80R8954 CLG-F
 
  By: Noriega H.B. No. 2584
 
 
 
   
 
 
A BILL TO BE ENTITLED
AN ACT
relating to payment for health care services provided to a Medicaid
recipient under a managed care plan; providing a penalty.
       BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
       SECTION 1.  Section 533.005(a), Government Code, is amended
to read as follows:
       (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 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
30th [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;
             (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 inspector
general;
             (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;
             (12)  if the commission finds that a managed care
organization has violated Subdivision (11), a requirement that the
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;
             (13)  a requirement that the organization use advanced
practice nurses in addition to physicians as primary care providers
to increase the availability of primary care providers in the
organization's provider network;
             (14)  a requirement that the managed care organization
reimburse a federally qualified health center or rural health
clinic for health care services provided to a recipient outside of
regular business hours, including on a weekend day or holiday, at a
rate that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician; [and]
             (15)  a requirement that the managed care organization
develop, implement, and maintain a system for tracking and
resolving all provider appeals related to claims payment, including
a process that will require:
                   (A)  a tracking mechanism to document the status
and final disposition of each provider's claims payment appeal;
                   (B)  the contracting with physicians who are not
network providers and who are of the same or related specialty as
the appealing physician to resolve claims disputes related to
denial on the basis of medical necessity that remain unresolved
subsequent to a provider appeal; and
                   (C)  the determination of the physician resolving
the dispute to be binding on the managed care organization and
provider; and
             (16)  a provision prohibiting a managed care
organization that has paid a claim to a physician or provider for
health care services rendered to a recipient under a managed care
plan from charging the payment back to the physician or provider,
including by withholding payment for other services, unless an
independent audit determines that an error made by the physician or
provider caused an overpayment by the managed care organization in
an amount that equals at least five percent of the amount of the
entire payment made.
       SECTION 2.  Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.0052 to read as follows:
       Sec. 533.0052.  PENALTY FOR VIOLATION OF CERTAIN REQUIRED
CONTRACT PROVISIONS. Notwithstanding any other law, if a clean
claim, as defined by Section 843.336, Insurance Code, submitted to
a managed care organization is payable and the managed care
organization does not make a determination that the claim is
payable and pay the claim on or before the date required by the
contract under Section 533.005(a)(7), the managed care
organization is subject to an administrative penalty imposed by the
commission in the amount of $1,000 for each day that the claim
remains unpaid.
       SECTION 3.  Sections 533.007(i) and (j), Government Code,
are amended to read as follows:
       (i)  Not later than the 30th [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 pay the additional reimbursement[,] not
later than the 60th [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 60th [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 60th [90th] day
after the date the provider filed the complaint until the date the
entire amount of the additional reimbursement is paid.
       SECTION 4.  The changes in law made by this Act apply only to
a contract with a managed care organization entered into or renewed
on or after the effective date of this Act. A contract with a
managed care organization 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, 2007.