Bill Text: TX HB2222 | 2019-2020 | 86th Legislature | Introduced


Bill Title: Relating to the administration and oversight of the Medicaid and child health plan programs.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2019-03-06 - Referred to Human Services [HB2222 Detail]

Download: Texas-2019-HB2222-Introduced.html
  86R7658 MM-D
 
  By: Raymond H.B. No. 2222
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the administration and oversight of the Medicaid and
  child health plan programs.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter C, Chapter 531, Government Code, is
  amended by adding Section 531.1133 to read as follows:
         Sec. 531.1133.  PROVIDER NOT LIABLE FOR MANAGED CARE
  ORGANIZATION OVERPAYMENT OR DEBT. (a)  If the commission's office
  of inspector general makes a determination to recoup an overpayment
  or debt from a managed care organization that contracts with the
  commission to provide health care services to Medicaid recipients,
  a provider that contracts with the managed care organization may
  not be held liable for the good faith provision of services under
  the provider's contract with the managed care organization that
  were provided with prior authorization.
         (b)  This section does not:
               (1)  limit the office of inspector general's authority
  to recoup an overpayment or debt from a provider that is owed by the
  provider as a result of the provider's failure to comply with
  applicable law or a contract provision, notwithstanding any prior
  authorization for a service provided; or
               (2)  apply to an action brought under Chapter 36, Human
  Resources Code.
         SECTION 2.  Section 533.00281, Government Code, is
  redesignated as Section 533.0121, Government Code, and amended to
  read as follows:
         Sec. 533.0121 [533.00281].  UTILIZATION REVIEW AND
  FINANCIAL AUDIT PROCESS FOR [STAR + PLUS] MEDICAID MANAGED CARE
  ORGANIZATIONS. (a) The commission's office responsible for [of]
  contract management shall establish an annual utilization review
  and financial audit process for managed care organizations
  participating in the [STAR + PLUS] Medicaid managed care program.
  The commission shall determine the topics to be examined in a [the]
  review [process], except that with respect to a managed care
  organization participating in the STAR+PLUS Medicaid managed care
  program, the review [process] must include a thorough investigation
  of the [each managed care] organization's procedures for
  determining whether a recipient should be enrolled in the STAR+PLUS
  [STAR + PLUS] home and community-based services and supports (HCBS)
  program, including the conduct of functional assessments for that
  purpose and records relating to those assessments.
         (b)  The commission's office responsible for [of] contract
  management shall use the utilization review and financial audit
  process established under this section to review each fiscal year:
               (1)  each managed care organization [every managed care
  organization] participating in the [STAR + PLUS] Medicaid managed
  care program in this state for that organization's first five years
  of participation; [or]
               (2)  each managed care organization providing health
  care services to a population of recipients new to receiving those
  services through a Medicaid [only the] managed care delivery model
  for the first three years that the organization provides those
  services to that population; or
               (3)  managed care organizations that, using a
  risk-based assessment process and evaluation of prior history, the
  office determines have a higher likelihood of contract or financial
  noncompliance [inappropriate client placement in the STAR + PLUS
  home and community-based services and supports (HCBS) program].
         (c)  In addition to the reviews required by Subsection (b),
  the commission's office responsible for contract management shall
  use the utilization review and financial audit process established
  under this section to review each managed care organization
  participating in the Medicaid managed care program at least once
  every five years.
         (d)  In conjunction with the commission's office responsible
  for [of] contract management, the commission shall provide a report
  to the standing committees of the senate and house of
  representatives with jurisdiction over Medicaid not later than
  December 1 of each year. The report must:
               (1)  summarize the results of the [utilization] reviews
  conducted under this section during the preceding fiscal year;
               (2)  provide analysis of errors committed by each
  reviewed managed care organization; and
               (3)  extrapolate those findings and make
  recommendations for improving the efficiency of the Medicaid
  managed care program.
         (e)  If a [utilization] review conducted under this section
  results in a determination to recoup money from a managed care
  organization, the provider protections from liability under
  Section 531.1133 apply [a service provider who contracts with the
  managed care organization may not be held liable for the good faith
  provision of services based on an authorization from the managed
  care organization].
         SECTION 3.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.0031 to read as follows:
         Sec. 533.0031.  MEDICAID MANAGED CARE PLAN ACCREDITATION.  
  (a)  Notwithstanding Section 533.004 or any other law requiring the
  commission to contract with a managed care organization to provide
  health care services to recipients, the commission may contract
  with a managed care organization to provide those services only if
  the managed care plan offered by the organization is accredited by a
  nationally recognized accrediting entity.
         (b)  This section does not apply to a managed care
  organization that contracts with the commission to provide only
  dental or medical transportation services.
         SECTION 4.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.00611 to read as follows:
         Sec. 533.00611.  STANDARDS FOR DETERMINING MEDICAL
  NECESSITY. (a)  Except as provided by Subsection (b), the
  commission shall establish standards that govern the processes,
  criteria, and guidelines under which managed care organizations
  determine the medical necessity of a health care service covered by
  Medicaid. In establishing standards under this section, the
  commission shall:
