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Amend CSHB 2292 (Senate committee printing) by adding the
following appropriately numbered SECTIONS to Article 2 of the bill
and renumbering subsequent SECTIONS of the bill accordingly:
SECTION _____. Section 533.005, Government Code, is amended
to read as follows:
Sec. 533.005. REQUIRED CONTRACT PROVISIONS. (a) A
contract between a managed care organization and the commission for
the organization to provide health care services to recipients must
contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation and provider payment rates that ensure
the cost-effective provision of quality health care;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than the
45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to exceed
60 days, specified by a written agreement between the physician or
provider and the managed care organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the managed
care organization, inform the organization of the recipient's
Medicaid certification date;
(9) a requirement that the managed care organization
comply with Section 533.006 as a condition of contract retention
and renewal; [and]
(10) a requirement that the managed care organization
provide the information required by Section 533.012 and otherwise
comply and cooperate with the commission's office of investigations
and enforcement;
(11) a requirement that the managed care
organization's usages of out-of-network providers or groups of
out-of-network providers may not exceed limits for those usages
relating to total inpatient admissions, total outpatient services,
and emergency room admissions determined by the commission; and
(12) a requirement that a managed care organization
reimburse an out-of-network provider for health care services at a
rate that is equal to the allowable rate for those services, as
determined under Sections 32.028 and 32.0281, Human Resources Code,
unless a different out-of-network payment rate is negotiated with
the out-of-network provider.
(b) In accordance with Subsection (a)(12), all
post-stabilization services provided by an out-of-network provider
must be reimbursed by the managed care organization at the
allowable rate for those services until the managed care
organization arranges for the timely transfer of the recipient, as
determined by the recipient's attending physician, to a provider in
the network or until an out-of-network payment rate is negotiated
with the out-of-network provider. A managed care organization may
not refuse to reimburse an out-of-network provider for emergency or
post-stabilization services provided as a result of the managed
care organization's failure to arrange for and authorize a timely
transfer of a recipient.
SECTION _____. Section 533.007, Government Code, is amended
by adding Subsections (g), (h), (i), (j), and (k) to read as
follows:
(g) To ensure appropriate access to an adequate provider
network, each managed care organization that contracts with the
commission to provide health care services to recipients in a
health care service region shall submit to the commission, in the
format and manner prescribed by the commission, a report detailing
the number, type, and scope of services provided by out-of-network
providers to recipients enrolled in a managed care plan provided by
the managed care organization. If, as determined by the
commission, a managed care organization exceeds maximum limits
established by the commission for out-of-network access to health
care services, or if, based on an investigation by the commission of
a provider complaint regarding reimbursement, the commission
determines that a managed care organization did not reimburse an
out-of-network provider based on a reasonable reimbursement
methodology, the commission shall initiate a corrective action plan
requiring the managed care organization to maintain an adequate
provider network, provide reimbursement to support that network,
and educate recipients enrolled in managed care plans provided by
the managed care organization regarding the proper use of the
provider network under the plan.
(h) The corrective action plan required by Subsection (g)
must include at least one of the following elements:
(1) a requirement that reimbursements paid by the
managed care organization to out-of-network providers for a health
care service provided to a recipient enrolled in a managed care plan
provided by the managed care organization equal the allowable rate
for the service, as determined under Sections 32.028 and 32.0281,
Human Resources Code, for all health care services provided during
the period:
(A) the managed care organization is not in
compliance with the utilization benchmarks determined by the
commission; or
(B) the managed care organization is not
reimbursing out-of-network providers based on a reasonable
methodology, as determined by the commission;
(2) an immediate freeze on the enrollment of
additional recipients in a managed care plan provided by the
managed care organization, to continue until the commission
determines that the provider network under the managed care plan
can adequately meet the needs of additional recipients; and
(3) other actions the commission determines are
necessary to ensure that recipients enrolled in a managed care plan
provided by the managed care organization have access to
appropriate health care services and that providers are properly
reimbursed for providing medically necessary health care services
to those recipients.
(i) Not later than the 60th day after the date a provider
files a complaint with the commission regarding reimbursement for
or overuse of out-of-network providers by a managed care
organization, the commission shall provide to the provider a report
regarding the conclusions of the commission's investigation. The
report must include:
(1) a description of the corrective action, if any,
required of the managed care organization that was the subject of
the complaint; and
(2) if applicable, a conclusion regarding the amount
of reimbursement owed to an out-of-network provider.
(j) If, after an investigation, the commission determines
that additional reimbursement is owed to a provider, the managed
care organization shall, not later than the 90th day after the date
the provider filed the complaint, pay the additional reimbursement
or provide to the provider a reimbursement payment plan under which
the managed care organization must pay the entire amount of the
additional reimbursement not later than the 120th day after the
date the provider filed the complaint. If the managed care
organization does not pay the entire amount of the additional
reimbursement on or before the 90th day after the date the provider
filed the complaint, the commission may require the managed care
organization to pay interest on the unpaid amount. If required by
the commission, interest accrues at a rate of 18 percent simple
interest per year on the unpaid amount from the 90th day after the
date the provider filed the complaint until the date the entire
amount of the additional reimbursement is paid.
(k) The commission shall pursue any appropriate remedy
authorized in the contract between the managed care organization
and the commission if the managed care organization fails to comply
with a corrective action plan under Subsection (g).