Bill Text: TX HB4178 | 2019-2020 | 86th Legislature | Comm Sub
Bill Title: Relating to the operation and administration of certain health and human services programs, including the Medicaid managed care program.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2019-05-02 - Committee report sent to Calendars [HB4178 Detail]
Download: Texas-2019-HB4178-Comm_Sub.html
86R27018 JG-D | |||
By: Frank | H.B. No. 4178 | ||
Substitute the following for H.B. No. 4178: | |||
By: Klick | C.S.H.B. No. 4178 |
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relating to the operation and administration of certain health and | ||
human services programs, including the Medicaid managed care | ||
program. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 531.001, Government Code, is amended by | ||
adding Subdivision (4-c) to read as follows: | ||
(4-c) "Medicaid managed care organization" means a | ||
managed care organization as defined by Section 533.001 that | ||
contracts with the commission under Chapter 533 to provide health | ||
care services to Medicaid recipients. | ||
SECTION 2. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Section 531.02112 to read as follows: | ||
Sec. 531.02112. POLICIES FOR IMPLEMENTING CHANGES TO | ||
PAYMENT RATES UNDER MEDICAID AND CHILD HEALTH PLAN PROGRAM. (a) | ||
The commission shall adopt policies related to the determination of | ||
fees, charges, and rates for payments under Medicaid and the child | ||
health plan program to ensure, to the greatest extent possible, | ||
that changes to a fee schedule are implemented in a way that | ||
minimizes administrative complexity, financial uncertainty, and | ||
retroactive adjustments for providers. | ||
(b) In adopting policies under Subsection (a), the | ||
commission shall: | ||
(1) develop a process for individuals and entities | ||
that deliver services under the Medicaid managed care program to | ||
provide oral or written input on the proposed policies; and | ||
(2) ensure that managed care organizations and the | ||
entity serving as the state's Medicaid claims administrator under | ||
the Medicaid fee-for-service delivery model are provided a period | ||
of not less than 45 days before the effective date of a final fee | ||
schedule change to make any necessary administrative or systems | ||
adjustments to implement the change. | ||
(c) This section does not apply to changes to the fees, | ||
charges, or rates for payments made to a nursing facility or to | ||
capitation rates paid to a Medicaid managed care organization. | ||
SECTION 3. Section 531.02118, Government Code, is amended | ||
by amending Subsection (c) and adding Subsections (e) and (f) to | ||
read as follows: | ||
(c) In streamlining the Medicaid provider credentialing | ||
process under this section, the commission may designate a | ||
centralized credentialing entity and, if a centralized | ||
credentialing entity is designated, shall [ |
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(1) share information in the database established | ||
under Subchapter C, Chapter 32, Human Resources Code, with the | ||
centralized credentialing entity to reduce the submission of | ||
duplicative information or documents necessary for both Medicaid | ||
enrollment and credentialing; and | ||
(2) require all Medicaid managed care organizations | ||
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for the collection and sharing of information. | ||
(e) To the extent permitted by federal law, the commission | ||
shall use available Medicare data to streamline the enrollment and | ||
credentialing of Medicaid providers by reducing the submission of | ||
duplicative information or documents. | ||
(f) The commission shall develop and implement a process to | ||
expedite the Medicaid provider enrollment process for a health care | ||
provider who is providing health care services through a single | ||
case agreement to a Medicaid recipient with primary insurance | ||
coverage. The commission shall use a provider's national provider | ||
identifier number to enroll a provider under this subsection. In | ||
this subsection, "national provider identifier number" has the | ||
meaning assigned by Section 531.021182. | ||
SECTION 4. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Section 531.021182 to read as follows: | ||
Sec. 531.021182. USE OF NATIONAL PROVIDER IDENTIFIER | ||
NUMBER. (a) In this section, "national provider identifier | ||
number" means the national provider identifier number required | ||
under Section 1128J(e), Social Security Act (42 U.S.C. Section | ||
1320a-7k(e)). | ||
(b) The commission shall transition from using a | ||
state-issued provider identifier number to using only a national | ||
provider identifier number in accordance with this section. | ||
(c) The commission shall implement a Medicaid provider | ||
management and enrollment system and, following that | ||
implementation, use only a national provider identifier number to | ||
enroll a provider in Medicaid. | ||
(d) The commission shall implement a modernized claims | ||
processing system and, following that implementation, use only a | ||
national provider identifier number to process claims for and | ||
authorize Medicaid services. | ||
SECTION 5. Section 531.024(b), Government Code, is amended | ||
