Bill Text: TX SB1140 | 2019-2020 | 86th Legislature | Comm Sub

Bill Title: Relating to an independent medical review of certain determinations by the Health and Human Services Commission or a Medicaid managed care organization.

Spectrum: Slight Partisan Bill (Democrat 3-1)

Status: (Engrossed) 2019-05-21 - Placed on General State Calendar [SB1140 Detail]

Download: Texas-2019-SB1140-Comm_Sub.html
  By: Watson, et al. S.B. No. 1140
  relating to an independent medical review of certain determinations
  by the Health and Human Services Commission or a Medicaid managed
  care organization.
         SECTION 1.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.00715 to read as follows:
         Sec. 533.00715.  INDEPENDENT APPEALS PROCEDURE. (a)  In
  this section, "third-party arbiter" means a third-party medical
  review organization that provides objective, unbiased medical
  necessity determinations conducted by clinical staff with
  education and practice in the same or similar practice area as the
  procedure for which an independent determination of medical
  necessity is sought.
         (b)  The commission, using money appropriated for the
  purpose, shall contract with at least three independent,
  third-party arbiters to resolve an appeal of:
               (1)  a Medicaid managed care organization adverse
  benefit determination made on the basis of medical necessity;
               (2)  a denial by the commission of eligibility for a
  Medicaid program on the basis of the recipient's or applicant's
  medical and functional needs; and
               (3)  an action, as defined by 42 C.F.R. Section
  431.201, by the commission based on the recipient's medical and
  functional needs.
         (c)  An appeal described by Subsection (b)(1) occurs after
  the Medicaid managed care organization internal appeal decision is
  issued and before the Medicaid fair hearing, and the appeal is
  granted when a recipient contests the internal appeal decision.  An
  appeal described by Subsection (b)(2) or (3) occurs after the
  commission's denial is issued or action is taken and before the
  Medicaid fair hearing.
         (d)  The commission shall establish a common procedure for
  appeals. The procedure must provide that a health care service
  ordered by a health care provider is presumed medically necessary
  and the commission or Medicaid managed care organization bears the
  burden of proof to show the health care service is not medically
  necessary.  The third-party arbiter shall conduct the appeal within
  a period specified by the commission.  The commission shall also
  establish a procedure for expedited appeals that allows a
  third-party arbiter to:
               (1)  identify an appeal that requires an expedited
  resolution; and
               (2)  resolve the appeal within a specified period.
         (e)  Subject to Subsection (f), the commission shall ensure
  an appeal is randomly assigned to a third-party arbiter.
         (f)  The commission shall ensure each third-party arbiter
  has the necessary medical expertise to resolve an appeal.
         (g)  A third-party arbiter shall establish and maintain an
  Internet portal through which a recipient may track the status and
  final disposition of an appeal.
         (h)  A third-party arbiter shall educate recipients
               (1)  appeals processes and options;
               (2)  proper and improper denials of health care
  services on the basis of medical necessity; and
               (3)  information available through the commission's
  office of the ombudsman.
         (i)  A third-party arbiter may share with Medicaid managed
  care organizations information regarding:
               (1)  appeals processes; and
               (2)  the types of documents the arbiter may require
  from the organization to resolve appeals.
         (j)  A third-party arbiter shall notify the commission of the
  final disposition of each appeal.  The commission shall review
  aggregate denial data categorized by Medicaid managed care plan to
  identify trends and determine whether a Medicaid managed care
  organization is disproportionately denying prior authorization
  requests from a single provider or set of providers.
         SECTION 2.  As soon as practicable after the effective date
  of this Act, the executive commissioner of the Health and Human
  Services Commission shall adopt the rules necessary to implement
  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 September 1, 2019.