Texas 2025 - 89th Regular

Texas House Bill HB5183 Compare Versions

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1	1		By: Frank H.B. No. 5183
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4	6		A BILL TO BE ENTITLED
5	7		AN ACT
6	8		relating to contracts with managed care organizations, including
7	9		the procurement of managed care contracts, under Medicaid and the
8	10		child health plan program.
9	11		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	12		SECTION 1. Subchapter E, Chapter 540, Government Code, is
11	13		amended by adding Sections 540.02041, 540.02042, and
12	14		540.02043533.0038 to read as follows:
13	15		Sec. 540.02041. DURATION OF CONTRACTS. (a) Contracts the
14	16		commission signs with managed care organizations do not have a set
15	17		term length.
16	18		(b) A contract the commission signs with a managed care
17	19		organization shall not be terminated except through the process
18	20		described in Sec. 540.02042(h) and (i) or upon the request of the
19	21		managed care organization.
20	22		Sec. 540.02042. PERFORMANCE MEASURES. (a) The programs to
21	23		which this section applies include STAR, STAR Kids, STAR + Plus, and
22	24		the child health plan program.
23	25		(b) The commission shall adopt and publish clear and
24	26		comprehensive measures by which the quality and performance of
25	27		managed care organizations will be measured.
26	28		(c) In adopting the measures under Subsection (a), the
27	29		commission shall consider:
28	30		(1) cost efficiency, quality of care, experience of
29	31		care, and member and provider satisfaction;
30	32		(2) the size and quality of a managed care
31	33		organization's provider network; and
32	34		(3) past experience of the managed care organization
33	35		in providing similar services in this or other states.
34	36		(d) The measures shall include:
35	37		(1) outcome-based performance measures described by
36	38		Section 533.0051;
37	39		(2) the most recent results from the Agency for
38	40		Healthcare Research and Quality's Consumer Assessment of
39	41		Healthcare Providers and Systems (CAHPS) Health Plan Survey; and
40	42		(3) Healthcare Effectiveness Data and Information Set
41	43		(HEDIS) measurement results.
42	44		(e) The commission may adopt measures only after a public
43	45		hearing and comment process that considers proposed measures.
44	46		(f) A managed care organization is responsible for
45	47		providing the commission with data necessary for the commission to
46	48		determine whether the applicant has met the qualifying criteria.
47	49		(g) The commission shall:
48	50		(1) monthly evaluate a managed care organization
49	51		performance and quality by region; and
50	52		(2) post on its Internet website the results of the
51	53		monthly evaluations conducted under this section in a format that
52	54		is readily accessible to and understandable by a member of the
53	55		public.
54	56		(h) If a managed care organization that has contracted with
55	57		the commission under this section fails to comply with the terms of
56	58		its contract and the commission determines the managed care
57	59		organization has not made substantial efforts to mitigate or remedy
58	60		the noncompliance, or if its results on the measurements described
59	61		in subsection (b) are in the bottom quartile of all plans operating
60	62		in the state in the same program, or if their results on the
61	63		measurements described in subsection (b) are the lowest in the
62	64		region, the commissioner shall pursue the following remedies in
63	65		addition to any remedies available to the commission under the
64	66		contract, in this order:
65	67		(1) require submission of and compliance with a
66	68		corrective action plan;
67	69		(2) seek recovery of actual damages or liquidated
68	70		damages specified in the contract;
69	71		(3) suspend default enrollment of recipients to the
70	72		managed care organization in one or more regions; and
71	73		(4) terminate the contract.
72	74		(i) If the commission has taken remedies described in
73	75		(h)(1), (h)(2), and (h)(3), and the plan has not shown significant
74	76		improvement over 18 months, then the commission shall take the
75	77		action described by (h)(4).
76	78		Sec. 540.02043. LIMITS ON MANAGED CARE ORGANIZATIONS. (a)
77	79		The commission shall limit the number of managed care organizations
78	80		operating in each Medicaid program in each region.
79	81		(b) In each Medicaid program, the commission may limit the
80	82		number of regions in which a managed care organization may operate.