to read as follows: | ||
(b) The rules promulgated under Subsection (a)(7) must | ||
provide due process to an applicant for Medicaid services or | ||
programs and to a Medicaid recipient who seeks a Medicaid service, | ||
including a service that requires prior authorization. The rules | ||
must provide the protections for applicants and recipients required | ||
by 42 C.F.R. Part 431, Subpart E, including requiring that: | ||
(1) the written notice to an individual of the | ||
individual's right to a hearing must: | ||
(A) contain a clear [ |
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(i) the adverse determination and the | ||
circumstances under which Medicaid is continued if a hearing is | ||
requested; and | ||
(ii) the fair hearing process, including | ||
the individual's ability to use an independent review process; and | ||
(B) be mailed at least 10 days before the date the | ||
individual's Medicaid eligibility or service is scheduled to be | ||
terminated, suspended, or reduced, except as provided by 42 C.F.R. | ||
Section 431.213 or 431.214; and | ||
(2) if a hearing is requested before the date a | ||
Medicaid recipient's service, including a service that requires | ||
prior authorization, is scheduled to be terminated, suspended, or | ||
reduced, the agency may not take that proposed action before a | ||
decision is rendered after the hearing unless: | ||
(A) it is determined at the hearing that the sole | ||
issue is one of federal or state law or policy; and | ||
(B) the agency promptly informs the recipient in | ||
writing that services are to be terminated, suspended, or reduced | ||
pending the hearing decision. | ||
SECTION 6. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Sections 531.024162, 531.024163, and 531.024164 | ||
to read as follows: | ||
Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID | ||
COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS. | ||
(a) The commission shall ensure that notice sent by the commission | ||
or a Medicaid managed care organization to a Medicaid recipient or | ||
provider regarding the denial of coverage or prior authorization | ||
for a service includes: | ||
(1) information required by federal and state law and | ||
applicable regulations; | ||
(2) for the recipient, a clear and easy-to-understand | ||
explanation of the reason for the denial; and | ||
(3) for the provider, a thorough and detailed clinical | ||
explanation of the reason for the denial, including, as applicable, | ||
information required under Subsection (b). | ||
(b) The commission or a Medicaid managed care organization | ||
that receives from a provider a coverage or prior authorization | ||
request that contains insufficient or inadequate documentation to | ||
approve the request shall issue a notice to the provider and the | ||
Medicaid recipient on whose behalf the request was submitted. The | ||
notice issued under this subsection must: | ||
(1) include a section specifically for the provider | ||
that contains: | ||
(A) a clear and specific list and description of | ||
the documentation necessary for the commission or organization to | ||
make a final determination on the request; | ||
(B) the applicable timeline, based on the | ||
requested service, for the provider to submit the documentation and | ||
a description of the reconsideration process described by Section | ||
533.00284, if applicable; and | ||
(C) information on the manner through which a | ||
provider may contact a Medicaid managed care organization or other | ||
entity as required by Section 531.024163; and | ||
(2) be sent to the provider: | ||
(A) using the provider's preferred method of | ||
contact most recently provided to the commission or the Medicaid | ||
managed care organization and using any alternative and known | ||
methods of contact; and | ||
(B) as applicable, through an electronic | ||
notification on an Internet portal. | ||
Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING | ||
MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive | ||
commissioner by rule shall require each Medicaid managed care | ||
organization or other entity responsible for authorizing coverage | ||
for health care services under Medicaid to ensure that the | ||
organization or entity maintains on the organization's or entity's | ||
Internet website in an easily searchable and accessible format: | ||
(1) the applicable timelines for prior authorization | ||
requirements, including: | ||
(A) the time within which the organization or | ||
entity must make a determination on a prior authorization request; | ||
(B) a description of the notice the organization | ||
or entity provides to a provider and Medicaid recipient regarding | ||
the documentation required to complete a determination on a prior | ||
authorization request; and | ||
(C) the deadline by which the organization or | ||
entity is required to submit the notice described by Paragraph (B); | ||
and | ||
(2) an accurate and up-to-date catalogue of coverage | ||
criteria and prior authorization requirements, including: | ||
(A) for a prior authorization requirement first | ||
imposed on or after September 1, 2019, the effective date of the | ||
requirement; | ||
(B) a list or description of any necessary or | ||
