Texas 2019 - 86th Regular

Texas Senate Bill SB1207 Compare Versions

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Old	New		Differences
1		-	S.B. No. 1207
	1	+	86R31958 LED-D
	2	+	By: Perry, et al. S.B. No. 1207
	3	+	(Krause, Parker, Leach, Davis of Harris)
	4	+	Substitute the following for S.B. No. 1207: No.
2	5
3	6
	7	+	A BILL TO BE ENTITLED
4	8		AN ACT
5	9		relating to the operation and administration of Medicaid, including
6	10		the Medicaid managed care program and the medically dependent
7	11		children (MDCP) waiver program.
8	12		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	13		SECTION 1. Section 531.001, Government Code, is amended by
10	14		adding Subdivision (4-c) to read as follows:
11	15		(4-c) "Medicaid managed care organization" means a
12	16		managed care organization as defined by Section 533.001 that
13	17		contracts with the commission under Chapter 533 to provide health
14	18		care services to Medicaid recipients.
15		-	SECTION 2. Section 531.024, Government Code, is amended by
16		-	amending Subsection (b) and adding Subsection (c) to read as
17		-	follows:
18		-	(b) The rules promulgated under Subsection (a)(7) must
19		-	provide due process to an applicant for Medicaid services and to a
20		-	Medicaid recipient who seeks a Medicaid service, including a
21		-	service that requires prior authorization. The rules must provide
22		-	the protections for applicants and recipients required by 42 C.F.R.
23		-	Part 431, Subpart E, including requiring that:
24		-	(1) the written notice to an individual of the
25		-	individual's right to a hearing must:
26		-	(A) contain an explanation of the circumstances
27		-	under which Medicaid is continued if a hearing is requested; and
28		-	(B) be delivered by mail, and postmarked [mailed]
29		-	at least 10 business days, before the date the individual's
30		-	Medicaid eligibility or service is scheduled to be terminated,
31		-	suspended, or reduced, except as provided by 42 C.F.R. Section
32		-	431.213 or 431.214; and
33		-	(2) if a hearing is requested before the date a
34		-	Medicaid recipient's service, including a service that requires
35		-	prior authorization, is scheduled to be terminated, suspended, or
36		-	reduced, the agency may not take that proposed action before a
37		-	decision is rendered after the hearing unless:
38		-	(A) it is determined at the hearing that the sole
39		-	issue is one of federal or state law or policy; and
40		-	(B) the agency promptly informs the recipient in
41		-	writing that services are to be terminated, suspended, or reduced
42		-	pending the hearing decision.
43		-	(c) The commission shall develop a process to address a
44		-	situation in which:
45		-	(1) an individual does not receive adequate notice as
46		-	required by Subsection (b)(1); or
47		-	(2) the notice required by Subsection (b)(1) is
48		-	delivered without a postmark.
49		-	SECTION 3. (a) To the extent of any conflict, Section
50		-	531.024162, Government Code, as added by this section, prevails
51		-	over any provision of another Act of the 86th Legislature, Regular
52		-	Session, 2019, relating to notice requirements regarding Medicaid
53		-	coverage or prior authorization denials or incomplete requests,
54		-	that becomes law.
55		-	(b) Subchapter B, Chapter 531, Government Code, is amended
56		-	by adding Sections 531.024162, 531.024163, 531.024164, 531.0601,
57		-	531.0602, 531.06021, 531.0603, and 531.0604 to read as follows:
	19	+	SECTION 2. Section 531.02444, Government Code, is amended
	20	+	by amending Subsection (a) and adding Subsections (d) and (e) to
	21	+	read as follows:
	22	+	(a) The executive commissioner shall develop and implement:
	23	+	(1) a Medicaid buy-in program for persons with
	24	+	disabilities as authorized by the Ticket to Work and Work
	25	+	Incentives Improvement Act of 1999 (Pub. L. No. 106-170) or the
	26	+	Balanced Budget Act of 1997 (Pub. L. No. 105-33); and
	27	+	(2) subject to Subsection (d) as authorized by the
	28	+	Deficit Reduction Act of 2005 (Pub. L. No. 109-171), a Medicaid
	29	+	buy-in program for children with disabilities that are [is]
	30	+	described by 42 U.S.C. Section 1396a(cc)(1) and whose family
	31	+	incomes do not exceed 300 percent of the applicable federal poverty
	32	+	level.
	33	+	(d) The executive commissioner by rule shall increase the
	34	+	maximum family income prescribed by Subsection (a)(2) for
	35	+	determining eligibility of children with disabilities for the
	36	+	buy-in program under that subdivision to the maximum family income
	37	+	amount for which federal matching funds are available, considering
	38	+	available appropriations for that purpose.
	39	+	(e) The commission shall, at the request of a child's
	40	+	legally authorized representative, conduct a disability
	41	+	determination assessment of the child to determine the child's
	42	+	eligibility for the buy-in program under Subsection (a)(2). The
	43	+	commission shall directly conduct the disability determination
	44	+	assessment and may not contract with a Medicaid managed care
	45	+	organization or other entity to conduct the assessment.
	46	+	SECTION 3. Subchapter B, Chapter 531, Government Code, is
	47	+	amended by adding Sections 531.024162, 531.024163, 531.024164,
	48	+	531.0601, 531.0602, and 531.06021 to read as follows:
58	49		Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID
59	50		COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
60	51		(a) The commission shall ensure that notice sent by the commission
61	52		or a Medicaid managed care organization to a Medicaid recipient or
62		-	provider regarding the denial, partial denial, reduction, or
63		-	termination of coverage or denial of prior authorization for a
64		-	service includes:
	53	+	provider regarding the denial of coverage or prior authorization
	54	+	for a service includes:
65	55		(1) information required by federal and state law and
66	56		applicable regulations;
67		-	(2) for the recipient:
68		-	(A) a clear and easy-to-understand explanation
69		-	of the reason for the decision, including a clear explanation of the
70		-	medical basis, applying the policy or accepted standard of medical
71		-	practice to the recipient's particular medical circumstances;
72		-	(B) a copy of the information sent to the
73		-	provider; and
74		-	(C) an educational component that includes a
75		-	description of the recipient's rights, an explanation of the
76		-	process related to appeals and Medicaid fair hearings, and a
77		-	description of the role of an external medical review; and
	57	+	(2) for the recipient, a clear and easy-to-understand
	58	+	explanation of the reason for the denial; and
78	59		(3) for the provider, a thorough and detailed clinical
79		-	explanation of the reason for the ~~decision~~, including, as
80		-	~~applicable,~~ information required under Subsection (b).
