S.B. No. 1207
AN ACT
relating to the operation and administration of Medicaid, including
the Medicaid managed care program and the medically dependent
children (MDCP) waiver program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.001, Government Code, is amended by
adding Subdivision (4-c) to read as follows:
(4-c) "Medicaid managed care organization" means a
managed care organization as defined by Section 533.001 that
contracts with the commission under Chapter 533 to provide health
care services to Medicaid recipients.
SECTION 2. Section 531.024, Government Code, is amended by
amending Subsection (b) and adding Subsection (c) to read as
follows:
(b) The rules promulgated under Subsection (a)(7) must
provide due process to an applicant for Medicaid services and to a
Medicaid recipient who seeks a Medicaid service, including a
service that requires prior authorization. The rules must provide
the protections for applicants and recipients required by 42 C.F.R.
Part 431, Subpart E, including requiring that:
(1) the written notice to an individual of the
individual's right to a hearing must:
(A) contain an explanation of the circumstances
under which Medicaid is continued if a hearing is requested; and
(B) be delivered by mail, and postmarked [mailed]
at least 10 business days, before the date the individual's
Medicaid eligibility or service is scheduled to be terminated,
suspended, or reduced, except as provided by 42 C.F.R. Section
431.213 or 431.214; and
(2) if a hearing is requested before the date a
Medicaid recipient's service, including a service that requires
prior authorization, is scheduled to be terminated, suspended, or
reduced, the agency may not take that proposed action before a
decision is rendered after the hearing unless:
(A) it is determined at the hearing that the sole
issue is one of federal or state law or policy; and
(B) the agency promptly informs the recipient in
writing that services are to be terminated, suspended, or reduced
pending the hearing decision.
(c) The commission shall develop a process to address a
situation in which:
(1) an individual does not receive adequate notice as
required by Subsection (b)(1); or
(2) the notice required by Subsection (b)(1) is
delivered without a postmark.
SECTION 3. (a) To the extent of any conflict, Section
531.024162, Government Code, as added by this section, prevails
over any provision of another Act of the 86th Legislature, Regular
Session, 2019, relating to notice requirements regarding Medicaid
coverage or prior authorization denials or incomplete requests,
that becomes law.
(b) Subchapter B, Chapter 531, Government Code, is amended
by adding Sections 531.024162, 531.024163, 531.024164, 531.0601,
531.0602, 531.06021, 531.0603, and 531.0604 to read as follows:
Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID
COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
(a) The commission shall ensure that notice sent by the commission
or a Medicaid managed care organization to a Medicaid recipient or
provider regarding the denial, partial denial, reduction, or
termination of coverage or denial of prior authorization for a
service includes:
(1) information required by federal and state law and
applicable regulations;
(2) for the recipient:
(A) a clear and easy-to-understand explanation
of the reason for the decision, including a clear explanation of the
medical basis, applying the policy or accepted standard of medical
practice to the recipient's particular medical circumstances;
(B) a copy of the information sent to the
provider; and
(C) an educational component that includes a
description of the recipient's rights, an explanation of the
process related to appeals and Medicaid fair hearings, and a
description of the role of an external medical review; and
(3) for the provider, a thorough and detailed clinical
explanation of the reason for the decision, including, as
applicable, information required under Subsection (b).
(b) The commission or a Medicaid managed care organization
that receives from a provider a coverage or prior authorization
request that contains insufficient or inadequate documentation to
approve the request shall issue a notice to the provider and the
Medicaid recipient on whose behalf the request was submitted. The
notice issued under this subsection must:
(1) include a section specifically for the provider
that contains:
(A) a clear and specific list and description of
the documentation necessary for the commission or organization to
make a final determination on the request;
(B) the applicable timeline, based on the
requested service, for the provider to submit the documentation and
a description of the reconsideration process described by Section
533.00284, if applicable; and
(C) information on the manner through which a
provider may contact a Medicaid managed care organization or other
entity as required by Section 531.024163; and
(2) be sent:
(A) to the provider:
(i) using the provider's preferred method
of communication, to the extent practicable using existing
resources; and
(ii) as applicable, through an electronic
notification on an Internet portal; and
(B) to the recipient using the recipient's
preferred method of communication, to the extent practicable using
existing resources.
Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING
MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive
commissioner by rule shall require each Medicaid managed care
organization or other entity responsible for authorizing coverage
for health care services under Medicaid to ensure that the
organization or entity maintains on the organization's or entity's
Internet website in an easily searchable and accessible format:
(1) the applicable timelines for prior authorization
requirements, including:
(A) the time within which the organization or
entity must make a determination on a prior authorization request;
(B) a description of the notice the organization
or entity provides to a provider and Medicaid recipient on whose
behalf the request was submitted regarding the documentation
required to complete a determination on a prior authorization
request; and
(C) the deadline by which the organization or
entity is required to submit the notice described by Paragraph (B);
and
(2) an accurate and up-to-date catalogue of coverage
criteria and prior authorization requirements, including:
(A) for a prior authorization requirement first
imposed on or after September 1, 2019, the effective date of the
requirement;
(B) a list or description of any supporting or
other documentation necessary to obtain prior authorization for a
specified service; and
(C) the date and results of each review of the
prior authorization requirement conducted under Section 533.00283,
if applicable.
(b) The executive commissioner by rule shall require each
Medicaid managed care organization or other entity responsible for
authorizing coverage for health care services under Medicaid to:
(1) adopt and maintain a process for a provider or
Medicaid recipient to contact the organization or entity to clarify
prior authorization requirements or to assist the provider in
submitting a prior authorization request; and
(2) ensure that the process described by Subdivision
(1) is not arduous or overly burdensome to a provider or recipient.
Sec. 531.024164. EXTERNAL MEDICAL REVIEW. (a) In this
section, "external medical reviewer" and "reviewer" mean 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 in accordance with applicable state law
and rules.
(b) The commission shall contract with an independent
external medical reviewer to conduct external medical reviews and
review:
(1) the resolution of a Medicaid recipient appeal
related to a reduction in or denial of services on the basis of
medical necessity in the Medicaid managed care program; or
(2) a denial by the commission of eligibility for a
Medicaid program in which eligibility is based on a Medicaid
recipient's medical and functional needs.
(c) A Medicaid managed care organization may not have a
financial relationship with or ownership interest in the external
medical reviewer with which the commission contracts.
(d) The external medical reviewer with which the commission
contracts must:
(1) be overseen by a medical director who is a
physician licensed in this state; and
(2) employ or be able to consult with staff with
experience in providing private duty nursing services and long-term
services and supports.
(e) The commission shall establish a common procedure for
reviews. To the greatest extent possible, the procedure must
reduce administrative burdens on providers and the submission of
duplicative information or documents. Medical necessity under the
procedure must be based on publicly available, up-to-date,
evidence-based, and peer-reviewed clinical criteria. The reviewer
shall conduct the review within a period specified by the
commission. The commission shall also establish a procedure and
time frame for expedited reviews that allows the reviewer to:
(1) identify an appeal that requires an expedited
resolution; and
(2) resolve the review of the appeal within a
specified period.
(f) A Medicaid recipient or applicant, or the recipient's or
applicant's parent or legally authorized representative, must
affirmatively request an external medical review. If requested:
(1) an external medical review described by Subsection
(b)(1) occurs after the internal Medicaid managed care organization
appeal and before the Medicaid fair hearing and is granted when a
Medicaid recipient contests the internal appeal decision of the
Medicaid managed care organization; and
(2) an external medical review described by Subsection
(b)(2) occurs after the eligibility denial and before the Medicaid
fair hearing.
(g) The external medical reviewer's determination of
medical necessity establishes the minimum level of services a
Medicaid recipient must receive, except that the level of services
may not exceed the level identified as medically necessary by the
ordering health care provider.
(h) The external medical reviewer shall require a Medicaid
managed care organization, in an external medical review relating
to a reduction in services, to submit a detailed reason for the
reduction and supporting documents.
(i) To the extent money is appropriated for this purpose,
the commission shall publish data regarding prior authorizations
reviewed by the external medical reviewer, including the rate of
prior authorization denials overturned by the external medical
reviewer and additional information the commission and the external
medical reviewer determine appropriate.
Sec. 531.0601. LONG-TERM CARE SERVICES WAIVER PROGRAM
INTEREST LISTS. (a) This section applies only to a child who is
enrolled in the medically dependent children (MDCP) waiver program
but becomes ineligible for services under the program because the
child no longer meets:
(1) the level of care criteria for medical necessity
for nursing facility care; or
(2) the age requirement for the program.
