CHAPTER 533. IMPLEMENTATION OF MEDICAID MANAGED CARE PROGRAM
GOVERNMENT CODE
TITLE 4. EXECUTIVE BRANCH
SUBTITLE I. HEALTH AND HUMAN SERVICES
CHAPTER 533. IMPLEMENTATION OF MEDICAID MANAGED CARE PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 533.001. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services Commission
or an agency operating part of the state Medicaid managed care
program, as appropriate.
(2) "Commissioner" means the commissioner of health and human
services.
(3) "Health and human services agencies" has the meaning
assigned by Section 531.001.
(4) "Managed care organization" means a person who is authorized
or otherwise permitted by law to arrange for or provide a managed
care plan.
(5) "Managed care plan" means a plan under which a person
undertakes to provide, arrange for, pay for, or reimburse any
part of the cost of any health care services. A part of the plan
must consist of arranging for or providing health care services
as distinguished from indemnification against the cost of those
services on a prepaid basis through insurance or otherwise. The
term includes a primary care case management provider network.
The term does not include a plan that indemnifies a person for
the cost of health care services through insurance.
(6) "Recipient" means a recipient of medical assistance under
Chapter 32, Human Resources Code.
(7) "Health care service region" or "region" means a Medicaid
managed care service area as delineated by the commission.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.002. PURPOSE. The commission shall implement the
Medicaid managed care program as part of the health care delivery
system developed under Chapter 532 by contracting with managed
care organizations in a manner that, to the extent possible:
(1) improves the health of Texans by:
(A) emphasizing prevention;
(B) promoting continuity of care; and
(C) providing a medical home for recipients;
(2) ensures that each recipient receives high quality,
comprehensive health care services in the recipient's local
community;
(3) encourages the training of and access to primary care
physicians and providers;
(4) maximizes cooperation with existing public health entities,
including local departments of health;
(5) provides incentives to managed care organizations to improve
the quality of health care services for recipients by providing
value-added services; and
(6) reduces administrative and other nonfinancial barriers for
recipients in obtaining health care services.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.0025. DELIVERY OF SERVICES. (a) In this section,
"medical assistance" has the meaning assigned by Section 32.003,
Human Resources Code.
(b) Except as otherwise provided by this section and
notwithstanding any other law, the commission shall provide
medical assistance for acute care through the most cost-effective
model of Medicaid managed care as determined by the commission.
If the commission determines that it is more cost-effective, the
commission may provide medical assistance for acute care in a
certain part of this state or to a certain population of
recipients using:
(1) a health maintenance organization model, including the acute
care portion of Medicaid Star + Plus pilot programs;
(2) a primary care case management model;
(3) a prepaid health plan model;
(4) an exclusive provider organization model; or
(5) another Medicaid managed care model or arrangement.
(c) In determining whether a model or arrangement described by
Subsection (b) is more cost-effective, the commissioner must
consider:
(1) the scope, duration, and types of health benefits or
services to be provided in a certain part of this state or to a
certain population of recipients;
(2) administrative costs necessary to meet federal and state
statutory and regulatory requirements;
(3) the anticipated effect of market competition associated with
the configuration of Medicaid service delivery models determined
by the commission; and
(4) the gain or loss to this state of a tax collected under
Chapter 222, Insurance Code.
(d) If the commission determines that it is not more
cost-effective to use a Medicaid managed care model to provide
certain types of medical assistance for acute care in a certain
area or to certain medical assistance recipients as prescribed by
this section, the commission shall provide medical assistance for
acute care through a traditional fee-for-service arrangement.
(e) Notwithstanding Subsection (b)(1), the commission may not
provide medical assistance using a health maintenance
organization in Cameron County, Hidalgo County, or Maverick
County.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.29, eff. Sept. 1,
2003.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.119, eff. September 1, 2005.
Sec. 533.0026. DIRECT ACCESS TO EYE HEALTH CARE SERVICES UNDER
MEDICAID MANAGED CARE MODEL OR ARRANGEMENT. (a) Notwithstanding
any other law, the commission shall ensure that a managed care
plan offered by a managed care organization that contracts with
the commission under this chapter and any other Medicaid managed
care model or arrangement implemented under this chapter allow a
Medicaid recipient who receives services through the plan or
other model or arrangement to, in the manner and to the extent
required by Section 32.072, Human Resources Code:
(1) select an in-network ophthalmologist or therapeutic
optometrist in the managed care network to provide eye health
care services, other than surgery; and
(2) have direct access to the selected in-network
ophthalmologist or therapeutic optometrist for the provision of
the nonsurgical services.
(b) This section does not affect the obligation of an
ophthalmologist or therapeutic optometrist in a managed care
network to comply with the terms and conditions of the managed
care plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
268, Sec. 21(b), eff. September 1, 2007.
Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. In awarding
contracts to managed care organizations, the commission shall:
(1) give preference to organizations that have significant
participation in the organization's provider network from each
health care provider in the region who has traditionally provided
care to Medicaid and charity care patients;
(2) give extra consideration to organizations that agree to
assure continuity of care for at least three months beyond the
period of Medicaid eligibility for recipients;
(3) consider the need to use different managed care plans to
meet the needs of different populations; and
(4) consider the ability of organizations to process Medicaid
claims electronically.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997. Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 2, eff.
June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.02, eff.
Sept. 1, 1999.
