By: Watson, Hinojosa, West S.B. No. 1140
A BILL TO BE ENTITLED
AN ACT
relating to an independent medical review of certain determinations
by the Health and Human Services Commission or a Medicaid managed
care organization.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.00715 to read as follows:
Sec. 533.00715. INDEPENDENT APPEALS PROCEDURE. (a) In
this section, "third-party arbiter" means a third-party medical
review organization that provides objective, unbiased medical
necessity determinations conducted by clinical staff with
education and practice in the same or similar practice area as the
procedure for which an independent determination of medical
necessity is sought.
(b) The commission, using money appropriated for the
purpose, shall contract with at least three independent,
third-party arbiters to resolve an appeal of:
(1) a Medicaid managed care organization adverse
benefit determination made on the basis of medical necessity;
(2) a denial by the commission of eligibility for a
Medicaid program on the basis of the recipient's or applicant's
medical and functional needs; and
(3) an action, as defined by 42 C.F.R. Section
431.201, by the commission based on the recipient's medical and
functional needs.
(c) An appeal described by Subsection (b)(1) occurs after
the Medicaid managed care organization internal appeal decision is
issued and before the Medicaid fair hearing, and the appeal is
granted when a recipient contests the internal appeal decision. An
appeal described by Subsection (b)(2) or (3) occurs after the
commission's denial is issued or action is taken and before the
Medicaid fair hearing.
(d) The commission shall establish a common procedure for
appeals. The procedure must provide that a health care service
ordered by a health care provider is presumed medically necessary
and the commission or Medicaid managed care organization bears the
burden of proof to show the health care service is not medically
necessary. The third-party arbiter shall conduct the appeal within
a period specified by the commission. The commission shall also
establish a procedure for expedited appeals that allows a
third-party arbiter to:
(1) identify an appeal that requires an expedited
resolution; and
(2) resolve the appeal within a specified period.
(e) Subject to Subsection (f), the commission shall ensure
an appeal is randomly assigned to a third-party arbiter.
(f) The commission shall ensure each third-party arbiter
has the necessary medical expertise to resolve an appeal.
(g) A third-party arbiter shall establish and maintain an
Internet portal through which a recipient may track the status and
final disposition of an appeal.
(h) A third-party arbiter shall educate recipients
regarding:
(1) appeals processes and options;
(2) proper and improper denials of health care
services on the basis of medical necessity; and
(3) information available through the commission's
office of the ombudsman.
(i) A third-party arbiter may share with Medicaid managed
care organizations information regarding:
(1) appeals processes; and
(2) the types of documents the arbiter may require
from the organization to resolve appeals.
(j) A third-party arbiter shall notify the commission of the
final disposition of each appeal. The commission shall review
aggregate denial data categorized by Medicaid managed care plan to
identify trends and determine whether a Medicaid managed care
organization is disproportionately denying prior authorization
requests from a single provider or set of providers.
SECTION 2. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall adopt the rules necessary to implement
this Act.
SECTION 3. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4. This Act takes effect September 1, 2019.