Bill Text: TX SB1105 | 2019-2020 | 86th Legislature | Comm Sub


Bill Title: Relating to the administration and operation of Medicaid, including Medicaid managed care.

Spectrum: Bipartisan Bill

Status: (Engrossed) 2019-05-23 - House appoints conferees-reported [SB1105 Detail]

Download: Texas-2019-SB1105-Comm_Sub.html
  86R33484 LED-D
 
  By: Kolkhorst, et al. S.B. No. 1105
 
  (Frank, Klick)
 
  Substitute the following for S.B. No. 1105:  No.
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the administration and operation of Medicaid, including
  Medicaid managed care.
         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 Sections 531.02112, 531.021182, 531.02131,
  531.02142, 531.024162, 531.024163, 531.0319, and 531.0511 to read
  as follows:
         Sec. 531.02112.  POLICIES FOR IMPLEMENTING CHANGES TO
  PAYMENT RATES UNDER MEDICAID. (a) The commission shall adopt
  policies related to the determination of fees, charges, and rates
  for payments under Medicaid to ensure, to the greatest extent
  possible, that changes to a fee schedule are implemented in a way
  that minimizes administrative complexity, financial uncertainty,
  and retroactive adjustments for providers.
         (b)  In adopting policies under Subsection (a), the
  commission shall:
               (1)  develop a process for individuals and entities
  that deliver services under the Medicaid managed care program to
  provide oral or written input on the proposed policies; and
               (2)  ensure that managed care organizations and the
  entity serving as the state's Medicaid claims administrator under
  the Medicaid fee-for-service delivery model are provided a period
  of not less than 45 days before the effective date of a final fee
  schedule change to make any necessary administrative or systems
  adjustments to implement the change.
         (c)  This section does not apply to changes to the fees,
  charges, or rates for payments made to a nursing facility or to
  capitation rates paid to a Medicaid managed care organization.
         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)  The commission shall transition from using a
  state-issued provider identifier number to using only a national
  provider identifier number in accordance with this section.
         (c)  The commission shall implement a Medicaid provider
  management and enrollment system and, following that
  implementation, use only a national provider identifier number to
  enroll a provider in Medicaid.
         (d)  The commission shall implement a modernized claims
  processing system and, following that implementation, use only a
  national provider identifier number to process claims for and
  authorize Medicaid services.
         Sec. 531.02131.  GRIEVANCES RELATED TO MEDICAID.  (a)  The
  commission shall adopt a definition of "grievance" related to
  Medicaid and ensure the definition is consistent among divisions
  within the commission to ensure all grievances are managed
  consistently.
         (b)  The commission shall standardize Medicaid grievance
  data reporting and tracking among divisions within the commission.
         (c)  The commission shall implement a no-wrong-door system
  for Medicaid grievances reported to the commission.
         (d)  The commission shall establish a procedure for
  expedited resolution of a grievance related to Medicaid that allows
  the commission to:
               (1)  identify a grievance related to a Medicaid access
  to care issue that is urgent and requires an expedited resolution;
  and
               (2)  resolve the grievance within a specified period.
         (e)  The commission shall verify grievance data reported by a
  Medicaid managed care organization.
         (f)  The commission shall:
               (1)  aggregate Medicaid recipient and provider
  grievance data to provide a comprehensive data set of grievances;
  and
               (2)  make the aggregated data available to the
  legislature and the public in a manner that does not allow for the
  identification of a particular recipient or provider.
         Sec. 531.02142.  PUBLIC ACCESS TO CERTAIN MEDICAID DATA.
  (a) To the extent permitted by federal law, the commission in
  consultation and collaboration with the appropriate advisory
  committees related to Medicaid shall make available to the public
  on the commission's Internet website in an easy-to-read format data
  relating to the quality of health care received by Medicaid
  recipients and the health outcomes of those recipients. Data made
  available to the public under this section must be made available in
  a manner that does not identify or allow for the identification of
  individual recipients.
         (b)  In performing its duties under this section, the
  commission may collaborate with an institution of higher education
  or another state agency with experience in analyzing and producing
  public use data.
         Sec. 531.024162.  NOTICE REQUIREMENTS REGARDING MEDICAID
  COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
  (a)  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 and state law and
  applicable regulations;
               (2)  for the recipient, a clear and easy-to-understand
  explanation of the reason for the denial; and
               (3)  for the provider, a thorough and detailed clinical
  explanation of the reason for the denial, including, as applicable,
  information required under Subsection (b).
         (b)  The commission or a Medicaid managed care organization
  that receives from a provider a coverage or prior authorization
  request that contains insufficient or inadequate documentation to
  approve the request shall issue a notice to the provider and the
  Medicaid recipient on whose behalf the request was submitted.  The
  notice issued under this subsection must:
               (1)  include a section specifically for the provider
  that contains:
                     (A)  a clear and specific list and description of
  the documentation necessary for the commission or organization to
  make a final determination on the request;
                     (B)  the applicable timeline, based on the
  requested service, for the provider to submit the documentation and