	60	+	explanation of the reason for the denial, including, as applicable,
	61	+	information required under Subsection (b).
81	62		(b) The commission or a Medicaid managed care organization
82	63		that receives from a provider a coverage or prior authorization
83	64		request that contains insufficient or inadequate documentation to
84	65		approve the request shall issue a notice to the provider and the
85	66		Medicaid recipient on whose behalf the request was submitted. The
86	67		notice issued under this subsection must:
87	68		(1) include a section specifically for the provider
88	69		that contains:
89	70		(A) a clear and specific list and description of
90	71		the documentation necessary for the commission or organization to
91	72		make a final determination on the request;
92	73		(B) the applicable timeline, based on the
93	74		requested service, for the provider to submit the documentation and
94	75		a description of the reconsideration process described by Section
95	76		533.00284, if applicable; and
96	77		(C) information on the manner through which a
97	78		provider may contact a Medicaid managed care organization or other
98	79		entity as required by Section 531.024163; and
99		-	(2) be sent:
100		-	(A) to the provider:
101		-	(i) using the provider's preferred method
102		-	of communication, to the extent practicable using existing
103		-	resources; and
104		-	(ii) as applicable, through an electronic
105		-	notification on an Internet portal; and
106		-	(B) to the recipient using the recipient's
107		-	preferred method of communication, to the extent practicable using
108		-	existing resources.
	80	+	(2) be sent to the provider:
	81	+	(A) using the provider's preferred method of
	82	+	contact most recently provided to the commission or the Medicaid
	83	+	managed care organization and using any alternative and known
	84	+	methods of contact; and
	85	+	(B) as applicable, through an electronic
	86	+	notification on an Internet portal.
109	87		Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING
110	88		MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive
111	89		commissioner by rule shall require each Medicaid managed care
112	90		organization or other entity responsible for authorizing coverage
113	91		for health care services under Medicaid to ensure that the
114	92		organization or entity maintains on the organization's or entity's
115	93		Internet website in an easily searchable and accessible format:
116	94		(1) the applicable timelines for prior authorization
117	95		requirements, including:
118	96		(A) the time within which the organization or
119	97		entity must make a determination on a prior authorization request;
120	98		(B) a description of the notice the organization
121	99		or entity provides to a provider and Medicaid recipient on whose
122	100		behalf the request was submitted regarding the documentation
123	101		required to complete a determination on a prior authorization
124	102		request; and
125	103		(C) the deadline by which the organization or
126	104		entity is required to submit the notice described by Paragraph (B);
127	105		and
128	106		(2) an accurate and up-to-date catalogue of coverage
129	107		criteria and prior authorization requirements, including:
130	108		(A) for a prior authorization requirement first
131	109		imposed on or after September 1, 2019, the effective date of the
132	110		requirement;
133	111		(B) a list or description of any supporting or
134	112		other documentation necessary to obtain prior authorization for a
135	113		specified service; and
136	114		(C) the date and results of each review of the
137	115		prior authorization requirement conducted under Section 533.00283,
138	116		if applicable.
139	117		(b) The executive commissioner by rule shall require each
140	118		Medicaid managed care organization or other entity responsible for
141	119		authorizing coverage for health care services under Medicaid to:
142	120		(1) adopt and maintain a process for a provider or
143	121		Medicaid recipient to contact the organization or entity to clarify
144	122		prior authorization requirements or to assist the provider in
145	123		submitting a prior authorization request; and
146	124		(2) ensure that the process described by Subdivision
147	125		(1) is not arduous or overly burdensome to a provider or recipient.
148	126		Sec. 531.024164. EXTERNAL MEDICAL REVIEW. (a) In this
149	127		section, "external medical reviewer" and "reviewer" mean a
150	128		third-party medical review organization that provides objective,
151	129		unbiased medical necessity determinations conducted by clinical
152	130		staff with education and practice in the same or similar practice
153	131		area as the procedure for which an independent determination of
154	132		medical necessity is sought in accordance with applicable state law
155	133		and rules.
156	134		(b) The commission shall contract with an independent
157	135		external medical reviewer to conduct external medical reviews and
158	136		review:
159	137		(1) the resolution of a Medicaid recipient appeal
160	138		related to a reduction in or denial of services on the basis of
161	139		medical necessity in the Medicaid managed care program; or
162	140		(2) a denial by the commission of eligibility for a
163	141		Medicaid program in which eligibility is based on a Medicaid
164	142		recipient's medical and functional needs.
165	143		(c) A Medicaid managed care organization may not have a
166	144		financial relationship with or ownership interest in the external
167	145		medical reviewer with which the commission contracts.
168	146		(d) The external medical reviewer with which the commission
169	147		contracts must:
170	148		(1) be overseen by a medical director who is a
171	149		physician licensed in this state; and
172	150		(2) employ or be able to consult with staff with
173	151		experience in providing private duty nursing services and long-term
174	152		services and supports.
175	153		(e) The commission shall establish a common procedure for
176		-	reviews. To the greatest extent possible, the procedure must
177		-	reduce administrative burdens on providers and the submission of
178		-	duplicative information or documents. Medical necessity under the
179		-	procedure must be based on publicly available, up-to-date,
180		-	evidence-based, and peer-reviewed clinical criteria. The reviewer
181		-	shall conduct the review within a period specified by the
182		-	commission. The commission shall also establish a procedure and
183		-	time frame for expedited reviews that allows the reviewer to:
184		-	(1) identify an appeal that requires an expedited
185		-	resolution; and
186		-	(2) resolve the review of the appeal within a
187		-	specified period.
188		-	(f) A Medicaid recipient or applicant, or the recipient's or
189		-	applicant's parent or legally authorized representative, must
190		-	affirmatively request an external medical review. If requested:
191		-	(1) an external medical review described by Subsection
	154	+	reviews. Medical necessity under the procedure must be based on
	155	+	publicly available, up-to-date, evidence-based, and peer-reviewed
	156	+	clinical criteria. The reviewer shall conduct the review within a
	157	+	period specified by the commission. The commission shall also
	158	+	establish a procedure for expedited reviews that allows the
	159	+	reviewer to identify an appeal that requires an expedited
	160	+	resolution.
