SB 1105, Hse 2nd Rdg, Amnd #1

(1) On page 4, line 17, strike "of coverage or" and substitute ", partial denial, reduction, or termination of coverage or denial of".

(2) On page 4, strike lines 21 and 22 and substitute the following:

(2) for the recipient:

(A) a clear and easy-to-understand explanation of the reason for the decision, including a clear explanation of the medical basis, applying the policy or accepted standard of medical practice to the recipient's particular medical circumstances;

(B) a copy of the information sent to the provider; and

(C) an educational component that includes a description of the recipient's rights and an explanation of the process related to appeals and Medicaid fair hearings; and

(3) On page 4, line 24, strike "denial" and substitute "decision".

(4) On page 5, line 11, between "documentation" and "and", insert ";".

(5) On page 5, strike lines 12 and 13.

(6) On page 5, strike lines 17-23 and substitute the following:

(A) to the provider:

(i) using the provider's preferred method of communication, to the extent practicable using existing resources; and

(ii) as applicable, through an electronic notification on an Internet portal; and

(B) to the recipient using the recipient's preferred method of communication, to the extent practicable using existing resources.

(7) On page 6, line 21, strike "necessary or".

(8) On page 6, line 22, between "supporting" and "documentation", insert "or other".

(9) On page 7, lines 5 and 6, strike "or recipient".

(10) On page 8, strike lines 2 and 3 and substitute the following:

Care Advisory Committee described by [~~established under~~] Section 533.00254.

(11) On page 8, line 5, strike "(f), (g), and (h)" and substitute "(k), (l), and (m)".

(12) On page 8, line 6, strike "(f)" and substitute "(k)".

(13) On page 8, line 16, strike "(g)" and substitute "(l)".

(14) On page 8, line 18, strike "(f)" and substitute "(k)".

(15) On page 8, line 19, strike "(h) Subsections (f) and (g)" and substitute the following "(m) Subsections (k) and (l)".

(16) On page 8, line 22, strike "533.00282, 533.00283, 533.00284" and substitute "533.002821, 533.00283".

(17) On page 8, line 24, strike "533.00282" and substitute "533.002821".

(18) On page 8, line 24, between "PROCEDURES." and "Section", insert "(a)".

(19) On page 8, following line 27, add the following:

(b) In addition to the requirements of Section 533.005, a contract between a Medicaid managed care organization and the commission must require that the organization review and issue determinations on prior authorization requests with respect to a recipient who is hospitalized at the time of the request according to the following time frames:

(1) within one business day after receiving the request, except as provided by Subdivisions (2) and (3);

(2) within 72 hours after receiving the request if the request is submitted by a provider of acute care inpatient services for services or equipment necessary to discharge the recipient from an inpatient facility; or

(3) within one hour after receiving the request if the request is related to poststabilization care or a life-threatening condition.

(c) The executive commissioner by rule shall establish the time frame for a Medicaid managed care organization to review and issue determinations on prior authorization requests with respect to a recipient who is not hospitalized at the time of the request.

(20) On page 9, line 2, between "organization" and "shall", insert ", in consultation with the organization's provider advisory group required by contract,".

(21) Strike page 9, line 21, through page 11, line 4.

(22) On page 13, line 1, strike "533.00284" and substitute "533.002821".

(23) On page 13, line 2, strike "applies" and substitute "and Section 533.005, Government Code, as amended by this Act, apply".

(24) On page 13, line 6, strike "The" and substitute "As soon as practicable after the effective date of this Act but not later than September 1, 2020, the".

(25) On page 13, strike line 10 and substitute the following:

Section 533.002821, Government Code, as added by this Act, and Section 533.005, Government Code, as amended by this Act.

(26) Add the following appropriately numbered SECTIONS to the bill and renumber the SECTIONS of the bill accordingly:

SECTION ____. Subchapter A, Chapter 533, Government Code, is amended by adding Section 533.00254 to read as follows:

Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE. (a) The STAR Kids Managed Care Advisory Committee established by the executive commissioner under Section 531.012 shall:

(1) advise the commission on the operation of the STAR Kids managed care program under Section 533.00253; and

(2) make recommendations for improvements to that program.

(b) On September 1, 2023:

(1) the advisory committee is abolished; and

(2) this section expires.

SECTION ____. Section 533.005, Government Code, is amended by adding Subsection (o) to read as follows:

(o) In addition to the requirements of Subsection (a), a contract between a Medicaid managed care organization and the commission must contain a requirement that the organization review and issue determinations with respect to a patient who is hospitalized at the time of the determination according to the time frames required by Section 533.002821.