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A BILL TO BE ENTITLED
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AN ACT
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relating to a utilization review process for managed care |
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organizations participating in the STAR + PLUS Medicaid managed |
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care program. |
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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 533.00281 to read as follows: |
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Sec. 533.00281. UTILIZATION REVIEW FOR STAR + PLUS MEDICAID |
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MANAGED CARE ORGANIZATIONS. (a) The commission's office of |
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contract management shall establish an annual utilization review |
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process for managed care organizations participating in the STAR + |
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PLUS Medicaid managed care program. The commission shall determine |
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the topics to be examined in the review process, except that the |
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review process must include a thorough investigation of each |
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managed care organization's procedures for determining whether a |
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recipient should be enrolled in the STAR + PLUS home and |
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community-based services and supports (HCBS) program, including |
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the conduct of functional assessments for that purpose and records |
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relating to those assessments. |
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(b) The office of contract management shall use the |
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utilization review process to review each fiscal year: |
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(1) every managed care organization participating in |
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the STAR + PLUS Medicaid managed care program; or |
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(2) only the managed care organizations that, using a |
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risk-based assessment process, the office determines have a higher |
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likelihood of inappropriate client placement in the STAR + PLUS |
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home and community-based services and supports (HCBS) program. |
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(c) Notwithstanding Subsection (b), during the state fiscal |
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biennium ending August 31, 2015, the office of contract management |
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shall use the utilization review process to review every managed |
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care organization participating in the STAR + PLUS Medicaid managed |
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care program. This subsection expires September 1, 2016. |
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(d) In conjunction with the commission's office of contract |
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management, the commission shall provide a report to the standing |
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committees of the senate and house of representatives with |
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jurisdiction over the Medicaid program not later than December 1 of |
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each year. The report must: |
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(1) summarize the results of the utilization reviews |
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conducted under this section during the preceding fiscal year; |
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(2) provide analysis of errors committed by each |
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reviewed managed care organization; and |
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(3) extrapolate those findings and make |
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recommendations for improving the efficiency of the program. |
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(e) If a utilization review conducted under this section |
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results in a determination to recoup money from a managed care |
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organization, a service provider who contracts with the managed |
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care organization may not be held liable for the good faith |
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provision of services based on an authorization from the managed |
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care organization. |
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SECTION 2. The Health and Human Services Commission shall |
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provide the first report required by Subsection (d), Section |
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533.00281, Government Code, as added by this Act, not later than |
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December 1, 2014. |
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SECTION 3. 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 4. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2013. |