supporting documentation necessary to obtain prior authorization | ||
for a specified service; and | ||
(C) the date and results of each review of the | ||
prior authorization requirement conducted under Section 533.00283, | ||
if applicable. | ||
(b) The executive commissioner by rule shall require each | ||
Medicaid managed care organization or other entity responsible for | ||
authorizing coverage for health care services under Medicaid to: | ||
(1) adopt and maintain a process for a provider or | ||
Medicaid recipient to contact the organization or entity to clarify | ||
prior authorization requirements or assist the provider or | ||
recipient in submitting a prior authorization request; and | ||
(2) ensure that the process described by Subdivision | ||
(1) is not arduous or overly burdensome to a provider or recipient. | ||
Sec. 531.024164. INDEPENDENT REVIEW ORGANIZATIONS. (a) In | ||
this section, "independent review organization" means an | ||
organization certified under Chapter 4202, Insurance Code. | ||
(b) The commission shall contract with an independent | ||
review organization to make review determinations with respect to: | ||
(1) a Medicaid managed care organization's resolution | ||
of an internal appeal challenging a medical necessity | ||
determination; | ||
(2) a denial by the commission of eligibility for a | ||
Medicaid program on the basis of the Medicaid recipient's or | ||
applicant's medical and functional needs; and | ||
(3) an action, as defined by 42 C.F.R. Section | ||
431.201, by the commission based on the recipient's medical and | ||
functional needs. | ||
(c) The executive commissioner by rule shall determine: | ||
(1) the manner in which an independent review | ||
organization is to settle the disputes; | ||
(2) when, in the appeals process, an organization may | ||
be accessed; and | ||
(3) the recourse available after the organization | ||
makes a review determination. | ||
(d) The commission shall ensure that a contract entered into | ||
under Subsection (b): | ||
(1) requires an independent review organization to | ||
make a review determination in a timely manner; | ||
(2) provides procedures to protect the | ||
confidentiality of medical records transmitted to the organization | ||
for use in conducting an independent review; | ||
(3) sets minimum qualifications for and requires the | ||
independence of each physician or other health care provider making | ||
a review determination on behalf of the organization; | ||
(4) specifies the procedures to be used by the | ||
organization in making review determinations; | ||
(5) requires the timely notice to a Medicaid recipient | ||
of the results of an independent review, including the clinical | ||
basis for the review determination; | ||
(6) requires that the organization report the | ||
following aggregate information to the commission in the form and | ||
manner and at the times prescribed by the commission: | ||
(A) the number of requests for independent | ||
reviews received by the independent review organization; | ||
(B) the number of independent reviews conducted; | ||
(C) the number of review determinations made: | ||
(i) in favor of a Medicaid managed care | ||
organization; and | ||
(ii) in favor of a Medicaid recipient; | ||
(D) the number of review determinations that | ||
resulted in a Medicaid managed care organization deciding to cover | ||
the service at issue; | ||
(E) a summary of the disputes at issue in | ||
independent reviews; | ||
(F) a summary of the services that were the | ||
subject of independent reviews; and | ||
(G) the average time the organization took to | ||
complete an independent review and make a review determination; and | ||
(7) requires that, in addition to the aggregate | ||
information required by Subdivision (6), the organization include | ||
in the report the information required by that subdivision | ||
categorized by Medicaid managed care organization. | ||
(e) An independent review organization with which the | ||
commission contracts under this section shall: | ||
(1) obtain all information relating to the internal | ||
appeal at issue, as applicable, from the Medicaid managed care | ||
organization and the provider in accordance with time frames | ||
prescribed by the commission; | ||
(2) obtain all information relating to the denial or | ||
action at issue, as applicable, from the commission and provider in | ||
accordance with time frames prescribed by the commission; | ||
(3) assign a physician or other health care provider | ||
with appropriate expertise as a reviewer to make a review | ||
determination; | ||
(4) for each review, perform a check to ensure that the | ||
organization and the physician or other health care provider | ||
assigned to make a review determination do not have a conflict of | ||
interest, as defined in the contract entered into between the | ||
commission and the organization; | ||
(5) communicate procedural rules, approved by the | ||
commission, and other information regarding the appeals process to | ||
all parties; and | ||
(6) render a timely review determination, as | ||
determined by the commission. | ||
(f) The commission shall ensure that the commission, the | ||
Medicaid managed care organization, the provider, and the Medicaid | ||
