Bill Text: TX SB1105 | 2019-2020 | 86th Legislature | Comm Sub
Bill Title: Relating to the administration and operation of Medicaid, including Medicaid managed care.
Spectrum: Bipartisan Bill
Status: (Engrossed - Dead) 2019-05-23 - House appoints conferees-reported [SB1105 Detail]
Download: Texas-2019-SB1105-Comm_Sub.html
86R33484 LED-D | ||
By: Kolkhorst, et al. | S.B. No. 1105 | |
(Frank, Klick) | ||
Substitute the following for S.B. No. 1105: No. |
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relating to the administration and operation of Medicaid, including | ||
Medicaid managed care. | ||
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 Sections 531.02112, 531.021182, 531.02131, | ||
531.02142, 531.024162, 531.024163, 531.0319, and 531.0511 to read | ||
as follows: | ||
Sec. 531.02112. POLICIES FOR IMPLEMENTING CHANGES TO | ||
PAYMENT RATES UNDER MEDICAID. (a) The commission shall adopt | ||
policies related to the determination of fees, charges, and rates | ||
for payments under Medicaid 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. | ||
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. | ||
Sec. 531.02131. GRIEVANCES RELATED TO MEDICAID. (a) The | ||
commission shall adopt a definition of "grievance" related to | ||
Medicaid and ensure the definition is consistent among divisions | ||
within the commission to ensure all grievances are managed | ||
consistently. | ||
(b) The commission shall standardize Medicaid grievance | ||
data reporting and tracking among divisions within the commission. | ||
(c) The commission shall implement a no-wrong-door system | ||
for Medicaid grievances reported to the commission. | ||
(d) The commission shall establish a procedure for | ||
expedited resolution of a grievance related to Medicaid that allows | ||
the commission to: | ||
(1) identify a grievance related to a Medicaid access | ||
to care issue that is urgent and requires an expedited resolution; | ||
and | ||
(2) resolve the grievance within a specified period. | ||
(e) The commission shall verify grievance data reported by a | ||
Medicaid managed care organization. | ||
(f) The commission shall: | ||
(1) aggregate Medicaid recipient and provider | ||
grievance data to provide a comprehensive data set of grievances; | ||
and | ||
(2) make the aggregated data available to the | ||
legislature and the public in a manner that does not allow for the | ||
identification of a particular recipient or provider. | ||
Sec. 531.02142. PUBLIC ACCESS TO CERTAIN MEDICAID DATA. | ||
(a) To the extent permitted by federal law, the commission in | ||
consultation and collaboration with the appropriate advisory | ||
committees related to Medicaid shall make available to the public | ||
on the commission's Internet website in an easy-to-read format data | ||
relating to the quality of health care received by Medicaid | ||
recipients and the health outcomes of those recipients. Data made | ||
available to the public under this section must be made available in | ||
a manner that does not identify or allow for the identification of | ||
individual recipients. | ||
(b) In performing its duties under this section, the | ||
commission may collaborate with an institution of higher education | ||
or another state agency with experience in analyzing and producing | ||
public use data. | ||
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 on whose | ||
behalf the request was submitted 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. 531.0319. 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 by the commission. | ||
Sec. 531.0511. MEDICALLY DEPENDENT CHILDREN WAIVER | ||
PROGRAM: CONSUMER DIRECTION OF SERVICES. Notwithstanding Sections | ||
531.051(c)(1) and (d), a consumer direction model implemented under | ||
Section 531.051, including the consumer-directed service option, | ||
for the delivery of services under the medically dependent children | ||
(MDCP) waiver program must allow for the delivery of all services | ||
and supports available under that program through consumer | ||
direction. | ||
SECTION 3. Section 533.00253(a)(1), Government Code, is | ||
amended to read as follows: | ||
(1) "Advisory committee" means the STAR Kids Managed | ||
Care Advisory Committee established by the executive commissioner | ||
under Section 531.012 [ |
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SECTION 4. Section 533.00253, Government Code, is amended | ||
by adding Subsections (f), (g), and (h) to read as follows: | ||
(f) Using existing resources, the executive commissioner in | ||
consultation and collaboration with the advisory committee shall | ||
determine the feasibility of providing Medicaid benefits to | ||
children enrolled in the STAR Kids managed care program under: | ||
