81R23323 ALB-F

By: Davis of Harris, Guillen H.B. No. 3231

A BILL TO BE ENTITLED

AN ACT

relating to clarification of legislative intent regarding enrollment of newborns in Medicaid managed care plans and validating related acts and decisions.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. CLARIFICATION OF INTENT OF LEGISLATION. (a) In 1993, this state began the transition to managed care for certain recipients of Medicaid services with pilot programs in Travis County and the tri-county area of Jefferson, Chambers, and Galveston Counties. Since that time, Medicaid managed care has been implemented in six additional service areas consisting of territory in Bexar, Tarrant, Lubbock, Harris, Dallas, El Paso, and Nueces Counties. Total enrollment in Medicaid managed care is currently more than 2.5 million.

(b) In 1999, the legislature enacted H.B. No. 2896 (Chapter 1447, Acts of the 76th Legislature, Regular Session, 1999) and H.B. No. 2641 (Chapter 1460, Acts of the 76th Legislature, Regular Session, 1999). Both bills included identical amendments to Section 533.0075, Government Code, as originally enacted in 1997, and addressed enrollment of Medicaid recipients in managed care programs.

(c) The 1999 amendments added Subdivisions (4), (5), and (6) to Section 533.0075, Government Code. Subdivision (4) required the Health and Human Services Commission to develop and implement an expedited process for determining eligibility for and enrolling pregnant women and newborns in managed care plans. Subdivision (5) required the commission to ensure immediate access to prenatal services and newborn care for pregnant women and newborns enrolled in managed care plans. Subdivision (6) required the commission to temporarily assign newborns to the traditional fee-for-services component of Medicaid for a period not to exceed 60 days or the date on which the newborn's eligibility determination is completed.

(d) The legislature, in enacting Subdivisions (4), (5), and (6) of Section 533.0075, Government Code, understood that the Health and Human Services Commission had enrolled newborns in Medicaid managed care plans and intended that the commission would continue to enroll newborns in Medicaid managed care plans. In particular, the legislature intended that, under the express terms of Subdivision (4), the commission would expedite the enrollment of newborns whose Medicaid eligibility is known at the time of birth into managed care plans to ensure access to care and to avoid delays in payment for services. The legislature has appropriated state and federal funds to the commission for the payment of capitated rates to managed care organizations that have contracted with the commission to provide this coverage to newborns.

(e) Subdivision (6) of Section 533.0075, Government Code, was intended to address delays in payment that health care providers in Medicaid managed care pilot areas experienced at the time of the subdivision's enactment for services provided to a newborn who was ultimately enrolled in Medicaid but whose Medicaid eligibility was not determined at the time of birth. The legislature, in enacting Subdivision (6), did not intend to nullify or supersede Subdivisions (4) and (5) or prohibit enrollment of newborns in a Medicaid managed care plan. Rather, the legislature intended to ensure that a newborn whose Medicaid eligibility was not known or not determined at birth would receive medically necessary care after the newborn's birth but before completion of the Medicaid eligibility determination process, and that a provider who provides care for the newborn receives reimbursement for the provider's services.

(f) The legislature understands that the delays in payment that prompted the enactment of Subdivision (6) have largely been resolved by more efficient and timely enrollment processes and that providers who supply services to newborns do not experience delays or denials of payment solely because of a delay in Medicaid eligibility determination. Accordingly, the legislature finds that the purposes of Subdivision (6) have been fulfilled and the requirements of that provision are no longer necessary to ensure appropriate payment of providers of services to newborns.

SECTION 2. CLARIFYING AMENDMENT. Section 533.0075, Government Code, is amended to read as follows:

Sec. 533.0075. RECIPIENT ENROLLMENT. The commission shall:

(1) encourage recipients to choose appropriate managed care plans and primary health care providers by:

(A) providing initial information to recipients and providers in a region about the need for recipients to choose plans and providers not later than the 90th day before the date on which the commission plans to begin to provide health care services to recipients in that region through managed care;

(B) providing follow-up information before assignment of plans and providers and after assignment, if necessary, to recipients who delay in choosing plans and providers; and

(C) allowing plans and providers to provide information to recipients or engage in marketing activities under marketing guidelines established by the commission under Section 533.008 after the commission approves the information or activities;

(2) consider the following factors in assigning managed care plans and primary health care providers to recipients who fail to choose plans and providers:

(A) the importance of maintaining existing provider-patient and physician-patient relationships, including relationships with specialists, public health clinics, and community health centers;

(B) to the extent possible, the need to assign family members to the same providers and plans; and

(C) geographic convenience of plans and providers for recipients;

(3) retain responsibility for enrollment and disenrollment of recipients in managed care plans, except that the commission may delegate the responsibility to an independent contractor who receives no form of payment from, and has no financial ties to, any managed care organization;

(4) develop and implement an expedited process for determining eligibility for and enrolling pregnant women and newborn infants in managed care plans; and

(5) ensure immediate access to prenatal services and newborn care for pregnant women and newborn infants enrolled in managed care plans, including ensuring that a pregnant woman may obtain an appointment with an obstetrical care provider for an initial maternity evaluation not later than the 30th day after the date the woman applies for Medicaid[; and

[(6) temporarily assign Medicaid-eligible newborn infants to the traditional fee-for-service component of the state Medicaid program for a period not to exceed the earlier of:

[(A) 60 days; or

[(B) the date on which the Texas Department of Human Services has completed the newborn's Medicaid eligibility determination, including assignment of the newborn's Medicaid eligibility number].

SECTION 3. VALIDATION OF ACTS OR DECISIONS BY HEALTH AND HUMAN SERVICES COMMISSION. (a) A governmental act taken or a decision made by the Health and Human Services Commission before the effective date of this Act to enroll a newborn infant in a managed care organization under the terms of a contract for managed care services authorized by Section 533.0075, Government Code, is conclusively presumed, as of the date the act or decision occurred, to be valid and to have occurred in accordance with all applicable law.

(b) This section does not apply to:

(1) an act or decision that was void at the time the act or decision occurred;

(2) an act or decision that violates the terms of federal law or a federal waiver; or

(3) an act or decision that, under a statute of this state or the United States, was a misdemeanor or felony at the time the act or decision occurred.

SECTION 4. EFFECTIVE DATE. This Act takes effect immediately if it receives a vote of two-thirds of all the members elected to each house, as provided by Section 39, Article III, Texas Constitution. If this Act does not receive the vote necessary for immediate effect, this Act takes effect September 1, 2009.