	161	+	(f) An external medical review described by Subsection
192	162		(b)(1) occurs after the internal Medicaid managed care organization
193	163		appeal and before the Medicaid fair hearing and is granted when a
194	164		Medicaid recipient contests the internal appeal decision of the
195		-	Medicaid managed care organization; and
196		-	(2) an external medical review described by Subsection
197		-	(b)(2) occurs after the eligibility denial and before the Medicaid
198		-	fair hearing.
	165	+	Medicaid managed care organization. An external medical review
	166	+	described by Subsection (b)(2) occurs after the eligibility denial
	167	+	and before the Medicaid fair hearing. The Medicaid recipient or
	168	+	applicant, or the recipient's or applicant's parent or legally
	169	+	authorized representative, must affirmatively opt out of the
	170	+	external medical review to proceed to a Medicaid fair hearing
	171	+	without first participating in the external medical review.
199	172		(g) The external medical reviewer's determination of
200	173		medical necessity establishes the minimum level of services a
201	174		Medicaid recipient must receive, except that the level of services
202	175		may not exceed the level identified as medically necessary by the
203	176		ordering health care provider.
204	177		(h) The external medical reviewer shall require a Medicaid
205	178		managed care organization, in an external medical review relating
206	179		to a reduction in services, to submit a detailed reason for the
207	180		reduction and supporting documents.
208		-	(i) To the extent money is appropriated for this purpose,
209		-	the commission shall publish data regarding prior authorizations
210		-	reviewed by the external medical reviewer, including the rate of
211		-	prior authorization denials overturned by the external medical
212		-	reviewer and additional information the commission and the external
213		-	medical reviewer determine appropriate.
214	181		Sec. 531.0601. LONG-TERM CARE SERVICES WAIVER PROGRAM
215	182		INTEREST LISTS. (a) This section applies only to a child who is
216	183		enrolled in the medically dependent children (MDCP) waiver program
217	184		but becomes ineligible for services under the program because the
218	185		child no longer meets:
219	186		(1) the level of care criteria for medical necessity
220	187		for nursing facility care; or
221	188		(2) the age requirement for the program.
222	189		(b) A legally authorized representative of a child who is
223	190		notified by the commission that the child is no longer eligible for
224	191		the medically dependent children (MDCP) waiver program following a
225	192		Medicaid fair hearing, or without a Medicaid fair hearing if the
226	193		representative opted in writing to forego the hearing, may request
227	194		that the commission:
228	195		(1) return the child to the interest list for the
229	196		program unless the child is ineligible due to the child's age; or
230	197		(2) place the child on the interest list for another
231	198		Section 1915(c) waiver program.
232	199		(c) At the time a child's legally authorized representative
233	200		makes a request under Subsection (b), the commission shall:
234	201		(1) for a child who becomes ineligible for the reason
235	202		described by Subsection (a)(1), place the child:
236	203		(A) on the interest list for the medically
237	204		dependent children (MDCP) waiver program in the first position on
238	205		the list; or
239	206		(B) except as provided by Subdivision (3), on the
240	207		interest list for another Section 1915(c) waiver program in a
241	208		position relative to other persons on the list that is based on the
242	209		date the child was initially placed on the interest list for the
243	210		medically dependent children (MDCP) waiver program;
244	211		(2) except as provided by Subdivision (3), for a child
245	212		who becomes ineligible for the reason described by Subsection
246	213		(a)(2), place the child on the interest list for another Section
247	214		1915(c) waiver program in a position relative to other persons on
248	215		the list that is based on the date the child was initially placed on
249	216		the interest list for the medically dependent children (MDCP)
250	217		waiver program; or
251	218		(3) for a child who becomes ineligible for a reason
252	219		described by Subsection (a) and who is already on an interest list
253	220		for another Section 1915(c) waiver program, move the child to a
254	221		position on the interest list relative to other persons on the list
255	222		that is based on the date the child was initially placed on the
256	223		interest list for the medically dependent children (MDCP) waiver
257	224		program, if that date is earlier than the date the child was
258	225		initially placed on the interest list for the other waiver program.
259		-	(d) Notwithstanding Subsection (c)(1)(B) or (c)(2), a child
260		-	may be placed on an interest list for a Section 1915(c) waiver
261		-	program in the position described by those subsections only if the
262		-	child has previously been placed on the interest list for that
263		-	waiver program.
264		-	(e) At the time the commission provides notice to a legally
	226	+	(d) At the time the commission provides notice to a legally
265	227		authorized representative that a child is no longer eligible for
266	228		the medically dependent children (MDCP) waiver program following a
267	229		Medicaid fair hearing, or without a Medicaid fair hearing if the
268	230		representative opted in writing to forego the hearing, the
269		-	commission shall inform the representative in writing about:
270		-	(1) the options under this section for placing the
271		-	child on an interest list; and
272		-	(2) the process for applying for the Medicaid buy-in
273		-	program for children with disabilities implemented under Section
274		-	531.02444.
275		-	(f) This section expires December 1, 2021.
	231	+	commission shall inform the representative in writing about the
	232	+	options under this section for placing the child on an interest
	233	+	list.
276	234		Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
277		-	PROGRAM ~~ASSESSMENTS AND~~ REASSESSMENTS. (a) The commission shall
278		-	~~ensure that the~~ care coordinator for a Medicaid managed care
279		-	~~organization under the~~ STAR Kids managed care program provides the
280		-	~~results of~~ the ~~initial assessment~~ or ~~annual reassessment of medical~~
281		-	~~necessity to the parent or~~ legally authorized representative of a
282		-	~~recipient receiving~~ benefits under the medically dependent
283		-	~~children (MDCP) waiver~~ program for review. The commission shall
284		-	~~ensure the provision of~~ the results does not delay the
285		-	~~determination of the services to be~~ provided to the recipient or the
286		-	~~ability to authorize and initiate~~ services.
