By: Zaffirini S.B. No. 1588
A BILL TO BE ENTITLED
AN ACT
1-1 relating to fraud control procedures for the Medicaid managed care
1-2 program.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subchapter A, Chapter 533, Government Code, is
1-5 amended by adding Section 533.012 to read as follows:
1-6 Sec. 533.012. INFORMATION FOR FRAUD CONTROL. (a) Each
1-7 managed care organization contracting with the commission under
1-8 this chapter shall submit to the commission:
1-9 (1) a description of any financial or other business
1-10 relationship between the organization and any subcontractor
1-11 providing health care services under the contract;
1-12 (2) a copy of any contract between the organization
1-13 and a subcontractor relating to the delivery of or payment for
1-14 health care services; and
1-15 (3) a description of the fraud control program used by
1-16 any subcontractor that delivers health care services.
1-17 (b) The information submitted under this section must be
1-18 submitted in the form required by the commission and be updated as
1-19 required by the commission.
1-20 (c) The commission's office of investigations and
1-21 enforcement shall review the information submitted under this
1-22 section as appropriate in the investigation of fraud in the
1-23 Medicaid managed care program. The comptroller may review the
1-24 information in connection with the health care fraud study
2-1 conducted by the comptroller.
2-2 SECTION 2. Section 533.005, Government Code, is amended to
2-3 read as follows:
2-4 Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
2-5 between a managed care organization and the commission for the
2-6 organization to provide health care services to recipients must
2-7 contain:
2-8 (1) procedures to ensure accountability to the state
2-9 for the provision of health care services, including procedures for
2-10 financial reporting, quality assurance, utilization review, and
2-11 assurance of contract and subcontract compliance;
2-12 (2) capitation and provider payment rates that ensure
2-13 the cost-effective provision of quality health care;
2-14 (3) a requirement that the managed care organization
2-15 provide ready access to a person who assists recipients in
2-16 resolving issues relating to enrollment, plan administration,
2-17 education and training, access to services, and grievance
2-18 procedures;
2-19 (4) a requirement that the managed care organization
2-20 provide ready access to a person who assists providers in resolving
2-21 issues relating to payment, plan administration, education and
2-22 training, and grievance procedures;
2-23 (5) a requirement that the managed care organization
2-24 provide information and referral about the availability of
2-25 educational, social, and other community services that could
2-26 benefit a recipient;
3-1 (6) procedures for recipient outreach and education;
3-2 (7) a requirement that the managed care organization
3-3 make payment to a physician or provider for health care services
3-4 rendered to a recipient under a managed care plan not later than
3-5 the 45th day after the date a claim for payment is received with
3-6 documentation reasonably necessary for the managed care
3-7 organization to process the claim, or within a period, not to
3-8 exceed 60 days, specified by a written agreement between the
3-9 physician or provider and the managed care organization;
3-10 (8) a requirement that the commission, on the date of
3-11 a recipient's enrollment in a managed care plan issued by the
3-12 managed care organization, inform the organization of the
3-13 recipient's Medicaid recertification date; [and]
3-14 (9) a requirement that the managed care organization
3-15 comply with Section 533.006 as a condition of contract retention
3-16 and renewal; and
3-17 (10) a requirement that the managed care organization
3-18 provide the information required by Section 533.012 and otherwise
3-19 comply and cooperate with the commission's office of investigations
3-20 and enforcement.
3-21 SECTION 3. This Act takes effect September 1, 1999.
3-22 SECTION 4. The change in law made by this Act applies only
3-23 to a contract with a managed care organization entered into or
3-24 renewed on or after the effective date of this Act. A contract
3-25 entered into before the effective date of this Act is governed by
3-26 the law as it existed immediately before the effective date of this
4-1 Act, and that law is continued in effect for that purpose.
4-2 SECTION 5. The importance of this legislation and the
4-3 crowded condition of the calendars in both houses create an
4-4 emergency and an imperative public necessity that the
4-5 constitutional rule requiring bills to be read on three several
4-6 days in each house be suspended, and this rule is hereby suspended.