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A BILL TO BE ENTITLED
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AN ACT
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relating to reimbursement for certain ambulance services provided |
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to persons enrolled in the Medicaid managed care program and the |
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inclusion of certain ambulance service providers in the health care |
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provider networks of Medicaid managed care organizations. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Section 533.0067 to read as follows: |
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Sec. 533.0067. AMBULANCE SERVICE PROVIDERS. Subject to |
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Section 32.047, Human Resources Code, and any other provision that |
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excludes a provider based on the provider's conduct that |
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constitutes fraud, waste, or abuse, but notwithstanding any other |
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law, the commission shall require that each managed care |
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organization that contracts with the commission under any Medicaid |
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managed care model or arrangement to provide health care services |
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to recipients in a region: |
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(1) include in the organization's provider network |
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each person providing ambulance services in the region who: |
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(A) agrees to comply with the terms and |
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conditions of the organization; |
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(B) agrees to abide by the standards of care |
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required by the organization; and |
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(C) has the credentials required by the |
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organization; and |
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(2) negotiate in good faith with each ambulance |
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service provider identified in Subdivision (1), including |
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negotiating in good faith to reimburse the provider at a rate that |
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is equal to at least 95 percent of the allowable rate for ambulance |
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services under Section 32.028, Human Resources Code. |
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SECTION 2. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Section 533.01316 to read as follows: |
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Sec. 533.01316. REIMBURSEMENT FOR CERTAIN AMBULANCE |
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SERVICES. (a) This section applies with respect to a recipient of |
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medical assistance who is an enrollee in a managed care plan under |
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any Medicaid managed care model or arrangement. |
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(b) The commission shall ensure that a person providing |
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ambulance services to a Medicaid managed care enrollee is |
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reimbursed for nonemergency services provided to the enrollee at a |
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rate that is equal to: |
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(1) 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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services are provided by a provider who is not in the applicable |
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Medicaid managed care plan's service area or network of providers; |
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or |
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(2) at least 95 percent of the allowable rate for those |
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services as determined under Section 32.028, Human Resources Code, |
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if the services are provided by a provider who is in the applicable |
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Medicaid managed care plan's service area but who is not in the |
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plan's network of providers. |
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(c) The commission shall ensure that a person providing |
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ambulance services to a Medicaid managed care enrollee is |
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reimbursed for emergency services provided to the enrollee 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, regardless |
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of whether the services are provided by a provider in the applicable |
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Medicaid managed care plan's area of service or network of |
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providers. |
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SECTION 3. (a) The Health and Human Services Commission |
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shall, in a contract between the commission and a Medicaid managed |
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care organization under Chapter 533, Government Code, that is |
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entered into or renewed on or after the effective date of this Act, |
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require that the managed care organization comply with Sections |
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533.0067 and 533.01316, Government Code, as added by this Act. |
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(b) The Health and Human Services Commission shall seek to |
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amend each contract entered into with a Medicaid managed care |
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organization under Chapter 533, Government Code, before the |
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effective date of this Act to require those managed care |
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organizations to comply with Sections 533.0067 and 533.01316, |
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Government Code, as added by this Act. To the extent of a conflict |
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between Sections 533.0067 and 533.01316, Government Code, as added |
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by this Act, and a provision of a contract with a managed care |
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organization entered into before the effective date of this Act, |
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the contract provision prevails. |
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SECTION 4. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 5. This Act takes effect September 1, 2013. |