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 - Dead) 2019-03-06 - Referred to Human Services [HB2222 Detail]
Download: Texas-2019-HB2222-Introduced.html
86R7658 MM-D | ||
By: Raymond | H.B. No. 2222 |
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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 [ |
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FINANCIAL AUDIT PROCESS FOR [ |
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ORGANIZATIONS. (a) The commission's office responsible for [ |
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contract management shall establish an annual utilization review | ||
and financial audit process for managed care organizations | ||
participating in the [ |
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The commission shall determine the topics to be examined in a [ |
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review [ |
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organization participating in the STAR+PLUS Medicaid managed care | ||
program, the review [ |
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of the [ |
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determining whether a recipient should be enrolled in the STAR+PLUS | ||
[ |
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program, including the conduct of functional assessments for that | ||
purpose and records relating to those assessments. | ||
(b) The commission's office responsible for [ |
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management shall use the utilization review and financial audit | ||
process established under this section to review each fiscal year: | ||
(1) each managed care organization [ |
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care program in this state for that organization's first five years | ||
of participation; [ |
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(2) each managed care organization providing health | ||
care services to a population of recipients new to receiving those | ||
services through a Medicaid [ |
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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 [ |
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(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 [ |
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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 [ |
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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 [ |
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results in a determination to recoup money from a managed care | ||
organization, the provider protections from liability under | ||
Section 531.1133 apply [ |
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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[ |
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[ |
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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[ |
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[ |
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(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. |