recipient involved in a dispute, as applicable, do not have a choice | ||
in the reviewer who is assigned to perform the review. | ||
(g) In selecting an independent review organization with | ||
which to contract, the commission shall avoid conflicts of interest | ||
by considering and monitoring existing relationships between | ||
independent review organizations and Medicaid managed care | ||
organizations. | ||
(h) The executive commissioner shall adopt rules necessary | ||
to implement this section. | ||
SECTION 7. Section 531.02444, Government Code, is amended | ||
by amending Subsection (a) and adding Subsection (a-1) to read as | ||
follows: | ||
(a) The executive commissioner shall develop and implement: | ||
(1) to the extent permitted by a waiver sought by the | ||
commission under Section 1115 of the federal Social Security Act | ||
(42 U.S.C. Section 1315), a Medicaid buy-in program for persons | ||
with disabilities as authorized by the Ticket to Work and Work | ||
Incentives Improvement Act of 1999 (Pub. L. No. 106-170) or the | ||
Balanced Budget Act of 1997 (Pub. L. No. 105-33); and | ||
(2) subject to Subsection (a-1) as authorized by the | ||
Deficit Reduction Act of 2005 (Pub. L. No. 109-171), a Medicaid | ||
buy-in program for children with disabilities that is described by | ||
42 U.S.C. Section 1396a(cc)(1) whose family incomes do not exceed | ||
300 percent of the applicable federal poverty level. | ||
(a-1) The executive commissioner by rule shall increase the | ||
maximum family income prescribed by Subsection (a)(2) for | ||
determining eligibility for the buy-in program under that | ||
subdivision of a child who is eligible for the medically dependent | ||
children (MDCP) waiver program and is on the interest list for that | ||
program to the maximum family income amount allowable, considering | ||
available appropriations for that purpose. | ||
SECTION 8. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Sections 531.024441, 531.0319, 531.03191, and | ||
531.0602 to read as follows: | ||
Sec. 531.024441. MEDICAID BUY-IN FOR CHILDREN PROGRAM | ||
DISABILITY DETERMINATION ASSESSMENT. (a) The commission shall, at | ||
the request of a child's legally authorized representative, conduct | ||
a disability determination assessment of the child to determine the | ||
child's eligibility for the Medicaid buy-in for children program | ||
implemented under Section 531.02444. | ||
(b) The commission may seek a waiver to the state Medicaid | ||
plan under Section 1115 of the federal Social Security Act (42 | ||
U.S.C. Section 1315) to implement this section. | ||
Sec. 531.0319. PROCESS FOR ADOPTING AND AMENDING POLICIES | ||
APPLICABLE TO MEDICAID MEDICAL BENEFITS. The commission shall | ||
develop and implement a process for adopting and amending policies | ||
applicable to Medicaid medical benefits under the Medicaid managed | ||
care delivery model. The commission shall seek input from the state | ||
Medicaid managed care advisory committee in developing and | ||
implementing the process. | ||
Sec. 531.03191. MEDICAID MEDICAL BENEFITS POLICY MANUAL. | ||
(a) To the greatest extent possible, the commission shall | ||
consolidate policy manuals, handbooks, and other informational | ||
documents into one Medicaid medical benefits policy manual to | ||
clarify and provide guidance on the policies under the Medicaid | ||
managed care delivery model. | ||
(b) The commission shall periodically update the Medicaid | ||
medical benefits policy manual described by this section to reflect | ||
policies adopted or amended using the process under Section | ||
531.0319. | ||
Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER | ||
PROGRAM REASSESSMENTS. (a) To the extent allowed by federal law, | ||
the commission shall streamline the annual reassessment for making | ||
a medical necessity determination for a recipient participating in | ||
the medically dependent children (MDCP) waiver program. The annual | ||
reassessment should focus on significant changes in function that | ||
may affect medical necessity. | ||
(b) The commission shall ensure that the care coordinator | ||
for a Medicaid managed care organization under the STAR Kids | ||
managed care program provides the results of the reassessment to | ||
the parent or legally authorized representative of a recipient | ||
described by Subsection (a) for review. The commission shall | ||
ensure the provision of the results does not delay the | ||
determination of the services to be provided to the recipient or the | ||
ability to authorize and initiate services. | ||
(c) The commission shall require the parent's or | ||
representative's signature to verify the parent or representative | ||
received the results of the reassessment from the care coordinator | ||
under Subsection (b). A Medicaid managed care organization may not | ||
delay the delivery of care pending the signature. | ||
(d) The commission shall provide a parent or representative | ||
who disagrees with the results of the reassessment an opportunity | ||
to dispute the reassessment with the commission through a | ||
peer-to-peer review with the treating physician of choice. | ||
(e) This section does not affect any rights of a recipient | ||
