BILL ANALYSIS |
C.S.H.B. 3982 |
By: Raymond |
Human Services |
Committee Report (Substituted) |
BACKGROUND AND PURPOSE
Interested parties contend that the Medicaid process is laden with inefficiencies that discourage many healthcare providers from participating in the program, thus hindering Medicaid recipients' ability to receive adequate care. C.S.H.B. 3982 seeks to address these issues by clarifying contract requirements, providing certain protections to providers, and providing for a certain pilot program and study.
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CRIMINAL JUSTICE IMPACT
It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.
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RULEMAKING AUTHORITY
It is the committee's opinion that rulemaking authority is expressly granted to the executive commissioner of the Health and Human Services Commission in SECTION 1 of this bill.
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ANALYSIS
C.S.H.B. 3982 amends the Government Code to remove the requirement that the Health and Human Services Commission (HHSC), if it is cost-effective and feasible, implement an electronic visit verification system to electronically verify and document, through a telephone or computer-based system, basic information relating to the delivery of Medicaid acute nursing services. The bill instead requires HHSC, in accordance with federal law, to implement an electronic visit verification system to electronically verify through a telephone, global positioning, or computer-based system that personal care services or attendant care services provided to Medicaid recipients are provided to recipients in accordance with a prior authorization or plan of care. The bill requires the electronic visit verification system to allow verification of only specified information relating to the delivery of Medicaid services. The bill requires HHSC to establish minimum requirements for third-party entities seeking to provide electronic visit verification system services to health care providers providing Medicaid services and to certify that a third-party entity complies with those minimum requirements before the entity may provide electronic visit verification system services to a health care provider. The bill requires HHSC to inform each Medicaid recipient who receives personal care services or attendant care services that the health care provider providing the services and the recipient are each required to comply with the electronic visit verification system. The bill require a managed care organization that contracts with HHSC to provide health care services to Medicaid recipients who receive personal care services or attendant care services to also inform recipients enrolled in a managed care plan offered by the organization of those requirements.
C.S.H.B. 3982 requires the executive commissioner of HHSC, in implementing the electronic visit verification system, to adopt compliance standards for health care providers. The bill requires HHSC, in implementing the system, to ensure that the information required to be reported by health care providers is standardized across managed care organizations that contract with HHSC to provide health care services to Medicaid recipients and across HHSC programs and to ensure that time frames for the maintenance of electronic visit verification data by health care providers align with claims payment time frames. The bill requires the executive commissioner, in establishing the compliance standards, to consider the administrative burdens placed on health care providers required to comply with the standards and the benefits of using emerging technologies for ensuring compliance. The bill sets out certain requirements for a health care provider that provides personal care services or attendant care services to Medicaid recipients. The bill authorizes HHSC to recognize a health care provider's proprietary electronic visit verification system as complying with the bill's electronic visit verification system provisions and, contingent on HHSC making certain determinations regarding the system, to allow the health care provider to use that system for a period determined by HHSC. The bill prohibits HHSC or a managed care organization that contracts with HHSC to provide health care services to Medicaid recipients from paying a reimbursement claim for personal care services or attendant care services provided to a recipient unless the information from the electronic visit verification system corresponds with the information contained in the claim and the services were provided consistent with a prior authorization or plan of care. The bill subjects a previously paid claim to retrospective review and recoupment if unverified. The bill requires HHSC to create a stakeholder work group comprised of representatives of affected health care providers, managed care organizations, and Medicaid recipients and to periodically solicit from that work group input regarding the ongoing operation of the electronic visit verification system. The bill authorizes the executive commissioner to adopt rules necessary to implement the bill's provisions relating to the electronic visit verification system and reimbursement of certain related claims.
C.S.H.B. 3982 grants a provider that contracts with a managed care organization under contract with HHSC to provide health care services to Medicaid recipients immunity from liability for the good faith provision of services under the provider's contract with the organization that were provided with prior authorization if the office of inspector general of HHSC makes a determination to recoup an overpayment or debt from the organization. This bill provision expressly does not limit the office's authority to recoup an overpayment or debt from a provider that is owed by the provider as a result of the provider's failure to comply with applicable law or a contract provision, notwithstanding any prior authorization for a service provided, or apply to an action brought under Human Resources Code provisions relating to Medicaid fraud prevention. The bill requires HHSC to provide to a provider that is a hospital written notice of any proposed recoupment of an overpayment or debt and any damages or penalties relating to a proposed recoupment of an overpayment or debt arising out of a fraud or abuse investigation not later than the 90th day before the date the overpayment or debt that is the subject of the notice must be paid.
