78R7271 CLG-F
By: Lindsay S.B. No. 1185
A BILL TO BE ENTITLED
AN ACT
relating to standards, guidelines, and contractual provisions of
Medicaid managed care plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Article 1.61, Insurance Code, is amended to read
as follows:
Art. 1.61. MEDICAID MANAGED CARE ORGANIZATIONS
[ORGANIZATION: FISCAL SOLVENCY AND COMPLAINT SYSTEM GUIDELINES].
(a) In this article, "managed care organization" and "managed care
plan" have the meanings assigned by Section 533.001, Government
Code. A managed care organization or managed care plan that serves
Medicaid clients is subject to Chapter 843 of this code and any
other state law applicable to a managed care organization or
managed care plan, except to the extent of a conflict with Chapter
32, Human Resources Code, or other state or federal law applicable
to the state Medicaid program or the administration of Medicaid
funds in this state.
(b) In consultation [conjunction] with the [Texas Department
of] Health and Human Services Commission, the department, as
necessary or appropriate, shall establish performance, operation,
quality of care, and financial [fiscal solvency] standards,
standards relating to access to good quality health care services,
and complaint system guidelines that are specific to [for] managed
care organizations that serve Medicaid clients. In establishing
standards under this article, the department shall:
(1) include measures to monitor and assess the
performance of managed care organizations relating to the health
status and outcome of care for Medicaid clients; and
(2) ensure that:
(A) to the extent possible, each Medicaid client
can receive good quality health care services in the client's local
community under a managed care plan provided through a managed care
organization delivery network;
(B) managed care plans are provided through
managed care organization delivery networks with adequate capacity
to provide good quality health care services to Medicaid clients;
(C) managed care plans provide timely access and
appropriate referrals for specialty care; and
(D) managed care plans fully reimburse all
reasonable charges of out-of-network physicians and providers for
health care services provided to the plans' Medicaid clients.
(c) Complaint system guidelines [Guidelines] must require
that information regarding a managed care organization's complaint
process be made available in an appropriate communication format to
each Medicaid client when the person enrolls in the program.
SECTION 2. Section 533.005, Government Code, is amended to
read as follows:
Sec. 533.005. REQUIRED CONTRACT PROVISIONS. 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 for network
physicians and providers 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 and with the Texas
Department of Insurance in connection with all audits,
[commission's office of] investigations, and enforcement actions;
and
(11) a requirement that the managed care organization
fully reimburse all reasonable charges of an out-of-network
physician or provider that provides health care services to a
recipient.
SECTION 3. Sections 12.017 and 533.047, Health and Safety
Code, are repealed.
SECTION 4. The change in law made by this Act to Section
533.005, Government Code, applies only to a contract with a managed
care organization entered into or renewed on or after the effective
date of this Act. A contract entered into before the effective date
of this Act is governed by the law as it existed immediately before
the effective date of this Act, and that law is continued in effect
for that purpose.
SECTION 5. This Act takes effect September 1, 2003.