's completed care needs assessment before the
233	233	assessment is used to determine the services to be provided to the
234	234	recipient. The commission shall require the parent's or
235	235	representative's electronic signature to verify the parent or
236	236	representative received the opportunity to review and comment on
237	237	the assessment and indicate whether the parent or representative
238	238	agrees with the assessment or disagrees and wishes to dispute the
239	239	assessment based on medical necessity. The commission shall
240	240	provide a parent or representative who disagrees with a care needs
241	241	assessment an opportunity to dispute the assessment with the
242	242	commission.
243	243	(g) The commission, in consultation with stakeholders,
244	244	shall redesign the care needs assessment used in the STAR Kids
245	245	managed care program to ensure the assessment collects useable data
246	246	pertinent to a child's physical, behavioral, and long-term care
247	247	needs. This subsection expires September 1, 2021.
248	248	SECTION 11. Subchapter A, Chapter 533, Government Code, is
249	249	amended by adding Sections 533.002533 and 533.00271 to read as
250	250	follows:
251	251	Sec. 533.002533. CONTINUATION OF STAR KIDS MANAGED CARE
252	252	ADVISORY COMMITTEE. The commission shall periodically evaluate
253	253	whether to continue the STAR Kids Managed Care Advisory Committee
254	254	established under former Section 533.00254 as a forum to identify
255	255	and make recommendations for resolving eligibility, clinical, and
256	256	administrative issues with the STAR Kids managed care program.
257	257	Sec. 533.00271. EXTERNAL QUALITY REVIEW ORGANIZATION:
258	258	EVALUATION OF MEDICAID MANAGED CARE GENERALLY. (a) The commission
259	259	annually shall identify and study areas of Medicaid managed care
260	260	organization services for which the commission needs additional
261	261	information. The external quality review organization annually
262	262	shall study and report to the commission on at least three measures
263	263	related to the identified areas and included in the core set of
264	264	children's health care quality measures or core set of adults'
265	265	health care quality measures published by the United States
266	266	Department of Health and Human Services.
267	267	(b) The external quality review organization annually
268	268	shall:
269	269	(1) compare private health plans, including
270	270	not-for-profit community health plans and for-profit health plans,
271	271	and managed care plans offered through contracts under this
272	272	chapter; and
273	273	(2) report to the commission the comparison between
274	274	those plans on the following under the plans:
275	275	(A) rates of:
276	276	(i) inquiries about services and benefits;
277	277	(ii) inquiries and complaints about access
278	278	to a provider in an enrollee's local area;
279	279	(iii) formal complaints; and
280	280	(iv) service denials;
281	281	(B) outcomes of internal appeals, including the
282	282	number of appeals reversed;
283	283	(C) outcomes of fair hearing requests, if
284	284	applicable;
285	285	(D) constituent complaints brought to the health
286	286	plan's or Medicaid managed care organization's attention by an
287	287	individual or entity, including a state legislator or the
288	288	commission; and
289	289	(E) data disaggregated by the individual or
290	290	entity that initiated an inquiry or complaint.
291	291	(c) The commission shall require each Medicaid managed care
292	292	organization to submit monthly the information described by
293	293	Subsection (b).
294	294	SECTION 12. Section 533.005, Government Code, is amended by
295	295	amending Subsection (a) and adding Subsection (g) to read as
296	296	follows:
297	297	(a) A contract between a managed care organization and the
298	298	commission for the organization to provide health care services to
299	299	recipients must contain:
300	300	(1) procedures to ensure accountability to the state
301	301	for the provision of health care services, including procedures for
302	302	financial reporting, quality assurance, utilization review, and
303	303	assurance of contract and subcontract compliance;
304	304	(2) capitation rates that ensure the cost-effective
305	305	provision of quality health care;
306	306	(3) a requirement that the managed care organization
307	307	provide ready access to a person who assists recipients in
308	308	resolving issues relating to enrollment, plan administration,
309	309	education and training, access to services, and grievance
310	310	procedures;
311	311	(4) a requirement that the managed care organization
312	312	provide ready access to a person who assists providers in resolving
313	313	issues relating to payment, plan administration, education and
314	314	training, and grievance procedures;
315	315	(5) a requirement that the managed care organization
316	316	provide information and referral about the availability of
317	317	educational, social, and other community services that could
318	318	benefit a recipient;
319	319	(6) procedures for recipient outreach and education;
320	320	(7) a requirement that the managed care organization
321	321	make payment to a physician or provider for health care services
322	322	rendered to a recipient under a managed care plan on any claim for
323	323	payment that is received with documentation reasonably necessary
324	324	for the managed care organization to process the claim:
325	325	(A) not later than:
326	326	(i) the 10th day after the date the claim is
327	327	received if the claim relates to services provided by a nursing
328	328	facility, intermediate care facility, or group home;
329	329	(ii) the 30th day after the date the claim
330	330	is received if the claim relates to the provision of long-term
331	331	services and supports not subject to Subparagraph (i); and
332	332	(iii) the 45th day after the date the claim
333	333	is received if the claim is not subject to Subparagraph (i) or (ii);
334	334	or
335	335	(B) within a period, not to exceed 60 days,
336	336	specified by a written agreement between the physician or provider
337	337	and the managed care organization;
338	338	(7-a) a requirement that the managed care organization
339	339	demonstrate to the commission that the organization pays claims
340	340	described by Subdivision (7)(A)(ii) on average not later than the
341	341	21st day after the date the claim is received by the organization;
342	342	(7-b) a requirement that the managed care organization
343	343	pay liquidated damages for each failure, as determined by the
344	344	commission, to comply with Subdivision (7) in an amount that is a
345	345	reasonable forecast of the damages caused by the noncompliance;
346	346	(8) a requirement that the commission, on the date of a
347	347	recipient's enrollment in a managed care plan issued by the managed
348	348	care organization, inform the organization of the recipient's
349	349	Medicaid certification date;
350	350	(9) a requirement that the managed care organization
351	351	comply with Section 533.006 as a condition of contract retention
352	352	and renewal;
353	353	(10) a requirement that the managed care organization
354	354	provide the information required by Section 533.012 and otherwise
355	355	comply and cooperate with the commission's office of inspector
356	356	general and the office of the attorney general;
357	357	(11) a requirement that the managed care
358	358	organization's usages of out-of-network providers or groups of
359	359	out-of-network providers may not exceed limits for those usages
360	360	relating to total inpatient admissions, total outpatient services,
361	361	and emergency room admissions determined by the commission;
362	362	(12) if the commission finds that a managed care
363	363	organization has violated Subdivision (11), a requirement that the
364	364	managed care organization reimburse an out-of-network provider for
365	365	health care services at a rate that is equal to the allowable rate
366	366	for those services, as determined under Sections 32.028 and
367	367	32.0281, Human Resources Code;
368	368	(13) a requirement that, notwithstanding any other
369	369	law, including Sections 843.312 and 1301.052, Insurance Code, the
370	370	organization:
371	371	(A) use advanced practice registered nurses and
372	372	physician assistants in addition to physicians as primary care