	235	+	PROGRAM REASSESSMENTS. (a) The commission shall ensure that the
	236	+	care coordinator for a Medicaid managed care organization under the
	237	+	STAR Kids managed care program provides the results of the annual
	238	+	medical necessity determination reassessment to the parent or
	239	+	legally authorized representative of a recipient receiving
	240	+	benefits under the medically dependent children (MDCP) waiver
	241	+	program for review. The commission shall ensure the provision of
	242	+	the results does not delay the determination of the services to be
	243	+	provided to the recipient or the ability to authorize and initiate
	244	+	services.
287	245		(b) The commission shall require the parent's or
288	246		representative's signature to verify the parent or representative
289		-	received the results of the initial assessment or reassessment from
290		-	the care coordinator under Subsection (a). A Medicaid managed care
291		-	organization may not delay the delivery of care pending the
292		-	signature.
	247	+	received the results of the reassessment from the care coordinator
	248	+	under Subsection (a). A Medicaid managed care organization may not
	249	+	delay the delivery of care pending the signature.
293	250		(c) The commission shall provide a parent or representative
294		-	who disagrees with the results of the ~~initial assessment or~~
295		-	~~reassessment an opportunity to request~~ to dispute the ~~results~~ with
296		-	~~the Medicaid managed care~~ organization through a peer-to-peer
297		-	~~review with the treating~~ physician of choice.
	251	+	who disagrees with the results of the reassessment an opportunity
	252	+	to dispute the reassessment with the Medicaid managed care
	253	+	organization through a peer-to-peer review with the treating
	254	+	physician of choice.
298	255		(d) This section does not affect any rights of a recipient
299		-	to appeal an initial assessment or reassessment determination
300		-	through the Medicaid managed care organization's internal appeal
301		-	process, the Medicaid fair hearing process, or the external medical
302		-	review process.
	256	+	to appeal a reassessment determination through the Medicaid managed
	257	+	care organization's internal appeal process or through the Medicaid
	258	+	fair hearing process.
303	259		Sec. 531.06021. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
304		-	PROGRAM QUALITY MONITORING; REPORT. (a) The commission, based on
305		-	the state's external quality review organization's initial report
306		-	on the STAR Kids managed care program, shall determine whether the
307		-	findings of the report necessitate additional data and research to
308		-	improve the program. If the commission determines additional data
309		-	and research are needed, the commission, through the external
310		-	quality review organization, may:
	260	+	PROGRAM QUALITY MONITORING; REPORT. (a) The commission, through
	261	+	the state's external quality review organization, shall:
311	262		(1) conduct annual surveys of Medicaid recipients
312	263		receiving benefits under the medically dependent children (MDCP)
313	264		waiver program, or their representatives, using the Consumer
314	265		Assessment of Healthcare Providers and Systems;
315	266		(2) conduct annual focus groups with recipients
316	267		described by Subdivision (1) or their representatives on issues
317	268		identified through:
318	269		(A) the Consumer Assessment of Healthcare
319	270		Providers and Systems;
320	271		(B) other external quality review organization
321	272		activities; or
322	273		(C) stakeholders, including the STAR Kids
323	274		Managed Care Advisory Committee described by Section 533.00254; and
324		-	(3) in consultation with the STAR Kids Managed Care
325		-	Advisory Committee described by Section 533.00254 and as frequently
326		-	as feasible, calculate Medicaid managed care organizations'
	275	+	(3) as frequently as feasible but not less frequently
	276	+	than annually, calculate Medicaid managed care organizations'
327	277		performance on performance measures using available data sources
328		-	such as the collaborative innovation improvement network.
	278	+	such as the STAR Kids Screening and Assessment Instrument or the
	279	+	National Committee for Quality Assurance's Healthcare
	280	+	Effectiveness Data and Information Set (HEDIS) measures.
329	281		(b) Not later than the 30th day after the last day of each
330	282		state fiscal quarter, the commission shall submit to the governor,
331	283		the lieutenant governor, the speaker of the house of
332	284		representatives, the Legislative Budget Board, and each standing
333	285		legislative committee with primary jurisdiction over Medicaid a
334	286		report containing, for the most recent state fiscal quarter, the
335	287		following information and data related to access to care for
336	288		Medicaid recipients receiving benefits under the medically
337	289		dependent children (MDCP) waiver program:
338	290		(1) enrollment in the Medicaid buy-in for children
339	291		program implemented under Section 531.02444;
340	292		(2) requests relating to interest list placements
341	293		under Section 531.0601;
342	294		(3) use of the Medicaid escalation help line
343		-	established under Section 533.00253~~, if the help line was~~
344		-	~~operational during~~ the ~~applicable state fiscal quarter;~~
345		-	~~(4) use of, requests for, and outcomes of the~~ external
346		-	~~medical review procedure established under Section~~ 531.024164; and
	295	+	established under Section 533.00253;
	296	+	(4) use, requests to opt out, and outcomes of the
	297	+	external medical review procedure established under Section
	298	+	531.024164; and
347	299		(5) complaints relating to the medically dependent
348	300		children (MDCP) waiver program, categorized by disposition.
349		-	Sec. 531.0603. ELIGIBILITY OF CERTAIN CHILDREN FOR
350		-	MEDICALLY DEPENDENT CHILDREN (MDCP) OR DEAF-BLIND WITH MULTIPLE
351		-	DISABILITIES (DBMD) WAIVER PROGRAM. (a) Notwithstanding any
352		-	other law and to the extent allowed by federal law, in determining
353		-	eligibility of a child for the medically dependent children (MDCP)
354		-	waiver program, the deaf-blind with multiple disabilities (DBMD)
355		-	waiver program, or a "Money Follows the Person" demonstration
356		-	project, the commission shall consider whether the child:
357		-	(1) is diagnosed as having a condition included in the
358		-	list of compassionate allowances conditions published by the United
359		-	States Social Security Administration; or
360		-	(2) receives Medicaid hospice or palliative care
361		-	services.
362		-	(b) If the commission determines a child is eligible for a
363		-	waiver program under Subsection (a), the child's enrollment in the
364		-	applicable program is contingent on the availability of a slot in
365		-	the program. If a slot is not immediately available, the commission
366		-	shall place the child in the first position on the interest list for
367		-	the medically dependent children (MDCP) waiver program or
368		-	deaf-blind with multiple disabilities (DBMD) waiver program, as
369		-	applicable.
