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 each type of contract between the
1-13 organization and a subcontractor relating to the delivery of or
1-14 payment for 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 (d) For a subcontractor who reenrolled as a provider in the
2-3 Medicaid program as required by Section 2.07, Chapter 1153, Acts of
2-4 the 75th Legislature, Regular Session, 1997, or who modified a
2-5 contract in compliance with that section, a managed care
2-6 organization is not required to submit, and the provider is not
2-7 required to provide, fraud control information different than the
2-8 information submitted in connection with the reenrollment or
2-9 contract modification.
2-10 (e) Information submitted to the commission under Subsection
2-11 (a)(1) is confidential and not subject to disclosure under Chapter
2-12 552, Government Code.
2-13 SECTION 2. Section 533.005, Government Code, is amended to
2-14 read as follows:
2-15 Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
2-16 between a managed care organization and the commission for the
2-17 organization to provide health care services to recipients must
2-18 contain:
2-19 (1) procedures to ensure accountability to the state
2-20 for the provision of health care services, including procedures for
2-21 financial reporting, quality assurance, utilization review, and
2-22 assurance of contract and subcontract compliance;
2-23 (2) capitation and provider payment rates that ensure
2-24 the cost-effective provision of quality health care;
2-25 (3) a requirement that the managed care organization
2-26 provide ready access to a person who assists recipients in
3-1 resolving issues relating to enrollment, plan administration,
3-2 education and training, access to services, and grievance
3-3 procedures;
3-4 (4) a requirement that the managed care organization
3-5 provide ready access to a person who assists providers in resolving
3-6 issues relating to payment, plan administration, education and
3-7 training, and grievance procedures;
3-8 (5) a requirement that the managed care organization
3-9 provide information and referral about the availability of
3-10 educational, social, and other community services that could
3-11 benefit a recipient;
3-12 (6) procedures for recipient outreach and education;
3-13 (7) a requirement that the managed care organization
3-14 make payment to a physician or provider for health care services
3-15 rendered to a recipient under a managed care plan not later than
3-16 the 45th day after the date a claim for payment is received with
3-17 documentation reasonably necessary for the managed care
3-18 organization to process the claim, or within a period, not to
3-19 exceed 60 days, specified by a written agreement between the
3-20 physician or provider and the managed care organization;
3-21 (8) a requirement that the commission, on the date of
3-22 a recipient's enrollment in a managed care plan issued by the
3-23 managed care organization, inform the organization of the
3-24 recipient's Medicaid recertification date; [and]
3-25 (9) a requirement that the managed care organization
3-26 comply with Section 533.006 as a condition of contract retention
4-1 and renewal; and
4-2 (10) a requirement that the managed care organization
4-3 provide the information required by Section 533.012 and otherwise
4-4 comply and cooperate with the commission's office of investigations
4-5 and enforcement.
4-6 SECTION 3. This Act takes effect September 1, 1999.
4-7 SECTION 4. The change in law made by this Act applies only
4-8 to a contract with a managed care organization entered into or
4-9 renewed on or after the effective date of this Act. A contract
4-10 entered into before the effective date of this Act is governed by
4-11 the law as it existed immediately before the effective date of this
4-12 Act, and that law is continued in effect for that purpose.
4-13 SECTION 5. The importance of this legislation and the
4-14 crowded condition of the calendars in both houses create an
4-15 emergency and an imperative public necessity that the
4-16 constitutional rule requiring bills to be read on three several
4-17 days in each house be suspended, and this rule is hereby suspended.
_______________________________ _______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 1588 passed the Senate on
April 15, 1999, by the following vote: Yeas 30, Nays 0; and that
the Senate concurred in House amendment on May 28, 1999, by a
viva-voce vote.
_______________________________
Secretary of the Senate
I hereby certify that S.B. No. 1588 passed the House, with
amendment, on May 25, 1999, by a non-record vote.
_______________________________
Chief Clerk of the House
Approved:
_______________________________
Date
_______________________________
Governor