373	373	providers to increase the availability of primary care providers in
374	374	the organization's provider network; and
375	375	(B) treat advanced practice registered nurses
376	376	and physician assistants in the same manner as primary care
377	377	physicians with regard to:
378	378	(i) selection and assignment as primary
379	379	care providers;
380	380	(ii) inclusion as primary care providers in
381	381	the organization's provider network; and
382	382	(iii) inclusion as primary care providers
383	383	in any provider network directory maintained by the organization;
384	384	(14) a requirement that the managed care organization
385	385	reimburse a federally qualified health center or rural health
386	386	clinic for health care services provided to a recipient outside of
387	387	regular business hours, including on a weekend day or holiday, at a
388	388	rate that is equal to the allowable rate for those services as
389	389	determined under Section 32.028, Human Resources Code, if the
390	390	recipient does not have a referral from the recipient's primary
391	391	care physician;
392	392	(15) a requirement that the managed care organization
393	393	comply with the recipient appeals procedure established under
394	394	Section 533.00715 and develop, implement, and maintain a system for
395	395	tracking and resolving all provider appeals related to claims
396	396	payment, including a process that will require:
397	397	(A) a tracking mechanism to document the status
398	398	and final disposition of each provider's claims payment appeal;
399	399	(B) the contracting with physicians who are not
400	400	network providers and who are of the same or related specialty as
401	401	the appealing physician to resolve claims disputes related to
402	402	denial on the basis of medical necessity that remain unresolved
403	403	subsequent to a provider appeal;
404	404	(C) the determination of the physician resolving
405	405	the dispute to be binding on the managed care organization and
406	406	provider; and
407	407	(D) the managed care organization to allow a
408	408	provider with a claim that has not been paid before the time
409	409	prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
410	410	claim;
411	411	(16) a requirement that a medical director who is
412	412	authorized to make medical necessity determinations is available to
413	413	the region where the managed care organization provides health care
414	414	services;
415	415	(17) a requirement that the managed care organization
416	416	ensure that a medical director and patient care coordinators and
417	417	provider and recipient support services personnel are located in
418	418	the South Texas service region, if the managed care organization
419	419	provides a managed care plan in that region;
420	420	(18) a requirement that the managed care organization
421	421	provide special programs and materials for recipients with limited
422	422	English proficiency or low literacy skills;
423	423	(19) a requirement that the managed care organization
424	424	develop and establish a process for responding to provider appeals
425	425	in the region where the organization provides health care services;
426	426	(20) a requirement that the managed care organization:
427	427	(A) develop and submit to the commission, before
428	428	the organization begins to provide health care services to
429	429	recipients, a comprehensive plan that describes how the
430	430	organization's provider network complies with the provider access
431	431	standards established under Section 533.0061;
432	432	(B) as a condition of contract retention and
433	433	renewal:
434	434	(i) continue to comply with the provider
435	435	access standards established under Section 533.0061; and
436	436	(ii) make substantial efforts, as
437	437	determined by the commission, to mitigate or remedy any
438	438	noncompliance with the provider access standards established under
439	439	Section 533.0061;
440	440	(C) pay liquidated damages for each failure, as
441	441	determined by the commission, to comply with the provider access
442	442	standards established under Section 533.0061 in amounts that are
443	443	reasonably related to the noncompliance; and
444	444	(D) regularly, as determined by the commission,
445	445	submit to the commission and make available to the public a report
446	446	containing data on the sufficiency of the organization's provider
447	447	network with regard to providing the care and services described
448	448	under Section 533.0061(a-1) [533.0061(a)] and specific data with
449	449	respect to access to primary care, specialty care, long-term
450	450	services and supports, nursing services, and therapy services on
451	451	the average length of time between:
452	452	(i) the date a provider requests prior
453	453	authorization for the care or service and the date the organization
454	454	approves or denies the request; and
455	455	(ii) the date the organization approves a
456	456	request for prior authorization for the care or service and the date
457	457	the care or service is initiated;
458	458	(21) a requirement that the managed care organization
459	459	demonstrate to the commission, before the organization begins to
460	460	provide health care services to recipients, that, subject to the
461	461	provider access standards established under Section 533.0061:
462	462	(A) the organization's provider network has the
463	463	capacity to serve the number of recipients expected to enroll in a
464	464	managed care plan offered by the organization;
465	465	(B) the organization's provider network
466	466	includes:
467	467	(i) a sufficient number of primary care
468	468	providers;
469	469	(ii) a sufficient variety of provider
470	470	types;
471	471	(iii) a sufficient number of providers of
472	472	long-term services and supports and specialty pediatric care
473	473	providers of home and community-based services; and
474	474	(iv) providers located throughout the
475	475	region where the organization will provide health care services;
476	476	and
477	477	(C) health care services will be accessible to
478	478	recipients through the organization's provider network to a
479	479	comparable extent that health care services would be available to
480	480	recipients under a fee-for-service or primary care case management
481	481	model of Medicaid managed care;
482	482	(22) a requirement that the managed care organization
483	483	develop a monitoring program for measuring the quality of the
484	484	health care services provided by the organization's provider
485	485	network that:
486	486	(A) incorporates the National Committee for
487	487	Quality Assurance's Healthcare Effectiveness Data and Information
488	488	Set (HEDIS) measures and the core sets of children's and adults'
489	489	health care quality measures published by the United States
490	490	Department of Health and Human Services;
491	491	(B) focuses on measuring outcomes; and
492	492	(C) includes the collection and analysis of
493	493	clinical data relating to prenatal care, preventive care, mental
494	494	health care, and the treatment of acute and chronic health
495	495	conditions and substance abuse;
496	496	(23) subject to Subsection (a-1), a requirement that
497	497	the managed care organization develop, implement, and maintain an
498	498	outpatient pharmacy benefit plan for its enrolled recipients:
499	499	(A) that exclusively employs the vendor drug
500	500	program formulary and preserves the state's ability to reduce
501	501	waste, fraud, and abuse under Medicaid;
502	502	(B) that adheres to the applicable preferred drug
503	503	list adopted by the commission under Section 531.072;
504	504	(C) that includes the prior authorization
505	505	procedures and requirements prescribed by or implemented under
506	506	Sections 531.073(b), (c), and (g) for the vendor drug program;
507	507	(D) for purposes of which the managed care
508	508	organization:
509	509	(i) may not negotiate or collect rebates
510	510	associated with pharmacy products on the vendor drug program
511	511	formulary; and
512	512	(ii) may not receive drug rebate or pricing
513	513	information that is confidential under Section 531.071;
514	514	(E) that complies with the prohibition under
515	515	Section 531.089;
516	516	(F) under which the managed care organization may
517	517	not prohibit, limit, or interfere with a recipient's selection of a