C.S.H.B. 3982 removes the specification that the Medicaid managed care program to which statutory provisions relating to a utilization review process for Medicaid managed care organizations apply is the STAR + PLUS Medicaid managed care program, with certain exceptions, and includes a financial audit process as an aspect of the utilization review process the office of contract management of HHSC is required to establish for managed care organizations participating in the Medicaid managed care program. The bill revises the purposes for which the office must use the utilization review and financial audit process and requires the office, in addition to conducting certain reviews, to use the utilization review and financial audit process to review each managed care organization participating in the Medicaid managed care program at least once every five years. The bill replaces a provision prohibiting a service provider who contracts with a managed care organization from being held liable for the good faith provision of services based on an authorization from the organization if a utilization review results in a determination to recoup money from the organization with a provision applying the bill's provisions relating to provider immunity from liability for a managed care organization overpayment or debt if a utilization or financial audit review results in such a determination.
C.S.H.B. 3982 requires a Medicaid managed care contract between a managed care organization and HHSC to contain capitation rates that ensure access to quality health care; a requirement that the organization demonstrate to HHSC that, within each provider category and service delivery area designated by HHSC, the organization pays at least 98 percent of claims for health care services rendered to a Medicaid recipient under a managed care plan that are received with documentation reasonably necessary to process the claims by certain prescribed deadlines; a requirement that the organization establish an electronic process for use by providers in submitting claims documentation that complies with requirements for an electronic process applicable to a provider protection plan and allows providers to submit additional documentation on a claim when the organization determines the claim was not submitted with documentation reasonably necessary to process the claim; and a requirement that the organization make available on the organization's website summary information that is accessible to the public regarding the number of provider appeals and the disposition of those appeals, organized by provider and service types. The bill removes as a required Medicaid managed care contract provision a provision that prohibits a managed care organization from implementing significant, nonnegotiated, across-the-board provider reimbursement rate reductions, subject to certain exceptions, and revises certain other required Medicaid managed care contract provisions relating to claims payments, limits on the use of out-of-network providers or groups of out‑of‑network providers, a system for tracking and resolving provider appeals, the provision of services in the South Texas service region, a requirement regarding a report on the sufficiency of a managed care organization's provider network, and a requirement regarding the accessibility of health care services through a managed care organization's provider network. The bill requires a Medicaid managed care contract to provide that, if the managed care organization has an ownership interest in a health care provider in the organization's provider network, the organization must include in the provider network at least one other health care provider of the same type in which the organization does not have an ownership interest, unless the organization is able to demonstrate to HHSC that the provider included in the provider network is the only provider located in an area that meets requirements established by HHSC relating to the time and distance a recipient is expected to travel to receive services, and that the organization may not give preference in authorizing referrals to the provider in which the organization has an ownership interest as compared to other providers of the same or similar services participating in the organization's provider network.
C.S.H.B. 3982 requires HHSC, except as otherwise provided by a settlement agreement filed with and approved by a court, to require a managed care organization that contracts with HHSC to provide health care services to Medicaid recipients to approve or pend a request from a provider of acute care inpatient services for prior authorization for specified services or equipment not later than 72 hours after receiving the request to allow for a safe and timely discharge of a patient from an inpatient facility; ensure that the provider has an opportunity to engage in direct discussions with the organization regarding the appropriate level of post-acute care while a request for prior authorization is pending; contact, notify, and negotiate with the provider before approving a prior authorization request for personal care services or attendant care services with an expiration date different from the expiration date requested by the provider; submit to a provider of personal care services or attendant care services any change to a recipient's service plan relating to those services not later than the fifth day before the date the plan is to be effective for purposes of giving the provider time to initiate the change and the recipient an opportunity to agree to the change, unless the organization is changing the plan in order to meet an emerging need for personal care services or attendant care services; include on subsequent prior authorization requests approved with a retroactive effective date an expiration date that takes into account the date the service change was implemented by the provider; and provide complete electronic access to prior authorizations through the organization's electronic process as required by the bill. The bill clarifies and revises certain requirements for the provider protection plan developed and implemented by HHSC under the Medicaid managed care program.