Sec. 533.004. MANDATORY CONTRACTS. (a) In providing health
care services through Medicaid managed care to recipients in a
health care service region, the commission shall contract with a
managed care organization in that region that is licensed under
Chapter 843, Insurance Code, to provide health care in that
region and that is:
(1) wholly owned and operated by a hospital district in that
region;
(2) created by a nonprofit corporation that:
(A) has a contract, agreement, or other arrangement with a
hospital district in that region or with a municipality in that
region that owns a hospital licensed under Chapter 241, Health
and Safety Code, and has an obligation to provide health care to
indigent patients; and
(B) under the contract, agreement, or other arrangement, assumes
the obligation to provide health care to indigent patients and
leases, manages, or operates a hospital facility owned by the
hospital district or municipality; or
(3) created by a nonprofit corporation that has a contract,
agreement, or other arrangement with a hospital district in that
region under which the nonprofit corporation acts as an agent of
the district and assumes the district's obligation to arrange for
services under the Medicaid expansion for children as authorized
by Chapter 444, Acts of the 74th Legislature, Regular Session,
1995.
(b) A managed care organization described by Subsection (a) is
subject to all terms and conditions to which other managed care
organizations are subject, including all contractual, regulatory,
and statutory provisions relating to participation in the
Medicaid managed care program.
(c) The commission shall make the awarding and renewal of a
mandatory contract under this section to a managed care
organization affiliated with a hospital district or municipality
contingent on the district or municipality entering into a
matching funds agreement to expand Medicaid for children as
authorized by Chapter 444, Acts of the 74th Legislature, Regular
Session, 1995. The commission shall make compliance with the
matching funds agreement a condition of the continuation of the
contract with the managed care organization to provide health
care services to recipients.
(d) Subsection (c) does not apply if:
(1) the commission does not expand Medicaid for children as
authorized by Chapter 444, Acts of the 74th Legislature, Regular
Session, 1995; or
(2) a waiver from a federal agency necessary for the expansion
is not granted.
(e) In providing health care services through Medicaid managed
care to recipients in a health care service region, with the
exception of the Harris service area for the STAR Medicaid
managed care program, as defined by the commission as of
September 1, 1999, the commission shall also contract with a
managed care organization in that region that holds a certificate
of authority as a health maintenance organization under Chapter
843, Insurance Code, and that:
(1) is certified under Section 162.001, Occupations Code;
(2) is created by The University of Texas Medical Branch at
Galveston; and
(3) has obtained a certificate of authority as a health
maintenance organization to serve one or more counties in that
region from the Texas Department of Insurance before September 2,
1999.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997. Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 3, eff.
June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.03, eff.
Sept. 1, 1999; Acts 2001, 77th Leg., ch. 1420, Sec. 14.766, eff.
Sept. 1, 2001; Acts 2003, 78th Leg., ch. 1276, Sec. 10A.515, eff.
Sept. 1, 2003.
Sec. 533.005. REQUIRED CONTRACT PROVISIONS. (a) A contract
between a managed care organization and the commission for the
organization to provide health care services to recipients must
contain:
(1) procedures to ensure accountability to the state for the
provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation rates that ensure the cost-effective provision of
quality health care;
(3) a requirement that the managed care organization provide
ready access to a person who assists recipients in resolving
issues relating to enrollment, plan administration, education and
training, access to services, and grievance procedures;
(4) a requirement that the managed care organization provide
ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization provide
information and referral about the availability of educational,
social, and other community services that could benefit a
recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization make
payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than
the 45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to
exceed 60 days, specified by a written agreement between the
physician or provider and the managed care organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the
managed care organization, inform the organization of the
recipient's Medicaid certification date;
(9) a requirement that the managed care organization comply with
Section 533.006 as a condition of contract retention and renewal;
(10) a requirement that the managed care organization provide
the information required by Section 533.012 and otherwise comply
and cooperate with the commission's office of inspector general;
(11) a requirement that the managed care organization's usages
of out-of-network providers or groups of out-of-network providers
may not exceed limits for those usages relating to total
inpatient admissions, total outpatient services, and emergency
room admissions determined by the commission;
(12) if the commission finds that a managed care organization
has violated Subdivision (11), a requirement that the managed
care organization reimburse an out-of-network provider for health
care services at a rate that is equal to the allowable rate for
those services, as determined under Sections 32.028 and 32.0281,
Human Resources Code;
(13) a requirement that the organization use advanced practice
nurses in addition to physicians as primary care providers to
increase the availability of primary care providers in the
organization's provider network;
(14) a requirement that the managed care organization reimburse
a federally qualified health center or rural health clinic for
health care services provided to a recipient outside of regular
business hours, including on a weekend day or holiday, at a rate
that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician; and
(15) a requirement that the managed care organization develop,
implement, and maintain a system for tracking and resolving all
provider appeals related to claims payment, including a process
that will require:
(A) a tracking mechanism to document the status and final
disposition of each provider's claims payment appeal;
(B) the contracting with physicians who are not network
providers and who are of the same or related specialty as the
appealing physician to resolve claims disputes related to denial
on the basis of medical necessity that remain unresolved
subsequent to a provider appeal; and
(C) the determination of the physician resolving the dispute to
be binding on the managed care organization and provider.
(b) In accordance with Subsection (a)(12), all
post-stabilization services provided by an out-of-network
provider must be reimbursed by the managed care organization at
the allowable rate for those services until the managed care
organization arranges for the timely transfer of the recipient,
as determined by the recipient's attending physician, to a
provider in the network. A managed care organization may not
refuse to reimburse an out-of-network provider for emergency or
post-stabilization services provided as a result of the managed
care organization's failure to arrange for and authorize a timely
transfer of a recipient.
