Bill Text: TX HB3119 | 2023-2024 | 88th Legislature | Engrossed


Bill Title: Relating to requirements applicable to certain third-party health insurers in relation to Medicaid.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Engrossed - Dead) 2023-05-16 - Referred to Health & Human Services [HB3119 Detail]

Download: Texas-2023-HB3119-Engrossed.html
  88R19014 JG-F
 
  By: Smithee H.B. No. 3119
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to requirements applicable to certain third-party health
  insurers in relation to Medicaid.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 531.024131(a), Government Code, is
  amended to read as follows:
         (a)  If cost-effective, the commission may:
               (1)  contract to expand all or part of the billing
  coordination system established under Section 531.02413 to process
  claims for services provided through other benefits programs
  administered by the commission or a health and human services
  agency;
               (2)  expand any other billing coordination tools and
  resources used to process claims for health care services provided
  through Medicaid to process claims for services provided through
  other benefits programs administered by the commission or a health
  and human services agency; and
               (3)  expand the scope of persons about whom information
  is collected under Section 32.0424(a) [32.042], Human Resources
  Code, to include recipients of services provided through other
  benefits programs administered by the commission or a health and
  human services agency.
         SECTION 2.  Section 32.0421(a), Human Resources Code, is
  amended to read as follows:
         (a)  The commission may impose an administrative penalty on a
  person who does not comply with a request for information made under
  Section 32.0424(a) [32.042(b)].
         SECTION 3.  Section 32.0424, Human Resources Code, is
  amended by amending Subsections (a), (c), and (d) and adding
  Subsections (b-1), (b-2), and (f) to read as follows:
         (a)  A third-party health insurer shall [is required to]
  provide to the commission or the commission's designee, on the
  commission's or the commission's designee's request, information in
  a form prescribed by the executive commissioner necessary to
  determine:
               (1)  the period during which an individual entitled to
  medical assistance, the individual's spouse, or the individual's
  dependents may be, or may have been, covered by coverage issued by
  the health insurer;
               (2)  the nature of the coverage; and
               (3)  the name, address, and identifying number of the
  health plan under which the person may be, or may have been,
  covered.
         (b-1)  Except as provided by Subsection (b-2), a third-party
  health insurer that requires prior authorization for an item or
  service provided to an individual entitled to medical assistance
  shall accept authorization provided by the commission or the
  commission's designee that the item or service is covered under the
  medical assistance program as if that authorization is a prior
  authorization made by the third-party health insurer for the item
  or service.
         (b-2)  Subsection (b-1) does not apply to a third-party
  health insurer with respect to providing:
               (1)  hospital insurance benefits or supplementary
  insurance benefits under Part A or B of Title XVIII of the Social
  Security Act (42 U.S.C. Section 1395c et seq. or 1395j et seq.);
               (2)  a health care prepayment plan under Section
  1833(a)(1)(A), Social Security Act (42 U.S.C. Section
  1395l(a)(1)(A));
               (3)  a Medicare Advantage plan under Part C of Title
  XVIII of the Social Security Act (42 U.S.C. Section 1395w-21 et
  seq.);
               (4)  a prescription drug plan as a prescription drug
  plan sponsor under Part D of Title XVIII of the Social Security Act
  (42 U.S.C. Section 1395w-101 et seq.); or
               (5)  a reasonable cost reimbursement plan under Section
  1876, Social Security Act (42 U.S.C. Section 1395mm).
         (c)  Not later than the 60th day after the date a [A]
  third-party health insurer receives an [shall respond to any]
  inquiry from [by] the commission or the commission's designee
  regarding a claim for payment for any health care item or service
  submitted to the insurer [reimbursed by the commission under the
  medical assistance program] not later than the third anniversary of
  the date the health care item or service was provided, the insurer
  shall respond to the inquiry.
         (d)  A third-party health insurer may not deny a claim
  submitted by the commission or the commission's designee for which
  payment was made under the medical assistance program solely on the
  basis of the date of submission of the claim, the type or format of
  the claim form, [or] a failure to present proper documentation at
  the point of service that is the basis of the claim, or, for a
  responsible third-party health insurer, other than an insurer
  described by Subsection (b-2), a failure to obtain prior
  authorization for the item or service for which the claim is being
  submitted, if:
               (1)  the claim is submitted by the commission or the
  commission's designee not later than the third anniversary of the
  date the item or service was provided; and
               (2)  any action by the commission or the commission's
  designee to enforce the state's rights with respect to the claim is
  commenced not later than the sixth anniversary of the date the
  commission or the commission's designee submits the claim.
         (f)  In this section, "third-party health insurer" means a
  health insurer or other person that is legally responsible by state
  or federal law or private agreement to pay some or all claims for
  health care items or services provided to an individual.  The term
  includes:
               (1)  a person providing a self-insured plan;
               (2)  a person providing a group health plan as defined
  by Section 607 of the Employee Retirement Income Security Act of
  1974 (29 U.S.C. Section 1167);
               (3)  a person providing a service benefit plan;
               (4)  a managed care organization; and
               (5)  a pharmacy benefit manager.
         SECTION 4.  The following provisions of the Human Resources
  Code are repealed:
               (1)  Section 32.042; and
               (2)  Section 32.0424(e).
         SECTION 5.  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 6.  This Act takes effect September 1, 2023.
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