(b) A legally authorized representative of a child who is
notified by the commission that the child is no longer eligible for
the medically dependent children (MDCP) waiver program following a
Medicaid fair hearing, or without a Medicaid fair hearing if the
representative opted in writing to forego the hearing, may request
that the commission:
(1) return the child to the interest list for the
program unless the child is ineligible due to the child's age; or
(2) place the child on the interest list for another
Section 1915(c) waiver program.
(c) At the time a child's legally authorized representative
makes a request under Subsection (b), the commission shall:
(1) for a child who becomes ineligible for the reason
described by Subsection (a)(1), place the child:
(A) on the interest list for the medically
dependent children (MDCP) waiver program in the first position on
the list; or
(B) except as provided by Subdivision (3), on the
interest list for another Section 1915(c) waiver program in a
position relative to other persons on the list that is based on the
date the child was initially placed on the interest list for the
medically dependent children (MDCP) waiver program;
(2) except as provided by Subdivision (3), for a child
who becomes ineligible for the reason described by Subsection
(a)(2), place the child on the interest list for another Section
1915(c) waiver program in a position relative to other persons on
the list that is based on the date the child was initially placed on
the interest list for the medically dependent children (MDCP)
waiver program; or
(3) for a child who becomes ineligible for a reason
described by Subsection (a) and who is already on an interest list
for another Section 1915(c) waiver program, move the child to a
position on the interest list relative to other persons on the list
that is based on the date the child was initially placed on the
interest list for the medically dependent children (MDCP) waiver
program, if that date is earlier than the date the child was
initially placed on the interest list for the other waiver program.
(d) Notwithstanding Subsection (c)(1)(B) or (c)(2), a child
may be placed on an interest list for a Section 1915(c) waiver
program in the position described by those subsections only if the
child has previously been placed on the interest list for that
waiver program.
(e) At the time the commission provides notice to a legally
authorized representative that a child is no longer eligible for
the medically dependent children (MDCP) waiver program following a
Medicaid fair hearing, or without a Medicaid fair hearing if the
representative opted in writing to forego the hearing, the
commission shall inform the representative in writing about:
(1) the options under this section for placing the
child on an interest list; and
(2) the process for applying for the Medicaid buy-in
program for children with disabilities implemented under Section
531.02444.
(f) This section expires December 1, 2021.
Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
PROGRAM ASSESSMENTS AND REASSESSMENTS. (a) The commission shall
ensure that the care coordinator for a Medicaid managed care
organization under the STAR Kids managed care program provides the
results of the initial assessment or annual reassessment of medical
necessity to the parent or legally authorized representative of a
recipient receiving benefits under the medically dependent
children (MDCP) waiver program for review. The commission shall
ensure the provision of the results does not delay the
determination of the services to be provided to the recipient or the
ability to authorize and initiate services.
(b) The commission shall require the parent's or
representative's signature to verify the parent or representative
received the results of the initial assessment or reassessment from
the care coordinator under Subsection (a). A Medicaid managed care
organization may not delay the delivery of care pending the
signature.
(c) The commission shall provide a parent or representative
who disagrees with the results of the initial assessment or
reassessment an opportunity to request to dispute the results with
the Medicaid managed care organization through a peer-to-peer
review with the treating physician of choice.
(d) This section does not affect any rights of a recipient
to appeal an initial assessment or reassessment determination
through the Medicaid managed care organization's internal appeal
process, the Medicaid fair hearing process, or the external medical
review process.
Sec. 531.06021. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
PROGRAM QUALITY MONITORING; REPORT. (a) The commission, based on
the state's external quality review organization's initial report
on the STAR Kids managed care program, shall determine whether the
findings of the report necessitate additional data and research to
improve the program. If the commission determines additional data
and research are needed, the commission, through the external
quality review organization, may:
(1) conduct annual surveys of Medicaid recipients
receiving benefits under the medically dependent children (MDCP)
waiver program, or their representatives, using the Consumer
Assessment of Healthcare Providers and Systems;
(2) conduct annual focus groups with recipients
described by Subdivision (1) or their representatives on issues
identified through:
(A) the Consumer Assessment of Healthcare
Providers and Systems;
(B) other external quality review organization
activities; or
(C) stakeholders, including the STAR Kids
Managed Care Advisory Committee described by Section 533.00254; and
(3) in consultation with the STAR Kids Managed Care
Advisory Committee described by Section 533.00254 and as frequently
as feasible, calculate Medicaid managed care organizations'
performance on performance measures using available data sources
such as the collaborative innovation improvement network.
