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).