Texas 2025 - 89th Regular

Texas House Bill HB5185 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		By: Frank H.B. No. 5185
	2	+
	3	+
2	4
3	5
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 2. 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 3. 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 4. 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
117	119		significant participation in the organization's provider network
118	120		from each health care provider in the region who has traditionally
119	121		provided care to Medicaid and charity care patients;
120	122		(2) give extra consideration to an organization that
121	123		agrees to assure continuity of care for at least three months beyond
122	124		a recipient's Medicaid eligibility period;
123	125		(3) consider the need to use different managed care
124	126		plans to 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 5. This Act takes effect September 1, 2025.