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A BILL TO BE ENTITLED
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AN ACT
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relating to the provision and delivery of benefits to certain |
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recipients under Medicaid. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 531.024164(e), Government Code, is |
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amended to read as follows: |
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(e) The commission shall establish a common procedure for |
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conducting external medical reviews. [To the greatest extent |
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possible, the procedure must reduce administrative burdens on |
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providers and the submission of duplicative information or |
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documents. Medical necessity under the procedure must be based on |
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publicly available, up-to-date, evidence-based, and peer-reviewed |
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clinical criteria. The reviewer shall conduct the review within a |
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period specified by the commission.] The [commission shall also |
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establish a] procedure [and time frame for expedited reviews that |
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allows the reviewer to]: |
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(1) must conform to the utilization review and |
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independent review process under Title 14, Insurance Code [identify |
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an appeal that requires an expedited resolution]; [and] |
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(2) must include, at a minimum, the following |
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requirements: |
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(A) a requirement that the person requesting the |
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external review timely deliver to the external reviewer the |
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recipient's relevant personal and medical information, including, |
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except as provided by Paragraph (B), the recipient's written |
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statement; |
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(B) in the instance the review relates to a |
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life-threatening condition, a requirement that instead of |
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obtaining a written statement from the recipient the reviewer |
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directly contact: |
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(i) the recipient or recipient's parent or |
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legally authorized representative; and |
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(ii) the recipient's health care provider; |
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(C) a requirement that the reviewer notify the |
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recipient or recipient's parent or legally authorized |
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representative, the recipient's health care provider, and the |
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commission if the reviewer does not receive the information |
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described by Paragraph (A) within three business days after the |
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date the reviewer is assigned to conduct the review; and |
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(D) a requirement that the reviewer request and |
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maintain any other relevant information not provided under |
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Paragraph (A) that is necessary to conduct the review, including: |
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(i) identifying information about the |
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recipient, the recipient's treating health care providers, health |
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care facilities providing care to the recipient, and the |
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recipient's managed care plan; |
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(ii) the recipient's plan of care; |
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(iii) clinical information about the |
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recipient's diagnosis and medical history related to the diagnosis; |
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(iv) the recipient's prognosis; and |
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(v) the recipient's treatment plan |
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prescribed by a health care provider and the provider's |
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justification of the services contained in the plan; |
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(3) must ensure that the recipient and the recipient's |
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health care provider are given the opportunity to provide input and |
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additional evidence during the review; and |
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(4) may not prohibit a recipient, a recipient's parent |
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or legally authorized representative, or the recipient's health |
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care provider from submitting any information or documentation the |
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person determines relevant to [resolve] the review [of the appeal |
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within a specified period]. |
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SECTION 2. Section 533.038, Government Code, is amended by |
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amending Subsections (a), (g), and (h) and adding Subsection (j) to |
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read as follows: |
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(a) In this section: |
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(1) "Complex medical needs" means: |
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(A) the condition of having one or more chronic |
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health problems that: |
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(i) affect multiple organ systems; and |
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(ii) reduce cognitive or physical |
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functioning and require the use of medication, durable medical |
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equipment, therapy, surgery, or other treatments; or |
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(B) a life-limiting illness or rare pediatric |
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disease, as defined by Section 529(a)(3) of the Food and Drug |
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Administration Safety and Innovation Act (21 U.S.C. 360ff(a)). |
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(2) [,] "Medicaid wrap-around benefit" means a |
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Medicaid-covered service, including a pharmacy or medical benefit, |
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that is provided to a recipient with both Medicaid and primary |
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health benefit plan coverage when the recipient has exceeded the |
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primary health benefit plan coverage limit or when the service is |
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not covered by the primary health benefit plan issuer. |
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(3) "Specialty provider" means a person who provides |
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health-related goods or services to a recipient, including a |
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provider of medication, therapy services, durable medical |
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equipment, life-sustaining or life-stabilizing treatment, or any |
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other treatment, services, equipment, or supplies necessary to |
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improve health outcomes, prevent emergency room visits, maintain |
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health care in the home and community, and avoid admission to a |
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health care facility or other institution. |
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(g) The commission shall develop a clear and easy process, |
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to be implemented through a contract, that allows a recipient with |
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complex medical needs who has established a relationship at any |
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time with a specialty provider to continue receiving care from that |
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provider, regardless of: |
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(1) whether the recipient has primary health benefit |
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plan coverage in addition to Medicaid coverage; |
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(2) the date the recipient enrolled in the managed |
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care plan provided by the Medicaid managed care organization; or |
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(3) whether the provider is an in-network provider. |
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(h) If a recipient who has complex medical needs and who |
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does not have primary health benefit plan coverage wants to |
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continue to receive care from a specialty provider that is not in |
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the provider network of the Medicaid managed care organization |
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offering the managed care plan in which the recipient is enrolled, |
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the managed care organization shall develop a simple, timely, and |
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efficient process to and shall make a good-faith effort to, |
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negotiate a single-case agreement with the specialty provider. |
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Until the Medicaid managed care organization and the specialty |
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provider enter into the single-case agreement, the specialty |
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provider shall be reimbursed in accordance with the applicable |
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reimbursement methodology specified in commission rule, including |
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1 T.A.C. Section 353.4. |
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(j) The cancellation of a contract between a Medicaid |
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managed care organization and a specialty provider under which the |
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provider agrees to provide in-network services to recipients does |
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not void or otherwise affect that organization's duty under |
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Subsection (g) to provide continuity of care to recipients with |
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complex medical needs, except if the cancellation is the result of |
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fraud, waste, or abuse, as determined by the commission's office of |
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inspector general. In the event of cancellation, the recipient has |
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the right to select the recipient's preferred specialty provider. |
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SECTION 3. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 4. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2023. |