Bill Text: TX SB2239 | 2019-2020 | 86th Legislature | Introduced
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) 2019-03-21 - Referred to Health & Human Services [SB2239 Detail]
Download: Texas-2019-SB2239-Introduced.html
86R10228 JG-D | ||
By: Kolkhorst | S.B. No. 2239 |
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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. PROCEDURE FOR IMPLEMENTING CHANGES TO | ||
PAYMENT RATES UNDER MEDICAID AND CHILD HEALTH PLAN PROGRAM. (a) In | ||
adopting rules and standards related to the determination of fees, | ||
charges, and rates for payments under Medicaid and the child health | ||
plan program, the executive commissioner, in consultation with the | ||
advisory committee established under Subsection (b), shall adopt | ||
rules to ensure that changes to the fees, charges, and rates are | ||
implemented in accordance with this section and in a way that | ||
minimizes administrative complexity and financial uncertainty. | ||
(b) The executive commissioner shall establish an advisory | ||
committee to provide input for the adoption of rules and standards | ||
that comply with this section. The advisory committee is composed | ||
of representatives of managed care organizations and providers | ||
under Medicaid and the child health plan program. The advisory | ||
committee is abolished on the date the rules that comply with this | ||
section are adopted. This subsection expires September 1, 2021. | ||
(c) Before implementing a change to the fees, charges, and | ||
rates for payments under Medicaid or the child health plan program, | ||
the commission shall: | ||
(1) before or at the time notice of the proposed change | ||
is published under Subdivision (2), notify managed care | ||
organizations and the entity serving as the state's Medicaid claims | ||
administrator under the Medicaid fee-for-service delivery model of | ||
the proposed change; | ||
(2) publish notice of the proposed change: | ||
(A) for public comment in the Texas Register for | ||
a period of not less than 60 days; and | ||
(B) on the commission's and state Medicaid claims | ||
administrator's Internet websites during the period specified | ||
under Paragraph (A); | ||
(3) publish notice of a final determination to make | ||
the proposed change: | ||
(A) in the Texas Register for a period of not less | ||
than 30 days before the change becomes effective; and | ||
(B) on the commission's and state Medicaid claims | ||
administrator's Internet websites during the period specified | ||
under Paragraph (A); and | ||
(4) provide managed care organizations and the entity | ||
serving as the state's Medicaid claims administrator under the | ||
Medicaid fee-for-service delivery model with a period of not less | ||
than 30 days before the effective date of the final change to make | ||
any necessary administrative or systems adjustments to implement | ||
the change. | ||
(d) If changes to the fees, charges, or rates for payments | ||
under Medicaid or the child health plan program are mandated by the | ||
legislature or federal government on a date that does not fall | ||
within the time frame for the implementation of those changes | ||
described by this section, the commission shall: | ||
(1) prorate the amount of the change over the fee, | ||
charge, or rate period; and | ||
(2) publish the proration schedule described by | ||
Subdivision (1) in the Texas Register along with the notice | ||
provided under Subsection (c)(3). | ||
(e) This section does not apply to changes to the fees, | ||
charges, or rates for payments made to a nursing facility. | ||
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) Beginning September 1, 2020, the commission: | ||
(1) may not use a state-issued provider identifier | ||
number to identify a Medicaid provider; | ||
(2) shall use only a national provider identifier | ||
number to identify a Medicaid provider; and | ||
(3) must allow a Medicaid provider to bill for | ||
Medicaid services using the provider's national provider | ||
identifier number. | ||
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, 531.0319, and 531.0602 to | ||
read as follows: | ||
Sec. 531.024162. NOTICE REQUIREMENTS REGARDING DENIAL OF | ||
COVERAGE OR PRIOR AUTHORIZATION. 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 law; | ||
(2) a clear and easy-to-understand explanation of the | ||
reason for the denial for the recipient; and | ||
(3) a clinical explanation of the reason for the | ||
denial for the provider. | ||
Sec. 531.0319. MEDICAID MEDICAL POLICY MANUAL. (a) The | ||
commission shall develop and publish on the commission's Internet | ||
website a Medicaid medical policy manual. The manual must: | ||
(1) be updated monthly, as necessary; | ||
(2) primarily address the managed care delivery model | ||
for Medicaid benefits; | ||
(3) include a description of each service covered | ||
under Medicaid, including the scope, duration, and amount of | ||
coverage; and | ||
(4) direct Medicaid providers to the Medicaid managed | ||
care manual that applies to the provider for specific prior | ||
authorization and billing policies. | ||
(b) The commission shall publish the Medicaid medical | ||
policy manual not later than January 1, 2020. Beginning on that | ||