(c) The executive commissioner shall adopt rules regarding the
days, times of days, and holidays that are considered to be
outside of regular business hours for purposes of Subsection
(a)(14).
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997. Amended by Acts 1999, 76th Leg., ch. 493, Sec. 2, eff.
Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1447, Sec. 4, eff. June
19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.04, eff. Sept.
1, 1999; Acts 2003, 78th Leg., ch. 198, Sec. 2.35, eff. Sept. 1,
2003.
Amended by:
Acts 2005, 79th Leg., Ch.
349, Sec. 6(a), eff. September 1, 2005.
Sec. 533.0051. PERFORMANCE MEASURES AND INCENTIVES FOR
VALUE-BASED CONTRACTS. (a) The commission shall establish
outcome-based performance measures and incentives to include in
each contract between a health maintenance organization and the
commission for the provision of health care services to
recipients that is procured and managed under a value-based
purchasing model. The performance measures and incentives must
be designed to facilitate and increase recipients' access to
appropriate health care services.
(b) Subject to Subsection (c), the commission shall include the
performance measures and incentives established under Subsection
(a) in each contract described by that subsection in addition to
all other contract provisions required by this chapter.
(c) The commission may use a graduated approach to including the
performance measures and incentives established under Subsection
(a) in contracts described by that subsection to ensure
incremental and continued improvements over time.
(d) Subject to Subsection (f), the commission shall assess the
feasibility and cost-effectiveness of including provisions in a
contract described by Subsection (a) that require the health
maintenance organization to provide to the providers in the
organization's provider network pay-for-performance opportunities
that support quality improvements in the care of Medicaid
recipients. Pay-for-performance opportunities may include
incentives for providers to provide care after normal business
hours and to participate in the early and periodic screening,
diagnosis, and treatment program and other activities that
improve Medicaid recipients' access to care. If the commission
determines that the provisions are feasible and may be
cost-effective, the commission shall develop and implement a
pilot program in at least one health care service region under
which the commission will include the provisions in contracts
with health maintenance organizations offering managed care plans
in the region.
(e) The commission shall post the financial statistical report
on the commission's web page in a comprehensive and
understandable format.
(f) The commission shall, to the extent possible, base an
assessment of feasibility and cost-effectiveness under Subsection
(d) on publicly available, scientifically valid, evidence-based
criteria appropriate for assessing the Medicaid population.
(g) In performing the commission's duties under Subsection (d)
with respect to assessing feasibility and cost-effectiveness, the
commission may consult with physicians, including those with
expertise in quality improvement and performance measurement, and
hospitals.
Added by Acts 2007, 80th Leg., R.S., Ch.
268, Sec. 10, eff. September 1, 2007.
Sec. 533.006. PROVIDER NETWORKS. (a) The commission shall
require that each managed care organization that contracts with
the commission to provide health care services to recipients in a
region:
(1) seek participation in the organization's provider network
from:
(A) each health care provider in the region who has
traditionally provided care to Medicaid recipients;
(B) each hospital in the region that has been designated as a
disproportionate share hospital under the state Medicaid program;
and
(C) each specialized pediatric laboratory in the region,
including those laboratories located in children's hospitals; and
(2) include in its provider network for not less than three
years:
(A) each health care provider in the region who:
(i) previously provided care to Medicaid and charity care
recipients at a significant level as prescribed by the
commission;
(ii) agrees to accept the prevailing provider contract rate of
the managed care organization; and
(iii) has the credentials required by the managed care
organization, provided that lack of board certification or
accreditation by the Joint Commission on Accreditation of
Healthcare Organizations may not be the sole ground for exclusion
from the provider network;
(B) each accredited primary care residency program in the
region; and
(C) each disproportionate share hospital designated by the
commission as a statewide significant traditional provider.
(b) A contract between a managed care organization and the
commission for the organization to provide health care services
to recipients in a health care service region that includes a
rural area must require that the organization include in its
provider network rural hospitals, physicians, home and community
support services agencies, and other rural health care providers
who:
(1) are sole community providers;
(2) provide care to Medicaid and charity care recipients at a
significant level as prescribed by the commission;
(3) agree to accept the prevailing provider contract rate of the
managed care organization; and
(4) have the credentials required by the managed care
organization, provided that lack of board certification or
accreditation by the Joint Commission on Accreditation of
Healthcare Organizations may not be the sole ground for exclusion
from the provider network.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997. Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 5, eff.
June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.05, eff.
Sept. 1, 1999.
Sec. 533.007. CONTRACT COMPLIANCE. (a) The commission shall
review each managed care organization that contracts with the
commission to provide health care services to recipients through
a managed care plan issued by the organization to determine
whether the organization is prepared to meet its contractual
obligations.
(b) Each managed care organization that contracts with the
commission to provide health care services to recipients in a
health care service region shall submit an implementation plan
not later than the 90th day before the date on which the
commission plans to begin to provide health care services to
recipients in that region through managed care. The
implementation plan must include:
(1) specific staffing patterns by function for all operations,
including enrollment, information systems, member services,
quality improvement, claims management, case management, and
provider and recipient training; and
(2) specific time frames for demonstrating preparedness for
implementation before the date on which the commission plans to
begin to provide health care services to recipients in that
region through managed care.
(c) The commission shall respond to an implementation plan not
later than the 10th day after the date a managed care
organization submits the plan if the plan does not adequately
meet preparedness guidelines.