to appeal a reassessment determination through the Medicaid managed | ||
care organization's internal appeal process or through the Medicaid | ||
fair hearing process. | ||
SECTION 9. Section 531.072(c), Government Code, is amended | ||
to read as follows: | ||
(c) In making a decision regarding the placement of a drug | ||
on each of the preferred drug lists, the commission shall consider: | ||
(1) the recommendations of the Drug Utilization Review | ||
Board under Section 531.0736; | ||
(2) the clinical efficacy of the drug; | ||
(3) the price of competing drugs after deducting any | ||
federal and state rebate amounts; [ |
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(4) the impact on recipient health outcomes and | ||
continuity of care; and | ||
(5) program benefit offerings solely or in conjunction | ||
with rebates and other pricing information. | ||
SECTION 10. Section 531.0736(c), Government Code, is | ||
amended to read as follows: | ||
(c) The executive commissioner shall determine the | ||
composition of the board, which must: | ||
(1) comply with applicable federal law, including 42 | ||
C.F.R. Section 456.716; | ||
(2) include five [ |
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organizations to represent each managed care product, no more than | ||
two of whom are voting members and at least [ |
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one of whom must be a physician and one of whom must be a pharmacist; | ||
(3) include at least 17 physicians and pharmacists | ||
who: | ||
(A) provide services across the entire | ||
population of Medicaid recipients and represent different | ||
specialties, including at least one of each of the following types | ||
of physicians: | ||
(i) a pediatrician; | ||
(ii) a primary care physician; | ||
(iii) an obstetrician and gynecologist; | ||
(iv) a child and adolescent psychiatrist; | ||
and | ||
(v) an adult psychiatrist; and | ||
(B) have experience in either developing or | ||
practicing under a preferred drug list; and | ||
(4) include not less than two [ |
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least one of whom is a nonvoting member. | ||
SECTION 11. Section 531.0737, Government Code, is amended | ||
to read as follows: | ||
Sec. 531.0737. DRUG UTILIZATION REVIEW BOARD: CONFLICTS OF | ||
INTEREST. (a) A voting member of the Drug Utilization Review | ||
Board must disclose any [ |
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ownership interest, or other conflict of interest with a pharmacy | ||
benefit manager, Medicaid managed care organization, or | ||
pharmaceutical manufacturer or labeler or with an entity engaged by | ||
the commission to assist in the development of the preferred drug | ||
lists or in the administration of the Medicaid Drug Utilization | ||
Review Program. | ||
(b) The executive commissioner may adopt [ |
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and conflicts or require [ |
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conflict-of-interest policy that applies to the board. | ||
SECTION 12. Section 533.00253(a)(1), Government Code, is | ||
amended to read as follows: | ||
(1) "Advisory committee" means the STAR Kids Managed | ||
Care Advisory Committee described by [ |
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533.00254. | ||
SECTION 13. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Sections 533.00254, 533.00282, 533.00283, and | ||
533.00284 to read as follows: | ||
Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE. | ||
(a) The STAR Kids Managed Care Advisory Committee established by | ||
the executive commissioner under Section 531.012 shall: | ||
(1) advise the commission on the operation of the STAR | ||
Kids managed care program under Section 533.00253; and | ||
(2) make recommendations for improvements to that | ||
program. | ||
(b) On September 1, 2023: | ||
(1) the advisory committee is abolished; and | ||
(2) this section expires. | ||
Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION | ||
PROCEDURES. (a) Section 4201.304, Insurance Code, does not apply | ||
to a Medicaid managed care organization or a utilization review | ||
agent who conducts utilization reviews for a Medicaid managed care | ||
organization. | ||
(b) In addition to the requirements of Section 533.005, a | ||
contract between a Medicaid managed care organization and the | ||
commission must require that: | ||
(1) before issuing an adverse determination on a prior | ||
authorization request, the organization provide the physician | ||
requesting the prior authorization with a reasonable opportunity to | ||
discuss the request with another physician who practices in the | ||
same or a similar specialty, but not necessarily the same | ||
subspecialty, and has experience in treating the same category of | ||
population as the recipient on whose behalf the request is | ||
submitted; | ||
(2) the organization review and issue determinations | ||
on prior authorization requests according to the following time | ||
frames: | ||
(A) with respect to a recipient who is | ||
hospitalized at the time of the request: | ||
(i) within one business day after receiving | ||
the request, except as provided by Subparagraphs (ii) and (iii); | ||
(ii) within 72 hours after receiving the | ||