81	83		SECTION 3. Section 62.002, Health and Safety Code, is
82	84		amended by adding Subsection (5) to read as follows:
83	85		(5) "Region" means a service area delineated by the
84	86		commission.
85	87		SECTION 4. Section 62.155, Health and Safety Code, is
86	88		amended by amending Subsection (a) and adding Subsections (e) and
87	89		(f) to read as follows:
88	90		(a) Following the termination of a health plan provider's
89	91		contract in a region, the commission may select a health plan
90	92		provider to operate in that region [The commission shall select the
91	93		health plan providers] under the program through a competitive
92	94		procurement process. A health plan provider, other than a state
93	95		administered primary care case management network, must hold a
94	96		certificate of authority or other appropriate license issued by the
95	97		Texas Department of Insurance that authorizes the health plan
96	98		provider to provide the type of child health plan offered and must
97	99		satisfy, except as provided by this chapter, any applicable
98	100		requirement of the Insurance Code or another insurance law of this
99	101		state.
100	102		(e) The commission shall limit the number of health plan
101	103		providers operating under the program in each region of the state.
102	104		(f) The commission may limit the number of regions in which
103	105		a health plan provider may operate under the program.
104	106		(g) Contracts the commission signs with health plan
105	107		providers do not have a set term length.
106	108		(h) A contract the commission signs with a managed care
107	109		organization shall not be terminated except through the process
108	110		described in Sec. 540.02042(h) and (i) or upon the request of the
109	111		health plan provider.
110	112		SECTION 5. Section 540.0204, Government Code, is amended to
111	113		read as follows:
112	114		Sec. 540.0204. CONTRACT CONSIDERATIONS RELATING TO MANAGED
113	115		CARE ORGANIZATIONS. Following the termination of a managed care
114	116		organization's contract, [I]in awarding a contract[s] to a managed
115	117		care organization[s] in that region, the commission shall:
116	118		(1) give preference to an organization that has significant
117	119		participation in the organization's provider network from each
118	120		health care provider in the region who has traditionally provided
119	121		care to Medicaid and charity care patients;
120	122		(2) give extra consideration to an organization that agrees
121	123		to assure continuity of care for at least three months beyond a
122	124		recipient's Medicaid eligibility period;
123	125		(3) consider the need to use different managed care plans to
124	126		meet the needs of different populations; and
125	127		(4) consider the ability of an organization to process
126	128		Medicaid claims electronically.
127	129		SECTION 6. (a) The Health and Human Services Commission
128	130		shall enter into contracts with the managed care organizations that
129	131		had contracts in effect as of January 1, 2025 for the STAR, CHIP,
130	132		and STAR Kids programs. These contracts shall be subject to
131	133		Sections 540.0204, 540.02041, and 540.02042 of the Government Code
132	134		and Section 62.155 of the Health and Safety Code. The commission
133	135		shall cancel all procurements for the STAR, CHIP, or STAR Kids
134	136		programs that were pending as of January 1, 2025.
135	137		(b) As specified in the notice of intent to award, the
136	138		commission shall enter into contracts with managed care
137	139		organizations that are awardees designated in the notice of intent
138	140		to award of any pending procurements. These contracts shall be
139	141		subject to Sections 540.0204, 540.02041, and 540.02042 of the
140	142		Government Code and Section 62.155 of the Health and Safety Code.
141	143		(c) By January 1, 2030, the Health and Human Services
142	144		Commission shall have entered into contracts with the managed care
143	145		organizations for the Star + Plus program that had contracts in
144	146		effect as of January 1, 2029 for the Star + Plus program. These
145	147		contracts shall be subject to Sections 540.0204, 540.02041, and
146	148		540.02042 of the Government Code and Section 62.155 of the Health
147	149		and Safety Code.
148	150		(d) A Medicaid recipient or child health plan program
149	151		participant enrolled in a managed care plan with a contract
150	152		described by Subsection (a) shall continue enrollment in the
151	153		managed care plan until the recipient or participant chooses to be
152	154		enrolled in a different managed care plan, is no longer eligible for
153	155		services, or is enrolled in a plan subject to contract termination
154	156		in the region in which the recipient or participant resides.
155	157		SECTION 7. This Act takes effect September 1, 2025.