C.S.H.B. 3982 prohibits a managed care organization that contracts with HHSC to provide health care services to Medicaid recipients from implementing a significant, as determined by HHSC in accordance with the bill's provisions, across-the-board provider reimbursement rate reduction unless the organization receives prior approval from HHSC and, at least 90 days before the proposed rate reduction is to take effect, provides HHSC and affected providers with written notice of the proposed rate reduction and makes a good faith effort to negotiate the reduction with the affected providers. The bill establishes that an across-the-board provider reimbursement rate reduction is considered to have received prior approval of HHSC unless HHSC issues a written statement of disapproval not later than the 45th day after the date HHSC receives notice of the proposed rate reduction from the organization. The bill requires a managed care organization that proposes an across-the-board provider reimbursement rate reduction in accordance with these provisions and subsequently rejects alternative rate reductions suggested by an affected provider to provide the provider with written notice of that rejection, including an explanation of the grounds for the rejection, before implementing any rate reduction. The bill's provisions restricting certain reimbursement rate reductions expressly do not apply to rate reductions that are implemented because of reductions to the Medicaid fee schedule or cost containment initiatives that are specifically directed by the legislature and implemented by HHSC. The bill repeals a provision establishing that a provider reimbursement rate reduction is considered to have received prior approval of HHSC unless HHSC issues a written statement of disapproval not later than the 45th day after the date HHSC receives notice of the proposed rate reduction from the managed care organization.
C.S.H.B. 3982 requires HHSC to establish standards that govern the processes, criteria, and guidelines under which managed care organizations determine the medical necessity of a health care service covered by Medicaid. The bill requires HHSC, in establishing those standards, to ensure that each Medicaid recipient has equal access in scope and duration to the same covered health care services for which the recipient is eligible regardless of the managed care organization with which the recipient is enrolled; provide managed care organizations with flexibility to approve covered medically necessary services for recipients that may not be within prescribed criteria and guidelines; require managed care organizations to make available to providers all criteria and guidelines used to determine medical necessity through an Internet portal accessible by the providers; ensure that managed care organizations consistently apply the same medical necessity criteria and guidelines for the approval of services and in retrospective utilization reviews; and ensure that managed care organizations include in any service or prior authorization denial specific information about the medical necessity criteria or guidelines that were not met. The bill's provisions relating to standards for determining medical necessity expressly do not apply to or affect the authority of HHSC to determine medical necessity for home and community-based services provided under the STAR + PLUS Medicaid managed care program or to conduct utilization reviews of those services.
C.S.H.B. 3982 revises certain HHSC requirements regarding the administration of Medicaid managed care contracts by requiring HHSC to decrease certain administrative burdens by allowing managed care organizations to provide updated contact information in addition to updated address information directly to HHSC, specifying that the state system in which HHSC corrects that information is the state eligibility system, removing the requirement that HHSC decrease certain administrative burdens by reviewing the appropriateness of primary care case management requirements in the admission and clinical criteria process, and requiring the portal through which providers in any managed care organization's provider network may submit acute care services and long-term services and supports claims to comply with certain provider protection plan requirements regarding an electronic process. The bill specifies certain circumstances under which HHSC is required to allow a Medicaid recipient who is enrolled in a managed care plan under the Medicaid managed care program to disenroll from that plan and enroll in another managed care plan at any time for cause in accordance with federal law and removes the requirement that HHSC allow such a Medicaid recipient do so once for any reason after certain periods. The bill requires HHSC to implement a process by which HHSC verifies that a recipient is permitted to disenroll from one managed care plan offered by a managed care organization and enroll in another plan, including a plan offered by another managed care organization, before the disenrollment occurs.