request if the request is submitted by a provider of acute care | ||
inpatient services for services or equipment necessary to discharge | ||
the recipient from an inpatient facility; or | ||
(iii) within one hour after receiving the | ||
request if the request is related to poststabilization care or a | ||
life-threatening condition; or | ||
(B) with respect to a recipient who is not | ||
hospitalized at the time of the request: | ||
(i) within three business days after | ||
receiving the request; or | ||
(ii) if the period prescribed by | ||
Subparagraph (i) is not appropriate, within the time appropriate to | ||
the circumstances relating to the delivery of the services to the | ||
recipient and to the recipient's condition, provided that, when | ||
issuing a determination related to poststabilization care after | ||
emergency treatment as requested by a treating physician or other | ||
health care provider, the agent shall issue the determination to | ||
the treating physician or other health care provider not later than | ||
one hour after the time of the request; and | ||
(3) the organization: | ||
(A) have appropriate personnel reasonably | ||
available at a toll-free telephone number to respond to a prior | ||
authorization request between 6 a.m. and 6 p.m. central time Monday | ||
through Friday on each day that is not a legal holiday and between 9 | ||
a.m. and noon central time on Saturday, Sunday, and legal holidays; | ||
(B) have a telephone system capable of receiving | ||
and recording incoming telephone calls for prior authorization | ||
requests after 6 p.m. central time Monday through Friday and after | ||
noon central time on Saturday, Sunday, and legal holidays; and | ||
(C) have appropriate personnel to respond to each | ||
call described by Paragraph (B) not later than 24 hours after | ||
receiving the call. | ||
Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION | ||
REQUIREMENTS. (a) Each Medicaid managed care organization shall | ||
develop and implement a process to conduct an annual review of the | ||
organization's prior authorization requirements, other than a | ||
prior authorization requirement prescribed by or implemented under | ||
Section 531.073 for the vendor drug program. In conducting a | ||
review, the organization must: | ||
(1) solicit, receive, and consider input from | ||
providers in the organization's provider network; and | ||
(2) ensure that each prior authorization requirement | ||
is based on accurate, up-to-date, evidence-based, and | ||
peer-reviewed clinical criteria that distinguish, as appropriate, | ||
between categories, including age, of recipients for whom prior | ||
authorization requests are submitted. | ||
(b) A Medicaid managed care organization may not impose a | ||
prior authorization requirement, other than a prior authorization | ||
requirement prescribed by or implemented under Section 531.073 for | ||
the vendor drug program, unless the organization has reviewed the | ||
requirement during the most recent annual review required under | ||
this section. | ||
Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE | ||
DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In | ||
addition to the requirements of Section 533.005, a contract between | ||
a Medicaid managed care organization and the commission must | ||
include a requirement that the organization establish a process for | ||
reconsidering an adverse determination on a prior authorization | ||
request that resulted solely from the submission of insufficient or | ||
inadequate documentation. | ||
(b) The process for reconsidering an adverse determination | ||
on a prior authorization request under this section must: | ||
(1) allow a provider to, not later than the seventh | ||
business day following the date of the determination, submit any | ||
documentation that was identified as insufficient or inadequate in | ||
the notice provided under Section 531.024162; | ||
(2) allow the provider requesting the prior | ||
authorization to discuss the request with another provider who | ||
practices in the same or a similar specialty, but not necessarily | ||
the same subspecialty, and has experience in treating the same | ||
category of population as the recipient on whose behalf the request | ||
is submitted; and | ||
(3) require the Medicaid managed care organization to, | ||
not later than the first business day following the date the | ||
provider submits sufficient and adequate documentation under | ||
Subdivision (1), amend the determination to approve the prior | ||
authorization request. | ||
(c) An adverse determination on a prior authorization | ||
request is considered a denial of services in an evaluation of the | ||
Medicaid managed care organization only if the determination is not | ||
amended under Subsection (b)(3). | ||
(d) The process for reconsidering an adverse determination | ||
on a prior authorization request under this section does not | ||
affect: | ||
(1) any related timelines, including the timeline for | ||
an internal appeal, a Medicaid fair hearing, or a review conducted | ||
by an independent review organization; or | ||
(2) any rights of a recipient to appeal a | ||
determination on a prior authorization request. | ||
