88R13596 BDP-F
By: Oliverson H.B. No. 4823
A BILL TO BE ENTITLED
AN ACT
relating to the provision and delivery of benefits to certain
recipients under Medicaid.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.024164(e), Government Code, is
amended to read as follows:
(e) The commission shall establish a common procedure for
conducting external medical 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) must conform to the utilization review and
independent review process under Title 14, Insurance Code [identify
an appeal that requires an expedited resolution]; [and]
(2) must include, at a minimum, the following
requirements:
(A) a requirement that the person requesting the
external review timely deliver to the external reviewer the
recipient's relevant personal and medical information, including,
except as provided by Paragraph (B), the recipient's written
statement;
(B) in the instance the review relates to a
life-threatening condition, a requirement that instead of
obtaining a written statement from the recipient the reviewer
directly contact:
(i) the recipient or recipient's parent or
legally authorized representative; and
(ii) the recipient's health care provider;
(C) a requirement that the reviewer notify the
recipient or recipient's parent or legally authorized
representative, the recipient's health care provider, and the
commission if the reviewer does not receive the information
described by Paragraph (A) within three business days after the
date the reviewer is assigned to conduct the review; and
(D) a requirement that the reviewer request and
maintain any other relevant information not provided under
Paragraph (A) that is necessary to conduct the review, including:
(i) identifying information about the
recipient, the recipient's treating health care providers, health
care facilities providing care to the recipient, and the
recipient's managed care plan;
(ii) the recipient's plan of care;
(iii) clinical information about the
recipient's diagnosis and medical history related to the diagnosis;
(iv) the recipient's prognosis; and
(v) the recipient's treatment plan
prescribed by a health care provider and the provider's
justification of the services contained in the plan;
(3) must ensure that the recipient and the recipient's
health care provider are given the opportunity to provide input and
additional evidence during the review; and
(4) may not prohibit a recipient, a recipient's parent
or legally authorized representative, or the recipient's health
care provider from submitting any information or documentation the
person determines relevant to [resolve] the review [of the appeal
within a specified period].
SECTION 2. Section 533.038, Government Code, is amended by
amending Subsections (a), (g), and (h) and adding Subsection (j) to
read as follows:
(a) In this section:
(1) "Complex medical needs" means:
(A) the condition of having one or more chronic
health problems that:
(i) affect multiple organ systems; and
(ii) reduce cognitive or physical
functioning and require the use of medication, durable medical
equipment, therapy, surgery, or other treatments; or
(B) a life-limiting illness or rare pediatric
disease, as defined by Section 529(a)(3) of the Food and Drug
Administration Safety and Innovation Act (21 U.S.C. 360ff(a)).
(2) [,] "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.
(3) "Specialty provider" means a person who provides
health-related goods or services to a recipient, including a
provider of medication, therapy services, durable medical
equipment, life-sustaining or life-stabilizing treatment, or any
other treatment, services, equipment, or supplies necessary to
improve health outcomes, prevent emergency room visits, maintain
health care in the home and community, and avoid admission to a
health care facility or other institution.
(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 at any
time with a specialty provider to continue receiving care from that
provider, regardless of:
(1) whether the recipient has primary health benefit
plan coverage in addition to Medicaid coverage;
(2) the date the recipient enrolled in the managed
care plan provided by the Medicaid managed care organization; or
(3) whether the provider is an in-network provider.
(h) If a recipient who has complex medical needs and who
does not have primary health benefit plan coverage wants to
continue to receive care from a specialty provider that is not in
the provider network of the Medicaid managed care organization
offering the managed care plan in which the recipient is enrolled,
the managed care organization shall develop a simple, timely, and
efficient process to and shall make a good-faith effort to,
negotiate a single-case agreement with the specialty provider.
Until the Medicaid managed care organization and the specialty
provider enter into the single-case agreement, the specialty
provider shall be reimbursed in accordance with the applicable
reimbursement methodology specified in commission rule, including
1 T.A.C. Section 353.4.
(j) The cancellation of a contract between a Medicaid
managed care organization and a specialty provider under which the
provider agrees to provide in-network services to recipients does
not void or otherwise affect that organization's duty under
Subsection (g) to provide continuity of care to recipients with
complex medical needs, except if the cancellation is the result of
fraud, waste, or abuse, as determined by the commission's office of
inspector general. In the event of cancellation, the recipient has
the right to select the recipient's preferred specialty provider.
SECTION 3. 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 4. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2023.