Bill Text: TX SB1207 | 2019-2020 | 86th Legislature | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to the operation and administration of Medicaid, including the Medicaid managed care program and the medically dependent children (MDCP) waiver program.
Spectrum: Slight Partisan Bill (Republican 5-2)
Status: (Passed) 2019-06-10 - Effective on 9/1/19 [SB1207 Detail]
Download: Texas-2019-SB1207-Comm_Sub.html
Bill Title: Relating to the operation and administration of Medicaid, including the Medicaid managed care program and the medically dependent children (MDCP) waiver program.
Spectrum: Slight Partisan Bill (Republican 5-2)
Status: (Passed) 2019-06-10 - Effective on 9/1/19 [SB1207 Detail]
Download: Texas-2019-SB1207-Comm_Sub.html
86R31958 LED-D | ||
By: Perry, et al. | S.B. No. 1207 | |
(Krause, Parker, Leach, Davis of Harris) | ||
Substitute the following for S.B. No. 1207: No. |
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relating to the operation and administration of Medicaid, including | ||
the Medicaid managed care program and the medically dependent | ||
children (MDCP) waiver program. | ||
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. Section 531.02444, Government Code, is amended | ||
by amending Subsection (a) and adding Subsections (d) and (e) to | ||
read as follows: | ||
(a) The executive commissioner shall develop and implement: | ||
(1) a Medicaid buy-in program for persons with | ||
disabilities as authorized by the Ticket to Work and Work | ||
Incentives Improvement Act of 1999 (Pub. L. No. 106-170) or the | ||
Balanced Budget Act of 1997 (Pub. L. No. 105-33); and | ||
(2) subject to Subsection (d) as authorized by the | ||
Deficit Reduction Act of 2005 (Pub. L. No. 109-171), a Medicaid | ||
buy-in program for children with disabilities that are [ |
||
described by 42 U.S.C. Section 1396a(cc)(1) and whose family | ||
incomes do not exceed 300 percent of the applicable federal poverty | ||
level. | ||
(d) The executive commissioner by rule shall increase the | ||
maximum family income prescribed by Subsection (a)(2) for | ||
determining eligibility of children with disabilities for the | ||
buy-in program under that subdivision to the maximum family income | ||
amount for which federal matching funds are available, considering | ||
available appropriations for that purpose. | ||
(e) The commission shall, at the request of a child's | ||
legally authorized representative, conduct a disability | ||
determination assessment of the child to determine the child's | ||
eligibility for the buy-in program under Subsection (a)(2). The | ||
commission shall directly conduct the disability determination | ||
assessment and may not contract with a Medicaid managed care | ||
organization or other entity to conduct the assessment. | ||
SECTION 3. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Sections 531.024162, 531.024163, 531.024164, | ||
531.0601, 531.0602, and 531.06021 to read as follows: | ||
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 supporting or | ||
other 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 to assist the provider 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. 531.024164. EXTERNAL MEDICAL REVIEW. (a) In this | ||
section, "external medical reviewer" and "reviewer" mean 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 in accordance with applicable state law | ||
and rules. | ||
(b) The commission shall contract with an independent | ||
external medical reviewer to conduct external medical reviews and | ||
review: | ||
(1) the resolution of a Medicaid recipient appeal | ||
related to a reduction in or denial of services on the basis of | ||
medical necessity in the Medicaid managed care program; or | ||
(2) a denial by the commission of eligibility for a | ||
Medicaid program in which eligibility is based on a Medicaid | ||
recipient's medical and functional needs. | ||
(c) A Medicaid managed care organization may not have a | ||
financial relationship with or ownership interest in the external | ||
medical reviewer with which the commission contracts. | ||
(d) The external medical reviewer with which the commission | ||
contracts must: | ||
(1) be overseen by a medical director who is a | ||
physician licensed in this state; and | ||
(2) employ or be able to consult with staff with | ||
experience in providing private duty nursing services and long-term | ||
services and supports. | ||
(e) The commission shall establish a common procedure for | ||
reviews. Medical necessity under the procedure must be based on | ||
publicly available, up-to-date, evidence-based, and peer-reviewed | ||
clinical criteria. The reviewer shall conduct the review within a | ||
period specified by the commission. The commission shall also | ||
establish a procedure for expedited reviews that allows the | ||
reviewer to identify an appeal that requires an expedited | ||
resolution. | ||
(f) An external medical review described by Subsection | ||
(b)(1) occurs after the internal Medicaid managed care organization | ||
appeal and before the Medicaid fair hearing and is granted when a | ||