370		-	Sec. 531.0604. MEDICALLY DEPENDENT CHILDREN PROGRAM
371		-	ELIGIBILITY REQUIREMENTS; NURSING FACILITY LEVEL OF CARE. To the
372		-	extent allowed by federal law, the commission may not require that a
373		-	child reside in a nursing facility for an extended period of time to
374		-	meet the nursing facility level of care required for the child to be
375		-	determined eligible for the medically dependent children (MDCP)
376		-	waiver program.
377	301		SECTION 4. Section 533.00253(a)(1), Government Code, is
378	302		amended to read as follows:
379	303		(1) "Advisory committee" means the STAR Kids Managed
380	304		Care Advisory Committee described by [established under] Section
381	305		533.00254.
382	306		SECTION 5. Section 533.00253, Government Code, is amended
383		-	by amending Subsection (c) and adding Subsections (c-1), (c-2),
384		-	(f), (g), (h), (i), (j), (k), and (l) to read as follows:
385		-	(c) The commission may require that care management
386		-	services made available as provided by Subsection (b)(7):
387		-	(1) incorporate best practices, as determined by the
388		-	commission;
389		-	(2) integrate with a nurse advice line to ensure
390		-	appropriate redirection rates;
391		-	(3) use an identification and stratification
392		-	methodology that identifies recipients who have the greatest need
393		-	for services;
394		-	(4) provide a care needs assessment for a recipient
395		-	[that is comprehensive, holistic, consumer-directed,
396		-	evidence-based, and takes into consideration social and medical
397		-	issues, for purposes of prioritizing the recipient's needs that
398		-	threaten independent living];
399		-	(5) are delivered through multidisciplinary care
400		-	teams located in different geographic areas of this state that use
401		-	in-person contact with recipients and their caregivers;
402		-	(6) identify immediate interventions for transition
403		-	of care;
404		-	(7) include monitoring and reporting outcomes that, at
405		-	a minimum, include:
406		-	(A) recipient quality of life;
407		-	(B) recipient satisfaction; and
408		-	(C) other financial and clinical metrics
409		-	determined appropriate by the commission; and
410		-	(8) use innovations in the provision of services.
	307	+	by adding Subsections (c-1), (c-2), (f), (g), and (h) to read as
	308	+	follows:
411	309		(c-1) To improve the care needs assessment tool used for
412	310		purposes of a care needs assessment provided as a component of care
413	311		management services and to improve the initial assessment and
414	312		reassessment processes, the commission in consultation and
415	313		collaboration with the advisory committee shall consider changes
416	314		that will:
417	315		(1) reduce the amount of time needed to complete the
418	316		care needs assessment initially and at reassessment; and
419	317		(2) improve training and consistency in the completion
420	318		of the care needs assessment using the tool and in the initial
421	319		assessment and reassessment processes across different Medicaid
422	320		managed care organizations and different service coordinators
423	321		within the same Medicaid managed care organization.
424	322		(c-2) To the extent feasible and allowed by federal law, the
425	323		commission shall streamline the STAR Kids managed care program
426	324		annual care needs reassessment process for a child who has not had a
427	325		significant change in function that may affect medical necessity.
428	326		(f) The commission shall operate a Medicaid escalation help
429	327		line through which Medicaid recipients receiving benefits under the
430		-	medically dependent children (MDCP) waiver program or the
431		-	deaf-blind with multiple disabilities (DBMD) waiver program and
432		-	their legally authorized representatives, parents, guardians, or
433		-	other representatives have access to assistance. The escalation
434		-	help line must be:
	328	+	medically dependent children (MDCP) waiver program and their
	329	+	legally authorized representatives, parents, guardians, or other
	330	+	representatives have access to assistance. The escalation help
	331	+	line must be:
435	332		(1) dedicated to assisting families of Medicaid
436	333		recipients receiving benefits under the medically dependent
437		-	children (MDCP) waiver program or the deaf-blind with multiple
438		-	disabilities (DBMD) waiver program in navigating and resolving
439		-	issues related to the STAR Kids managed care program, including
440		-	complying with requirements related to the continuation of benefits
441		-	during an internal appeal, a Medicaid fair hearing, or a review
442		-	conducted by an external medical reviewer; and
	334	+	children (MDCP) waiver program in navigating and resolving issues
	335	+	related to the STAR Kids managed care program; and
443	336		(2) operational at all times, including evenings,
444	337		weekends, and holidays.
445	338		(g) The commission shall ensure staff operating the
446	339		Medicaid escalation help line:
447	340		(1) return a telephone call not later than two hours
448	341		after receiving the call during standard business hours; and
449	342		(2) return a telephone call not later than four hours
450	343		after receiving the call during evenings, weekends, and holidays.
451	344		(h) The commission shall require a Medicaid managed care
452	345		organization participating in the STAR Kids managed care program
453	346		to:
454	347		(1) designate an individual as a single point of
455	348		contact for the Medicaid escalation help line; and
456	349		(2) authorize that individual to take action to
457	350		resolve escalated issues.
458		-	(i) To the extent feasible, a Medicaid managed care
459		-	organization shall provide information that will enable staff
460		-	operating the Medicaid escalation help line to assist recipients,
461		-	such as information related to service coordination and prior
462		-	authorization denials.
463		-	(j) Not later than September 1, 2020, the commission shall
464		-	assess the utilization of the Medicaid escalation help line and
465		-	determine the feasibility of expanding the help line to additional
466		-	Medicaid programs that serve medically fragile children.
467		-	(k) Subsections (f), (g), (h), (i), and (j) and this
468		-	subsection expire September 1, 2024.
469		-	(l) Not later than September 1, 2020, the commission shall
470		-	evaluate risk-adjustment methods used for recipients under the STAR
471		-	Kids managed care program, including recipients with private health
472		-	benefit plan coverage, in the quality-based payment program under
473		-	Chapter 536 to ensure that higher-volume providers are not unfairly
474		-	penalized. This subsection expires January 1, 2021.