518	518	pharmacy or pharmacist of the recipient's choice for the provision
519	519	of pharmaceutical services under the plan through the imposition of
520	520	different copayments;
521	521	(G) that allows the managed care organization or
522	522	any subcontracted pharmacy benefit manager to contract with a
523	523	pharmacist or pharmacy providers separately for specialty pharmacy
524	524	services, except that:
525	525	(i) the managed care organization and
526	526	pharmacy benefit manager are prohibited from allowing exclusive
527	527	contracts with a specialty pharmacy owned wholly or partly by the
528	528	pharmacy benefit manager responsible for the administration of the
529	529	pharmacy benefit program; and
530	530	(ii) the managed care organization and
531	531	pharmacy benefit manager must adopt policies and procedures for
532	532	reclassifying prescription drugs from retail to specialty drugs,
533	533	and those policies and procedures must be consistent with rules
534	534	adopted by the executive commissioner and include notice to network
535	535	pharmacy providers from the managed care organization;
536	536	(H) under which the managed care organization may
537	537	not prevent a pharmacy or pharmacist from participating as a
538	538	provider if the pharmacy or pharmacist agrees to comply with the
539	539	financial terms and conditions of the contract as well as other
540	540	reasonable administrative and professional terms and conditions of
541	541	the contract;
542	542	(I) under which the managed care organization may
543	543	include mail-order pharmacies in its networks, but may not require
544	544	enrolled recipients to use those pharmacies, and may not charge an
545	545	enrolled recipient who opts to use this service a fee, including
546	546	postage and handling fees;
547	547	(J) under which the managed care organization or
548	548	pharmacy benefit manager, as applicable, must pay claims in
549	549	accordance with Section 843.339, Insurance Code; and
550	550	(K) under which the managed care organization or
551	551	pharmacy benefit manager, as applicable:
552	552	(i) to place a drug on a maximum allowable
553	553	cost list, must ensure that:
554	554	(a) the drug is listed as "A" or "B"
555	555	rated in the most recent version of the United States Food and Drug
556	556	Administration's Approved Drug Products with Therapeutic
557	557	Equivalence Evaluations, also known as the Orange Book, has an "NR"
558	558	or "NA" rating or a similar rating by a nationally recognized
559	559	reference; and
560	560	(b) the drug is generally available
561	561	for purchase by pharmacies in the state from national or regional
562	562	wholesalers and is not obsolete;
563	563	(ii) must provide to a network pharmacy
564	564	provider, at the time a contract is entered into or renewed with the
565	565	network pharmacy provider, the sources used to determine the
566	566	maximum allowable cost pricing for the maximum allowable cost list
567	567	specific to that provider;
568	568	(iii) must review and update maximum
569	569	allowable cost price information at least once every seven days to
570	570	reflect any modification of maximum allowable cost pricing;
571	571	(iv) must, in formulating the maximum
572	572	allowable cost price for a drug, use only the price of the drug and
573	573	drugs listed as therapeutically equivalent in the most recent
574	574	version of the United States Food and Drug Administration's
575	575	Approved Drug Products with Therapeutic Equivalence Evaluations,
576	576	also known as the Orange Book;
577	577	(v) must establish a process for
578	578	eliminating products from the maximum allowable cost list or
579	579	modifying maximum allowable cost prices in a timely manner to
580	580	remain consistent with pricing changes and product availability in
581	581	the marketplace;
582	582	(vi) must:
583	583	(a) provide a procedure under which a
584	584	network pharmacy provider may challenge a listed maximum allowable
585	585	cost price for a drug;
586	586	(b) respond to a challenge not later
587	587	than the 15th day after the date the challenge is made;
588	588	(c) if the challenge is successful,
589	589	make an adjustment in the drug price effective on the date the
590	590	challenge is resolved[,] and make the adjustment applicable to all
591	591	similarly situated network pharmacy providers, as determined by the
592	592	managed care organization or pharmacy benefit manager, as
593	593	appropriate;
594	594	(d) if the challenge is denied,
595	595	provide the reason for the denial; and
596	596	(e) report to the commission every 90
597	597	days the total number of challenges that were made and denied in the
598	598	preceding 90-day period for each maximum allowable cost list drug
599	599	for which a challenge was denied during the period;
600	600	(vii) must notify the commission not later
601	601	than the 21st day after implementing a practice of using a maximum
602	602	allowable cost list for drugs dispensed at retail but not by mail;
603	603	and
604	604	(viii) must provide a process for each of
605	605	its network pharmacy providers to readily access the maximum
606	606	allowable cost list specific to that provider;
607	607	(24) a requirement that the managed care organization
608	608	and any entity with which the managed care organization contracts
609	609	for the performance of services under a managed care plan disclose,
610	610	at no cost, to the commission and, on request, the office of the
611	611	attorney general all discounts, incentives, rebates, fees, free
612	612	goods, bundling arrangements, and other agreements affecting the
613	613	net cost of goods or services provided under the plan;
614	614	(25) a requirement that the managed care organization
615	615	not implement significant, nonnegotiated, across-the-board
616	616	provider reimbursement rate reductions unless:
617	617	(A) subject to Subsection (a-3), the
618	618	organization has the prior approval of the commission to make the
619	619	reductions [reduction]; or
620	620	(B) the rate reductions are based on changes to
621	621	the Medicaid fee schedule or cost containment initiatives
622	622	implemented by the commission; [and]
623	623	(26) a requirement that the managed care organization
624	624	make initial and subsequent primary care provider assignments and
625	625	changes;
626	626	(27) a requirement that the managed care organization
627	627	pend a prior authorization request or claim awaiting a peer-to-peer
628	628	review;
629	629	(28) a requirement that the managed care organization:
630	630	(A) timely respond to prior authorization
631	631	requests;
632	632	(B) not deny a reasonable prior authorization
633	633	request or claim for a technical or minimal error;
634	634	(C) not abuse the appeals process to deter a
635	635	recipient or provider from requesting health care services; and
636	636	(D) pay liquidated damages for each failure, as
637	637	determined by the commission, to comply with this subdivision in an
638	638	amount that is a reasonable forecast of the damages caused by the
639	639	noncompliance;
640	640	(29) a requirement that the managed care organization:
641	641	(A) automatically, without a request from a
642	642	recipient or program, continue to provide the pre-reduction or
643	643	pre-denial level of services to the recipient during an internal
644	644	appeal or an appeal to the third-party arbiter described by Section
645	645	533.00715 of a reduction in or denial of services, unless the
646	646	recipient or the recipient's parent on behalf of the recipient opts
647	647	out of the automatic continuation of services;
648	648	(B) provide the commission and the recipient with
649	649	a notice of continuing services, receipt of which is verified by
650	650	electronic signature or through other electronic means; and
651	651	(C) pay liquidated damages for each failure, as
652	652	determined by the commission, to comply with this subdivision in an
653	653	amount that is a reasonable forecast of the damages caused by the
654	654	noncompliance; and
655	655	(30) a requirement that the managed care organization,
656	656	after a prior authorization denial or adverse benefit
657	657	determination, provide a recipient with a letter that includes a
658	658	thorough and detailed explanation for the prior authorization
659	659	denial or adverse determination.
