Texas 2019 - 86th Regular

Texas Senate Bill SB1140 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	By: Watson, et al. S.B. No. 1140
2		-	(Frank)
	1	+	By: Watson, Hinojosa, West S.B. No. 1140
3	2
4	3
5	4		A BILL TO BE ENTITLED
6	5		AN ACT
7	6		relating to an independent medical review of certain determinations
8	7		by the Health and Human Services Commission or a Medicaid managed
9	8		care organization.
10	9		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	10		SECTION 1. Subchapter A, Chapter 533, Government Code, is
12	11		amended by adding Section 533.00715 to read as follows:
13	12		Sec. 533.00715. INDEPENDENT APPEALS PROCEDURE. (a) In
14	13		this section, "third-party arbiter" means a third-party medical
15	14		review organization that provides objective, unbiased medical
16	15		necessity determinations conducted by clinical staff with
17	16		education and practice in the same or similar practice area as the
18	17		procedure for which an independent determination of medical
19	18		necessity is sought.
20	19		(b) The commission, using money appropriated for the
21	20		purpose, shall contract with at least three independent,
22	21		third-party arbiters to resolve an appeal of:
23	22		(1) a Medicaid managed care organization adverse
24	23		benefit determination made on the basis of medical necessity;
25	24		(2) a denial by the commission of eligibility for a
26	25		Medicaid program on the basis of the recipient's or applicant's
27	26		medical and functional needs; and
28	27		(3) an action, as defined by 42 C.F.R. Section
29	28		431.201, by the commission based on the recipient's medical and
30	29		functional needs.
31	30		(c) An appeal described by Subsection (b)(1) occurs after
32	31		the Medicaid managed care organization internal appeal decision is
33	32		issued and before the Medicaid fair hearing, and the appeal is
34	33		granted when a recipient contests the internal appeal decision. An
35	34		appeal described by Subsection (b)(2) or (3) occurs after the
36	35		commission's denial is issued or action is taken and before the
37	36		Medicaid fair hearing.
38	37		(d) The commission shall establish a common procedure for
39	38		appeals. The procedure must provide that a health care service
40	39		ordered by a health care provider is presumed medically necessary
41	40		and the commission or Medicaid managed care organization bears the
42	41		burden of proof to show the health care service is not medically
43	42		necessary. The third-party arbiter shall conduct the appeal within
44	43		a period specified by the commission. The commission shall also
45	44		establish a procedure for expedited appeals that allows a
46	45		third-party arbiter to:
47	46		(1) identify an appeal that requires an expedited
48	47		resolution; and
49	48		(2) resolve the appeal within a specified period.
50	49		(e) Subject to Subsection (f), the commission shall ensure
51	50		an appeal is randomly assigned to a third-party arbiter.
52	51		(f) The commission shall ensure each third-party arbiter
53	52		has the necessary medical expertise to resolve an appeal.
54	53		(g) A third-party arbiter shall establish and maintain an
55	54		Internet portal through which a recipient may track the status and
56	55		final disposition of an appeal.
57	56		(h) A third-party arbiter shall educate recipients
58	57		regarding:
59	58		(1) appeals processes and options;
60	59		(2) proper and improper denials of health care
61	60		services on the basis of medical necessity; and
62	61		(3) information available through the commission's
63	62		office of the ombudsman.
64	63		(i) A third-party arbiter may share with Medicaid managed
65	64		care organizations information regarding:
66	65		(1) appeals processes; and
67	66		(2) the types of documents the arbiter may require
68	67		from the organization to resolve appeals.
69	68		(j) A third-party arbiter shall notify the commission of the
70	69		final disposition of each appeal. The commission shall review
71	70		aggregate denial data categorized by Medicaid managed care plan to
72	71		identify trends and determine whether a Medicaid managed care
73	72		organization is disproportionately denying prior authorization
74	73		requests from a single provider or set of providers.
75	74		SECTION 2. As soon as practicable after the effective date
76	75		of this Act, the executive commissioner of the Health and Human
77	76		Services Commission shall adopt the rules necessary to implement
78	77		this Act.
79	78		SECTION 3. If before implementing any provision of this Act
80	79		a state agency determines that a waiver or authorization from a
81	80		federal agency is necessary for implementation of that provision,
82	81		the agency affected by the provision shall request the waiver or
83	82		authorization and may delay implementing that provision until the
84	83		waiver or authorization is granted.
85	84		SECTION 4. This Act takes effect September 1, 2019.