475	351		SECTION 6. Subchapter A, Chapter 533, Government Code, is
476	352		amended by adding Sections 533.00254, 533.00282, 533.00283,
477		-	533.00284~~, 533.002841~~, and 533.038 to read as follows:
	353	+	533.00284, and 533.038 to read as follows:
478	354		Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
479	355		(a) The STAR Kids Managed Care Advisory Committee established by
480	356		the executive commissioner under Section 531.012 shall:
481	357		(1) advise the commission on the operation of the STAR
482	358		Kids managed care program under Section 533.00253; and
483	359		(2) make recommendations for improvements to that
484	360		program.
485		-	(b) On ~~December 31~~, 2023:
	361	+	(b) On September 1, 2023:
486	362		(1) the advisory committee is abolished; and
487	363		(2) this section expires.
488	364		Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION
489	365		PROCEDURES. (a) Section 4201.304(a)(2), Insurance Code, does not
490	366		apply to a Medicaid managed care organization or a utilization
491	367		review agent who conducts utilization reviews for a Medicaid
492	368		managed care organization.
493	369		(b) In addition to the requirements of Section 533.005, a
494	370		contract between a Medicaid managed care organization and the
495	371		commission must require that:
496	372		(1) before issuing an adverse determination on a prior
497	373		authorization request, the organization provide the physician
498	374		requesting the prior authorization with a reasonable opportunity to
499	375		discuss the request with another physician who practices in the
500	376		same or a similar specialty, but not necessarily the same
501	377		subspecialty, and has experience in treating the same category of
502	378		population as the recipient on whose behalf the request is
503	379		submitted; and
504	380		(2) the organization review and issue determinations
505	381		on prior authorization requests with respect to a recipient who is
506	382		not hospitalized at the time of the request according to the
507	383		following time frames:
508	384		(A) within three business days after receiving
509	385		the request; or
510	386		(B) within the time frame and following the
511	387		process established by the commission if the organization receives
512	388		a request for prior authorization that does not include sufficient
513	389		or adequate documentation.
514		-	(c) In consultation with the state Medicaid managed care
515		-	advisory committee, the commission shall establish a process for
516		-	use by a Medicaid managed care organization that receives a prior
517		-	authorization request, with respect to a recipient who is not
518		-	hospitalized at the time of the request, that does not include
519		-	sufficient or adequate documentation. The process must provide a
520		-	time frame within which a provider may submit the necessary
521		-	documentation. The time frame must be longer than the time frame
522		-	specified by Subsection (b)(2)(A) within which a Medicaid managed
523		-	care organization must issue a determination on a prior
524		-	authorization request.
	390	+	(c) The commission shall establish a process consistent
	391	+	with 42 C.F.R. Section 438.210 for use by a Medicaid managed care
	392	+	organization that receives a prior authorization request, with
	393	+	respect to a recipient who is not hospitalized at the time of the
	394	+	request, that does not include sufficient or adequate
	395	+	documentation. The process must provide a time frame within which a
	396	+	provider may submit the necessary documentation.
525	397		Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION
526		-	REQUIREMENTS. (a) Each Medicaid managed care organization, in
527		-	consultation with the organization's provider advisory group
528		-	required by contract, shall develop and implement a process to
529		-	conduct an annual review of the organization's prior authorization
530		-	requirements, other than a prior authorization requirement
531		-	prescribed by or implemented under Section 531.073 for the vendor
532		-	drug program. In conducting a review, the organization must:
	398	+	REQUIREMENTS. (a) Each Medicaid managed care organization shall
	399	+	develop and implement a process to conduct an annual review of the
	400	+	organization's prior authorization requirements, other than a
	401	+	prior authorization requirement prescribed by or implemented under
	402	+	Section 531.073 for the vendor drug program. In conducting a
	403	+	review, the organization must:
533	404		(1) solicit, receive, and consider input from
534	405		providers in the organization's provider network; and
535	406		(2) ensure that each prior authorization requirement
536	407		is based on accurate, up-to-date, evidence-based, and
537	408		peer-reviewed clinical criteria that distinguish, as appropriate,
538	409		between categories, including age, of recipients for whom prior
539	410		authorization requests are submitted.
540	411		(b) A Medicaid managed care organization may not impose a
541	412		prior authorization requirement, other than a prior authorization
542	413		requirement prescribed by or implemented under Section 531.073 for
543	414		the vendor drug program, unless the organization has reviewed the
544	415		requirement during the most recent annual review required under
545	416		this section.
546		-	(c) The commission shall periodically review each Medicaid
547		-	managed care organization to ensure the organization's compliance
548		-	with this section.
549	417		Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE
550	418		DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In
551		-	consultation with the state Medicaid managed care advisory
552		-	committee, the commission shall establish a uniform process and
553		-	timeline for Medicaid managed care organizations to reconsider an
554		-	adverse determination on a prior authorization request that
555		-	resulted solely from the submission of insufficient or inadequate
556		-	documentation. In addition to the requirements of Section 533.005,
557		-	a contract between a Medicaid managed care organization and the
558		-	commission must include a requirement that the organization
559		-	implement the process and timeline.
560		-	(b) The process and timeline must:
561		-	(1) allow a provider to submit any documentation that
562		-	was identified as insufficient or inadequate in the notice provided
563		-	under Section 531.024162;
	419	+	addition to the requirements of Section 533.005, a contract between
	420	+	a Medicaid managed care organization and the commission must
	421	+	include a requirement that the organization establish a process for
	422	+	reconsidering an adverse determination on a prior authorization
	423	+	request that resulted solely from the submission of insufficient or
	424	+	inadequate documentation.
	425	+	(b) The process for reconsidering an adverse determination
	426	+	on a prior authorization request under this section must:
	427	+	(1) allow a provider to, not later than the seventh
	428	+	business day following the date of the determination, submit any
	429	+	documentation that was identified as insufficient or inadequate in
	430	+	the notice provided under Section 531.024162;
564	431		(2) allow the provider requesting the prior
565	432		authorization to discuss the request with another provider who
566	433		practices in the same or a similar specialty, but not necessarily
567	434		the same subspecialty, and has experience in treating the same
568	435		category of population as the recipient on whose behalf the request
569		-	is submitted; and
570		-	(3) require the Medicaid managed care organization to
571		-	amend the determination on the prior authorization request as
572		-	necessary, considering the additional documentation.