(d) Each managed care organization that contracts with the
commission to provide health care services to recipients in a
region shall submit status reports on the implementation plan not
later than the 60th day and the 30th day before the date on which
the commission plans to begin to provide health care services to
recipients in that region through managed care and every 30th day
after that date until the 180th day after that date.
(e) The commission shall conduct a compliance and readiness
review of each managed care organization that contracts with the
commission not later than the 15th day before the date on which
the commission plans to begin the enrollment process in a region
and again not later than the 15th day before the date on which
the commission plans to begin to provide health care services to
recipients in that region through managed care. The review must
include an on-site inspection and tests of service authorization
and claims payment systems, including the ability of the managed
care organization to process claims electronically, complaint
processing systems, and any other process or system required by
the contract.
(f) The commission may delay enrollment of recipients in a
managed care plan issued by a managed care organization if the
review reveals that the managed care organization is not prepared
to meet its contractual obligations. The commission shall notify
a managed care organization of a decision to delay enrollment in
a plan issued by that organization.
(g) To ensure appropriate access to an adequate provider
network, each managed care organization that contracts with the
commission to provide health care services to recipients in a
health care service region shall submit to the commission, in the
format and manner prescribed by the commission, a report
detailing the number, type, and scope of services provided by
out-of-network providers to recipients enrolled in a managed care
plan provided by the managed care organization. If, as determined
by the commission, a managed care organization exceeds maximum
limits established by the commission for out-of-network access to
health care services, or if, based on an investigation by the
commission of a provider complaint regarding reimbursement, the
commission determines that a managed care organization did not
reimburse an out-of-network provider based on a reasonable
reimbursement methodology, the commission shall initiate a
corrective action plan requiring the managed care organization to
maintain an adequate provider network, provide reimbursement to
support that network, and educate recipients enrolled in managed
care plans provided by the managed care organization regarding
the proper use of the provider network under the plan.
(h) The corrective action plan required by Subsection (g) must
include at least one of the following elements:
(1) a requirement that reimbursements paid by the managed care
organization to out-of-network providers for a health care
service provided to a recipient enrolled in a managed care plan
provided by the managed care organization equal the allowable
rate for the service, as determined under Sections 32.028 and
32.0281, Human Resources Code, for all health care services
provided during the period:
(A) the managed care organization is not in compliance with the
utilization benchmarks determined by the commission; or
(B) the managed care organization is not reimbursing
out-of-network providers based on a reasonable methodology, as
determined by the commission;
(2) an immediate freeze on the enrollment of additional
recipients in a managed care plan provided by the managed care
organization, to continue until the commission determines that
the provider network under the managed care plan can adequately
meet the needs of additional recipients; and
(3) other actions the commission determines are necessary to
ensure that recipients enrolled in a managed care plan provided
by the managed care organization have access to appropriate
health care services and that providers are properly reimbursed
for providing medically necessary health care services to those
recipients.
(i) Not later than the 60th day after the date a provider files
a complaint with the commission regarding reimbursement for or
overuse of out-of-network providers by a managed care
organization, the commission shall provide to the provider a
report regarding the conclusions of the commission's
investigation. The report must include:
(1) a description of the corrective action, if any, required of
the managed care organization that was the subject of the
complaint; and
(2) if applicable, a conclusion regarding the amount of
reimbursement owed to an out-of-network provider.
(j) If, after an investigation, the commission determines that
additional reimbursement is owed to a provider, the managed care
organization shall, not later than the 90th day after the date
the provider filed the complaint, pay the additional
reimbursement or provide to the provider a reimbursement payment
plan under which the managed care organization must pay the
entire amount of the additional reimbursement not later than the
120th day after the date the provider filed the complaint. If the
managed care organization does not pay the entire amount of the
additional reimbursement on or before the 90th day after the date
the provider filed the complaint, the commission may require the
managed care organization to pay interest on the unpaid amount.
If required by the commission, interest accrues at a rate of 18
percent simple interest per year on the unpaid amount from the
90th day after the date the provider filed the complaint until
the date the entire amount of the additional reimbursement is
paid.
(k) The commission shall pursue any appropriate remedy
authorized in the contract between the managed care organization
and the commission if the managed care organization fails to
comply with a corrective action plan under Subsection (g).
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997. Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 6, eff.
June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.06, eff.
Sept. 1, 1999; Acts 2003, 78th Leg., ch. 198, Sec. 2.203, eff.
Sept. 1, 2003.
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission
shall make every effort to improve the administration of
contracts with managed care organizations. To improve the
administration of these contracts, the commission shall:
(1) ensure that the commission has appropriate expertise and
qualified staff to effectively manage contracts with managed care
organizations under the Medicaid managed care program;
(2) evaluate options for Medicaid payment recovery from managed
care organizations if the enrollee dies or is incarcerated or if
an enrollee is enrolled in more than one state program or is
covered by another liable third party insurer;
(3) maximize Medicaid payment recovery options by contracting
with private vendors to assist in the recovery of capitation
payments, payments from other liable third parties, and other
payments made to managed care organizations with respect to
enrollees who leave the managed care program;
(4) decrease the administrative burdens of managed care for the
state, the managed care organizations, and the providers under
managed care networks to the extent that those changes are
compatible with state law and existing Medicaid managed care
contracts, including decreasing those burdens by:
(A) where possible, decreasing the duplication of administrative
reporting requirements for the managed care organizations, such
as requirements for the submission of encounter data, quality
reports, historically underutilized business reports, and claims
payment summary reports;
(B) allowing managed care organizations to provide updated
address information directly to the commission for correction in
the state system;
(C) promoting consistency and uniformity among managed care
organization policies, including policies relating to the
preauthorization process, lengths of hospital stays, filing
deadlines, levels of care, and case management services; and
(D) reviewing the appropriateness of primary care case
management requirements in the admission and clinical criteria
process, such as requirements relating to including a separate
cover sheet for all communications, submitting handwritten
communications instead of electronic or typed review processes,
and admitting patients listed on separate notifications; and
(5) reserve the right to amend the managed care organization's
process for resolving provider appeals of denials based on
medical necessity to include an independent review process
established by the commission for final determination of these
disputes.