  a description of the reconsideration process described by Section
  533.00284, if applicable; and
                     (C)  information on the manner through which a
  provider may contact a Medicaid managed care organization or other
  entity as required by Section 531.024163; and
               (2)  be sent to the provider:
                     (A)  using the provider's preferred method of
  contact most recently provided to the commission or the Medicaid
  managed care organization and using any alternative and known
  methods of contact; and
                     (B)  as applicable, through an electronic
  notification on an Internet portal.
         Sec. 531.024163.  ACCESSIBILITY OF INFORMATION REGARDING
  MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) 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 the
  organization or entity maintains on the organization's or entity's
  Internet website in an easily searchable and accessible format:
               (1)  the applicable timelines for prior authorization
  requirements, including:
                     (A)  the time within which the organization or
  entity must make a determination on a prior authorization request;
                     (B)  a description of the notice the organization
  or entity provides to a provider and Medicaid recipient on whose
  behalf the request was submitted regarding the documentation
  required to complete a determination on a prior authorization
  request; and
                     (C)  the deadline by which the organization or
  entity is required to submit the notice described by Paragraph (B);
  and
               (2)  an accurate and up-to-date catalogue of coverage
  criteria and prior authorization requirements, including:
                     (A)  for a prior authorization requirement first
  imposed on or after September 1, 2019, the effective date of the
  requirement;
                     (B)  a list or description of any necessary or
  supporting documentation necessary to obtain prior authorization
  for a specified service; and
                     (C)  the date and results of each review of the
  prior authorization requirement conducted under Section 533.00283,
  if applicable.
         (b)  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:
               (1)  adopt and maintain a process for a provider or
  Medicaid recipient to contact the organization or entity to clarify
  prior authorization requirements or assist the provider or
  recipient in submitting a prior authorization request; and
               (2)  ensure that the process described by Subdivision
  (1) is not arduous or overly burdensome to a provider or recipient.
         Sec. 531.0319.  MEDICAID MEDICAL BENEFITS POLICY MANUAL.
  (a) To the greatest extent possible, the commission shall
  consolidate policy manuals, handbooks, and other informational
  documents into one Medicaid medical benefits policy manual to
  clarify and provide guidance on the policies under the Medicaid
  managed care delivery model.
         (b)  The commission shall periodically update the Medicaid
  medical benefits policy manual described by this section to reflect
  policies adopted or amended by the commission.
         Sec. 531.0511.  MEDICALLY DEPENDENT CHILDREN WAIVER
  PROGRAM:  CONSUMER DIRECTION OF SERVICES. Notwithstanding Sections
  531.051(c)(1) and (d), a consumer direction model implemented under
  Section 531.051, including the consumer-directed service option,
  for the delivery of services under the medically dependent children
  (MDCP) waiver program must allow for the delivery of all services
  and supports available under that program through consumer
  direction.
         SECTION 3.  Section 533.00253(a)(1), Government Code, is
  amended to read as follows:
               (1)  "Advisory committee" means the STAR Kids Managed
  Care Advisory Committee established by the executive commissioner 
  under Section 531.012 [533.00254].
         SECTION 4.  Section 533.00253, Government Code, is amended
  by adding Subsections (f), (g), and (h) to read as follows:
         (f)  Using existing resources, the executive commissioner in
  consultation and collaboration with the advisory committee shall
  determine the feasibility of providing Medicaid benefits to
  children enrolled in the STAR Kids managed care program under:
               (1)  an accountable care organization model in
  accordance with guidelines established by the Centers for Medicare
  and Medicaid Services; or
               (2)  an alternative model developed by or in
  collaboration with the Centers for Medicare and Medicaid Services
  Innovation Center.
         (g)  Not later than December 1, 2022, the commission shall
  prepare and submit a written report to the legislature of the
  executive commissioner's determination under Subsection (f).
         (h)  Subsections (f) and (g) and this subsection expire
  September 1, 2023.
         SECTION 5.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Sections 533.00282, 533.00283, 533.00284, and
  533.0031 to read as follows:
         Sec. 533.00282.  UTILIZATION REVIEW PROCEDURES. Section
  4201.304, Insurance Code, does not apply to a Medicaid managed care
  organization or a utilization review agent who conducts utilization
  reviews for a Medicaid managed care organization.
         Sec. 533.00283.  ANNUAL REVIEW OF PRIOR AUTHORIZATION
  REQUIREMENTS. (a) Each Medicaid managed care organization shall
  develop and implement a process to conduct an annual review of the
  organization's prior authorization requirements, other than a
  prior authorization requirement prescribed by or implemented under
  Section 531.073 for the vendor drug program. In conducting a
  review, the organization must:
               (1)  solicit, receive, and consider input from
  providers in the organization's provider network; and
               (2)  ensure that each prior authorization requirement
  is based on accurate, up-to-date, evidence-based, and
  peer-reviewed clinical criteria that distinguish, as appropriate,
  between categories, including age, of recipients for whom prior
  authorization requests are submitted.
         (b)  A Medicaid managed care organization may not impose a
  prior authorization requirement, other than a prior authorization