SECTION 14. Section 533.0071, Government Code, is amended | ||
to read as follows: | ||
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission | ||
shall make every effort to improve the administration of contracts | ||
with Medicaid managed care organizations. To improve the | ||
administration of these contracts, the commission shall: | ||
(1) ensure that the commission has appropriate | ||
expertise and qualified staff to effectively manage contracts with | ||
managed care organizations under the Medicaid managed care program; | ||
(2) evaluate options for Medicaid payment recovery | ||
from managed care organizations if the enrollee dies or is | ||
incarcerated or if an enrollee is enrolled in more than one state | ||
program or is covered by another liable third party insurer; | ||
(3) maximize Medicaid payment recovery options by | ||
contracting with private vendors to assist in the recovery of | ||
capitation payments, payments from other liable third parties, and | ||
other payments made to managed care organizations with respect to | ||
enrollees who leave the managed care program; | ||
(4) decrease the administrative burdens of managed | ||
care for the state, the managed care organizations, and the | ||
providers under managed care networks to the extent that those | ||
changes are compatible with state law and existing Medicaid managed | ||
care contracts, including decreasing those burdens by: | ||
(A) where possible, decreasing the duplication | ||
of administrative reporting and process requirements for the | ||
managed care organizations and providers, such as requirements for | ||
the submission of encounter data, quality reports, historically | ||
underutilized business reports, and claims payment summary | ||
reports; | ||
(B) allowing managed care organizations to | ||
provide updated address information directly to the commission for | ||
correction in the state system; | ||
(C) promoting consistency and uniformity among | ||
managed care organization policies, including policies relating to | ||
the preauthorization process, lengths of hospital stays, filing | ||
deadlines, levels of care, and case management services; | ||
(D) reviewing the appropriateness of primary | ||
care case management requirements in the admission and clinical | ||
criteria process, such as requirements relating to including a | ||
separate cover sheet for all communications, submitting | ||
handwritten communications instead of electronic or typed review | ||
processes, and admitting patients listed on separate | ||
notifications; and | ||
(E) providing a portal through which providers in | ||
any managed care organization's provider network may submit acute | ||
care services and long-term services and supports claims; and | ||
(5) ensure that the commission's fair hearing process | ||
and [ |
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process for resolving recipient and provider appeals of denials | ||
based on medical necessity [ |
||
process established by the commission for final determination of | ||
these disputes. | ||
SECTION 15. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Sections 533.038 and 533.039 to read as follows: | ||
Sec. 533.038. COORDINATION OF BENEFITS. (a) In this | ||
section, "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. | ||
(b) The commission, in consultation with Medicaid managed | ||
care organizations and the state Medicaid managed care advisory | ||
committee, shall develop and implement a policy that ensures the | ||
coordinated and timely delivery of Medicaid wrap-around benefits to | ||
recipients. In developing and implementing the policy under this | ||
subsection, the commission shall consider: | ||
(1) streamlining a Medicaid managed care | ||
organization's prior approval of services that are not | ||
traditionally covered by primary health benefit plan coverage; | ||
(2) including the cost of providing a Medicaid | ||
wrap-around benefit in a Medicaid managed care organization's | ||
financial reports and in computing capitation rates, if the | ||
Medicaid managed care organization provides the wrap-around | ||
benefit in good faith and follows commission policies; | ||
(3) reducing health care provider and recipient | ||
abrasion resulting from the recovery process when a recipient's | ||
primary health benefit plan issuer should have been the primary | ||
payor of a claim; | ||
(4) efficiently providing Medicaid reimbursement for | ||
services ordered, referred, prescribed, or delivered by a health | ||
care provider who is primarily providing services to a recipient | ||
through primary health benefit plan coverage; | ||
(5) allowing a recipient with complex medical needs | ||
who has established a relationship with a specialty provider in an | ||
area outside of the recipient's Medicaid managed care | ||
organization's service delivery area to continue receiving care | ||
from that provider; and | ||
(6) allowing a recipient using a prescription drug | ||
previously paid for under the recipient's primary health benefit | ||
plan coverage to continue receiving the prescription drug without | ||
requiring additional prior authorization. | ||
(c) The executive commissioner may seek a waiver from the | ||
federal government as needed to: | ||
