88R19014 JG-F
By: Smithee H.B. No. 3119
A BILL TO BE ENTITLED
AN ACT
relating to requirements applicable to certain third-party health
insurers in relation to Medicaid.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.024131(a), Government Code, is
amended to read as follows:
(a) If cost-effective, the commission may:
(1) contract to expand all or part of the billing
coordination system established under Section 531.02413 to process
claims for services provided through other benefits programs
administered by the commission or a health and human services
agency;
(2) expand any other billing coordination tools and
resources used to process claims for health care services provided
through Medicaid to process claims for services provided through
other benefits programs administered by the commission or a health
and human services agency; and
(3) expand the scope of persons about whom information
is collected under Section 32.0424(a) [32.042], Human Resources
Code, to include recipients of services provided through other
benefits programs administered by the commission or a health and
human services agency.
SECTION 2. Section 32.0421(a), Human Resources Code, is
amended to read as follows:
(a) The commission may impose an administrative penalty on a
person who does not comply with a request for information made under
Section 32.0424(a) [32.042(b)].
SECTION 3. Section 32.0424, Human Resources Code, is
amended by amending Subsections (a), (c), and (d) and adding
Subsections (b-1), (b-2), and (f) to read as follows:
(a) A third-party health insurer shall [is required to]
provide to the commission or the commission's designee, on the
commission's or the commission's designee's request, information in
a form prescribed by the executive commissioner necessary to
determine:
(1) the period during which an individual entitled to
medical assistance, the individual's spouse, or the individual's
dependents may be, or may have been, covered by coverage issued by
the health insurer;
(2) the nature of the coverage; and
(3) the name, address, and identifying number of the
health plan under which the person may be, or may have been,
covered.
(b-1) Except as provided by Subsection (b-2), a third-party
health insurer that requires prior authorization for an item or
service provided to an individual entitled to medical assistance
shall accept authorization provided by the commission or the
commission's designee that the item or service is covered under the
medical assistance program as if that authorization is a prior
authorization made by the third-party health insurer for the item
or service.
(b-2) Subsection (b-1) does not apply to a third-party
health insurer with respect to providing:
(1) hospital insurance benefits or supplementary
insurance benefits under Part A or B of Title XVIII of the Social
Security Act (42 U.S.C. Section 1395c et seq. or 1395j et seq.);
(2) a health care prepayment plan under Section
1833(a)(1)(A), Social Security Act (42 U.S.C. Section
1395l(a)(1)(A));
(3) a Medicare Advantage plan under Part C of Title
XVIII of the Social Security Act (42 U.S.C. Section 1395w-21 et
seq.);
(4) a prescription drug plan as a prescription drug
plan sponsor under Part D of Title XVIII of the Social Security Act
(42 U.S.C. Section 1395w-101 et seq.); or
(5) a reasonable cost reimbursement plan under Section
1876, Social Security Act (42 U.S.C. Section 1395mm).
(c) Not later than the 60th day after the date a [A]
third-party health insurer receives an [shall respond to any]
inquiry from [by] the commission or the commission's designee
regarding a claim for payment for any health care item or service
submitted to the insurer [reimbursed by the commission under the
medical assistance program] not later than the third anniversary of
the date the health care item or service was provided, the insurer
shall respond to the inquiry.
(d) A third-party health insurer may not deny a claim
submitted by the commission or the commission's designee for which
payment was made under the medical assistance program solely on the
basis of the date of submission of the claim, the type or format of
the claim form, [or] a failure to present proper documentation at
the point of service that is the basis of the claim, or, for a
responsible third-party health insurer, other than an insurer
described by Subsection (b-2), a failure to obtain prior
authorization for the item or service for which the claim is being
submitted, if:
(1) the claim is submitted by the commission or the
commission's designee not later than the third anniversary of the
date the item or service was provided; and
(2) any action by the commission or the commission's
designee to enforce the state's rights with respect to the claim is
commenced not later than the sixth anniversary of the date the
commission or the commission's designee submits the claim.
(f) In this section, "third-party health insurer" means a
health insurer or other person that is legally responsible by state
or federal law or private agreement to pay some or all claims for
health care items or services provided to an individual. The term
includes:
(1) a person providing a self-insured plan;
(2) a person providing a group health plan as defined
by Section 607 of the Employee Retirement Income Security Act of
1974 (29 U.S.C. Section 1167);
(3) a person providing a service benefit plan;
(4) a managed care organization; and
(5) a pharmacy benefit manager.
SECTION 4. The following provisions of the Human Resources
Code are repealed:
(1) Section 32.042; and
(2) Section 32.0424(e).
SECTION 5. 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 6. This Act takes effect September 1, 2023.