660	660	(g) The commission shall provide guidance and additional
661	661	education to managed care organizations regarding requirements
662	662	under federal law and Subsection (a)(29) to continue to provide
663	663	services during an internal appeal and a Medicaid fair hearing.
664	664	SECTION 13. Section 533.0051, Government Code, is amended
665	665	by adding Subsection (h) to read as follows:
666	666	(h) To monitor performance measures, the commission shall
667	667	develop a data-sharing platform that enables divisions within the
668	668	commission to electronically view data and access data analysis in
669	669	a single location.
670	670	SECTION 14. Subchapter A, Chapter 533, Government Code, is
671	671	amended by adding Section 533.0058 to read as follows:
672	672	Sec. 533.0058. STAR HEALTH PROGRAM: INITIAL THERAPY
673	673	EVALUATION. A Medicaid managed care organization that provides
674	674	health care services under the STAR Health program may not require
675	675	prior authorization for an initial therapy evaluation for a
676	676	recipient.
677	677	SECTION 15. The heading to Section 533.0061, Government
678	678	Code, is amended to read as follows:
679	679	Sec. 533.0061. PROVIDER ACCESS STANDARDS AND NETWORK
680	680	ADEQUACY; REPORT.
681	681	SECTION 16. Section 533.0061, Government Code, is amended
682	682	by amending Subsection (a) and adding Subsections (a-1), (b-1),
683	683	(b-2), (b-3), (b-4), (d), and (e) to read as follows:
684	684	(a) In this section:
685	685	(1) "Access to care" means access to care and services
686	686	available under Medicaid at least to the same extent that similar
687	687	care and services are available to the general population in the
688	688	recipient's geographic area.
689	689	(2) "Network adequacy" means the adequacy of a
690	690	Medicaid managed care organization's provider network determined
691	691	according to standards established by federal law.
692	692	(a-1) The commission shall establish minimum provider
693	693	access standards for the provider network of a managed care
694	694	organization that contracts with the commission to provide health
695	695	care services to recipients. The access standards must ensure that
696	696	a Medicaid managed care organization provides recipients
697	697	sufficient access to:
698	698	(1) preventive care;
699	699	(2) primary care;
700	700	(3) specialty care;
701	701	(4) after-hours urgent care;
702	702	(5) chronic care;
703	703	(6) long-term services and supports;
704	704	(7) nursing services;
705	705	(8) therapy services, including services provided in a
706	706	clinical setting or in a home or community-based setting; and
707	707	(9) any other services identified by the commission.
708	708	(b-1) Except as provided by Subsection (b-4), the
709	709	commission shall use travel time and distance standards to measure
710	710	network adequacy.
711	711	(b-2) In determining network adequacy, the commission shall
712	712	use automated data validation and calculation tools to decrease
713	713	processing time and resources required for calculating provider
714	714	distance and travel time.
715	715	(b-3) The commission shall integrate access to care data
716	716	with network adequacy data to evaluate and monitor provider network
717	717	adequacy based on both provider location and availability.
718	718	(b-4) To account for differences in recipient population
719	719	and provider entity size, the commission shall establish provider
720	720	network adequacy standards, other than travel time and distance
721	721	standards, applicable in assessing the network adequacy for
722	722	personal care attendants and providers of long-term services and
723	723	supports who travel to a recipient to provide care. The external
724	724	quality review organization shall periodically evaluate and report
725	725	to the commission on personal care attendant network adequacy.
726	726	(d) The executive commissioner by rule shall ensure that an
727	727	evaluation of a Medicaid managed care organization's provider
728	728	network adequacy conducted by the commission or the external
729	729	quality review organization with information obtained from a
730	730	managed care organization's provider network directory is based on
731	731	the total number of providers listed in the directory. The
732	732	commission or external quality review organization must consider a
733	733	provider with incorrect contact information or who is no longer
734	734	participating in Medicaid as having no appointment availability for
735	735	purposes of the evaluation.
736	736	(e) The external quality review organization shall use
737	737	existing encounter data to monitor a Medicaid managed care
738	738	organization's network adequacy and the accuracy of the
739	739	organization's provider directories.
740	740	SECTION 17. Section 533.0063, Government Code, is amended
741	741	by adding Subsection (d) to read as follows:
742	742	(d) The commission shall use the commission's master file of
743	743	Medicaid providers to validate the provider network directory of a
744	744	managed care organization described by Subsection (a).