Added by Acts 2005, 79th Leg., Ch.
349, Sec. 6(b), eff. September 1, 2005.
Sec. 533.0072. INTERNET POSTING OF SANCTIONS IMPOSED FOR
CONTRACTUAL VIOLATIONS. (a) The commission shall prepare and
maintain a record of each enforcement action initiated by the
commission that results in a sanction, including a penalty, being
imposed against a managed care organization for failure to comply
with the terms of a contract to provide health care services to
recipients through a managed care plan issued by the
organization.
(b) The record must include:
(1) the name and address of the organization;
(2) a description of the contractual obligation the organization
failed to meet;
(3) the date of determination of noncompliance;
(4) the date the sanction was imposed;
(5) the maximum sanction that may be imposed under the contract
for the violation; and
(6) the actual sanction imposed against the organization.
(c) The commission shall post and maintain the records required
by this section on the commission's Internet website in English
and Spanish. The records must be posted in a format that is
readily accessible to and understandable by a member of the
public. The commission shall update the list of records on the
website at least quarterly.
(d) The commission may not post information under this section
that relates to a sanction while the sanction is the subject of
an administrative appeal or judicial review.
(e) A record prepared under this section may not include
information that is excepted from disclosure under Chapter 552.
(f) The executive commissioner shall adopt rules as necessary to
implement this section.
Added by Acts 2005, 79th Leg., Ch.
349, Sec. 6(b), eff. September 1, 2005.
Sec. 533.0075. RECIPIENT ENROLLMENT. The commission shall:
(1) encourage recipients to choose appropriate managed care
plans and primary health care providers by:
(A) providing initial information to recipients and providers in
a region about the need for recipients to choose plans and
providers not later than the 90th day before the date on which
the commission plans to begin to provide health care services to
recipients in that region through managed care;
(B) providing follow-up information before assignment of plans
and providers and after assignment, if necessary, to recipients
who delay in choosing plans and providers; and
(C) allowing plans and providers to provide information to
recipients or engage in marketing activities under marketing
guidelines established by the commission under Section 533.008
after the commission approves the information or activities;
(2) consider the following factors in assigning managed care
plans and primary health care providers to recipients who fail to
choose plans and providers:
(A) the importance of maintaining existing provider-patient and
physician-patient relationships, including relationships with
specialists, public health clinics, and community health centers;
(B) to the extent possible, the need to assign family members to
the same providers and plans; and
(C) geographic convenience of plans and providers for
recipients;
(3) retain responsibility for enrollment and disenrollment of
recipients in managed care plans, except that the commission may
delegate the responsibility to an independent contractor who
receives no form of payment from, and has no financial ties to,
any managed care organization;
(4) develop and implement an expedited process for determining
eligibility for and enrolling pregnant women and newborn infants
in managed care plans; and
(5) ensure immediate access to prenatal services and newborn
care for pregnant women and newborn infants enrolled in managed
care plans, including ensuring that a pregnant woman may obtain
an appointment with an obstetrical care provider for an initial
maternity evaluation not later than the 30th day after the date
the woman applies for Medicaid.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997. Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 7, eff.
June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.07, eff.
Sept. 1, 1999.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
945, Sec. 2, eff. June 19, 2009.
Sec. 533.0076. LIMITATIONS ON RECIPIENT DISENROLLMENT. (a)
Except as provided by Subsections (b) and (c), and to the extent
permitted by federal law, the commission may prohibit a recipient
from disenrolling in a managed care plan under this chapter and
enrolling in another managed care plan during the 12-month period
after the date the recipient initially enrolls in a plan.
(b) At any time before the 91st day after the date of a
recipient's initial enrollment in a managed care plan under this
chapter, the recipient may disenroll in that plan for any reason
and enroll in another managed care plan under this chapter.
(c) The commission shall allow a recipient who is enrolled in a
managed care plan under this chapter to disenroll in that plan at
any time for cause in accordance with federal law.
Added by Acts 2001, 77th Leg., ch. 584, Sec. 6.
Sec. 533.008. MARKETING GUIDELINES. (a) The commission shall
establish marketing guidelines for managed care organizations
that contract with the commission to provide health care services
to recipients, including guidelines that prohibit:
(1) door-to-door marketing to recipients by managed care
organizations or agents of those organizations;
(2) the use of marketing materials with inaccurate or misleading
information;
(3) misrepresentations to recipients or providers;
(4) offering recipients material or financial incentives to
choose a managed care plan other than nominal gifts or free
health screenings approved by the commission that the managed
care organization offers to all recipients regardless of whether
the recipients enroll in the managed care plan;
(5) the use of marketing agents who are paid solely by
commission; and
(6) face-to-face marketing at public assistance offices by
managed care organizations or agents of those organizations.
