Bill Text: TX HB3548 | 2019-2020 | 86th Legislature | Introduced

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Bill Title: Relating to managing Medicaid recipient and provider complaints and appeals.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2019-03-18 - Referred to Human Services [HB3548 Detail]

Download: Texas-2019-HB3548-Introduced.html

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86R7735 LED-D
By: Rose H.B. No. 3548

A BILL TO BE ENTITLED
AN ACT
relating to managing Medicaid recipient and provider complaints and
appeals.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.02132 to read as follows:
Sec. 531.02132. MEDICAID COMPLAINTS AND APPEALS MANAGEMENT
SYSTEM. (a) In this section:
(1) "Appeal" includes all types of protests and
objections, including a request for a fair hearing and an appeal
through a Medicaid managed care organization's internal appeals
process.
(2) "Complaint" includes a telephone call, request for
assistance, inquiry, concern, grievance, and other requests for
information related to Medicaid from a recipient or provider.
(3) "Office" means the commission's office of
inspector general.
(b) The commission shall operate a system to manage Medicaid
recipient and provider complaints and appeals submitted to the
commission, the office, or a managed care organization that
contracts with the commission to provide health care services to
Medicaid recipients. The system must:
(1) provide the commission and the office with
immediate access to the complaint or appeal and, if applicable, a
denial of the complaint or appeal; and
(2) associate each complaint and appeal with the
recipient's or provider's Medicaid identification number.
(c) The commission shall ensure any Medicaid provider may
submit a complaint or appeal through the system, including a
provider that does not contract with a managed care organization
but treats a recipient enrolled in a managed care plan offered by
the managed care organization.
(d) A managed care organization shall regularly update the
system with:
(1) the status of a complaint or appeal;
(2) whether the organization determined a complaint
was valid or invalid and an explanation of that determination;
(3) steps the organization is taking to resolve the
complaint or appeal;
(4) the final resolution of the complaint or appeal;
and
(5) if the organization denies a complaint or appeal:
(A) the justification for denying the complaint
or appeal; and
(B) instructions for requesting an appeal of the
denial.
(e) The commission and the office shall develop a policy to
determine, with regard to a complaint or appeal submitted to the
commission or the office, whether to:
(1) direct the complaint or appeal to a managed care
organization to be resolved; or
(2) investigate the complaint or appeal internally.
(f) The policy described by Subsection (e) must require the
commission and the office to consider whether a recipient or
provider wishes to remain anonymous.
(g) To ensure complaints and appeals are managed
consistently, the commission shall ensure the definitions of a
complaint and an appeal are consistent among:
(1) commission employees and divisions within the
commission;
(2) managed care organizations that contract with the
commission to provide health care services to recipients;
(3) the office; and
(4) the commission's office of the ombudsman.
SECTION 2. Not later than January 1, 2020, the Health and
Human Services Commission shall develop the complaint and appeal
management system as required by Section 531.02132, Government
Code, as added by this Act.
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, 2019.