745	745	SECTION 18. Section 533.0071, Government Code, is amended
746	746	to read as follows:
747	747	Sec. 533.0071. ADMINISTRATION OF CONTRACTS. (a) The
748	748	commission shall make every effort to improve the administration of
749	749	contracts with Medicaid managed care organizations. To improve the
750	750	administration of these contracts, the commission shall:
751	751	(1) ensure that the commission has appropriate
752	752	expertise and qualified staff to effectively manage contracts with
753	753	managed care organizations under the Medicaid managed care program;
754	754	(2) evaluate options for Medicaid payment recovery
755	755	from managed care organizations if the enrollee dies or is
756	756	incarcerated or if an enrollee is enrolled in more than one state
757	757	program or is covered by another liable third party insurer;
758	758	(3) maximize Medicaid payment recovery options by
759	759	contracting with private vendors to assist in the recovery of
760	760	capitation payments, payments from other liable third parties, and
761	761	other payments made to managed care organizations with respect to
762	762	enrollees who leave the managed care program; and
763	763	(4) decrease the administrative burdens of managed
764	764	care for the state, the managed care organizations, and the
765	765	providers under managed care networks to the extent that those
766	766	changes are compatible with state law and existing Medicaid managed
767	767	care contracts, including decreasing those burdens by:
768	768	(A) where possible, decreasing the duplication
769	769	of administrative reporting and process requirements for the
770	770	managed care organizations and providers, such as requirements for
771	771	the submission of encounter data, quality reports, historically
772	772	underutilized business reports, and claims payment summary
773	773	reports;
774	774	(B) allowing managed care organizations to
775	775	provide updated address information directly to the commission for
776	776	correction in the state system;
777	777	(C) promoting consistency and uniformity among
778	778	managed care organization policies, including policies relating to
779	779	the preauthorization process, lengths of hospital stays, filing
780	780	deadlines, levels of care, and case management services;
781	781	(D) reviewing the appropriateness of primary
782	782	care case management requirements in the admission and clinical
783	783	criteria process, such as requirements relating to including a
784	784	separate cover sheet for all communications, submitting
785	785	handwritten communications instead of electronic or typed review
786	786	processes, and admitting patients listed on separate
787	787	notifications; and
788	788	(E) providing a portal through which providers in
789	789	any managed care organization's provider network may submit acute
790	790	care services and long-term services and supports claims[; and
791	791	[(5) reserve the right to amend the managed care
792	792	organization's process for resolving provider appeals of denials
793	793	based on medical necessity to include an independent review process
794	794	established by the commission for final determination of these
795	795	disputes].
796	796	(b) For a contract described by Subsection (a), the
797	797	commission shall:
798	798	(1) automate the process for receiving and tracking
799	799	contract amendment requests and incorporating an amendment into a
800	800	contract;
801	801	(2) make the most recent contract amendment
802	802	information readily available among divisions within the
803	803	commission; and
804	804	(3) provide technical assistance and education to help
805	805	a commission employee determine whether a requested contract
806	806	amendment is necessary or whether the issue could be resolved
807	807	through the uniform managed care manual, a memorandum, or guidance.
808	808	(c) The commission shall create a summary compliance
809	809	framework that summarizes contract provisions to help Medicaid
810	810	managed care organizations comply with those provisions.
811	811	(d) The commission shall annually review and assess
812	812	contract deliverables and eliminate unnecessary deliverables for
813	813	Medicaid managed care contracts. The commission may identify
814	814	measures to strengthen the contract deliverables and implement
815	815	those measures as needed.
816	816	SECTION 19. Subchapter A, Chapter 533, Government Code, is
817	817	amended by adding Section 533.00715 to read as follows:
818	818	Sec. 533.00715. INDEPENDENT APPEALS PROCEDURE. (a) In
819	819	this section, "third-party arbiter" means a third-party medical
820	820	review organization that provides objective, unbiased medical
821	821	necessity determinations conducted by clinical staff with
822	822	education and practice in the same or similar practice area as the
823	823	procedure for which an independent determination of medical
824	824	necessity is sought.
825	825	(b) The commission shall contract with an independent,
826	826	third-party arbiter to resolve recipient appeals related to a
827	827	reduction in or denial of health care services on the basis of
828	828	medical necessity in the Medicaid managed care program.
829	829	(c) The arbiter shall establish a common procedure for
830	830	appeals. The procedure must provide that a health care service
831	831	ordered by a health care provider is presumed medically necessary
832	832	and the Medicaid managed care organization bears the burden of
833	833	proof to show the health care service is not medically necessary.
834	834	The arbiter shall also establish a procedure for expedited appeals
835	835	that allows the arbiter to:
836	836	(1) identify an appeal that requires an expedited
837	837	resolution; and
838	838	(2) resolve the appeal within a specified period.
839	839	(d) The arbiter shall establish and maintain an Internet
840	840	portal through which a recipient may track the status and final
841	841	disposition of an appeal.
842	842	(e) The arbiter shall educate recipients and employees of
843	843	Medicaid managed care organizations regarding appeals processes,
844	844	options, and proper and improper denials of health care services on
845	845	the basis of medical necessity.
846	846	(f) The third-party arbiter shall review aggregate denial
847	847	data categorized by Medicaid managed care plan to identify trends
848	848	and determine whether a Medicaid managed care organization is
849	849	disproportionately denying prior authorization requests from a
850	850	single provider or set of providers.
851	851	SECTION 20. The heading to Section 533.0072, Government
852	852	Code, is amended to read as follows:
853	853	Sec. 533.0072. CORRECTIVE ACTION PLANS AND [INTERNET
854	854	POSTING OF] SANCTIONS IMPOSED FOR CONTRACTUAL VIOLATIONS.
855	855	SECTION 21. Section 533.0072, Government Code, is amended
856	856	by amending Subsections (a), (b), and (c) and adding Subsections
857	857	(b-1) and (b-2) to read as follows:
858	858	(a) The commission shall prepare and maintain a record of
859	859	each enforcement action initiated by the commission [that results
860	860	in a sanction, including a penalty, being imposed] against a
861	861	managed care organization for failure to comply with the terms of a
862	862	contract to provide health care services to recipients through a
863	863	managed care plan issued by the organization, including:
864	864	(1) an enforcement action that results in a sanction,
865	865	including a penalty;
866	866	(2) the imposition of a corrective action plan;
867	867	(3) the imposition of liquidated damages;
868	868	(4) the suspension of default enrollment; and
869	869	(5) the termination of the organization's contract.