(b) This section does not prohibit:
(1) the distribution of approved marketing materials at public
assistance offices; or
(2) the provision of information directly to recipients under
marketing guidelines established by the commission.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.009. SPECIAL DISEASE MANAGEMENT. (a) The commission
shall ensure that managed care organizations under contract with
the commission to provide health care services to recipients
develop and implement special disease management programs to
manage a disease or other chronic health conditions, such as
heart disease, chronic kidney disease and its medical
complications, respiratory illness, including asthma, diabetes,
end-stage renal disease, HIV infection, or AIDS, and with respect
to which the commission identifies populations for which disease
management would be cost-effective.
(b) A managed health care plan provided under this chapter must
provide disease management services in the manner required by the
commission, including:
(1) patient self-management education;
(2) provider education;
(3) evidence-based models and minimum standards of care;
(4) standardized protocols and participation criteria; and
(5) physician-directed or physician-supervised care.
(c) The executive commissioner, by rule, shall prescribe the
minimum requirements that a managed care organization, in
providing a disease management program, must meet to be eligible
to receive a contract under this section. The managed care
organization must, at a minimum, be required to:
(1) provide disease management services that have performance
measures for particular diseases that are comparable to the
relevant performance measures applicable to a provider of disease
management services under Section 32.059, Human Resources Code,
as added by Chapter 208, Acts of the 78th Legislature, Regular
Session, 2003; and
(2) show evidence of ability to manage complex diseases in the
Medicaid population.
(f) If a managed care organization implements a special disease
management program to manage chronic kidney disease and its
medical complications as provided by Subsection (a) and the
managed care organization develops a program to provide screening
for and diagnosis and treatment of chronic kidney disease and its
medical complications to recipients under the organization's
managed care plan, the program for screening, diagnosis, and
treatment must use generally recognized clinical practice
guidelines and laboratory assessments that identify chronic
kidney disease on the basis of impaired kidney function or the
presence of kidney damage.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997. Amended by Acts 2001, 77th Leg., ch. 698, Sec. 1, eff.
Sept. 1, 2001; Acts 2003, 78th Leg., ch. 589, Sec. 7, eff. June
20, 2003.
Amended by:
Acts 2005, 79th Leg., Ch.
349, Sec. 19(a), eff. September 1, 2005.
Acts 2005, 79th Leg., Ch.
1047, Sec. 1, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch.
921, Sec. 17.001(38), eff. September 1, 2007.
Sec. 533.010. SPECIAL PROTOCOLS. In conjunction with an
academic center, the commission may study the treatment of
indigent populations to develop special protocols for managed
care organizations to use in providing health care services to
recipients.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.011. PUBLIC NOTICE. Not later than the 30th day before
the commission plans to issue a request for applications to enter
into a contract with the commission to provide health care
services to recipients in a region, the commission shall publish
notice of and make available for public review the request for
applications and all related nonproprietary documents, including
the proposed contract.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.012. INFORMATION FOR FRAUD CONTROL. (a) Each managed
care organization contracting with the commission under this
chapter shall submit to the commission:
(1) a description of any financial or other business
relationship between the organization and any subcontractor
providing health care services under the contract;
(2) a copy of each type of contract between the organization and
a subcontractor relating to the delivery of or payment for health
care services;
(3) a description of the fraud control program used by any
subcontractor that delivers health care services; and
(4) a description and breakdown of all funds paid to the managed
care organization, including a health maintenance organization,
primary care case management, and an exclusive provider
organization, necessary for the commission to determine the
actual cost of administering the managed care plan.
(b) The information submitted under this section must be
submitted in the form required by the commission and be updated
as required by the commission.
(c) The commission's office of investigations and enforcement
shall review the information submitted under this section as
appropriate in the investigation of fraud in the Medicaid managed
care program.
(d) For a subcontractor who reenrolled as a provider in the
Medicaid program as required by Section 2.07, Chapter 1153, Acts
of the 75th Legislature, Regular Session, 1997, or who modified a
contract in compliance with that section, a managed care
organization is not required to submit, and the provider is not
required to provide, fraud control information different than the
information submitted in connection with the reenrollment or
contract modification.
(e) Information submitted to the commission under Subsection
(a)(1) is confidential and not subject to disclosure under
Chapter 552, Government Code.
Added by Acts 1999, 76th Leg., ch. 493, Sec. 1, eff. Sept. 1,
1999. Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.36, eff.
Sept. 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch.
268, Sec. 11(a), eff. September 1, 2007.
Sec. 533.013. PREMIUM PAYMENT RATE DETERMINATION; REVIEW AND
COMMENT. (a) In determining premium payment rates paid to a
managed care organization under a managed care plan, the
commission shall consider:
(1) the regional variation in costs of health care services;
(2) the range and type of health care services to be covered by
premium payment rates;
(3) the number of managed care plans in a region;
(4) the current and projected number of recipients in each
region, including the current and projected number for each
category of recipient;
(5) the ability of the managed care plan to meet costs of
operation under the proposed premium payment rates;
(6) the applicable requirements of the federal Balanced Budget
Act of 1997 and implementing regulations that require adequacy of
premium payments to managed care organizations participating in
the state Medicaid program;
(7) the adequacy of the management fee paid for assisting
enrollees of Supplemental Security Income (SSI) (42 U.S.C.
Section 1381 et seq.) who are voluntarily enrolled in the managed
care plan;
(8) the impact of reducing premium payment rates for the
category of recipients who are pregnant; and
(9) the ability of the managed care plan to pay under the
proposed premium payment rates inpatient and outpatient hospital
provider payment rates that are comparable to the inpatient and
outpatient hospital provider payment rates paid by the commission
under a primary care case management model or a partially
capitated model.