C.S.H.B. 3982 requires a managed care organization under contract with HHSC to provide health care services to Medicaid recipients to ensure that persons providing care coordination services through the organization coordinate with hospital discharge planners, who must notify the organization of an inpatient admission of a recipient, to facilitate the timely discharge of the recipient to the appropriate level of care and minimize potentially preventable readmissions. The bill requires the office of inspector general of HHSC, if the office intends to conduct a utilization review audit of a provider of services under a Medicaid managed care delivery model, to inform both the provider and the managed care organization with which the provider contracts of any applicable criteria and guidelines the office will use in the course of the audit. The bill requires the office to ensure that each person conducting such a utilization review audit has experience and training regarding the operations of managed care organizations. The bill prohibits the office, as the result of a utilization review audit, from recouping an overpayment or debt from a provider that contracts with a managed care organization based on a determination that a provided service was not medically necessary unless the office uses the same criteria and guidelines that were used by the organization in its determination of medical necessity for the service and verifies with the organization and the provider that the provider, at the time the service was delivered, had reasonable notice of the criteria and guidelines used by the organization to determine medical necessity and did not follow the criteria and guidelines used by the organization to determine medical necessity that were in effect at the time the service was delivered. The bill applies the provider protections from liability for a managed care organization's overpayment or debt under the bill's provisions to a utilization review audit conducted by the office that results in a determination to recoup money from a managed care organization that contracts with HHSC to provide health care services to Medicaid recipients.
C.S.H.B. 3982 requires HHSC to ensure that managed care organizations that contract with HHSC to provide health care services to Medicaid recipients have policies regarding treatment and services related to a recipient's inpatient hospital stay, including a behavioral health hospital stay, that is less than 48 hours. The bill requires HHSC, for purposes of that requirement, to ensure that the organization specifies certain criteria that warrant reimbursement of services related to the stay as either inpatient hospital services or outpatient hospital services, account for medical necessity based on recognized inpatient criteria, the severity of any psychological disorder, and the judgment of the treating physician or other provider, and do not permit classification of services as either inpatient or outpatient hospital services for purposes of reimbursement based solely on the duration of the stay; provides an opportunity for direct discussions regarding the medical necessity of a recipient's inpatient hospital admission; and reviews documentation in a recipient's medical record that supports the medical necessity of the inpatient hospital stay at the time of admission for reimbursement of services related to the stay.
C.S.H.B. 3982 requires the Medicaid waiver program or ICF-IID program that serves an individual with an intellectual or developmental disability who is receiving services under such a program and who requires medically necessary acute care services or long-term services and supports that are not available to the individual through the redesigned services delivery model to pay the cost of the service. The bill authorizes such a program to submit to HHSC a claim for reimbursement for the cost of that service and authorizes HHSC, if HHSC determines that a claim paid by HHSC should have been covered and paid by a managed care organization that contracts with HHSC, to recoup the entire cost of that claim from the organization.
C.S.H.B. 3982 includes a temporary provision set to expire January 1, 2019, to require HHSC to develop and implement a pilot program in up to three urban service delivery areas that is designed to increase the incidence of ambulance service providers directing recipients of Medicaid managed care program services who are experiencing a behavioral health emergency to more appropriate health care providers for treatment of behavioral health illnesses and, not later than December 1, 2018, to develop a report analyzing any cost savings and other benefits realized as a result of the pilot program and deliver the report to the governor, lieutenant governor, speaker of the house of representatives, and chairs of the standing legislative committees having primary jurisdiction over Medicaid.
C.S.H.B. 3982 includes a temporary provision set to expire December 31, 2017, to require HHSC, not later than November 30, 2017, to conduct a study to determine the cost-effectiveness and feasibility of providing prescription drug benefits to recipients of acute care services under Medicaid by pharmacies with a Class A pharmacy license through a single statewide prescription drug administrator that adheres to a pharmacy services reimbursement methodology that uses the most accurate and transparent ingredient drug pricing model, the National Average Drug Acquisition Cost published by the Centers for Medicare and Medicaid Services as the drug acquisition cost, and the most recent dispensing fee study contracted for by HHSC to set an accurate and transparent professional dispensing fee as defined by specified Texas Administrative Code provisions. The bill sets out certain requirements for HHSC in conducting the study and establishes that its provisions relating to the study expressly do not apply to the provision of prescription drug benefits by long-term care facility pharmacies and specialty pharmacies and expressly prohibits HHSC from considering such provision by such pharmacies. The bill requires HHSC to combine the study with any other similar study required to be conducted by HHSC and requires HHSC, not later than November 30, 2017, to report its findings to the legislature.
C.S.H.B. 3982 repeals Section 533.005(a-3), Government Code.
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EFFECTIVE DATE
September 1, 2017.
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COMPARISON OF ORIGINAL AND SUBSTITUTE
While C.S.H.B. 3982 may differ from the original in minor or nonsubstantive ways, the following comparison is organized and formatted in a manner that indicates the substantial differences between the introduced and committee substitute versions of the bill.
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