(b) Not later than the 30th day after the last day of each
state fiscal quarter, the commission shall submit to the governor,
the lieutenant governor, the speaker of the house of
representatives, the Legislative Budget Board, and each standing
legislative committee with primary jurisdiction over Medicaid a
report containing, for the most recent state fiscal quarter, the
following information and data related to access to care for
Medicaid recipients receiving benefits under the medically
dependent children (MDCP) waiver program:
(1) enrollment in the Medicaid buy-in for children
program implemented under Section 531.02444;
(2) requests relating to interest list placements
under Section 531.0601;
(3) use of the Medicaid escalation help line
established under Section 533.00253, if the help line was
operational during the applicable state fiscal quarter;
(4) use of, requests for, and outcomes of the external
medical review procedure established under Section 531.024164; and
(5) complaints relating to the medically dependent
children (MDCP) waiver program, categorized by disposition.
Sec. 531.0603. ELIGIBILITY OF CERTAIN CHILDREN FOR
MEDICALLY DEPENDENT CHILDREN (MDCP) OR DEAF-BLIND WITH MULTIPLE
DISABILITIES (DBMD) WAIVER PROGRAM. (a) Notwithstanding any
other law and to the extent allowed by federal law, in determining
eligibility of a child for the medically dependent children (MDCP)
waiver program, the deaf-blind with multiple disabilities (DBMD)
waiver program, or a "Money Follows the Person" demonstration
project, the commission shall consider whether the child:
(1) is diagnosed as having a condition included in the
list of compassionate allowances conditions published by the United
States Social Security Administration; or
(2) receives Medicaid hospice or palliative care
services.
(b) If the commission determines a child is eligible for a
waiver program under Subsection (a), the child's enrollment in the
applicable program is contingent on the availability of a slot in
the program. If a slot is not immediately available, the commission
shall place the child in the first position on the interest list for
the medically dependent children (MDCP) waiver program or
deaf-blind with multiple disabilities (DBMD) waiver program, as
applicable.
Sec. 531.0604. MEDICALLY DEPENDENT CHILDREN PROGRAM
ELIGIBILITY REQUIREMENTS; NURSING FACILITY LEVEL OF CARE. To the
extent allowed by federal law, the commission may not require that a
child reside in a nursing facility for an extended period of time to
meet the nursing facility level of care required for the child to be
determined eligible for the medically dependent children (MDCP)
waiver program.
SECTION 4. Section 533.00253(a)(1), Government Code, is
amended to read as follows:
(1) "Advisory committee" means the STAR Kids Managed
Care Advisory Committee described by [established under] Section
533.00254.
SECTION 5. Section 533.00253, Government Code, is amended
by amending Subsection (c) and adding Subsections (c-1), (c-2),
(f), (g), (h), (i), (j), (k), and (l) to read as follows:
(c) The commission may require that care management
services made available as provided by Subsection (b)(7):
(1) incorporate best practices, as determined by the
commission;
(2) integrate with a nurse advice line to ensure
appropriate redirection rates;
(3) use an identification and stratification
methodology that identifies recipients who have the greatest need
for services;
(4) provide a care needs assessment for a recipient
[that is comprehensive, holistic, consumer-directed,
evidence-based, and takes into consideration social and medical
issues, for purposes of prioritizing the recipient's needs that
threaten independent living];
(5) are delivered through multidisciplinary care
teams located in different geographic areas of this state that use
in-person contact with recipients and their caregivers;
(6) identify immediate interventions for transition
of care;
(7) include monitoring and reporting outcomes that, at
a minimum, include:
(A) recipient quality of life;
(B) recipient satisfaction; and
(C) other financial and clinical metrics
determined appropriate by the commission; and
(8) use innovations in the provision of services.
(c-1) To improve the care needs assessment tool used for
purposes of a care needs assessment provided as a component of care
management services and to improve the initial assessment and
reassessment processes, the commission in consultation and
collaboration with the advisory committee shall consider changes
that will:
(1) reduce the amount of time needed to complete the
care needs assessment initially and at reassessment; and
(2) improve training and consistency in the completion
of the care needs assessment using the tool and in the initial
assessment and reassessment processes across different Medicaid
managed care organizations and different service coordinators
within the same Medicaid managed care organization.