(b) In determining the maximum premium payment rates paid to a
managed care organization that is licensed under Chapter 843,
Insurance Code, the commission shall consider and adjust for the
regional variation in costs of services under the traditional
fee-for-service component of the state Medicaid program,
utilization patterns, and other factors that influence the
potential for cost savings. For a service area with a service
area factor of .93 or less, or another appropriate service area
factor, as determined by the commission, the commission may not
discount premium payment rates in an amount that is more than the
amount necessary to meet federal budget neutrality requirements
for projected fee-for-service costs unless:
(1) a historical review of managed care financial results among
managed care organizations in the service area served by the
organization demonstrates that additional savings are warranted;
(2) a review of Medicaid fee-for-service delivery in the service
area served by the organization has historically shown a
significant overutilization by recipients of certain services
covered by the premium payment rates in comparison to utilization
patterns throughout the rest of the state; or
(3) a review of Medicaid fee-for-service delivery in the service
area served by the organization has historically shown an
above-market cost for services for which there is substantial
evidence that Medicaid managed care delivery will reduce the cost
of those services.
(c) The premium payment rates paid to a managed care
organization that is licensed under Chapter 843, Insurance Code,
shall be established by a competitive bid process but may not
exceed the maximum premium payment rates established by the
commission under Subsection (b).
(d) Subsection (b) applies only to a managed care organization
with respect to Medicaid managed care pilot programs, Medicaid
behavioral health pilot programs, and Medicaid Star + Plus pilot
programs implemented in a health care service region after June
1, 1999.
Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19,
1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1,
1999. Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.516,
eff. Sept. 1, 2003.
Sec. 533.0131. USE OF ENCOUNTER DATA IN DETERMINING PREMIUM
PAYMENT RATES. (a) In determining premium payment rates and
other amounts paid to managed care organizations under a managed
care plan, the commission may not base or derive the rates or
amounts on or from encounter data, or incorporate in the
determination an analysis of encounter data, unless a certifier
of encounter data certifies that:
(1) the encounter data for the most recent state fiscal year is
complete, accurate, and reliable; and
(2) there is no statistically significant variability in the
encounter data attributable to incompleteness, inaccuracy, or
another deficiency as compared to equivalent data for similar
populations and when evaluated against professionally accepted
standards.
(b) For purposes of determining whether data is equivalent data
for similar populations under Subsection (a)(2), a certifier of
encounter data shall, at a minimum, consider:
(1) the regional variation in utilization patterns of recipients
and costs of health care services;
(2) the range and type of health care services to be covered by
premium payment rates;
(3) the number of managed care plans in the region; and
(4) the current number of recipients in each region, including
the number for each category of recipient.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1,
2001.
Sec. 533.01315. REIMBURSEMENT FOR SERVICES PROVIDED OUTSIDE OF
REGULAR BUSINESS HOURS. (a) This section applies only to a
recipient receiving medical assistance through any Medicaid
managed care model or arrangement.
(b) The commission shall ensure that a federally qualified
health center, rural health clinic, or municipal health
department's public clinic is reimbursed for health care services
provided to a recipient outside of regular business hours,
including on a weekend or holiday, at a rate that is equal to the
allowable rate for those services as determined under Section
32.028, Human Resources Code, regardless of whether the recipient
has a referral from the recipient's primary care provider.
(c) The executive commissioner shall adopt rules regarding the
days, times of days, and holidays that are considered to be
outside of regular business hours for purposes of Subsection (b).
Added by Acts 2007, 80th Leg., R.S., Ch.
298, Sec. 1, eff. September 1, 2007.
Sec. 533.0132. STATE TAXES. The commission shall ensure that
any experience rebate or profit sharing for managed care
organizations is calculated by treating premium, maintenance, and
other taxes under the Insurance Code and any other taxes payable
to this state as allowable expenses for purposes of determining
the amount of the experience rebate or profit sharing.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.30, eff. Sept. 1,
2003.
Sec. 533.014. PROFIT SHARING. (a) The commission shall adopt
rules regarding the sharing of profits earned by a managed care
organization through a managed care plan providing health care
services under a contract with the commission under this chapter.
(b) Any amount received by the state under this section shall be
deposited in the general revenue fund for the purpose of funding
the state Medicaid program.
Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19,
1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1,
1999.
Sec. 533.015. COORDINATION OF EXTERNAL OVERSIGHT ACTIVITIES. To
the extent possible, the commission shall coordinate all external
oversight activities to minimize duplication of oversight of
managed care plans under the state Medicaid program and
disruption of operations under those plans.
Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19,
1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1,
1999.
Sec. 533.016. PROVIDER REPORTING OF ENCOUNTER DATA. The
commission shall collaborate with managed care organizations that
contract with the commission and health care providers under the
organizations' provider networks to develop incentives and
mechanisms to encourage providers to report complete and accurate
encounter data to managed care organizations in a timely manner.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1,
2001.
Sec. 533.017. QUALIFICATIONS OF CERTIFIER OF ENCOUNTER DATA.
(a) The person acting as the state Medicaid director shall
appoint a person as the certifier of encounter data.
(b) The certifier of encounter data must have:
(1) demonstrated expertise in estimating premium payment rates
paid to a managed care organization under a managed care plan;
and
(2) access to actuarial expertise, including expertise in
estimating premium payment rates paid to a managed care
organization under a managed care plan.