Medicaid recipient contests the internal appeal decision of the | ||
Medicaid managed care organization. An external medical review | ||
described by Subsection (b)(2) occurs after the eligibility denial | ||
and before the Medicaid fair hearing. The Medicaid recipient or | ||
applicant, or the recipient's or applicant's parent or legally | ||
authorized representative, must affirmatively opt out of the | ||
external medical review to proceed to a Medicaid fair hearing | ||
without first participating in the external medical review. | ||
(g) The external medical reviewer's determination of | ||
medical necessity establishes the minimum level of services a | ||
Medicaid recipient must receive, except that the level of services | ||
may not exceed the level identified as medically necessary by the | ||
ordering health care provider. | ||
(h) The external medical reviewer shall require a Medicaid | ||
managed care organization, in an external medical review relating | ||
to a reduction in services, to submit a detailed reason for the | ||
reduction and supporting documents. | ||
Sec. 531.0601. LONG-TERM CARE SERVICES WAIVER PROGRAM | ||
INTEREST LISTS. (a) This section applies only to a child who is | ||
enrolled in the medically dependent children (MDCP) waiver program | ||
but becomes ineligible for services under the program because the | ||
child no longer meets: | ||
(1) the level of care criteria for medical necessity | ||
for nursing facility care; or | ||
(2) the age requirement for the program. | ||
(b) A legally authorized representative of a child who is | ||
notified by the commission that the child is no longer eligible for | ||
the medically dependent children (MDCP) waiver program following a | ||
Medicaid fair hearing, or without a Medicaid fair hearing if the | ||
representative opted in writing to forego the hearing, may request | ||
that the commission: | ||
(1) return the child to the interest list for the | ||
program unless the child is ineligible due to the child's age; or | ||
(2) place the child on the interest list for another | ||
Section 1915(c) waiver program. | ||
(c) At the time a child's legally authorized representative | ||
makes a request under Subsection (b), the commission shall: | ||
(1) for a child who becomes ineligible for the reason | ||
described by Subsection (a)(1), place the child: | ||
(A) on the interest list for the medically | ||
dependent children (MDCP) waiver program in the first position on | ||
the list; or | ||
(B) except as provided by Subdivision (3), on the | ||
interest list for another Section 1915(c) waiver program in a | ||
position relative to other persons on the list that is based on the | ||
date the child was initially placed on the interest list for the | ||
medically dependent children (MDCP) waiver program; | ||
(2) except as provided by Subdivision (3), for a child | ||
who becomes ineligible for the reason described by Subsection | ||
(a)(2), place the child on the interest list for another Section | ||
1915(c) waiver program in a position relative to other persons on | ||
the list that is based on the date the child was initially placed on | ||
the interest list for the medically dependent children (MDCP) | ||
waiver program; or | ||
(3) for a child who becomes ineligible for a reason | ||
described by Subsection (a) and who is already on an interest list | ||
for another Section 1915(c) waiver program, move the child to a | ||
position on the interest list relative to other persons on the list | ||
that is based on the date the child was initially placed on the | ||
interest list for the medically dependent children (MDCP) waiver | ||
program, if that date is earlier than the date the child was | ||
initially placed on the interest list for the other waiver program. | ||
(d) At the time the commission provides notice to a legally | ||
authorized representative that a child is no longer eligible for | ||
the medically dependent children (MDCP) waiver program following a | ||
Medicaid fair hearing, or without a Medicaid fair hearing if the | ||
representative opted in writing to forego the hearing, the | ||
commission shall inform the representative in writing about the | ||
options under this section for placing the child on an interest | ||
list. | ||
Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER | ||
PROGRAM REASSESSMENTS. (a) The commission shall ensure that the | ||
care coordinator for a Medicaid managed care organization under the | ||
STAR Kids managed care program provides the results of the annual | ||
medical necessity determination reassessment to the parent or | ||
legally authorized representative of a recipient receiving | ||
benefits under the medically dependent children (MDCP) waiver | ||
program for review. The commission shall ensure the provision of | ||
the results does not delay the determination of the services to be | ||
provided to the recipient or the ability to authorize and initiate | ||
services. | ||
(b) The commission shall require the parent's or | ||
representative's signature to verify the parent or representative | ||
received the results of the reassessment from the care coordinator | ||