(c-2) To the extent feasible and allowed by federal law, the
commission shall streamline the STAR Kids managed care program
annual care needs reassessment process for a child who has not had a
significant change in function that may affect medical necessity.
(f) The commission shall operate a Medicaid escalation help
line through which Medicaid recipients receiving benefits under the
medically dependent children (MDCP) waiver program or the
deaf-blind with multiple disabilities (DBMD) waiver program and
their legally authorized representatives, parents, guardians, or
other representatives have access to assistance. The escalation
help line must be:
(1) dedicated to assisting families of Medicaid
recipients receiving benefits under the medically dependent
children (MDCP) waiver program or the deaf-blind with multiple
disabilities (DBMD) waiver program in navigating and resolving
issues related to the STAR Kids managed care program, including
complying with requirements related to the continuation of benefits
during an internal appeal, a Medicaid fair hearing, or a review
conducted by an external medical reviewer; and
(2) operational at all times, including evenings,
weekends, and holidays.
(g) The commission shall ensure staff operating the
Medicaid escalation help line:
(1) return a telephone call not later than two hours
after receiving the call during standard business hours; and
(2) return a telephone call not later than four hours
after receiving the call during evenings, weekends, and holidays.
(h) The commission shall require a Medicaid managed care
organization participating in the STAR Kids managed care program
to:
(1) designate an individual as a single point of
contact for the Medicaid escalation help line; and
(2) authorize that individual to take action to
resolve escalated issues.
(i) To the extent feasible, a Medicaid managed care
organization shall provide information that will enable staff
operating the Medicaid escalation help line to assist recipients,
such as information related to service coordination and prior
authorization denials.
(j) Not later than September 1, 2020, the commission shall
assess the utilization of the Medicaid escalation help line and
determine the feasibility of expanding the help line to additional
Medicaid programs that serve medically fragile children.
(k) Subsections (f), (g), (h), (i), and (j) and this
subsection expire September 1, 2024.
(l) Not later than September 1, 2020, the commission shall
evaluate risk-adjustment methods used for recipients under the STAR
Kids managed care program, including recipients with private health
benefit plan coverage, in the quality-based payment program under
Chapter 536 to ensure that higher-volume providers are not unfairly
penalized. This subsection expires January 1, 2021.
SECTION 6. Subchapter A, Chapter 533, Government Code, is
amended by adding Sections 533.00254, 533.00282, 533.00283,
533.00284, 533.002841, and 533.038 to read as follows:
Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
(a) The STAR Kids Managed Care Advisory Committee established by
the executive commissioner under Section 531.012 shall:
(1) advise the commission on the operation of the STAR
Kids managed care program under Section 533.00253; and
(2) make recommendations for improvements to that
program.
(b) On December 31, 2023:
(1) the advisory committee is abolished; and
(2) this section expires.
Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION
PROCEDURES. (a) Section 4201.304(a)(2), Insurance Code, does not
apply to a Medicaid managed care organization or a utilization
review agent who conducts utilization reviews for a Medicaid
managed care organization.
(b) In addition to the requirements of Section 533.005, a
contract between a Medicaid managed care organization and the
commission must require that:
(1) before issuing an adverse determination on a prior
authorization request, the organization provide the physician
requesting the prior authorization with a reasonable opportunity to
discuss the request with another physician who practices in the
same or a similar specialty, but not necessarily the same
subspecialty, and has experience in treating the same category of
population as the recipient on whose behalf the request is
submitted; and
(2) the organization review and issue determinations
on prior authorization requests with respect to a recipient who is
not hospitalized at the time of the request according to the
following time frames:
(A) within three business days after receiving
the request; or
(B) within the time frame and following the
process established by the commission if the organization receives
a request for prior authorization that does not include sufficient
or adequate documentation.
(c) In consultation with the state Medicaid managed care
advisory committee, the commission shall establish a process for
use by a Medicaid managed care organization that receives a prior
authorization request, with respect to a recipient who is not
hospitalized at the time of the request, that does not include
sufficient or adequate documentation. The process must provide a
time frame within which a provider may submit the necessary
documentation. The time frame must be longer than the time frame
specified by Subsection (b)(2)(A) within which a Medicaid managed
care organization must issue a determination on a prior
authorization request.
Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION
REQUIREMENTS. (a) Each Medicaid managed care organization, in
consultation with the organization's provider advisory group
required by contract, shall develop and implement a process to
conduct an annual review of the organization's prior authorization
requirements, other than a prior authorization requirement
prescribed by or implemented under Section 531.073 for the vendor
drug program. In conducting a review, the organization must:
(1) solicit, receive, and consider input from
providers in the organization's provider network; and
(2) ensure that each prior authorization requirement
is based on accurate, up-to-date, evidence-based, and
peer-reviewed clinical criteria that distinguish, as appropriate,
between categories, including age, of recipients for whom prior
authorization requests are submitted.
(b) A Medicaid managed care organization may not impose a
prior authorization requirement, other than a prior authorization
requirement prescribed by or implemented under Section 531.073 for
the vendor drug program, unless the organization has reviewed the
requirement during the most recent annual review required under
this section.
(c) The commission shall periodically review each Medicaid
managed care organization to ensure the organization's compliance
with this section.
Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE
DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In
consultation with the state Medicaid managed care advisory
committee, the commission shall establish a uniform process and
timeline for Medicaid managed care organizations to reconsider an
adverse determination on a prior authorization request that
resulted solely from the submission of insufficient or inadequate
documentation. In addition to the requirements of Section 533.005,
a contract between a Medicaid managed care organization and the
commission must include a requirement that the organization
implement the process and timeline.
(b) The process and timeline must:
(1) allow a provider to submit any documentation that
was identified as insufficient or inadequate in the notice provided
under Section 531.024162;
(2) allow the provider requesting the prior
authorization to discuss the request with another provider who
practices in the same or a similar specialty, but not necessarily
the same subspecialty, and has experience in treating the same
category of population as the recipient on whose behalf the request
is submitted; and
(3) require the Medicaid managed care organization to
amend the determination on the prior authorization request as
necessary, considering the additional documentation.
(c) An adverse determination on a prior authorization
request is considered a denial of services in an evaluation of the
Medicaid managed care organization only if the determination is not
amended under Subsection (b)(3) to approve the request.
(d) The process and timeline for reconsidering an adverse
determination on a prior authorization request under this section
do not affect:
(1) any related timelines, including the timeline for
an internal appeal, a Medicaid fair hearing, or a review conducted
by an external medical reviewer; or
(2) any rights of a recipient to appeal a
determination on a prior authorization request.
Sec. 533.002841. MAXIMUM PERIOD FOR PRIOR AUTHORIZATION
DECISION; ACCESS TO CARE. The time frames prescribed by the
utilization review and prior authorization procedures described by
Section 533.00282 and the timeline for reconsidering an adverse
determination on a prior authorization described by Section
533.00284 together may not exceed the time frame for a decision
under federally prescribed time frames. It is the intent of the
legislature that these provisions allow sufficient time to provide
necessary documentation and avoid unnecessary denials without
delaying access to care.
Sec. 533.038. COORDINATION OF BENEFITS. (a) In this
section, "Medicaid wrap-around benefit" means a Medicaid-covered
service, including a pharmacy or medical benefit, that is provided
to a recipient with both Medicaid and primary health benefit plan
coverage when the recipient has exceeded the primary health benefit
plan coverage limit or when the service is not covered by the
primary health benefit plan issuer.
(b) The commission, in coordination with Medicaid managed
care organizations and in consultation with the STAR Kids Managed
Care Advisory Committee described by Section 533.00254, shall
develop and adopt a clear policy for a Medicaid managed care
organization to ensure the coordination and timely delivery of
Medicaid wrap-around benefits for recipients with both primary
health benefit plan coverage and Medicaid coverage. In developing
the policy, the commission shall consider requiring a Medicaid
managed care organization to allow, notwithstanding Sections
531.073 and 533.005(a)(23) or any other law, a recipient using a
prescription drug for which the recipient's primary health benefit
plan issuer previously provided coverage to continue receiving the
prescription drug without requiring additional prior
authorization.
(c) If the commission determines that a recipient's primary
health benefit plan issuer should have been the primary payor of a
claim, the Medicaid managed care organization that paid the claim
shall work with the commission on the recovery process and make
every attempt to reduce health care provider and recipient
abrasion.
(d) The executive commissioner may seek a waiver from the
federal government as needed to:
(1) address federal policies related to coordination
of benefits and third-party liability; and
(2) maximize federal financial participation for
recipients with both primary health benefit plan coverage and
Medicaid coverage.