870	870	(b) The record must include:
871	871	(1) the name and address of the organization;
872	872	(2) a description of the contractual obligation the
873	873	organization failed to meet;
874	874	(3) the date of determination of noncompliance;
875	875	(4) the date the sanction was imposed, if applicable;
876	876	(5) the maximum sanction that may be imposed under the
877	877	contract for the violation, if applicable; and
878	878	(6) the actual sanction imposed against the
879	879	organization, if applicable.
880	880	(b-1) In assessing liquidated damages against a Medicaid
881	881	managed care organization, the commission shall:
882	882	(1) include in the record prepared under Subsection
883	883	(a):
884	884	(A) each step taken in the process of
885	885	recommending and assessing liquidated damages; and
886	886	(B) the reason for any reduction of liquidated
887	887	damages from the recommended amount;
888	888	(2) assess liquidated damages in an amount that is
889	889	sufficient to ensure compliance with the uniform managed care
890	890	contract and is a reasonable forecast of the damages caused by the
891	891	noncompliance; and
892	892	(3) apply liquidated damages and other enforcement
893	893	actions consistently among Medicaid managed care organizations for
894	894	similar violations.
895	895	(b-2) If the commission reduces the sanction or penalty in
896	896	an enforcement action, the commission shall include in the record
897	897	prepared under Subsection (a) the reason for the reduction.
898	898	(c) The commission shall post and maintain the records
899	899	required by this section on the commission's Internet website in
900	900	English and Spanish. The commission's office of inspector general
901	901	shall post and maintain the records relating to corrective action
902	902	plans required by this section on the office's Internet website.
903	903	The records must be posted in a format that is readily accessible to
904	904	and understandable by a member of the public. The commission and
905	905	the office shall update the list of records on the website at least
906	906	quarterly.
907	907	SECTION 22. Section 533.0075, Government Code, is amended
908	908	to read as follows:
909	909	Sec. 533.0075. RECIPIENT ENROLLMENT. (a) The commission
910	910	shall:
911	911	(1) encourage recipients to choose appropriate
912	912	managed care plans and primary health care providers by:
913	913	(A) providing initial information to recipients
914	914	and providers in a region about the need for recipients to choose
915	915	plans and providers not later than the 90th day before the date on
916	916	which a managed care organization plans to begin to provide health
917	917	care services to recipients in that region through managed care;
918	918	(B) providing follow-up information before
919	919	assignment of plans and providers and after assignment, if
920	920	necessary, to recipients who delay in choosing plans and providers;
921	921	and
922	922	(C) allowing plans and providers to provide
923	923	information to recipients or engage in marketing activities under
924	924	marketing guidelines established by the commission under Section
925	925	533.008 after the commission approves the information or
926	926	activities;
927	927	(2) consider the following factors in assigning
928	928	managed care plans and primary health care providers to recipients
929	929	who fail to choose plans and providers:
930	930	(A) the importance of maintaining existing
931	931	provider-patient and physician-patient relationships, including
932	932	relationships with specialists, public health clinics, and
933	933	community health centers;
934	934	(B) to the extent possible, the need to assign
935	935	family members to the same providers and plans; [and]
936	936	(C) geographic convenience of plans and
937	937	providers for recipients;
938	938	(D) a recipient's previous plan assignment;
939	939	(E) the Medicaid managed care organization's
940	940	performance on quality assurance and improvement;
941	941	(F) enforcement actions, including liquidated
942	942	damages, imposed against the managed care organization;
943	943	(G) corrective action plans the commission has
944	944	required the managed care organization to implement; and
945	945	(H) other reasonable factors that support the
946	946	objectives of the managed care program;
947	947	(3) retain responsibility for enrollment and
948	948	disenrollment of recipients in managed care plans, except that the
949	949	commission may delegate the responsibility to an independent
950	950	contractor who receives no form of payment from, and has no
951	951	financial ties to, any managed care organization;
952	952	(4) develop and implement an expedited process for
953	953	determining eligibility for and enrolling pregnant women and
954	954	newborn infants in managed care plans; and
955	955	(5) ensure immediate access to prenatal services and
956	956	newborn care for pregnant women and newborn infants enrolled in
957	957	managed care plans, including ensuring that a pregnant woman may
958	958	obtain an appointment with an obstetrical care provider for an
959	959	initial maternity evaluation not later than the 30th day after the
960	960	date the woman applies for Medicaid.
961	961	(b) To help new recipients easily compare managed care plans
962	962	with regard to quality and patient satisfaction measures, the
963	963	commission shall incorporate information the commission determines
964	964	is relevant in Medicaid managed care report cards, including:
965	965	(1) feedback from recipient complaints;
966	966	(2) a Medicaid managed care organization's rate of
967	967	denials and appeals;
968	968	(3) outcomes of internal appeals; and
969	969	(4) information for each organization related to
970	970	independent appeals under Section 533.00715.
971	971	(c) After enrolling a recipient in the medically dependent
972	972	children (MDCP) waiver program or the STAR+PLUS Medicaid managed
973	973	care program, the commission shall require the recipient's or
974	974	legally authorized representative's electronic signature to verify
975	975	the recipient received the recipient handbook.
976	976	(d) The commission shall:
977	977	(1) survey a select sample of recipients receiving
978	978	benefits under the medically dependent children (MDCP) waiver
979	979	program or the STAR+PLUS Medicaid managed care program to determine
980	980	whether the recipients:
981	981	(A) received the recipient handbook required by
982	982	contract to be provided within the required period; and
983	983	(B) understand the information in the recipient
984	984	handbook; and
985	985	(2) provide a sample recipient handbook to Medicaid
986	986	managed care organizations.
987	987	SECTION 23. Subchapter A, Chapter 533, Government Code, is
988	988	amended by adding Section 533.0095 to read as follows:
989	989	Sec. 533.0095. CERTAIN PRIOR AUTHORIZATION EXTENSIONS. (a)
990	990	The commission shall establish a list of health care services and
991	991	prescription drugs for which a Medicaid managed care organization
992	992	must grant extended prior authorization periods or amounts, as
993	993	applicable, without requiring additional proof or documentation.
994	994	The commission shall also establish a list of chronic health and
995	995	mental health conditions the treatments for which a Medicaid
996	996	managed care organization must grant extended prior authorization
997	997	periods without requiring additional proof or documentation. The
998	998	commission shall establish the extended periods and amounts.
