1-1 By: Zaffirini S.B. No. 1588
1-2 (In the Senate - Filed March 12, 1999; March 15, 1999, read
1-3 first time and referred to Committee on Human Services;
1-4 April 6, 1999, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 5, Nays 0; April 6, 1999,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 1588 By: Zaffirini
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to fraud control procedures for the Medicaid managed care
1-11 program.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Subchapter A, Chapter 533, Government Code, is
1-14 amended by adding Section 533.012 to read as follows:
1-15 Sec. 533.012. INFORMATION FOR FRAUD CONTROL. (a) Each
1-16 managed care organization contracting with the commission under
1-17 this chapter shall submit to the commission:
1-18 (1) a description of any financial or other business
1-19 relationship between the organization and any subcontractor
1-20 providing health care services under the contract;
1-21 (2) a copy of any contract between the organization
1-22 and a subcontractor relating to the delivery of or payment for
1-23 health care services; and
1-24 (3) a description of the fraud control program used by
1-25 any subcontractor that delivers health care services.
1-26 (b) The information submitted under this section must be
1-27 submitted in the form required by the commission and be updated as
1-28 required by the commission.
1-29 (c) The commission's office of investigations and
1-30 enforcement shall review the information submitted under this
1-31 section as appropriate in the investigation of fraud in the
1-32 Medicaid managed care program. The comptroller may review the
1-33 information in connection with the health care fraud study
1-34 conducted by the comptroller.
1-35 SECTION 2. Section 533.005, Government Code, is amended to
1-36 read as follows:
1-37 Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
1-38 between a managed care organization and the commission for the
1-39 organization to provide health care services to recipients must
1-40 contain:
1-41 (1) procedures to ensure accountability to the state
1-42 for the provision of health care services, including procedures for
1-43 financial reporting, quality assurance, utilization review, and
1-44 assurance of contract and subcontract compliance;
1-45 (2) capitation and provider payment rates that ensure
1-46 the cost-effective provision of quality health care;
1-47 (3) a requirement that the managed care organization
1-48 provide ready access to a person who assists recipients in
1-49 resolving issues relating to enrollment, plan administration,
1-50 education and training, access to services, and grievance
1-51 procedures;
1-52 (4) a requirement that the managed care organization
1-53 provide ready access to a person who assists providers in resolving
1-54 issues relating to payment, plan administration, education and
1-55 training, and grievance procedures;
1-56 (5) a requirement that the managed care organization
1-57 provide information and referral about the availability of
1-58 educational, social, and other community services that could
1-59 benefit a recipient;
1-60 (6) procedures for recipient outreach and education;
1-61 (7) a requirement that the managed care organization
1-62 make payment to a physician or provider for health care services
1-63 rendered to a recipient under a managed care plan not later than
1-64 the 45th day after the date a claim for payment is received with
2-1 documentation reasonably necessary for the managed care
2-2 organization to process the claim, or within a period, not to
2-3 exceed 60 days, specified by a written agreement between the
2-4 physician or provider and the managed care organization;
2-5 (8) a requirement that the commission, on the date of
2-6 a recipient's enrollment in a managed care plan issued by the
2-7 managed care organization, inform the organization of the
2-8 recipient's Medicaid recertification date; [and]
2-9 (9) a requirement that the managed care organization
2-10 comply with Section 533.006 as a condition of contract retention
2-11 and renewal; and
2-12 (10) a requirement that the managed care organization
2-13 provide the information required by Section 533.012 and otherwise
2-14 comply and cooperate with the commission's office of investigations
2-15 and enforcement.
2-16 SECTION 3. This Act takes effect September 1, 1999.
2-17 SECTION 4. The change in law made by this Act applies only
2-18 to a contract with a managed care organization entered into or
2-19 renewed on or after the effective date of this Act. A contract
2-20 entered into before the effective date of this Act is governed by
2-21 the law as it existed immediately before the effective date of this
2-22 Act, and that law is continued in effect for that purpose.
2-23 SECTION 5. The importance of this legislation and the
2-24 crowded condition of the calendars in both houses create an
2-25 emergency and an imperative public necessity that the
2-26 constitutional rule requiring bills to be read on three several
2-27 days in each house be suspended, and this rule is hereby suspended.
2-28 * * * * *