  requirement prescribed by or implemented under Section 531.073 for
  the vendor drug program, unless the organization has reviewed the
  requirement during the most recent annual review required under
  this section.
         Sec. 533.00284.  RECONSIDERATION FOLLOWING ADVERSE
  DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In
  addition to the requirements of Section 533.005, a contract between
  a Medicaid managed care organization and the commission must
  include a requirement that the organization establish a process for
  reconsidering an adverse determination on a prior authorization
  request that resulted solely from the submission of insufficient or
  inadequate documentation.
         (b)  The process for reconsidering an adverse determination
  on a prior authorization request under this section must:
               (1)  allow a provider to, not later than the seventh
  business day following the date of the determination, submit any
  documentation that was identified as insufficient or inadequate in
  the notice provided under Section 531.024162;
               (2)  allow the provider requesting the prior
  authorization to discuss the request with another provider who
  practices in the same or a similar specialty, but not necessarily
  the same subspecialty, and has experience in treating the same
  category of population as the recipient on whose behalf the request
  is submitted;
               (3)  require the Medicaid managed care organization to,
  not later than the first business day following the date the
  provider submits sufficient and adequate documentation under
  Subdivision (1), amend the determination on the prior authorization
  request, as necessary, considering the additional documentation;
  and
               (4)  comply with 42 C.F.R. Section 438.210.
         (c)  An adverse determination on a prior authorization
  request is considered a denial of services in an evaluation of the
  Medicaid managed care organization only if the determination is not
  amended under Subsection (b)(3).
         (d)  The process for reconsidering an adverse determination
  on a prior authorization request under this section does not
  affect:
               (1)  any related timelines, including the timeline for
  an internal appeal or a Medicaid fair hearing; or
               (2)  any rights of a recipient to appeal a
  determination on a prior authorization request.
         Sec. 533.0031.  MEDICAID MANAGED CARE PLAN ACCREDITATION.
  (a)  A managed care plan offered by a Medicaid managed care
  organization must be accredited by a nationally recognized
  accreditation organization. The commission may choose whether to
  require all managed care plans offered by Medicaid managed care
  organizations to be accredited by the same organization or to allow
  for accreditation by different organizations.
         (b)  The commission may use the data, scoring, and other
  information provided to or received from an accreditation
  organization in the commission's contract oversight processes.
         SECTION 6.  The Health and Human Services Commission shall
  issue a request for information to seek information and comments
  regarding contracting with a managed care organization to arrange
  for or provide a managed care plan under the STAR Kids managed care
  program established under Section 533.00253, Government Code,
  throughout the state instead of on a regional basis.
         SECTION 7.  (a) Using available resources, the Health and
  Human Services Commission shall report available data on the 30-day
  limitation on reimbursement for inpatient hospital care provided to
  Medicaid recipients enrolled in the STAR+PLUS Medicaid managed care
  program under 1 T.A.C. Section 354.1072(a)(1) and other applicable
  law. To the extent data is available on the subject, the commission
  shall also report on:
               (1)  the number of Medicaid recipients affected by the
  limitation and their clinical outcomes; and
               (2)  the impact of the limitation on reducing
  unnecessary Medicaid inpatient hospital days and any cost savings
  achieved by the limitation under Medicaid.
         (b)  Not later than December 1, 2020, the Health and Human
  Services Commission shall submit the report containing the data
  described by Subsection (a) of this section to the governor, the
  legislature, and the Legislative Budget Board. The report required
  under this subsection may be combined with any other report
  required by this Act or other law.
         SECTION 8.  The policies for implementing changes to payment
  rates required by Section 531.02112, Government Code, as added by
  this Act, apply only to a change to a fee, charge, or rate that takes
  effect on or after January 1, 2021.
         SECTION 9.  The Health and Human Services Commission shall
  implement:
               (1)  the Medicaid provider management and enrollment
  system required by Section 531.021182(c), Government Code, as added
  by this Act, not later than September 1, 2020; and
               (2)  the modernized claims processing system required
  by Section 531.021182(d), Government Code, as added by this Act,
  not later than September 1, 2023.
         SECTION 10.  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 11.  (a) Section 533.00284, 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 533.00284, Government Code, as added by this Act.
         SECTION 12.  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, on or after the
  effective date of this Act comply with Section 533.0031, Government
  Code, as added by this Act, not later than September 1, 2022.
         SECTION 13.  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 14.  The Health and Human Services Commission is
  required to implement a provision of this Act only if the
  legislature appropriates money specifically for that purpose.  If
  the legislature does not appropriate money specifically for that
  purpose, the commission may, but is not required to, implement a
  provision of this Act using other appropriations available for that
  purpose.
         SECTION 15.  This Act takes effect September 1, 2019.
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