	436	+	is submitted;
	437	+	(3) require the Medicaid managed care organization to,
	438	+	not later than the first business day following the date the
	439	+	provider submits sufficient and adequate documentation under
	440	+	Subdivision (1), amend the determination on the prior authorization
	441	+	request as necessary, considering the additional documentation;
	442	+	and
	443	+	(4) comply with 42 C.F.R. Section 438.210.
573	444		(c) An adverse determination on a prior authorization
574	445		request is considered a denial of services in an evaluation of the
575	446		Medicaid managed care organization only if the determination is not
576	447		amended under Subsection (b)(3) to approve the request.
577		-	(d) The process ~~and timeline~~ for reconsidering an adverse
578		-	~~determination~~ on a prior authorization request under this section
579		-	~~do not~~ affect:
	448	+	(d) The process for reconsidering an adverse determination
	449	+	on a prior authorization request under this section does not
	450	+	affect:
580	451		(1) any related timelines, including the timeline for
581	452		an internal appeal, a Medicaid fair hearing, or a review conducted
582		-	by an ~~external medical reviewer~~; or
	453	+	by an independent review organization; or
583	454		(2) any rights of a recipient to appeal a
584	455		determination on a prior authorization request.
585		-	Sec. 533.002841. MAXIMUM PERIOD FOR PRIOR AUTHORIZATION
586		-	DECISION; ACCESS TO CARE. The time frames prescribed by the
587		-	utilization review and prior authorization procedures described by
588		-	Section 533.00282 and the timeline for reconsidering an adverse
589		-	determination on a prior authorization described by Section
590		-	533.00284 together may not exceed the time frame for a decision
591		-	under federally prescribed time frames. It is the intent of the
592		-	legislature that these provisions allow sufficient time to provide
593		-	necessary documentation and avoid unnecessary denials without
594		-	delaying access to care.
595	456		Sec. 533.038. COORDINATION OF BENEFITS. (a) In this
596	457		section, "Medicaid wrap-around benefit" means a Medicaid-covered
597	458		service, including a pharmacy or medical benefit, that is provided
598	459		to a recipient with both Medicaid and primary health benefit plan
599	460		coverage when the recipient has exceeded the primary health benefit
600	461		plan coverage limit or when the service is not covered by the
601	462		primary health benefit plan issuer.
602	463		(b) The commission, in coordination with Medicaid managed
603		-	care organizations and in consultation with the STAR Kids Managed
604		-	Care Advisory Committee described by Section 533.00254, shall
605		-	develop and adopt a clear policy for a Medicaid managed care
606		-	organization to ensure the coordination and timely delivery of
607		-	Medicaid wrap-around benefits for recipients with both primary
608		-	health benefit plan coverage and Medicaid coverage. In developing
609		-	the policy, the commission shall consider requiring a Medicaid
610		-	managed care organization to allow, notwithstanding Sections
611		-	531.073 and 533.005(a)(23) or any other law, a recipient using a
612		-	prescription drug for which the recipient's primary health benefit
613		-	plan issuer previously provided coverage to continue receiving the
614		-	prescription drug without requiring additional prior
615		-	authorization.
616		-	(c) If the commission determines that a recipient's primary
	464	+	care organizations, shall develop and adopt a clear policy for a
	465	+	Medicaid managed care organization to ensure the coordination and
	466	+	timely delivery of Medicaid wrap-around benefits for recipients
	467	+	with both primary health benefit plan coverage and Medicaid
	468	+	coverage. In developing the policy, the commission shall consider
	469	+	requiring a Medicaid managed care organization to allow,
	470	+	notwithstanding Sections 531.073 and 533.005(a)(23) or any other
	471	+	law, a recipient using a prescription drug for which the
	472	+	recipient's primary health benefit plan issuer previously provided
	473	+	coverage to continue receiving the prescription drug without
	474	+	requiring additional prior authorization.
	475	+	(c) To further assist with the coordination of benefits and
	476	+	to the extent allowed under federal requirements for third-party
	477	+	liability, the commission, in coordination with Medicaid managed
	478	+	care organizations, shall develop and maintain a list of services
	479	+	that are not traditionally covered by primary health benefit plan
	480	+	coverage that a Medicaid managed care organization may approve
	481	+	without having to coordinate with the primary health benefit plan
	482	+	issuer and that can be resolved through third-party liability
	483	+	resolution processes. The commission shall periodically review and
	484	+	update the list.
	485	+	(d) A Medicaid managed care organization that in good faith
	486	+	and following commission policies provides coverage for a Medicaid
	487	+	wrap-around benefit shall include the cost of providing the benefit
	488	+	in the organization's financial reports. The commission shall
	489	+	include the reported costs in computing capitation rates for the
	490	+	managed care organization.
	491	+	(e) If the commission determines that a recipient's primary
617	492		health benefit plan issuer should have been the primary payor of a
618	493		claim, the Medicaid managed care organization that paid the claim
619	494		shall work with the commission on the recovery process and make
620	495		every attempt to reduce health care provider and recipient
621	496		abrasion.
622		-	(d) The executive commissioner may seek a waiver from the
	497	+	(f) The executive commissioner may seek a waiver from the
623	498		federal government as needed to:
624	499		(1) address federal policies related to coordination
625	500		of benefits and third-party liability; and
626	501		(2) maximize federal financial participation for
627	502		recipients with both primary health benefit plan coverage and
628	503		Medicaid coverage.
629		-	(e) The commission may include in the Medicaid managed care
	504	+	(g) The commission may include in the Medicaid managed care
630	505		eligibility files an indication of whether a recipient has primary
631	506		health benefit plan coverage or is enrolled in a group health
632	507		benefit plan for which the commission provides premium assistance
633	508		under the health insurance premium payment program. For recipients
634	509		with that coverage or for whom that premium assistance is provided,
635	510		the files may include the following up-to-date, accurate
636	511		information related to primary health benefit plan coverage to the
637	512		extent the information is available to the commission:
638	513		(1) the health benefit plan issuer's name and address
639	514		and the recipient's policy number;
640	515		(2) the primary health benefit plan coverage start and
641	516		end dates; and
642	517		(3) the primary health benefit plan coverage benefits,
643	518		limits, copayment, and coinsurance information.