date, the commission may not use any prior Medicaid procedures | ||
manual for providers. This subsection expires September 1, 2021. | ||
Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER | ||
PROGRAM REASSESSMENTS. To the extent allowed by federal law, the | ||
commission shall require that a child participating in the | ||
medically dependent children (MDCP) waiver program be reassessed to | ||
determine whether the child meets the level of care criteria for | ||
medical necessity for nursing facility care only if the child has a | ||
significant change in function that may affect the medical | ||
necessity for that level of care instead of requiring that the | ||
reassessment be made annually. | ||
SECTION 7. 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 8. 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 [ |
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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 a consumer advocate who represents | ||
Medicaid recipients. | ||
SECTION 9. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Sections 533.00284 and 533.00285 to read as | ||
follows: | ||
Sec. 533.00284. ADOPTION OF PRIOR AUTHORIZATION PRACTICE | ||
GUIDELINES; ACCESSIBILITY. (a) In developing medical policies and | ||
standards for making medical necessity determinations for prior | ||
authorizations, each Medicaid managed care organization shall: | ||
(1) in consultation with health care providers in the | ||
organization's provider network, adopt practice guidelines that: | ||
(A) are based on valid and reliable clinical | ||
evidence or the medical consensus among health care professionals | ||
who practice in the applicable field; and | ||
(B) take into consideration the health care needs | ||
of the recipients enrolled in a managed care plan offered by the | ||
organization; and | ||
(2) develop a written process describing the method | ||
for periodically reviewing and amending utilization management | ||
clinical review criteria. | ||
(b) A Medicaid managed care organization shall annually | ||
review and, as necessary, update the practice guidelines adopted | ||
under Subsection (a)(1). | ||
(c) 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: | ||
(1) coverage criteria and prior authorization | ||
requirements are: | ||
(A) made available to recipients and providers on | ||
the organization's or entity's Internet website; and | ||
(B) communicated in a clear, concise, and easily | ||
understandable manner; | ||
(2) any necessary or supporting documents needed to | ||
obtain prior authorization are made available on a web page of the | ||
organization's or entity's Internet website accessible through a | ||
clearly marked link to the web page; and | ||
(3) the process for contacting the organization or | ||
entity for clarification or assistance in obtaining prior | ||
authorization is not arduous or overly burdensome to a recipient or | ||
provider. | ||
Sec. 533.00285. PRIOR AUTHORIZATION PROCEDURES. In | ||
addition to the requirements of Section 533.005, a contract between | ||
a Medicaid managed care organization and the commission described | ||
by that section must include: | ||
(1) time frames for the prior authorization of health | ||
care services that enable Medicaid providers to: | ||
(A) deliver those services in a timely manner; | ||
and | ||
(B) request a peer review regarding the prior | ||
authorization before the organization makes a final decision on the | ||
prior authorization; and | ||
(2) a requirement that the organization: | ||
(A) has appropriate personnel reasonably | ||
available at a toll-free telephone number to receive prior | ||
authorization requests 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 and Sunday; and | ||
(B) has 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 and Sunday. | ||
SECTION 10. 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 [ |
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process established by the commission for final determination of | ||
these disputes. | ||
SECTION 11. Section 533.0076(c), Government Code, is | ||
amended to read as follows: | ||
(c) The commission shall allow a recipient who is enrolled | ||
in a managed care plan under this chapter to disenroll from that | ||
plan and enroll in another managed care plan[ |
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SECTION 12. 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 coordination with Medicaid managed | ||
care organizations, shall develop and adopt a clear policy for a | ||
Medicaid managed care organization to ensure the coordination and | ||
timely delivery of Medicaid wrap-around benefits for recipients | ||
with both primary health benefit plan coverage and Medicaid | ||
coverage. | ||
(c) To further assist with the coordination of benefits, the | ||
commission, in coordination with Medicaid managed care | ||
organizations, shall develop and maintain a list of services that | ||
are not traditionally covered by primary health benefit plan | ||
coverage that a Medicaid managed care organization may approve | ||
without having to coordinate with the primary health benefit plan | ||
issuer and that can be resolved through third-party liability | ||
