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A BILL TO BE ENTITLED
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AN ACT
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relating to payment for health care services provided to a Medicaid |
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recipient under a managed care plan; providing a penalty. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 533.005(a), Government Code, is amended |
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to read as follows: |
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(a) A contract between a managed care organization and the |
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commission for the organization to provide health care services to |
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recipients must contain: |
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(1) procedures to ensure accountability to the state |
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for the provision of health care services, including procedures for |
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financial reporting, quality assurance, utilization review, and |
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assurance of contract and subcontract compliance; |
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(2) capitation rates that ensure the cost-effective |
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provision of quality health care; |
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(3) a requirement that the managed care organization |
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provide ready access to a person who assists recipients in |
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resolving issues relating to enrollment, plan administration, |
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education and training, access to services, and grievance |
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procedures; |
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(4) a requirement that the managed care organization |
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provide ready access to a person who assists providers in resolving |
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issues relating to payment, plan administration, education and |
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training, and grievance procedures; |
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(5) a requirement that the managed care organization |
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provide information and referral about the availability of |
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educational, social, and other community services that could |
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benefit a recipient; |
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(6) procedures for recipient outreach and education; |
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(7) a requirement that the managed care organization |
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make payment to a physician or provider for health care services |
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rendered to a recipient under a managed care plan not later than the |
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30th [45th] day after the date a claim for payment is received with |
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documentation reasonably necessary for the managed care |
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organization to process the claim[, or within a period, not to
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exceed 60 days, specified by a written agreement between the
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physician or provider and the managed care organization]; |
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(8) a requirement that the commission, on the date of a |
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recipient's enrollment in a managed care plan issued by the managed |
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care organization, inform the organization of the recipient's |
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Medicaid certification date; |
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(9) a requirement that the managed care organization |
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comply with Section 533.006 as a condition of contract retention |
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and renewal; |
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(10) a requirement that the managed care organization |
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provide the information required by Section 533.012 and otherwise |
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comply and cooperate with the commission's office of inspector |
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general; |
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(11) a requirement that the managed care |
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organization's usages of out-of-network providers or groups of |
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out-of-network providers may not exceed limits for those usages |
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relating to total inpatient admissions, total outpatient services, |
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and emergency room admissions determined by the commission; |
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(12) if the commission finds that a managed care |
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organization has violated Subdivision (11), a requirement that the |
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managed care organization reimburse an out-of-network provider for |
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health care services at a rate that is equal to the allowable rate |
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for those services, as determined under Sections 32.028 and |
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32.0281, Human Resources Code; |
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(13) a requirement that the organization use advanced |
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practice nurses in addition to physicians as primary care providers |
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to increase the availability of primary care providers in the |
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organization's provider network; |
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(14) a requirement that the managed care organization |
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reimburse a federally qualified health center or rural health |
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clinic for health care services provided to a recipient outside of |
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regular business hours, including on a weekend day or holiday, at a |
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rate that is equal to the allowable rate for those services as |
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determined under Section 32.028, Human Resources Code, if the |
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recipient does not have a referral from the recipient's primary |
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care physician; [and] |
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(15) a requirement that the managed care organization |
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develop, implement, and maintain a system for tracking and |
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resolving all provider appeals related to claims payment, including |
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a process that will require: |
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(A) a tracking mechanism to document the status |
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and final disposition of each provider's claims payment appeal; |
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(B) the contracting with physicians who are not |
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network providers and who are of the same or related specialty as |
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the appealing physician to resolve claims disputes related to |
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denial on the basis of medical necessity that remain unresolved |
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subsequent to a provider appeal; and |
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(C) the determination of the physician resolving |
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the dispute to be binding on the managed care organization and |
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provider; and |
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(16) a provision prohibiting a managed care |
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organization that has paid a claim to a physician or provider for |
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health care services rendered to a recipient under a managed care |
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plan from charging the payment back to the physician or provider, |
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including by withholding payment for other services, unless an |
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independent audit determines that an error made by the physician or |
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provider caused an overpayment by the managed care organization in |
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an amount that equals at least five percent of the amount of the |
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entire payment made. |
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SECTION 2. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Section 533.0052 to read as follows: |
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Sec. 533.0052. PENALTY FOR VIOLATION OF CERTAIN REQUIRED |
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CONTRACT PROVISIONS. Notwithstanding any other law, if a clean |
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claim, as defined by Section 843.336, Insurance Code, submitted to |
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a managed care organization is payable and the managed care |
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organization does not make a determination that the claim is |
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payable and pay the claim on or before the date required by the |
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contract under Section 533.005(a)(7), the managed care |
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organization is subject to an administrative penalty imposed by the |
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commission in the amount of $1,000 for each day that the claim |
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remains unpaid. |
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SECTION 3. Sections 533.007(i) and (j), Government Code, |
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are amended to read as follows: |
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(i) Not later than the 30th [60th] day after the date a |
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provider files a complaint with the commission regarding |
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reimbursement for or overuse of out-of-network providers by a |
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managed care organization, the commission shall provide to the |
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provider a report regarding the conclusions of the commission's |
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investigation. The report must include: |
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(1) a description of the corrective action, if any, |
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required of the managed care organization that was the subject of |
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the complaint; and |
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(2) if applicable, a conclusion regarding the amount |
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of reimbursement owed to an out-of-network provider. |
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(j) If, after an investigation, the commission determines |
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that additional reimbursement is owed to a provider, the managed |
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care organization shall pay the additional reimbursement[,] not |
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later than the 60th [90th] day after the date the provider filed the |
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complaint[, pay the additional reimbursement or provide to the
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provider a reimbursement payment plan under which the managed care
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organization must pay the entire amount of the additional
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reimbursement not later than the 120th day after the date the
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provider filed the complaint]. If the managed care organization |
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does not pay the entire amount of the additional reimbursement on or |
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before the 60th [90th] day after the date the provider filed the |
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complaint, the commission may require the managed care organization |
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to pay interest on the unpaid amount. If required by the |
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commission, interest accrues at a rate of 18 percent simple |
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interest per year on the unpaid amount from the 60th [90th] day |
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after the date the provider filed the complaint until the date the |
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entire amount of the additional reimbursement is paid. |
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SECTION 4. The changes in law made by this Act apply only to |
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a contract with a managed care organization entered into or renewed |
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on or after the effective date of this Act. A contract with a |
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managed care organization entered into before the effective date of |
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this Act is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 5. This Act takes effect September 1, 2007. |