under Subsection (a). A Medicaid managed care organization may not | ||
delay the delivery of care pending the signature. | ||
(c) The commission shall provide a parent or representative | ||
who disagrees with the results of the reassessment an opportunity | ||
to dispute the reassessment with the Medicaid managed care | ||
organization through a peer-to-peer review with the treating | ||
physician of choice. | ||
(d) This section does not affect any rights of a recipient | ||
to appeal a reassessment determination through the Medicaid managed | ||
care organization's internal appeal process or through the Medicaid | ||
fair hearing process. | ||
Sec. 531.06021. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER | ||
PROGRAM QUALITY MONITORING; REPORT. (a) The commission, through | ||
the state's external quality review organization, shall: | ||
(1) conduct annual surveys of Medicaid recipients | ||
receiving benefits under the medically dependent children (MDCP) | ||
waiver program, or their representatives, using the Consumer | ||
Assessment of Healthcare Providers and Systems; | ||
(2) conduct annual focus groups with recipients | ||
described by Subdivision (1) or their representatives on issues | ||
identified through: | ||
(A) the Consumer Assessment of Healthcare | ||
Providers and Systems; | ||
(B) other external quality review organization | ||
activities; or | ||
(C) stakeholders, including the STAR Kids | ||
Managed Care Advisory Committee described by Section 533.00254; and | ||
(3) as frequently as feasible but not less frequently | ||
than annually, calculate Medicaid managed care organizations' | ||
performance on performance measures using available data sources | ||
such as the STAR Kids Screening and Assessment Instrument or the | ||
National Committee for Quality Assurance's Healthcare | ||
Effectiveness Data and Information Set (HEDIS) measures. | ||
(b) Not later than the 30th day after the last day of each | ||
state fiscal quarter, the commission shall submit to the governor, | ||
the lieutenant governor, the speaker of the house of | ||
representatives, the Legislative Budget Board, and each standing | ||
legislative committee with primary jurisdiction over Medicaid a | ||
report containing, for the most recent state fiscal quarter, the | ||
following information and data related to access to care for | ||
Medicaid recipients receiving benefits under the medically | ||
dependent children (MDCP) waiver program: | ||
(1) enrollment in the Medicaid buy-in for children | ||
program implemented under Section 531.02444; | ||
(2) requests relating to interest list placements | ||
under Section 531.0601; | ||
(3) use of the Medicaid escalation help line | ||
established under Section 533.00253; | ||
(4) use, requests to opt out, and outcomes of the | ||
external medical review procedure established under Section | ||
531.024164; and | ||
(5) complaints relating to the medically dependent | ||
children (MDCP) waiver program, categorized by disposition. | ||
SECTION 4. Section 533.00253(a)(1), Government Code, is | ||
amended to read as follows: | ||
(1) "Advisory committee" means the STAR Kids Managed | ||
Care Advisory Committee described by [ |
||
533.00254. | ||
SECTION 5. Section 533.00253, Government Code, is amended | ||
by adding Subsections (c-1), (c-2), (f), (g), and (h) to read as | ||
follows: | ||
(c-1) To improve the care needs assessment tool used for | ||
purposes of a care needs assessment provided as a component of care | ||
management services and to improve the initial assessment and | ||
reassessment processes, the commission in consultation and | ||
collaboration with the advisory committee shall consider changes | ||
that will: | ||
(1) reduce the amount of time needed to complete the | ||
care needs assessment initially and at reassessment; and | ||
(2) improve training and consistency in the completion | ||
of the care needs assessment using the tool and in the initial | ||
assessment and reassessment processes across different Medicaid | ||
managed care organizations and different service coordinators | ||
within the same Medicaid managed care organization. | ||
(c-2) To the extent feasible and allowed by federal law, the | ||
commission shall streamline the STAR Kids managed care program | ||
annual care needs reassessment process for a child who has not had a | ||
significant change in function that may affect medical necessity. | ||
(f) The commission shall operate a Medicaid escalation help | ||
line through which Medicaid recipients receiving benefits under the | ||
medically dependent children (MDCP) waiver program and their | ||
legally authorized representatives, parents, guardians, or other | ||
representatives have access to assistance. The escalation help | ||
line must be: | ||
(1) dedicated to assisting families of Medicaid | ||
recipients receiving benefits under the medically dependent | ||
children (MDCP) waiver program in navigating and resolving issues | ||
related to the STAR Kids managed care program; and | ||
(2) operational at all times, including evenings, | ||