644		-	(f) To the extent allowed by federal law, the commission
	519	+	(h) To the extent allowed by federal law, the commission
645	520		shall maintain processes and policies to allow a health care
646	521		provider who is primarily providing services to a recipient through
647	522		primary health benefit plan coverage to receive Medicaid
648	523		reimbursement for services ordered, referred, or prescribed,
649	524		regardless of whether the provider is enrolled as a Medicaid
650	525		provider. The commission shall allow a provider who is not enrolled
651	526		as a Medicaid provider to order, refer, or prescribe services to a
652	527		recipient based on the provider's national provider identifier
653	528		number and may not require an additional state provider identifier
654	529		number to receive reimbursement for the services. The commission
655	530		may seek a waiver of Medicaid provider enrollment requirements for
656	531		providers of recipients with primary health benefit plan coverage
657	532		to implement this subsection.
658		-	(g) The commission shall develop a clear and easy process,
	533	+	(i) The commission shall develop a clear and easy process,
659	534		to be implemented through a contract, that allows a recipient with
660	535		complex medical needs who has established a relationship with a
661	536		specialty provider to continue receiving care from that provider.
662		-	SECTION 7. (a) Section 531.0601, Government Code, as added
663		-	by this Act, applies only to a child who becomes ineligible for the
664		-	medically dependent children (MDCP) waiver program on or after
	537	+	SECTION 7. (a) Section 531.02444(e), Government Code, as
	538	+	added by this Act, applies to a request for a disability
	539	+	determination assessment to determine eligibility for the Medicaid
	540	+	buy-in for children program made on or after the effective date of
	541	+	this Act.
	542	+	(b) Section 531.0601, Government Code, as added by this Act,
	543	+	applies only to a child who becomes ineligible for the medically
	544	+	dependent children (MDCP) waiver program on or after December 1,
	545	+	2019.
	546	+	(c) Section 531.0602, Government Code, as added by this Act,
	547	+	applies only to a reassessment of a child's eligibility for the
	548	+	medically dependent children (MDCP) waiver program made on or after
665	549		December 1, 2019.
666		-	(b) Section 531.0602, Government Code, as added by this Act,
667		-	applies only to an assessment or reassessment of a child's
668		-	eligibility for the medically dependent children (MDCP) waiver
669		-	program made on or after December 1, 2019.
670		-	(c) Notwithstanding Section 531.06021, Government Code, as
	550	+	(d) Notwithstanding Section 531.06021, Government Code, as
671	551		added by this Act, the Health and Human Services Commission shall
672	552		submit the first report required by that section not later than
673	553		September 30, 2020, for the state fiscal quarter ending August 31,
674	554		2020.
675		-	(d) Not later than March 1, 2020, the Health and Human
	555	+	(e) Not later than March 1, 2020, the Health and Human
676	556		Services Commission shall:
677	557		(1) develop a plan to improve the care needs
678	558		assessment tool and the initial assessment and reassessment
679	559		processes as required by Sections 533.00253(c-1) and (c-2),
680	560		Government Code, as added by this Act; and
681	561		(2) post the plan on the commission's Internet
682	562		website.
683		-	(e) Sections 533.00282 and 533.00284, Government Code, as
	563	+	(f) Sections 533.00282 and 533.00284, Government Code, as
684	564		added by this Act, apply only to a contract between the Health and
685	565		Human Services Commission and a Medicaid managed care organization
686	566		under Chapter 533, Government Code, that is entered into or renewed
687	567		on or after the effective date of this Act.
688		-	(f) As soon as practicable after the effective date of this
689		-	Act but not later than September 1, 2020, the Health and Human
690		-	Services Commission shall seek to amend contracts entered into with
691		-	Medicaid managed care organizations under Chapter 533, Government
692		-	Code, before the effective date of this Act to include the
693		-	provisions required by Sections 533.00282 and 533.00284,
694		-	Government Code, as added by this Act.
	568	+	(g) The Health and Human Services Commission shall seek to
	569	+	amend contracts entered into with Medicaid managed care
	570	+	organizations under Chapter 533, Government Code, before the
	571	+	effective date of this Act to include the provisions required by
	572	+	Sections 533.00282 and 533.00284, Government Code, as added by this
	573	+	Act.
695	574		SECTION 8. As soon as practicable after the effective date
696	575		of this Act, the executive commissioner of the Health and Human
697	576		Services Commission shall adopt rules necessary to implement the
698	577		changes in law made by this Act.
699	578		SECTION 9. If before implementing any provision of this Act
700	579		a state agency determines that a waiver or authorization from a
701	580		federal agency is necessary for implementation of that provision,
702	581		the agency affected by the provision shall request the waiver or
703	582		authorization and may delay implementing that provision until the
704	583		waiver or authorization is granted.
705	584		SECTION 10. The Health and Human Services Commission is
706	585		required to implement a provision of this Act only if the
707	586		legislature appropriates money specifically for that purpose. If
708	587		the legislature does not appropriate money specifically for that
709	588		purpose, the commission may, but is not required to, implement a
710	589		provision of this Act using other appropriations available for that
711	590		purpose.
712	591		SECTION 11. This Act takes effect September 1, 2019.
713		-	______________________________ ______________________________
714		-	President of the Senate Speaker of the House
715		-	I hereby certify that S.B. No. 1207 passed the Senate on
716		-	April 17, 2019, by the following vote: Yeas 30, Nays 1;
717		-	May 23, 2019, Senate refused to concur in House amendments and
718		-	requested appointment of Conference Committee; May 23, 2019, House
719		-	granted request of the Senate; May 26, 2019, Senate adopted
720		-	Conference Committee Report by the following vote: Yeas 30,
721		-	Nays 1.
722		-	______________________________
723		-	Secretary of the Senate
724		-	I hereby certify that S.B. No. 1207 passed the House, with
725		-	amendments, on May 20, 2019, by the following vote: Yeas 139,
726		-	Nays 0, two present not voting; May 23, 2019, House granted request
727		-	of the Senate for appointment of Conference Committee;
728		-	May 26, 2019, House adopted Conference Committee Report by the
729		-	following vote: Yeas 145, Nays 0, one present not voting.
730		-	______________________________
731		-	Chief Clerk of the House
732		-	Approved:
733		-	______________________________
734		-	Date
735		-	______________________________
736		-	Governor