By Maxey H.B. No. 1710
76R5071 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to fraud control procedures for the Medicaid managed care
1-3 program.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter A, Chapter 533, Government Code, is
1-6 amended by adding Section 533.012 to read as follows:
1-7 Sec. 533.012. INFORMATION FOR FRAUD CONTROL. (a) Each
1-8 managed care organization contracting with the commission under
1-9 this chapter shall submit to the commission:
1-10 (1) a description of any financial or other business
1-11 relationship between the organization and any subcontractor
1-12 providing health care services under the contract;
1-13 (2) a copy of any contract between the organization
1-14 and a subcontractor relating to the delivery of or payment for
1-15 health care services; and
1-16 (3) a description of the fraud control program used by
1-17 any subcontractor that delivers health care services.
1-18 (b) Each managed care organization contracting with the
1-19 commission under this chapter shall submit to the commission
1-20 specific information relating to each encounter in which a health
1-21 care service was provided to a recipient under the contract.
1-22 (c) The information submitted under this section must be
1-23 submitted in the form required by the commission. The information
1-24 submitted under Subsection (a) shall be updated as required by the
2-1 commission.
2-2 (d) The commission's office of investigations and
2-3 enforcement shall review the information submitted under this
2-4 section as appropriate in the investigation of fraud in the
2-5 Medicaid managed care program. The comptroller may review the
2-6 information in connection with the health care fraud study
2-7 conducted by the comptroller.
2-8 SECTION 2. Section 533.005, Government Code, is amended to
2-9 read as follows:
2-10 Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
2-11 between a managed care organization and the commission for the
2-12 organization to provide health care services to recipients must
2-13 contain:
2-14 (1) procedures to ensure accountability to the state
2-15 for the provision of health care services, including procedures for
2-16 financial reporting, quality assurance, utilization review, and
2-17 assurance of contract and subcontract compliance;
2-18 (2) capitation and provider payment rates that ensure
2-19 the cost-effective provision of quality health care;
2-20 (3) a requirement that the managed care organization
2-21 provide ready access to a person who assists recipients in
2-22 resolving issues relating to enrollment, plan administration,
2-23 education and training, access to services, and grievance
2-24 procedures;
2-25 (4) a requirement that the managed care organization
2-26 provide ready access to a person who assists providers in resolving
2-27 issues relating to payment, plan administration, education and
3-1 training, and grievance procedures;
3-2 (5) a requirement that the managed care organization
3-3 provide information and referral about the availability of
3-4 educational, social, and other community services that could
3-5 benefit a recipient;
3-6 (6) procedures for recipient outreach and education;
3-7 (7) a requirement that the managed care organization
3-8 make payment to a physician or provider for health care services
3-9 rendered to a recipient under a managed care plan not later than
3-10 the 45th day after the date a claim for payment is received with
3-11 documentation reasonably necessary for the managed care
3-12 organization to process the claim, or within a period, not to
3-13 exceed 60 days, specified by a written agreement between the
3-14 physician or provider and the managed care organization;
3-15 (8) a requirement that the commission, on the date of
3-16 a recipient's enrollment in a managed care plan issued by the
3-17 managed care organization, inform the organization of the
3-18 recipient's Medicaid recertification date; [and]
3-19 (9) a requirement that the managed care organization
3-20 comply with Section 533.006 as a condition of contract retention
3-21 and renewal; and
3-22 (10) a requirement that the managed care organization
3-23 provide the information required by Section 533.012 and otherwise
3-24 comply and cooperate with the commission's office of investigations
3-25 and enforcement.
3-26 SECTION 3. The change in law made by Section 2 of this Act
3-27 applies only to a contract with a managed care organization entered
4-1 into or renewed on or after the effective date of this Act. A
4-2 contract entered into before the effective date of this Act is
4-3 governed by the law as it existed immediately before the effective
4-4 date of this Act, and that law is continued in effect for that
4-5 purpose.
4-6 SECTION 4. The importance of this legislation and the
4-7 crowded condition of the calendars in both houses create an
4-8 emergency and an imperative public necessity that the
4-9 constitutional rule requiring bills to be read on three several
4-10 days in each house be suspended, and this rule is hereby suspended,
4-11 and that this Act take effect and be in force from and after its
4-12 passage, and it is so enacted.