999	999	(b) The commission shall establish the lists in
1000	1000	consultation with stakeholders, including physicians, hospitals,
1001	1001	patient advocacy groups, and Medicaid managed care organizations.
1002	1002	The commission shall consult with stakeholders through the Medicaid
1003	1003	managed care advisory committee.
1004	1004	(c) The commission's medical director shall solicit and
1005	1005	receive provider feedback regarding extended prior authorization
1006	1006	periods, including feedback related to which health care services,
1007	1007	prescription drugs, and health and mental health conditions should
1008	1008	be subject to extended prior authorization periods.
1009	1009	(d) The commission shall update the lists semiannually with
1010	1010	input from the medical care advisory committee established under
1011	1011	Section 32.022, Human Resources Code.
1012	1012	SECTION 24. The heading to Section 533.015, Government
1013	1013	Code, is amended to read as follows:
1014	1014	Sec. 533.015. [COORDINATION OF] EXTERNAL OVERSIGHT
1015	1015	ACTIVITIES.
1016	1016	SECTION 25. Section 533.015, Government Code, is amended by
1017	1017	adding Subsection (d) to read as follows:
1018	1018	(d) In overseeing Medicaid managed care organizations, the
1019	1019	commission's office of inspector general shall use a program
1020	1020	integrity methodology appropriate for managed care. The office may
1021	1021	explore different options to measure program integrity efforts,
1022	1022	including:
1023	1023	(1) quantifying and validating cost avoidance in a
1024	1024	managed care context; and
1025	1025	(2) adapting existing program integrity tools to
1026	1026	address specific risks and incentives related to risk-based and
1027	1027	value-based arrangements.
1028	1028	SECTION 26. Subchapter A, Chapter 533, Government Code, is
1029	1029	amended by adding Sections 533.026, 533.027, 533.028, and 533.031
1030	1030	to read as follows:
1031	1031	Sec. 533.026. ENHANCED DATA COLLECTION AND REPORTING OF
1032	1032	ADMINISTRATIVE COSTS; CONTRACT OVERSIGHT. (a) The commission
1033	1033	shall collect accurate, consistent, and verifiable data from
1034	1034	Medicaid managed care organizations, including line-item data for
1035	1035	administrative costs.
1036	1036	(b) The commission shall use data collected from a Medicaid
1037	1037	managed care organization under this section to:
1038	1038	(1) identify grievances, as defined by Section
1039	1039	533.027;
1040	1040	(2) monitor contract compliance;
1041	1041	(3) identify other programmatic issues; and
1042	1042	(4) identify whether the organization is:
1043	1043	(A) unnecessarily denying, reducing, or
1044	1044	otherwise failing to provide health care services to recipients;
1045	1045	(B) delaying or denying provider claims due to
1046	1046	technical or minimal errors; or
1047	1047	(C) otherwise engaging in behavior that merits an
1048	1048	enforcement action.
1049	1049	(c) A Medicaid managed care organization shall report
1050	1050	administrative costs in the organization's financial statistical
1051	1051	report and shall report those costs to the commission at least
1052	1052	annually. The commission shall report information provided under
1053	1053	this subsection annually to the lieutenant governor, the speaker of
1054	1054	the house, and each standing committee of the legislature with
1055	1055	jurisdiction over financing, operating, and overseeing Medicaid.
1056	1056	(d) The commission shall use data from grievances collected
1057	1057	under Section 533.027 for contract oversight and to determine
1058	1058	contract risk.
1059	1059	(e) The commission shall:
1060	1060	(1) provide financial subject matter expertise for
1061	1061	Medicaid managed care contract review and compliance oversight
1062	1062	among divisions within the commission;
1063	1063	(2) conduct extensive validation of Medicaid managed
1064	1064	care financial data; and
1065	1065	(3) analyze the ultimate underlying cause of an issue
1066	1066	to resolve that cause and prevent similar issues from arising in the
1067	1067	future within Medicaid managed care.
1068	1068	(f) The commission's office of inspector general shall
1069	1069	assist the commission in implementing this section.
1070	1070	Sec. 533.027. MANAGED CARE GRIEVANCES: PROCESSES AND
1071	1071	TRACKING. (a) In this section, "grievance" includes an inquiry
1072	1072	about services or benefits, an inquiry or complaint about access to
1073	1073	a provider in a recipient's local area, a formal complaint, a
1074	1074	request for internal appeal, a request for a fair hearing, and a
1075	1075	complaint brought by an individual or entity, including a
1076	1076	legislator or the commission, submitted to or received by:
1077	1077	(1) a commission employee;
1078	1078	(2) a Medicaid managed care organization;
1079	1079	(3) the commission's office of inspector general;
1080	1080	(4) the commission's office of the ombudsman;
1081	1081	(5) the office of ombudsman for Medicaid providers; or
1082	1082	(6) the Department of Family and Protective Services.
1083	1083	(b) The commission shall:
1084	1084	(1) provide education and training to commission
1085	1085	employees on the correct issue resolution processes for Medicaid
1086	1086	managed care grievances; and
1087	1087	(2) require those employees to promptly report
1088	1088	grievances into the commission's grievance tracking system to
1089	1089	enable employees to track and timely resolve grievances.
1090	1090	(c) To ensure all grievances are managed consistently, the
1091	1091	commission shall ensure the definition of a grievance is consistent
1092	1092	among:
1093	1093	(1) commission employees and divisions within the
1094	1094	commission;
1095	1095	(2) Medicaid managed care organizations;
1096	1096	(3) the commission's office of inspector general;
1097	1097	(4) the commission's office of the ombudsman;
1098	1098	(5) the office of ombudsman for Medicaid providers;
1099	1099	and
1100	1100	(6) the Department of Family and Protective Services.
1101	1101	(d) The commission shall enhance the Medicaid managed care
1102	1102	grievance-tracking system's reporting capabilities and standardize
1103	1103	data reporting among divisions within the commission.
1104	1104	(e) In coordination with the executive commissioner's
1105	1105	duties under Section 531.0171, the commission shall implement a
1106	1106	no-wrong-door system for Medicaid managed care grievances reported
1107	1107	to the commission. The commission shall ensure that commission
1108	1108	employees, Medicaid managed care organizations, the commission's
1109	1109	office of inspector general, the commission's office of the
1110	1110	ombudsman, the office of ombudsman for Medicaid providers, and the
1111	1111	Department of Family and Protective Services use common practices
1112	1112	and policies and provide consistent resolutions for Medicaid
1113	1113	managed care grievances.