resolution processes. The commission shall review and update the | ||
list quarterly. | ||
(d) A Medicaid managed care organization that in good faith | ||
and following commission policies provides coverage for a Medicaid | ||
wrap-around benefit shall include the cost of providing the benefit | ||
in the organization's financial reports. The commission shall | ||
include the reported costs in computing capitation rates for the | ||
managed care organization. | ||
(e) If the commission determines that a recipient's primary | ||
health benefit plan issuer should have been the primary payor of a | ||
claim, the Medicaid managed care organization that paid the claim | ||
shall work with the commission on the recovery process and make | ||
every attempt to reduce health care provider and recipient | ||
abrasion. | ||
(f) The executive commissioner may seek a waiver from the | ||
federal government as needed to: | ||
(1) address federal policies related to coordination | ||
of benefits and third-party liability; and | ||
(2) maximize federal financial participation for | ||
recipients with both primary health benefit plan coverage and | ||
Medicaid coverage. | ||
(g) Notwithstanding Sections 531.073 and 533.005(a)(23) or | ||
any other law, the commission shall ensure that a prescription drug | ||
that is covered under the Medicaid vendor drug program or other | ||
applicable formulary and is prescribed to a recipient with primary | ||
health benefit plan coverage is not subject to any prior | ||
authorization requirement if the primary health benefit plan issuer | ||
will pay at least $0.01 on the prescription drug claim. If the | ||
primary insurer will pay nothing on a prescription drug claim, the | ||
prescription drug is subject to any applicable Medicaid clinical or | ||
nonpreferred prior authorization requirement. | ||
(h) The commission shall ensure that the daily 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 | ||
must include the following up-to-date, accurate information | ||
related to primary health benefit plan coverage: | ||
(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. | ||
(i) The commission shall develop and implement processes | ||
and policies to allow a health care provider who is primarily | ||
providing services to a recipient through primary health benefit | ||
plan coverage to receive Medicaid reimbursement for services | ||
ordered, referred, prescribed, or delivered, regardless of whether | ||
the provider is enrolled as a Medicaid provider. The commission | ||
shall allow a provider who is not enrolled as a Medicaid provider to | ||
order, refer, prescribe, or deliver services to a recipient based | ||
on the provider's national provider identifier number and may not | ||
require an additional state provider identifier number to receive | ||
reimbursement for the services. The commission may seek a waiver of | ||
Medicaid provider enrollment requirements for providers of | ||
recipients with primary health benefit plan coverage to implement | ||
this subsection. | ||
(j) The commission shall develop and implement a clear and | ||
easy process to allow 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 | ||
if the provider will enter into a single-case agreement with the | ||
Medicaid managed care organization. A single-case agreement with a | ||
provider outside of the organization's service delivery area in | ||
accordance with this subsection is not considered an | ||
out-of-network agreement and must be included in the organization's | ||
network adequacy determination. | ||
(k) The commission shall develop and implement processes | ||
to: | ||
(1) reimburse a recipient with primary health benefit | ||
plan coverage who pays a copayment, coinsurance, or other | ||
cost-sharing amount out of pocket because the primary health | ||
benefit plan issuer refuses to enroll in Medicaid, enter into a | ||
single-case agreement, or bill the recipient's Medicaid managed | ||
care organization; and | ||
(2) capture encounter data for the Medicaid | ||
wrap-around benefits provided by the Medicaid managed care | ||
organization under this subsection. | ||
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 executive commissioner, in consultation with | ||
Medicaid managed care organizations, by rule shall develop and | ||
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 13. (a) Not later than December 31, 2019, the | ||
executive commissioner of the Health and Human Services Commission | ||
shall establish the advisory committee as required by Section | ||
531.02112(b), Government Code, as added by this Act. | ||
(b) The procedure for implementing changes to payment rates | ||
required by Section 531.02112, Government Code, as added by this | ||
Act, applies only to a change to a fee, charge, or rate that takes | ||
effect on or after January 1, 2021. | ||
SECTION 14. 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 15. 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 16. (a) Section 533.00285, 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 533.00285, Government Code, as added by this Act. | ||
SECTION 17. 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 18. This Act takes effect September 1, 2019. |