84R11113 KFF-F

By: Garcia S.B. No. 1475

A BILL TO BE ENTITLED

AN ACT

relating to establishing an enhanced Medicaid managed care consumer support system.

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

SECTION 1. Subchapter B, Chapter 531, Government Code, is amended by adding Section 531.02132 to read as follows:

Sec. 531.02132. MEDICAID MANAGED CARE CONSUMER SUPPORT SYSTEM. (a) In this section, "enhanced system" means the Medicaid managed care consumer support system established by this section.

(b) The commission shall develop and establish an enhanced Medicaid managed care consumer support system consisting of a connected network of Medicaid managed care consumer support staff that is organized for the purpose of:

(1) educating Medicaid managed care recipients regarding:

(A) the concept of managed care;

(B) their rights under the Medicaid program, including grievance and appeal procedures; and

(C) how to advocate for themselves; and

(2) ultimately reducing the need for the internal appeals process of managed care organizations under the Medicaid program and for the Medicaid fair hearing process.

(c) The enhanced system must be designed to:

(1) be fully integrated with:

(A) the unit of the commission's office of the ombudsman responsible for providing the Medicaid Managed Care Helpline; and

(B) the office of the state long-term care ombudsman established under Chapter 101, Human Resources Code;

(2) include specialized capacity to meet the needs of all current and future Medicaid managed care recipients, including children receiving dental benefits and other recipients receiving benefits, under the:

(A) STAR Medicaid managed care program;

(B) STAR + PLUS Medicaid managed care program, including the Texas Dual Eligibles Integrated Care Demonstration Project provided under that program;

(C) STAR Kids managed care program established under Section 533.00253;

(D) STAR Health program; and

(E) child health plan established under Chapter 62, Health and Safety Code;

(3) include adequate staffing to support timely access to the enhanced system by all Medicaid managed care recipients in this state;

(4) ensure that the enhanced system staff:

(A) receives sufficient training, including training in the Medicare program for the purpose of assisting recipients who are dually eligible for Medicare and Medicaid, and has sufficient authority to resolve barriers experienced by recipients to health care and long-term services and supports;

(B) has the capacity to actively refer recipients to community-based organizations that can assist the recipients with the appeals process, including preparation for appeals and representation, as needed, whether the appeal is an internal appeal provided by a managed care organization or an appeal under the Medicaid fair hearing process;

(C) is locally accessible through satellite offices in a network of regional hub sites with at least one office in each Medicaid managed care service area, patterned after similar satellite offices operated by:

(i) the following partners in the Health Information, Counseling, and Advocacy Program:

(a) area agencies on aging; and

(b) aging and disability resource centers established under the Aging and Disability Resource Center initiative funded in part by the federal Administration on Aging and the Centers for Medicare and Medicaid Services; and

(ii) the office of the state long-term care ombudsman; and

(D) has ready access to the upper management of the commission and managed care organizations participating in the Medicaid program that will enable staff to promptly identify and resolve both recipient-specific and systemic issues; and

(5) include an advisory interface with nonprofit, community-based organizations that routinely assist recipients in resolving Medicaid managed care issues, for purposes of timely identifying recurring, systemic issues.

(d) Enhanced system staff may include the employees of appropriate health and human services agencies and the staff of appropriate community partners under contract with the state.

(e) The commission's office of the ombudsman, or other division of the commission in which the enhanced system is established, must be:

(1) sufficiently independent from other aspects of the Medicaid managed care system and have no financial interest in the outcome of recipient grievances; and

(2) empowered to represent the best interests of recipients in problem resolution.

(f) The enhanced system staff shall collect and maintain statistical information on a Medicaid managed care service area basis and publish quarterly reports that:

(1) track the incidence of complaints and barriers identified by the enhanced system;

(2) identify trends and recurring barriers in delivery and access to Medicaid managed care in this state; and

(3) identify other problems occurring in the Medicaid managed care system.

SECTION 2. Not later than January 1, 2016, the Health and Human Services Commission shall establish the Medicaid managed care consumer support system required under Section 531.02132, Government Code, as added by this Act.

SECTION 3. If before implementing any provision of this Act a state agency determines that a waiver or authorization from a federal agency is necessary for implementation of that provision, the agency affected by the provision shall request the waiver or authorization and may delay implementing that provision until the waiver or authorization is granted.

SECTION 4. 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, 2015.