weekends, and holidays. | ||
(g) The commission shall ensure staff operating the | ||
Medicaid escalation help line: | ||
(1) return a telephone call not later than two hours | ||
after receiving the call during standard business hours; and | ||
(2) return a telephone call not later than four hours | ||
after receiving the call during evenings, weekends, and holidays. | ||
(h) The commission shall require a Medicaid managed care | ||
organization participating in the STAR Kids managed care program | ||
to: | ||
(1) designate an individual as a single point of | ||
contact for the Medicaid escalation help line; and | ||
(2) authorize that individual to take action to | ||
resolve escalated issues. | ||
SECTION 6. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Sections 533.00254, 533.00282, 533.00283, | ||
533.00284, and 533.038 to read as follows: | ||
Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE. | ||
(a) The STAR Kids Managed Care Advisory Committee established by | ||
the executive commissioner under Section 531.012 shall: | ||
(1) advise the commission on the operation of the STAR | ||
Kids managed care program under Section 533.00253; and | ||
(2) make recommendations for improvements to that | ||
program. | ||
(b) On September 1, 2023: | ||
(1) the advisory committee is abolished; and | ||
(2) this section expires. | ||
Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION | ||
PROCEDURES. (a) Section 4201.304(a)(2), 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. | ||
(b) In addition to the requirements of Section 533.005, a | ||
contract between a Medicaid managed care organization and the | ||
commission must require that: | ||
(1) before issuing an adverse determination on a prior | ||
authorization request, the organization provide the physician | ||
requesting the prior authorization with a reasonable opportunity to | ||
discuss the request with another physician 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; and | ||
(2) the organization review and issue determinations | ||
on prior authorization requests with respect to a recipient who is | ||
not hospitalized at the time of the request according to the | ||
following time frames: | ||
(A) within three business days after receiving | ||
the request; or | ||
(B) within the time frame and following the | ||
process established by the commission if the organization receives | ||
a request for prior authorization that does not include sufficient | ||
or adequate documentation. | ||
(c) The commission shall establish a process consistent | ||
with 42 C.F.R. Section 438.210 for use by a Medicaid managed care | ||
organization that receives a prior authorization request, with | ||
respect to a recipient who is not hospitalized at the time of the | ||
request, that does not include sufficient or adequate | ||
documentation. The process must provide a time frame within which a | ||
provider may submit the necessary documentation. | ||
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) to approve the request. | ||
(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, a Medicaid fair hearing, or a review conducted | ||
by an independent review organization; or | ||
(2) any rights of a recipient to appeal a | ||
determination on a prior authorization request. | ||
Sec. 533.038. COORDINATION OF BENEFITS. (a) In this | ||
section, "Medicaid wrap-around benefit" means a Medicaid-covered | ||
service, including a pharmacy or medical benefit, that is provided | ||
to a recipient with both Medicaid and primary health benefit plan | ||
coverage when the recipient has exceeded the primary health benefit | ||
plan coverage limit or when the service is not covered by the | ||
primary health benefit plan issuer. | ||
(b) The commission, in coordination with Medicaid managed | ||
care organizations, shall develop and adopt a clear policy for a | ||
Medicaid managed care organization to ensure the coordination and | ||
timely delivery of Medicaid wrap-around benefits for recipients | ||
with both primary health benefit plan coverage and Medicaid | ||
coverage. In developing the policy, the commission shall consider | ||
requiring a Medicaid managed care organization to allow, | ||
notwithstanding Sections 531.073 and 533.005(a)(23) or any other | ||
law, a recipient using a prescription drug for which the | ||
recipient's primary health benefit plan issuer previously provided | ||
coverage to continue receiving the prescription drug without | ||
requiring additional prior authorization. | ||
(c) To further assist with the coordination of benefits and | ||
to the extent allowed under federal requirements for third-party | ||
liability, the commission, in coordination with Medicaid managed | ||
care organizations, shall develop and maintain a list of services | ||
that are not traditionally covered by primary health benefit plan | ||
coverage that a Medicaid managed care organization may approve | ||
without having to coordinate with the primary health benefit plan | ||
issuer and that can be resolved through third-party liability | ||
resolution processes. The commission shall periodically review and | ||
