Bill Text: TX SB1193 | 2011-2012 | 82nd Legislature | Engrossed
Bill Title: Relating to coordination of services provided by Medicaid managed care organizations and certain community centers and local mental health or mental retardation authorities.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Engrossed - Dead) 2011-05-23 - Received from the Senate [SB1193 Detail]
Download: Texas-2011-SB1193-Engrossed.html
By: Rodriguez | S.B. No. 1193 |
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relating to coordination of services provided by Medicaid managed | ||
care organizations and certain community centers and local mental | ||
health or mental retardation authorities. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subsection (a), Section 533.005, Government | ||
Code, is amended to read as follows: | ||
(a) A contract between a managed care organization and the | ||
commission for the organization to provide health care services to | ||
recipients must contain: | ||
(1) procedures to ensure accountability to the state | ||
for the provision of health care services, including procedures for | ||
financial reporting, quality assurance, utilization review, and | ||
assurance of contract and subcontract compliance; | ||
(2) capitation rates that ensure the cost-effective | ||
provision of quality health care; | ||
(3) a requirement that the managed care organization | ||
provide ready access to a person who assists recipients in | ||
resolving issues relating to enrollment, plan administration, | ||
education and training, access to services, and grievance | ||
procedures; | ||
(4) a requirement that the managed care organization | ||
provide ready access to a person who assists providers in resolving | ||
issues relating to payment, plan administration, education and | ||
training, and grievance procedures; | ||
(5) a requirement that the managed care organization | ||
provide information and referral about the availability of | ||
educational, social, and other community services that could | ||
benefit a recipient; | ||
(6) procedures for recipient outreach and education; | ||
(7) a requirement that the managed care organization | ||
make payment to a physician or provider for health care services | ||
rendered to a recipient under a managed care plan not later than the | ||
45th day after the date a claim for payment is received with | ||
documentation reasonably necessary for the managed care | ||
organization to process the claim, or within a period, not to exceed | ||
60 days, specified by a written agreement between the physician or | ||
provider and the managed care organization; | ||
(8) a requirement that the commission, on the date of a | ||
recipient's enrollment in a managed care plan issued by the managed | ||
care organization, inform the organization of the recipient's | ||
Medicaid certification date; | ||
(9) a requirement that the managed care organization | ||
comply with Section 533.006 as a condition of contract retention | ||
and renewal; | ||
(10) a requirement that the managed care organization | ||
provide the information required by Section 533.012 and otherwise | ||
comply and cooperate with the commission's office of inspector | ||
general; | ||
(11) a requirement that the managed care | ||
organization's usages of out-of-network providers or groups of | ||
out-of-network providers may not exceed limits for those usages | ||
relating to total inpatient admissions, total outpatient services, | ||
and emergency room admissions determined by the commission; | ||
(12) if the commission finds that a managed care | ||
organization has violated Subdivision (11), a requirement that the | ||
managed care organization reimburse an out-of-network provider for | ||
health care services at a rate that is equal to the allowable rate | ||
for those services, as determined under Sections 32.028 and | ||
32.0281, Human Resources Code; | ||
(13) a requirement that the organization use advanced | ||
practice nurses in addition to physicians as primary care providers | ||
to increase the availability of primary care providers in the | ||
organization's provider network; | ||
(14) a requirement that the managed care organization | ||
reimburse a federally qualified health center or rural health | ||
clinic for health care services provided to a recipient outside of | ||
regular business hours, including on a weekend day or holiday, at a | ||
rate that is equal to the allowable rate for those services as | ||
determined under Section 32.028, Human Resources Code, if the | ||
recipient does not have a referral from the recipient's primary | ||
care physician; [ |
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(15) a requirement that the managed care organization | ||
develop, implement, and maintain a system for tracking and | ||
resolving all provider appeals related to claims payment, including | ||
a process that will require: | ||
(A) a tracking mechanism to document the status | ||
and final disposition of each provider's claims payment appeal; | ||
(B) the contracting with physicians who are not | ||
network providers and who are of the same or related specialty as | ||
the appealing physician to resolve claims disputes related to | ||
denial on the basis of medical necessity that remain unresolved | ||
subsequent to a provider appeal; and | ||
(C) the determination of the physician resolving | ||
the dispute to be binding on the managed care organization and | ||
provider; and | ||
(16) a requirement that the managed care organization | ||
coordinate the care of each recipient who is receiving services | ||
through the managed care organization and through a community | ||
center created under Subchapter A, Chapter 534, Health and Safety | ||
Code, or local mental health or mental retardation authority with | ||
the community center or authority, as applicable. | ||
SECTION 2. Subsection (d), Section 533.0352, Health and | ||
Safety Code, is amended to read as follows: | ||
(d) In developing the local service area plan, the local | ||
mental health or mental retardation authority shall: | ||
(1) solicit information regarding community needs | ||
from: | ||
(A) representatives of the local community; | ||
(B) consumers of community-based mental health | ||
and mental retardation services and members of the families of | ||
those consumers; | ||
(C) consumers of services of state schools for | ||
persons with mental retardation, members of families of those | ||
consumers, and members of state school volunteer services councils, | ||
if a state school is located in the local service area of the local | ||
authority; and | ||
(D) other interested persons; [ |
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(2) consider: | ||
(A) criteria for assuring accountability for, | ||
cost-effectiveness of, and relative value of service delivery | ||
options; | ||
(B) goals to minimize the need for state hospital | ||
and community hospital care; | ||
(C) goals to ensure a client with mental | ||
retardation is placed in the least restrictive environment | ||
appropriate to the person's care; | ||
(D) opportunities for innovation to ensure that | ||
the local authority is communicating to all potential and incoming | ||
consumers about the availability of services of state schools for | ||
persons with mental retardation in the local service area of the | ||
local authority; | ||
(E) goals to divert consumers of services from | ||
the criminal justice system; | ||
(F) goals to ensure that a child with mental | ||
illness remains with the child's parent or guardian as appropriate | ||
to the child's care; and | ||
(G) opportunities for innovation in services and | ||
service delivery; and | ||
(3) include strategies in the plan that are designed | ||
to coordinate the care of each consumer who is receiving services | ||
through the local mental health or mental retardation authority and | ||
through a Medicaid managed care organization with the managed care | ||
organization. | ||
SECTION 3. 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 4. This Act takes effect September 1, 2011. |