(1) address federal policies related to coordination | ||
of benefits, third-party liability, and provider enrollment | ||
relating to Medicaid wrap-around benefits; and | ||
(2) maximize federal financial participation for | ||
recipients with both primary health benefit plan coverage and | ||
Medicaid coverage. | ||
(d) The commission shall ensure that the Medicaid managed | ||
care eligibility files indicate whether a recipient has primary | ||
health benefit plan coverage or health insurance premium payment | ||
coverage. For a recipient who has that coverage, the files may | ||
include the following up-to-date, accurate information related to | ||
primary health benefit plan coverage to the extent the information | ||
has been made available to the commission by the primary health | ||
benefit plan issuer: | ||
(1) the health benefit plan issuer's name and address | ||
and the recipient's policy number; | ||
(2) the primary health benefit plan coverage start and | ||
end dates; | ||
(3) the primary health benefit plan coverage benefits, | ||
limits, copayment, and coinsurance information; and | ||
(4) any additional information that would be useful to | ||
ensure the coordination of benefits. | ||
Sec. 533.039. COORDINATION OF BENEFITS FOR PERSONS DUALLY | ||
ELIGIBLE UNDER MEDICAID AND MEDICARE. (a) In this section, | ||
"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 Medicare coverage when the | ||
recipient has exceeded the Medicare coverage limit or when the | ||
service is not covered by Medicare. | ||
(b) The commission, in consultation with Medicaid managed | ||
care organizations and the state Medicaid managed care advisory | ||
committee, shall implement a policy that ensures the coordinated | ||
and timely delivery of Medicaid wrap-around benefits. The policy | ||
must: | ||
(1) include a benefits equivalency crosswalk or other | ||
method for mapping equivalent benefits under Medicaid and Medicare; | ||
and | ||
(2) in a manner that is consistent with federal and | ||
state law, require sharing of information concerning third-party | ||
sources of coverage and reimbursement. | ||
SECTION 16. Section 62.152, Health and Safety Code, is | ||
amended to read as follows: | ||
Sec. 62.152. APPLICATION OF INSURANCE LAW. (a) To provide | ||
the flexibility necessary to satisfy the requirements of Title XXI | ||
of the Social Security Act (42 U.S.C. Section 1397aa et seq.), as | ||
amended, and any other applicable law or regulations, the child | ||
health plan is not subject to a law that requires: | ||
(1) coverage or the offer of coverage of a health care | ||
service or benefit; | ||
(2) coverage or the offer of coverage for the | ||
provision of services by a particular health care services | ||
provider, except as provided by Section 62.155(b); or | ||
(3) the use of a particular policy or contract form or | ||
of particular language in a policy or contract form. | ||
(b) Section 4201.304, Insurance Code, does not apply to a | ||
health plan provider or the provider's utilization review agent. | ||
SECTION 17. The policies for implementing changes to | ||
payment rates required by Section 531.02112, Government Code, as | ||
added by this Act, apply only to a change to a fee, charge, or rate | ||
that takes effect on or after January 1, 2021. | ||
SECTION 18. The Health and Human Services Commission shall | ||
implement: | ||
(1) the Medicaid provider management and enrollment | ||
system required by Section 531.021182(c), Government Code, as added | ||
by this Act, not later than September 1, 2020; and | ||
(2) the modernized claims processing system required | ||
by Section 531.021182(d), Government Code, as added by this Act, | ||
not later than September 1, 2023. | ||
SECTION 19. Not later than December 31, 2019, the Health and | ||
Human Services Commission shall develop, implement, and publish on | ||
the commission's Internet website the process required under | ||
Section 531.0319, Government Code, as added by this Act. | ||
SECTION 20. Section 531.0602, Government Code, as added by | ||
this Act, applies only to a reassessment of a child's eligibility | ||
for the medically dependent children (MDCP) waiver program made on | ||
or after December 1, 2019. | ||
SECTION 21. As soon as practicable after the effective date | ||
of this Act, the executive commissioner of the Health and Human | ||
Services Commission shall adopt rules necessary to implement the | ||
changes in law made by this Act. | ||
SECTION 22. (a) Sections 533.00282 and 533.00284, | ||
Government Code, as added by this Act, apply only to a contract | ||
between the Health and Human Services Commission and a Medicaid | ||
managed care organization under Chapter 533, Government Code, that | ||
is entered into or renewed on or after the effective date of this | ||
Act. | ||
(b) The Health and Human Services Commission shall seek to | ||
amend contracts entered into with Medicaid managed care | ||
organizations under Chapter 533, Government Code, before the | ||
effective date of this Act to include the provisions required by | ||
Sections 533.00282 and 533.00284, Government Code, as added by this | ||
Act. | ||
SECTION 23. 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 24. This Act takes effect September 1, 2019. |