update the list. | ||
(d) A Medicaid managed care organization that in good faith | ||
and following commission policies provides coverage for a Medicaid | ||
wrap-around benefit shall include the cost of providing the benefit | ||
in the organization's financial reports. The commission shall | ||
include the reported costs in computing capitation rates for the | ||
managed care organization. | ||
(e) If the commission determines that a recipient's primary | ||
health benefit plan issuer should have been the primary payor of a | ||
claim, the Medicaid managed care organization that paid the claim | ||
shall work with the commission on the recovery process and make | ||
every attempt to reduce health care provider and recipient | ||
abrasion. | ||
(f) The executive commissioner may seek a waiver from the | ||
federal government as needed to: | ||
(1) address federal policies related to coordination | ||
of benefits and third-party liability; and | ||
(2) maximize federal financial participation for | ||
recipients with both primary health benefit plan coverage and | ||
Medicaid coverage. | ||
(g) The commission may include in the Medicaid managed care | ||
eligibility files an indication of whether a recipient has primary | ||
health benefit plan coverage or is enrolled in a group health | ||
benefit plan for which the commission provides premium assistance | ||
under the health insurance premium payment program. For recipients | ||
with that coverage or for whom that premium assistance is provided, | ||
the files may include the following up-to-date, accurate | ||
information related to primary health benefit plan coverage to the | ||
extent the information is available to the commission: | ||
(1) the health benefit plan issuer's name and address | ||
and the recipient's policy number; | ||
(2) the primary health benefit plan coverage start and | ||
end dates; and | ||
(3) the primary health benefit plan coverage benefits, | ||
limits, copayment, and coinsurance information. | ||
(h) To the extent allowed by federal law, the commission | ||
shall maintain processes and policies to allow a health care | ||
provider who is primarily providing services to a recipient through | ||
primary health benefit plan coverage to receive Medicaid | ||
reimbursement for services ordered, referred, or prescribed, | ||
regardless of whether the provider is enrolled as a Medicaid | ||
provider. The commission shall allow a provider who is not enrolled | ||
as a Medicaid provider to order, refer, or prescribe services to a | ||
recipient based on the provider's national provider identifier | ||
number and may not require an additional state provider identifier | ||
number to receive reimbursement for the services. The commission | ||
may seek a waiver of Medicaid provider enrollment requirements for | ||
providers of recipients with primary health benefit plan coverage | ||
to implement this subsection. | ||
(i) The commission shall develop a clear and easy process, | ||
to be implemented through a contract, that allows a recipient with | ||
complex medical needs who has established a relationship with a | ||
specialty provider to continue receiving care from that provider. | ||
SECTION 7. (a) Section 531.02444(e), Government Code, as | ||
added by this Act, applies to a request for a disability | ||
determination assessment to determine eligibility for the Medicaid | ||
buy-in for children program made on or after the effective date of | ||
this Act. | ||
(b) Section 531.0601, Government Code, as added by this Act, | ||
applies only to a child who becomes ineligible for the medically | ||
dependent children (MDCP) waiver program on or after December 1, | ||
2019. | ||
(c) Section 531.0602, Government Code, as added by this Act, | ||
applies only to a reassessment of a child's eligibility for the | ||
medically dependent children (MDCP) waiver program made on or after | ||
December 1, 2019. | ||
(d) Notwithstanding Section 531.06021, Government Code, as | ||
added by this Act, the Health and Human Services Commission shall | ||
submit the first report required by that section not later than | ||
September 30, 2020, for the state fiscal quarter ending August 31, | ||
2020. | ||
(e) Not later than March 1, 2020, the Health and Human | ||
Services Commission shall: | ||
(1) develop a plan to improve the care needs | ||
assessment tool and the initial assessment and reassessment | ||
processes as required by Sections 533.00253(c-1) and (c-2), | ||
Government Code, as added by this Act; and | ||
(2) post the plan on the commission's Internet | ||
website. | ||
(f) Sections 533.00282 and 533.00284, Government Code, as | ||
added by this Act, apply 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. | ||
(g) 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 | ||
Sections 533.00282 and 533.00284, Government Code, as added by this | ||
Act. | ||
SECTION 8. 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 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. 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 11. This Act takes effect September 1, 2019. |