Texas 2023 - 88th Regular

Texas House Bill HB4823 Compare Versions

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Version 2 (New)

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1	1	88R13596 BDP-F
2	2	By: Oliverson H.B. No. 4823
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the provision and delivery of benefits to certain
8	8	recipients under Medicaid.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 531.024164(e), Government Code, is
11	11	amended to read as follows:
12	12	(e) The commission shall establish a common procedure for
13	13	conducting external medical reviews. [To the greatest extent
14	14	possible, the procedure must reduce administrative burdens on
15	15	providers and the submission of duplicative information or
16	16	documents. Medical necessity under the procedure must be based on
17	17	publicly available, up-to-date, evidence-based, and peer-reviewed
18	18	clinical criteria. The reviewer shall conduct the review within a
19	19	period specified by the commission.] The [commission shall also
20	20	establish a] procedure [and time frame for expedited reviews that
21	21	allows the reviewer to]:
22	22	(1) must conform to the utilization review and
23	23	independent review process under Title 14, Insurance Code [identify
24	24	an appeal that requires an expedited resolution]; [and]
25	25	(2) must include, at a minimum, the following
26	26	requirements:
27	27	(A) a requirement that the person requesting the
28	28	external review timely deliver to the external reviewer the
29	29	recipient's relevant personal and medical information, including,
30	30	except as provided by Paragraph (B), the recipient's written
31	31	statement;
32	32	(B) in the instance the review relates to a
33	33	life-threatening condition, a requirement that instead of
34	34	obtaining a written statement from the recipient the reviewer
35	35	directly contact:
36	36	(i) the recipient or recipient's parent or
37	37	legally authorized representative; and
38	38	(ii) the recipient's health care provider;
39	39	(C) a requirement that the reviewer notify the
40	40	recipient or recipient's parent or legally authorized
41	41	representative, the recipient's health care provider, and the
42	42	commission if the reviewer does not receive the information
43	43	described by Paragraph (A) within three business days after the
44	44	date the reviewer is assigned to conduct the review; and
45	45	(D) a requirement that the reviewer request and
46	46	maintain any other relevant information not provided under
47	47	Paragraph (A) that is necessary to conduct the review, including:
48	48	(i) identifying information about the
49	49	recipient, the recipient's treating health care providers, health
50	50	care facilities providing care to the recipient, and the
51	51	recipient's managed care plan;
52	52	(ii) the recipient's plan of care;
53	53	(iii) clinical information about the
54	54	recipient's diagnosis and medical history related to the diagnosis;
55	55	(iv) the recipient's prognosis; and
56	56	(v) the recipient's treatment plan
57	57	prescribed by a health care provider and the provider's
58	58	justification of the services contained in the plan;
59	59	(3) must ensure that the recipient and the recipient's
60	60	health care provider are given the opportunity to provide input and
61	61	additional evidence during the review; and
62	62	(4) may not prohibit a recipient, a recipient's parent
63	63	or legally authorized representative, or the recipient's health
64	64	care provider from submitting any information or documentation the
65	65	person determines relevant to [resolve] the review [of the appeal
66	66	within a specified period].
67	67	SECTION 2. Section 533.038, Government Code, is amended by
68	68	amending Subsections (a), (g), and (h) and adding Subsection (j) to
69	69	read as follows:
70	70	(a) In this section:
71	71	(1) "Complex medical needs" means:
72	72	(A) the condition of having one or more chronic
73	73	health problems that:
74	74	(i) affect multiple organ systems; and
75	75	(ii) reduce cognitive or physical
76	76	functioning and require the use of medication, durable medical
77	77	equipment, therapy, surgery, or other treatments; or
78	78	(B) a life-limiting illness or rare pediatric
79	79	disease, as defined by Section 529(a)(3) of the Food and Drug
80	80	Administration Safety and Innovation Act (21 U.S.C. 360ff(a)).
81	81	(2) [,] "Medicaid wrap-around benefit" means a
82	82	Medicaid-covered service, including a pharmacy or medical benefit,
83	83	that is provided to a recipient with both Medicaid and primary
84	84	health benefit plan coverage when the recipient has exceeded the
85	85	primary health benefit plan coverage limit or when the service is
86	86	not covered by the primary health benefit plan issuer.
87	87	(3) "Specialty provider" means a person who provides
88	88	health-related goods or services to a recipient, including a
89	89	provider of medication, therapy services, durable medical
90	90	equipment, life-sustaining or life-stabilizing treatment, or any
91	91	other treatment, services, equipment, or supplies necessary to
92	92	improve health outcomes, prevent emergency room visits, maintain
93	93	health care in the home and community, and avoid admission to a
94	94	health care facility or other institution.
95	95	(g) The commission shall develop a clear and easy process,
96	96	to be implemented through a contract, that allows a recipient with
97	97	complex medical needs who has established a relationship at any
98	98	time with a specialty provider to continue receiving care from that
99	99	provider, regardless of:
100	100	(1) whether the recipient has primary health benefit
101	101	plan coverage in addition to Medicaid coverage;
102	102	(2) the date the recipient enrolled in the managed
103	103	care plan provided by the Medicaid managed care organization; or
104	104	(3) whether the provider is an in-network provider.
105	105	(h) If a recipient who has complex medical needs and who
106	106	does not have primary health benefit plan coverage wants to
107	107	continue to receive care from a specialty provider that is not in
108	108	the provider network of the Medicaid managed care organization
109	109	offering the managed care plan in which the recipient is enrolled,
110	110	the managed care organization shall develop a simple, timely, and
111	111	efficient process to and shall make a good-faith effort to,
112	112	negotiate a single-case agreement with the specialty provider.
113	113	Until the Medicaid managed care organization and the specialty
114	114	provider enter into the single-case agreement, the specialty
115	115	provider shall be reimbursed in accordance with the applicable
116	116	reimbursement methodology specified in commission rule, including
117	117	1 T.A.C. Section 353.4.
118	118	(j) The cancellation of a contract between a Medicaid
119	119	managed care organization and a specialty provider under which the
120	120	provider agrees to provide in-network services to recipients does
121	121	not void or otherwise affect that organization's duty under
122	122	Subsection (g) to provide continuity of care to recipients with
123	123	complex medical needs, except if the cancellation is the result of
124	124	fraud, waste, or abuse, as determined by the commission's office of
125	125	inspector general. In the event of cancellation, the recipient has
126	126	the right to select the recipient's preferred specialty provider.
127	127	SECTION 3. If before implementing any provision of this Act
128	128	a state agency determines that a waiver or authorization from a
129	129	federal agency is necessary for implementation of that provision,
130	130	the agency affected by the provision shall request the waiver or
131	131	authorization and may delay implementing that provision until the
132	132	waiver or authorization is granted.
133	133	SECTION 4. This Act takes effect immediately if it receives
134	134	a vote of two-thirds of all the members elected to each house, as
135	135	provided by Section 39, Article III, Texas Constitution. If this
136	136	Act does not receive the vote necessary for immediate effect, this
137	137	Act takes effect September 1, 2023.