By: Frank H.B. No. 5185
A BILL TO BE ENTITLED
AN ACT
relating to contracts with managed care organizations, including
the procurement of managed care contracts, under Medicaid and the
child health plan program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter E, Chapter 540, Government Code, is
amended by adding Sections 540.02041, 540.02042, and
540.02043533.0038 to read as follows:
Sec. 540.02041. DURATION OF CONTRACTS. (a) Contracts the
commission signs with managed care organizations do not have a set
term length.
(b) A contract the commission signs with a managed care
organization shall not be terminated except through the process
described in Sec. 540.02042(h) and (i) or upon the request of the
managed care organization.
Sec. 540.02042. PERFORMANCE MEASURES. (a) The programs to
which this section applies include STAR, STAR Kids, STAR + Plus, and
the child health plan program.
(b) The commission shall adopt and publish clear and
comprehensive measures by which the quality and performance of
managed care organizations will be measured.
(c) In adopting the measures under Subsection (a), the
commission shall consider:
(1) cost efficiency, quality of care, experience of
care, and member and provider satisfaction;
(2) the size and quality of a managed care
organization's provider network; and
(3) past experience of the managed care organization
in providing similar services in this or other states.
(d) The measures shall include:
(1) outcome-based performance measures described by
Section 533.0051;
(2) the most recent results from the Agency for
Healthcare Research and Quality's Consumer Assessment of
Healthcare Providers and Systems (CAHPS) Health Plan Survey; and
(3) Healthcare Effectiveness Data and Information Set
(HEDIS) measurement results.
(e) The commission may adopt measures only after a public
hearing and comment process that considers proposed measures.
(f) A managed care organization is responsible for
providing the commission with data necessary for the commission to
determine whether the applicant has met the qualifying criteria.
(g) The commission shall:
(1) monthly evaluate a managed care organization
performance and quality by region; and
(2) post on its Internet website the results of the
monthly evaluations conducted under this section in a format that
is readily accessible to and understandable by a member of the
public.
(h) If a managed care organization that has contracted with
the commission under this section fails to comply with the terms of
its contract and the commission determines the managed care
organization has not made substantial efforts to mitigate or remedy
the noncompliance, or if its results on the measurements described
in subsection (b) are in the bottom quartile of all plans operating
in the state in the same program, or if their results on the
measurements described in subsection (b) are the lowest in the
region, the commissioner shall pursue the following remedies in
addition to any remedies available to the commission under the
contract, in this order:
(1) require submission of and compliance with a
corrective action plan;
(2) seek recovery of actual damages or liquidated
damages specified in the contract;
(3) suspend default enrollment of recipients to the
managed care organization in one or more regions; and
(4) terminate the contract.
(i) If the commission has taken remedies described in
(h)(1), (h)(2), and (h)(3), and the plan has not shown significant
improvement over 18 months, then the commission shall take the
action described by (h)(4).
Sec. 540.02043. LIMITS ON MANAGED CARE ORGANIZATIONS. (a)
The commission shall limit the number of managed care organizations
operating in each Medicaid program in each region.
(b) In each Medicaid program, the commission may limit the
number of regions in which a managed care organization may operate.
SECTION 2. Section 62.002, Health and Safety Code, is
amended by adding Subsection (5) to read as follows:
(5) "Region" means a service area delineated by the
commission.
SECTION 3. Section 62.155, Health and Safety Code, is
amended by amending Subsection (a) and adding Subsections (e) and
(f) to read as follows:
(a) Following the termination of a health plan provider's
contract in a region, the commission may select a health plan
provider to operate in that region [The commission shall select the
health plan providers] under the program through a competitive
procurement process. A health plan provider, other than a state
administered primary care case management network, must hold a
certificate of authority or other appropriate license issued by the
Texas Department of Insurance that authorizes the health plan
provider to provide the type of child health plan offered and must
satisfy, except as provided by this chapter, any applicable
requirement of the Insurance Code or another insurance law of this
state.
(e) The commission shall limit the number of health plan
providers operating under the program in each region of the state.
(f) The commission may limit the number of regions in which
a health plan provider may operate under the program.
(g) Contracts the commission signs with health plan
providers do not have a set term length.
(h) A contract the commission signs with a managed care
organization shall not be terminated except through the process
described in Sec. 540.02042(h) and (i) or upon the request of the
health plan provider.
SECTION 4. Section 540.0204, Government Code, is amended to
read as follows:
Sec. 540.0204. CONTRACT CONSIDERATIONS RELATING TO MANAGED
CARE ORGANIZATIONS. Following the termination of a managed care
organization's contract, [I]in awarding a contract[s] to a managed
care organization[s] in that region, the commission shall:
(1) give preference to an organization that has
significant participation in the organization's provider network
from each health care provider in the region who has traditionally
provided care to Medicaid and charity care patients;
(2) give extra consideration to an organization that
agrees to assure continuity of care for at least three months beyond
a recipient's Medicaid eligibility period;
(3) consider the need to use different managed care
plans to meet the needs of different populations; and
(4) consider the ability of an organization to process
Medicaid claims electronically.
SECTION 5. This Act takes effect September 1, 2025.