(e) The commission may include in the Medicaid managed care
eligibility files an indication of whether a recipient has primary
health benefit plan coverage or is enrolled in a group health
benefit plan for which the commission provides premium assistance
under the health insurance premium payment program. For recipients
with that coverage or for whom that premium assistance is provided,
the files may include the following up-to-date, accurate
information related to primary health benefit plan coverage to the
extent the information is available to the commission:
(1) the health benefit plan issuer's name and address
and the recipient's policy number;
(2) the primary health benefit plan coverage start and
end dates; and
(3) the primary health benefit plan coverage benefits,
limits, copayment, and coinsurance information.
(f) To the extent allowed by federal law, the commission
shall maintain processes and policies to allow a health care
provider who is primarily providing services to a recipient through
primary health benefit plan coverage to receive Medicaid
reimbursement for services ordered, referred, or prescribed,
regardless of whether the provider is enrolled as a Medicaid
provider. The commission shall allow a provider who is not enrolled
as a Medicaid provider to order, refer, or prescribe services to a
recipient based on the provider's national provider identifier
number and may not require an additional state provider identifier
number to receive reimbursement for the services. The commission
may seek a waiver of Medicaid provider enrollment requirements for
providers of recipients with primary health benefit plan coverage
to implement this subsection.
(g) The commission shall develop a clear and easy process,
to be implemented through a contract, that allows a recipient with
complex medical needs who has established a relationship with a
specialty provider to continue receiving care from that provider.
SECTION 7. (a) Section 531.0601, Government Code, as added
by this Act, applies only to a child who becomes ineligible for the
medically dependent children (MDCP) waiver program on or after
December 1, 2019.
(b) Section 531.0602, Government Code, as added by this Act,
applies only to an assessment or reassessment of a child's
eligibility for the medically dependent children (MDCP) waiver
program made on or after December 1, 2019.
(c) Notwithstanding Section 531.06021, Government Code, as
added by this Act, the Health and Human Services Commission shall
submit the first report required by that section not later than
September 30, 2020, for the state fiscal quarter ending August 31,
2020.
(d) Not later than March 1, 2020, the Health and Human
Services Commission shall:
(1) develop a plan to improve the care needs
assessment tool and the initial assessment and reassessment
processes as required by Sections 533.00253(c-1) and (c-2),
Government Code, as added by this Act; and
(2) post the plan on the commission's Internet
website.
(e) Sections 533.00282 and 533.00284, Government Code, as
added by this Act, apply only to a contract between the Health and
Human Services Commission and a Medicaid managed care organization
under Chapter 533, Government Code, that is entered into or renewed
on or after the effective date of this Act.
(f) As soon as practicable after the effective date of this
Act but not later than September 1, 2020, the Health and Human
Services Commission shall seek to amend contracts entered into with
Medicaid managed care organizations under Chapter 533, Government
Code, before the effective date of this Act to include the
provisions required by Sections 533.00282 and 533.00284,
Government Code, as added by this Act.
SECTION 8. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall adopt rules necessary to implement the
changes in law made by this Act.
SECTION 9. 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 10. The Health and Human Services Commission is
required to implement a provision of this Act only if the
legislature appropriates money specifically for that purpose. If
the legislature does not appropriate money specifically for that
purpose, the commission may, but is not required to, implement a
provision of this Act using other appropriations available for that
purpose.
SECTION 11. This Act takes effect September 1, 2019.
______________________________ ______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 1207 passed the Senate on
April 17, 2019, by the following vote: Yeas 30, Nays 1;
May 23, 2019, Senate refused to concur in House amendments and
requested appointment of Conference Committee; May 23, 2019, House
granted request of the Senate; May 26, 2019, Senate adopted
Conference Committee Report by the following vote: Yeas 30,
Nays 1.
______________________________
Secretary of the Senate
I hereby certify that S.B. No. 1207 passed the House, with
amendments, on May 20, 2019, by the following vote: Yeas 139,
Nays 0, two present not voting; May 23, 2019, House granted request
of the Senate for appointment of Conference Committee;
May 26, 2019, House adopted Conference Committee Report by the
following vote: Yeas 145, Nays 0, one present not voting.
______________________________
Chief Clerk of the House
Approved:
______________________________
Date
______________________________
Governor