1114	1114	(f) The commission in conjunction with the commission's
1115	1115	office of inspector general shall:
1116	1116	(1) implement a data analytics program to aggregate
1117	1117	rates of inquiries, complaints, calls, denials, and fair hearing
1118	1118	requests; and
1119	1119	(2) include the aggregate rating and data analysis in
1120	1120	each Medicaid managed care organization's quality rating.
1121	1121	Sec. 533.028. CARE COORDINATION AND CARE COORDINATORS. (a)
1122	1122	In this section, "care coordination" means assisting recipients to
1123	1123	develop a plan of care, including a service plan, that meets the
1124	1124	recipient's needs and coordinating the provision of Medicaid
1125	1125	benefits in a manner that is consistent with the plan of care. The
1126	1126	term is synonymous with "case management," "service coordination,"
1127	1127	and "service management."
1128	1128	(b) The commission shall ensure a person, including a case
1129	1129	manager, who is engaged by a Medicaid managed care organization to
1130	1130	provide care coordination benefits is consistently referred to as a
1131	1131	"care coordinator" throughout divisions within the commission and
1132	1132	across all Medicaid programs and services for recipients receiving
1133	1133	benefits under a managed care delivery model.
1134	1134	(c) The commission shall expeditiously develop materials
1135	1135	explaining the role of care coordinators by Medicaid managed care
1136	1136	product line. The commission shall establish clear expectations
1137	1137	that the care coordinator communicate with a recipient's health
1138	1138	care providers with the goal of ensuring coordinated, effective,
1139	1139	and efficient care delivery.
1140	1140	(d) The commission shall collect data on care coordination
1141	1141	touchpoints with recipients.
1142	1142	(e) The commission shall provide to each Medicaid managed
1143	1143	care organization information regarding best practices for care
1144	1144	coordination services for the organization to incorporate into
1145	1145	providing care.
1146	1146	(f) The commission shall require a Medicaid managed care
1147	1147	organization to offer a provider in the organization's provider
1148	1148	network the option to have an organization's care coordinator
1149	1149	on-site at the provider's practice. The commission shall ensure a
1150	1150	care coordinator is reimbursed for care coordination services
1151	1151	provided on-site and encourage managed care organizations to place
1152	1152	care coordinators on-site.
1153	1153	(g) In this subsection, "potentially preventable admission"
1154	1154	and "potentially preventable readmission" have the meanings
1155	1155	assigned by Section 536.001. The commission shall change the
1156	1156	methodology for calculating potentially preventable admissions and
1157	1157	potentially preventable readmissions to exclude from those
1158	1158	admission and readmission rates hospitalizations in which a
1159	1159	Medicaid managed care organization did not adequately coordinate
1160	1160	the patient's care. The methodology must apply to physical and
1161	1161	behavioral health conditions.
1162	1162	(h) The executive commissioner shall include a provision
1163	1163	establishing key performance metrics for care coordination in a
1164	1164	contract between a managed care organization and the commission for
1165	1165	the organization to provide health care services to recipients
1166	1166	receiving home and community-based services under the:
1167	1167	(1) STAR+PLUS Medicaid managed care program;
1168	1168	(2) STAR Kids managed care program; or
1169	1169	(3) STAR Health program.
1170	1170	(i) The commission shall establish for Medicaid managed
1171	1171	care organizations and ensure compliance with metrics for the
1172	1172	following:
1173	1173	(1) a dedicated toll-free care coordination telephone
1174	1174	number;
1175	1175	(2) the time frame for the return of telephone calls;
1176	1176	(3) notice of the name and telephone number of a
1177	1177	recipient's care coordinator;
1178	1178	(4) notice of changes in the name or telephone number
1179	1179	of a recipient's care coordinator;
1180	1180	(5) initiation of assessments and reassessments;
1181	1181	(6) establishment and regular updating of
1182	1182	comprehensive, person-centered individual service plans; and
1183	1183	(7) number of face-to-face and telephonic contacts for
1184	1184	each care coordination level.
1185	1185	Sec. 533.031. COORDINATION OF BENEFITS UNDER MEDICALLY
1186	1186	DEPENDENT CHILDREN (MDCP) WAIVER PROGRAM. The commission shall
1187	1187	prohibit a Medicaid managed care organization providing health care
1188	1188	services under the medically dependent children (MDCP) waiver
1189	1189	program from requiring additional authorization from an enrolled
1190	1190	child's health care provider for a service if the child's third
1191	1191	party health benefit plan issuer authorizes the service.
1192	1192	SECTION 27. Section 536.007, Government Code, is amended by
1193	1193	adding Subsection (b) to read as follows:
1194	1194	(b) The commission's medical director is responsible for
1195	1195	convening periodic meetings with Medicaid health care providers,
1196	1196	including hospitals, to analyze and evaluate all Medicaid managed
1197	1197	care and health care provider quality-based programs to ensure
1198	1198	feasibility and alignment among programs.
1199	1199	SECTION 28. As soon as practicable after the effective date
1200	1200	of this Act, the Health and Human Services Commission shall
1201	1201	implement the changes in law made by this Act.
1202	1202	SECTION 29. Section 533.005, Government Code, as amended by
1203	1203	this Act, applies only to a contract entered into or renewed on or
1204	1204	after the effective date of this Act. A contract entered into or
1205	1205	renewed before that date is governed by the law in effect on the
1206	1206	date the contract was entered into or renewed, and that law is
1207	1207	continued in effect for that purpose.
1208	1208	SECTION 30. If before implementing any provision of this
1209	1209	Act a state agency determines that a waiver or authorization from a
1210	1210	federal agency is necessary for implementation of that provision,
1211	1211	the agency affected by the provision shall request the waiver or
1212	1212	authorization and may delay implementing that provision until the
1213	1213	waiver or authorization is granted.
1214	1214	SECTION 31. If any provision of this Act or its application
1215	1215	to any person or circumstance is held invalid, the invalidity does
1216	1216	not affect other provisions or applications of this Act that can be
1217	1217	given effect without the invalid provision or application, and to
1218	1218	this end the provisions of this Act are declared to be severable.
1219	1219	SECTION 32. This Act takes effect September 1, 2019.