(c) A person may not be appointed under this section as the
certifier of encounter data if the person participated with the
commission in developing premium payment rates for managed care
organizations under managed care plans in this state during the
three-year period before the date the certifier is appointed.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1,
2001.
Sec. 533.018. CERTIFICATION OF ENCOUNTER DATA. (a) The
certifier of encounter data shall certify the completeness,
accuracy, and reliability of encounter data for each state fiscal
year.
(b) The commission shall make available to the certifier all
records and data the certifier considers appropriate for
evaluating whether to certify the encounter data. The commission
shall provide to the certifier selected resources and assistance
in obtaining, compiling, and interpreting the records and data.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1,
2001.
Sec. 533.019. VALUE-ADDED SERVICES. The commission shall
actively encourage managed care organizations that contract with
the commission to offer benefits, including health care services
or benefits or other types of services, that:
(1) are in addition to the services ordinarily covered by the
managed care plan offered by the managed care organization; and
(2) have the potential to improve the health status of enrollees
in the plan.
Added by Acts 2007, 80th Leg., R.S., Ch.
268, Sec. 12(a), eff. September 1, 2007.
Sec. 533.020. MANAGED CARE ORGANIZATIONS: FISCAL SOLVENCY AND
COMPLAINT SYSTEM GUIDELINES. (a) The Texas Department of
Insurance, in conjunction with the commission, shall establish
fiscal solvency standards and complaint system guidelines for
managed care organizations that serve Medicaid recipients.
(b) The guidelines must require that information regarding a
managed care organization's complaint process be made available
to a recipient in an appropriate communication format when the
recipient enrolls in the Medicaid managed care program.
Added by Acts 2007, 80th Leg., R.S., Ch.
730, Sec. 1K.001, eff. April 1, 2009.
Renumbered from Government Code, Section 533.019 by Acts 2009,
81st Leg., R.S., Ch.
87, Sec. 27.001(38), eff. September 1, 2009.
SUBCHAPTER B. REGIONAL ADVISORY COMMITTEES
Sec. 533.021. APPOINTMENT. Not later than the 180th day before
the date the commission plans to begin to provide health care
services to recipients in a health care service region through
managed care, the commission, in consultation with health and
human services agencies, shall appoint a Medicaid managed care
advisory committee for that region.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.022. COMPOSITION. A committee consists of
representatives from entities and communities in the region as
considered necessary by the commission to ensure representation
of interested persons, including representatives of:
(1) hospitals;
(2) managed care organizations;
(3) primary care providers;
(4) state agencies;
(5) consumer advocates;
(6) recipients;
(7) rural providers;
(8) long-term care providers;
(9) specialty care providers, including pediatric providers; and
(10) political subdivisions with a constitutional or statutory
obligation to provide health care to indigent patients.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.023. PRESIDING OFFICER; SUBCOMMITTEES. The
commissioner or the commissioner's designated representative
serves as the presiding officer of a committee. The presiding
officer may appoint subcommittees as necessary.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.024. MEETINGS. (a) A committee shall meet at least
quarterly for the first year after appointment of the committee
and at least annually after that time.
(b) A committee is subject to Chapter 551, Government Code.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.025. POWERS AND DUTIES. A committee shall:
(1) comment on the implementation of Medicaid managed care in
the region;
(2) provide recommendations to the commission on the improvement
of Medicaid managed care in the region not later than the 30th
day after the date of each committee meeting; and
(3) seek input from the public, including public comment at each
committee meeting.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.026. INFORMATION FROM COMMISSION. On request, the
commission shall provide to a committee information relating to
recipient enrollment and disenrollment, recipient and provider
complaints, administrative procedures, program expenditures, and
education and training procedures.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.027. COMPENSATION; REIMBURSEMENT. (a) A member of a
committee other than a representative of a health and human
services agency is not entitled to receive compensation or
reimbursement for travel expenses.
(b) A member of a committee who is an agency representative is
entitled to reimbursement for expenses incurred in the
performance of committee duties by the appointing agency in
accordance with the travel provisions for state employees in the
General Appropriations Act.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.028. OTHER LAW. Except as provided by this chapter, a
committee is subject to Article 6252-33, Revised Statutes.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
Sec. 533.029. FUNDING. The commission shall fund activities
under this section with money otherwise appropriated for that
purpose.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20,
1997.
SUBCHAPTER C. STATEWIDE ADVISORY COMMITTEE
Sec. 533.041. APPOINTMENT AND COMPOSITION. (a) The commission
shall appoint a state Medicaid managed care advisory committee.
The advisory committee consists of representatives of:
(1) hospitals;
(2) managed care organizations;
(3) primary care providers;
(4) state agencies;
(5) consumer advocates representing low-income recipients;
(6) consumer advocates representing recipients with a
disability;
(7) parents of children who are recipients;
(8) rural providers;
(9) advocates for children with special health care needs;
(10) pediatric health care providers, including specialty
providers;
(11) long-term care providers, including nursing home providers;
(12) obstetrical care providers;
(13) community-based organizations serving low-income children
and their families; and
(14) community-based organizations engaged in perinatal services
and outreach.
(b) The advisory committee must include a member of each
regional Medicaid managed care advisory committee appointed by
the commission under Subchapter B.
Added by Acts 1999, 76th Leg., ch. 1447, Sec. 9, eff. June 19,
1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.09, eff. Sept. 1,
1999.
Sec. 533.042. MEETINGS. The advisory committee shall meet at