Bill Text: TX SB2145 | 2023-2024 | 88th Legislature | Introduced
Bill Title: Relating to the provision and delivery of benefits to certain recipients under Medicaid.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2023-03-21 - Referred to Health & Human Services [SB2145 Detail]
Download: Texas-2023-SB2145-Introduced.html
88R13596 BDP-F | ||
By: Parker | S.B. No. 2145 |
|
||
|
||
relating to the provision and delivery of benefits to certain | ||
recipients under Medicaid. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 531.024164(e), Government Code, is | ||
amended to read as follows: | ||
(e) The commission shall establish a common procedure for | ||
conducting external medical reviews. [ |
||
(1) must conform to the utilization review and | ||
independent review process under Title 14, Insurance Code [ |
||
(2) must include, at a minimum, the following | ||
requirements: | ||
(A) a requirement that the person requesting the | ||
external review timely deliver to the external reviewer the | ||
recipient's relevant personal and medical information, including, | ||
except as provided by Paragraph (B), the recipient's written | ||
statement; | ||
(B) in the instance the review relates to a | ||
life-threatening condition, a requirement that instead of | ||
obtaining a written statement from the recipient the reviewer | ||
directly contact: | ||
(i) the recipient or recipient's parent or | ||
legally authorized representative; and | ||
(ii) the recipient's health care provider; | ||
(C) a requirement that the reviewer notify the | ||
recipient or recipient's parent or legally authorized | ||
representative, the recipient's health care provider, and the | ||
commission if the reviewer does not receive the information | ||
described by Paragraph (A) within three business days after the | ||
date the reviewer is assigned to conduct the review; and | ||
(D) a requirement that the reviewer request and | ||
maintain any other relevant information not provided under | ||
Paragraph (A) that is necessary to conduct the review, including: | ||
(i) identifying information about the | ||
recipient, the recipient's treating health care providers, health | ||
care facilities providing care to the recipient, and the | ||
recipient's managed care plan; | ||
(ii) the recipient's plan of care; | ||
(iii) clinical information about the | ||
recipient's diagnosis and medical history related to the diagnosis; | ||
(iv) the recipient's prognosis; and | ||
(v) the recipient's treatment plan | ||
prescribed by a health care provider and the provider's | ||
justification of the services contained in the plan; | ||
(3) must ensure that the recipient and the recipient's | ||
health care provider are given the opportunity to provide input and | ||
additional evidence during the review; and | ||
(4) may not prohibit a recipient, a recipient's parent | ||
or legally authorized representative, or the recipient's health | ||
care provider from submitting any information or documentation the | ||
person determines relevant to [ |
||
SECTION 2. Section 533.038, Government Code, is amended by | ||
amending Subsections (a), (g), and (h) and adding Subsection (j) to | ||
read as follows: | ||
(a) In this section: | ||
(1) "Complex medical needs" means: | ||
(A) the condition of having one or more chronic | ||
health problems that: | ||
(i) affect multiple organ systems; and | ||
(ii) reduce cognitive or physical | ||
functioning and require the use of medication, durable medical | ||
equipment, therapy, surgery, or other treatments; or | ||
(B) a life-limiting illness or rare pediatric | ||
disease, as defined by Section 529(a)(3) of the Food and Drug | ||
Administration Safety and Innovation Act (21 U.S.C. 360ff(a)). | ||
(2) [ |
||
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. | ||
(3) "Specialty provider" means a person who provides | ||
health-related goods or services to a recipient, including a | ||
provider of medication, therapy services, durable medical | ||
equipment, life-sustaining or life-stabilizing treatment, or any | ||
other treatment, services, equipment, or supplies necessary to | ||
improve health outcomes, prevent emergency room visits, maintain | ||
health care in the home and community, and avoid admission to a | ||
health care facility or other institution. | ||
(g) The commission shall develop a clear and easy process, | ||
to be implemented through a contract, that allows a recipient with | ||
complex medical needs who has established a relationship at any | ||
time with a specialty provider to continue receiving care from that | ||
provider, regardless of: | ||
(1) whether the recipient has primary health benefit | ||
plan coverage in addition to Medicaid coverage; | ||
(2) the date the recipient enrolled in the managed | ||
care plan provided by the Medicaid managed care organization; or | ||
(3) whether the provider is an in-network provider. | ||
(h) If a recipient who has complex medical needs and who | ||
does not have primary health benefit plan coverage wants to | ||
continue to receive care from a specialty provider that is not in | ||
the provider network of the Medicaid managed care organization | ||
offering the managed care plan in which the recipient is enrolled, | ||
the managed care organization shall develop a simple, timely, and | ||
efficient process to and shall make a good-faith effort to, | ||
negotiate a single-case agreement with the specialty provider. | ||
Until the Medicaid managed care organization and the specialty | ||
provider enter into the single-case agreement, the specialty | ||
provider shall be reimbursed in accordance with the applicable | ||
reimbursement methodology specified in commission rule, including | ||
1 T.A.C. Section 353.4. | ||
(j) The cancellation of a contract between a Medicaid | ||
managed care organization and a specialty provider under which the | ||
provider agrees to provide in-network services to recipients does | ||
not void or otherwise affect that organization's duty under | ||
Subsection (g) to provide continuity of care to recipients with | ||
complex medical needs, except if the cancellation is the result of | ||
fraud, waste, or abuse, as determined by the commission's office of | ||
inspector general. In the event of cancellation, the recipient has | ||
the right to select the recipient's preferred specialty provider. | ||
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 immediately if it receives | ||
a vote of two-thirds of all the members elected to each house, as | ||
provided by Section 39, Article III, Texas Constitution. If this | ||
Act does not receive the vote necessary for immediate effect, this | ||
Act takes effect September 1, 2023. |