(1) an accountable care organization model in | ||
accordance with guidelines established by the Centers for Medicare | ||
and Medicaid Services; or | ||
(2) an alternative model developed by or in | ||
collaboration with the Centers for Medicare and Medicaid Services | ||
Innovation Center. | ||
(g) Not later than December 1, 2022, the commission shall | ||
prepare and submit a written report to the legislature of the | ||
executive commissioner's determination under Subsection (f). | ||
(h) Subsections (f) and (g) and this subsection expire | ||
September 1, 2023. | ||
SECTION 5. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Sections 533.00282, 533.00283, 533.00284, and | ||
533.0031 to read as follows: | ||
Sec. 533.00282. UTILIZATION REVIEW PROCEDURES. 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. | ||
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; | ||
(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 on the prior authorization | ||
request, as necessary, considering the additional documentation; | ||
and | ||
(4) comply with 42 C.F.R. Section 438.210. | ||
(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 or a Medicaid fair hearing; or | ||
(2) any rights of a recipient to appeal a | ||
determination on a prior authorization request. | ||
Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION. | ||
(a) A managed care plan offered by a Medicaid managed care | ||
organization must be accredited by a nationally recognized | ||
accreditation organization. The commission may choose whether to | ||
require all managed care plans offered by Medicaid managed care | ||
organizations to be accredited by the same organization or to allow | ||
for accreditation by different organizations. | ||
(b) The commission may use the data, scoring, and other | ||
information provided to or received from an accreditation | ||
organization in the commission's contract oversight processes. | ||
SECTION 6. The Health and Human Services Commission shall | ||
issue a request for information to seek information and comments | ||
regarding contracting with a managed care organization to arrange | ||
for or provide a managed care plan under the STAR Kids managed care | ||
program established under Section 533.00253, Government Code, | ||
throughout the state instead of on a regional basis. | ||
SECTION 7. (a) Using available resources, the Health and | ||
Human Services Commission shall report available data on the 30-day | ||
limitation on reimbursement for inpatient hospital care provided to | ||
Medicaid recipients enrolled in the STAR+PLUS Medicaid managed care | ||
program under 1 T.A.C. Section 354.1072(a)(1) and other applicable | ||
law. To the extent data is available on the subject, the commission | ||
shall also report on: | ||
(1) the number of Medicaid recipients affected by the | ||
limitation and their clinical outcomes; and | ||
(2) the impact of the limitation on reducing | ||
unnecessary Medicaid inpatient hospital days and any cost savings | ||
achieved by the limitation under Medicaid. | ||
(b) Not later than December 1, 2020, the Health and Human | ||
Services Commission shall submit the report containing the data | ||
described by Subsection (a) of this section to the governor, the | ||
legislature, and the Legislative Budget Board. The report required | ||
under this subsection may be combined with any other report | ||
required by this Act or other law. | ||
SECTION 8. 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 9. 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 10. 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 11. (a) Section 533.00284, Government Code, as | ||
added by this Act, applies 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 | ||
Section 533.00284, Government Code, as added by this Act. | ||
SECTION 12. The Health and Human Services Commission shall | ||
require that a managed care plan offered by a managed care | ||
organization with which the commission enters into or renews a | ||
contract under Chapter 533, Government Code, on or after the | ||
effective date of this Act comply with Section 533.0031, Government | ||
Code, as added by this Act, not later than September 1, 2022. | ||
SECTION 13. 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 14. The Health and Human Services Commission is | ||
required to implement a provision of this Act only if the | ||
legislature appropriates money specifically for that purpose. If | ||
the legislature does not appropriate money specifically for that | ||
purpose, the commission may, but is not required to, implement a | ||
provision of this Act using other appropriations available for that | ||
purpose. | ||
SECTION 15. This Act takes effect September 1, 2019. |