               (1)  ensure that each recipient has equal access in
  scope and duration to the same covered health care services for
  which the recipient is eligible, regardless of the managed care
  organization with which the recipient is enrolled;
               (2)  provide managed care organizations with
  flexibility to approve covered medically necessary services for
  recipients that may not be within prescribed criteria and
  guidelines;
               (3)  require managed care organizations to make
  available to providers all criteria and guidelines used to
  determine medical necessity through an Internet portal accessible
  by the providers;
               (4)  ensure that managed care organizations
  consistently apply the same medical necessity criteria and
  guidelines for the approval of services and in retrospective
  utilization reviews; and
               (5)  ensure that managed care organizations include in
  any service or prior authorization denial specific information
  about the medical necessity criteria or guidelines that were not
  met.
         (b)  This section does not apply to or affect the
  commission's authority to:
               (1)  determine medical necessity for home and
  community-based services provided under the STAR+PLUS Medicaid
  managed care program; or
               (2)  conduct utilization reviews of those services.
         SECTION 5.  Section 533.0076, Government Code, is amended by
  amending Subsection (c) and adding Subsection (d) 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[:
               [(1)]  at any time for cause in accordance with federal
  law, including because:
               (1)  the recipient moves out of the managed care
  organization's service area;
               (2)  the plan does not, on the basis of moral or
  religious objections, cover the service the recipient seeks;
               (3)  the recipient needs related services to be
  performed at the same time, not all related services are available
  within the organization's provider network, and the recipient's
  primary care provider or another provider determines that receiving
  the services separately would subject the recipient to unnecessary
  risk;
               (4)  for recipients of long-term services or supports,
  the recipient would have to change the recipient's residential,
  institutional, or employment supports provider based on that
  provider's change in status from an in-network to an out-of-network
  provider with the managed care organization and, as a result, would
  experience a disruption in the recipient's residence or employment;
  or
               (5)  of another reason permitted under federal law,
  including poor quality of care, lack of access to services covered
  under the contract, or lack of access to providers experienced in
  dealing with the recipient's care needs[; and
               [(2)     once for any reason after the periods described
  by Subsections (a) and (b)].
         (d)  The commission shall implement a process by which the
  commission verifies that a recipient is permitted to disenroll from
  one managed care plan offered by a managed care organization and
  enroll in another managed care plan, including a plan offered by
  another managed care organization, before the disenrollment
  occurs.
         SECTION 6.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.0091 to read as follows:
         Sec. 533.0091.  CARE COORDINATION SERVICES. A managed care
  organization that contracts with the commission to provide health
  care services to recipients shall ensure that persons providing
  care coordination services through the organization coordinate
  with hospital discharge planners, who must notify the organization
  of an inpatient admission of a recipient, to facilitate the timely
  discharge of the recipient to the appropriate level of care and
  minimize potentially preventable readmissions, as defined by
  Section 536.001.
         SECTION 7.  Subchapter D, Chapter 62, Health and Safety
  Code, is amended by adding Section 62.1552 to read as follows:
         Sec. 62.1552.  MANAGED CARE PLAN ACCREDITATION. (a)
  Notwithstanding any other law requiring the commission to contract
  with a managed care organization to provide health benefits under
  the child health plan, the commission may contract with a managed
  care organization to provide those benefits only if the managed
  care plan offered by the organization is accredited by a nationally
  recognized accrediting entity.
         (b)  This section does not apply to a managed care
  organization that contracts with the commission to provide only
  dental benefits.
         SECTION 8.  (a)  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, or Chapter 62, Health
  and Safety Code, as applicable, on or after the effective date of
  this Act complies with Section 533.0031, Government Code, as added
  by this Act, or Section 62.1552, Health and Safety Code, as added by
  this Act, as applicable, not later than September 1, 2022.
         (b)  Notwithstanding Section 533.0031, Government Code, as
  added by this Act, or Section 62.1552, Health and Safety Code, as
  added by this Act, a managed care organization may continue
  providing health care services or health benefits under a contract
  with the Health and Human Services Commission entered into under
  Chapter 533, Government Code, or Chapter 62, Health and Safety
  Code, as applicable, before the effective date of this Act, until
  the earlier of:
               (1)  the termination of the contract; or
               (2)  the third anniversary of the effective date of a
  contract amendment requiring accreditation of the managed care plan
  offered by the managed care organization.
         (c)  Not later than March 31, 2020, the Health and Human
  Services Commission shall seek to amend contracts described by
  Subsection (b) of this section to ensure those contracts comply
  with Section 533.0031, Government Code, as added by this Act, or
  Section 62.1552, Health and Safety Code, as added by this Act, as
  applicable. To the extent of a conflict between Section 533.0031,
  Government Code, as added by this Act, or Section 62.1552, Health
  and Safety Code, as added by this Act, and a provision of a contract
  with a managed care organization entered into before the effective
  date of this Act, the contract provision prevails.
         SECTION 9.  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 10.  This Act takes effect September 1, 2019.
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