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A BILL TO BE ENTITLED
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AN ACT
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relating to decreasing administrative burdens of Medicaid managed |
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care for the state, the managed care organizations, and providers |
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under managed care networks. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 533.0071, Government Code, is amended to |
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read as follows: |
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Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The |
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commission shall make every effort to improve the administration of |
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contracts with managed care organizations. To improve the |
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administration of these contracts, the commission shall: |
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(1) ensure that the commission has appropriate |
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expertise and qualified staff to effectively manage contracts with |
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managed care organizations under the Medicaid managed care program; |
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(2) evaluate options for Medicaid payment recovery |
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from managed care organizations if the enrollee dies or is |
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incarcerated or if an enrollee is enrolled in more than one state |
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program or is covered by another liable third party insurer; |
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(3) maximize Medicaid payment recovery options by |
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contracting with private vendors to assist in the recovery of |
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capitation payments, payments from other liable third parties, and |
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other payments made to managed care organizations with respect to |
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enrollees who leave the managed care program; |
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(4) decrease the administrative burdens of managed |
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care for the state, the managed care organizations, and the |
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providers under managed care networks to the extent that those |
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changes are compatible with state law and existing Medicaid managed |
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care contracts, including decreasing those burdens by: |
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(A) where possible, decreasing the duplication |
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of administrative reporting requirements for the managed care |
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organizations, such as requirements for the submission of encounter |
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data, quality reports, historically underutilized business |
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reports, and claims payment summary reports; |
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(B) allowing managed care organizations to |
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provide updated address information directly to the commission for |
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correction in the state system; |
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(C) promoting consistency and uniformity among |
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managed care organization policies, including policies relating to |
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the [preauthorization process,] lengths of hospital stays, filing |
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deadlines, levels of care, and case management services; |
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(D) developing uniform efficiency standards and |
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requirements for managed care organizations for the submission and |
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tracking of preauthorization requests for services provided under |
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the Medicaid program [reviewing the appropriateness of primary
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care case management requirements in the admission and clinical
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criteria process, such as requirements relating to including a
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separate cover sheet for all communications, submitting
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handwritten communications instead of electronic or typed review
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processes, and admitting patients listed on separate
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notifications]; [and] |
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(E) providing a [single] portal through which |
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providers in any managed care organization's provider network may: |
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(i) submit electronic claims, prior |
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authorization requests, claims appeals, and reconsiderations, |
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clinical data, and other documentation that the managed care |
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organization requests for prior authorization and claims |
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processing; and |
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(ii) obtain electronic remittance advice, |
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explanation of benefits statements, and other standardized |
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reports; [and] |
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(F) requiring the use of standardized |
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application processes and forms for prompt credentialing of |
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providers in a managed care organization's network; and |
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(G) promoting prompt and accurate adjudication |
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of claims through: |
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(i) provider education on the proper |
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submission of clean claims and on appeals; |
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(ii) acceptance of uniform forms, including |
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the Centers for Medicare and Medicaid Services Forms 1500 and |
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UB-92, through an electronic portal; and |
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(iii) the establishment of standards for |
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claims payments in accordance with a provider's contract; |
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(5) reserve the right to amend the managed care |
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organization's process for resolving provider appeals of denials |
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based on medical necessity to include an independent review process |
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established by the commission for final determination of these |
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disputes; |
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(6) monitor and evaluate a managed care organization's |
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compliance with contractual requirements regarding: |
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(A) the reduction of administrative burdens for |
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network providers; and |
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(B) complaints regarding claims adjudication or |
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payment; |
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(7) measure the rates of retention by managed care |
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organizations of significant traditional providers; and |
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(8) develop adequate and clearly defined provider |
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network standards that are specific to provider type and that |
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ensure choice among multiple providers to the greatest extent |
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possible. |
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SECTION 2. 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 3. This Act takes effect September 1, 2013. |