SB 1207, Hse 2nd Rdg, Amnd #1

In determining eligibility for that program, the commission shall average contractual or seasonal income over the period the income is intended to cover or the period covered by the contract, as indicated by the individual earning the income.

(3) On page 2, between lines 14 and 15, insert the following:

(f) The commission shall develop and make available to the public a standard screening tool that uses clear, basic criteria to provide information about whether a child may meet the financial and disability-related eligibility requirements for the buy-in program under Subsection (a)(2).

(4) On page 2, line 22, strike "of coverage or" and substitute ", partial denial, reduction, or termination of coverage or denial of".

(____) On page 2, line 23, between "service" and "includes" insert "must be mailed 10 business days in advance and postmarked, and"

(5) On page 2, strike lines 26-27 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, an explanation of the process related to appeals and Medicaid fair hearings, and a description of the role of an external medical review; and

(6) On page 3, line 2, strike "denial" and substitute "decision".

(7) Strike page 3, line 22, through page 4, line 1, 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.

(8) On page 5, strike lines 2-3 and substitute the following:

(9) On page 6, line 15, after "reviews." insert "To the maximum extent possible, the procedure shall reduce administrative burden on providers and the submission of duplicative information or documents."

(10) On page 6, line 19, between "procedure" and "for", insert "and time frame".

(11) On page 6, strike lines 20-21 and substitute the following:

(1) identify an appeal that requires an expedited resolution; and

(2) resolve the review of the appeal within a specified period.

(12) On page 7, between lines 14 and 15, insert the following appropriately lettered subsection:

(____) To the extent money is appropriated for this purpose, the commission shall publish data regarding prior authorizations reviewed by the external medical reviewer, including the rate of prior authorization denials overturned by the external medical reviewer and additional information the commission and the external medical reviewer determine appropriate.

(13) Strike page 9, lines 11-13 and substitute the following:

commission shall inform the representative in writing about:

(1) the options under this section for placing the child on an interest list; and

(2) the process for applying for the Medicaid buy-in program for children with disabilities implemented under Section 531.02444, and the availability of the disability determination assessment for that program described by Section 531.02444(e).".

(14) On page 9, line 15, between "PROGRAM" and "REASSESSMENTS", insert "ASSESSMENTS AND".

(15) On page 9, lines 17-18, strike "annual medical necessity determination reassessment" and substitute "initial assessment or annual reassessment of medical necessity".

(16) On page 9, line 27, between "the" and "reassessment", insert "initial assessment or".

(17) On page 10, line 4, between "the" and "reassessment", insert "initial assessment or".

(18) On page 10, line 5, strike "to dispute the reassessment" and substitute "to request to dispute the results".

(19) On page 10, line 9, strike "a" and substitute "an initial assessment or".

(20) On page 11, line 1, between "(3)" and "as", insert "in consultation with the STAR Kids Managed Care Advisory Committee described by Section 533.00254 and".

(____) On page 11, line 4, strike "the STAR Kids Screening and Assessment Instrument or the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) measures." and insert "COIIN Project".

(21) On page 11, line 21, between "533.00253" and the underlined semicolon, insert ", if the help line was operational during the applicable state fiscal quarter".

(22) On page 12, line 6, strike "and (h)" and substitute "(h), (i), and (j)".

(____) On page 12, line 27, between "(MCDP)" and "waiver" insert "the deaf blind multiple disabilities (DBMD)".

(____) On page 12, line 27, strike "program" and insert "programs".

(23) On page 13, line 7, between "program" and the underlined semicolon, insert ", including complying with requirements related to the continuation of benefits during an internal appeal, a Medicaid fair hearing, or a review conducted by an external medical reviewer".

(____) On page 13, after line 22, insert "(g) The commission shall assess the utilization of the escalation help line and determine the feasibility of expanding the help line to additional Medicaid programs that serve medically fragile children by September 1, 2020."

(24) On page 13, between lines 22 and 23, insert the following:

(i) Subsections (f), (g), and (h) and this subsection expire September 1, 2024.

(j) Not later than September 1, 2020, the commission shall evaluate risk-adjustment methods used for recipients under the STAR Kids managed care program, including recipients with private health benefit plan coverage, in the quality-based payment program under Chapter 536 to ensure that higher-volume providers are not unfairly penalized. During the evaluation period, the commission may exclude recipients under the STAR Kids managed care program, including recipients with private health benefit plan coverage, from the potentially preventable event rate methodology. This subsection expires January 1, 2021.

(25) On page 13, line 25, between the comma and "and", insert "533.002841,".

(26) On page 15, line 8, strike "The" and substitute "In consultation with the state Medicaid managed care advisory committee, the".

(27) On page 15, line 9, strike "42 C.F.R. Section 438.210".

(28) On page 15, line 14, immediately following the underlined period, insert the following:

The time frame must be longer than the time frame specified by Subsection (b)(2)(A) within which a Medicaid managed care organization must issue a determination on a prior authorization request.

(____) On page 15, line 16, between "organization" and "shall", insert ", in consultation with the organization's provider advisory group required by contract."

(29) On page 16, line 2, add subsection "(c) The commission shall periodically review managed care organizations to ensure compliance with Subsection (a) ."

(30) On page 16, line 9, between "(a)" and "In", insert "In consultation with the state Medicaid managed care advisory committee, the commission shall establish a uniform process and timeline for Medicaid managed care organizations to reconsider an adverse determination on a prior authorization request that resulted solely from the submission of insufficient or inadequate documentation.".

(31) On page 16, line 12, strike "establish a process for" and substitute "implement the process and timeline."

(33) On page 16, line 16, strike "for reconsidering an adverse determination on a prior authorization request under this section" and substitute "and timeline".

(34) On page 16, lines 18-19, strike ", not later than the seventh business day following the date of the determination,".

(35) On page 16, line 27, immediately following the underlined semicolon, insert "and".

(36) On page 17, strike lines 1-4 and substitute the following:

(3) require the Medicaid managed care organization to amend the determination on the prior authorization

(37) On page 17, line 5, strike the underlined semicolon and substitute an underlined period.

(38) On page 17, strike lines 6-7.

(39) On page 17, line 12, between "process" and "for", insert "and timeline".

(40) On page 17, line 13, strike "does" and substitute "do".

(41) On page 17, line 17, strike "independent review organization" and substitute "external medical reviewer".

(42) On page 17, between lines 19 and 20, insert the following:

Sec. 533.002841. MAXIMUM PERIOD FOR PRIOR AUTHORIZATION DECISION; ACCESS TO CARE. The time frames prescribed by the utilization review and prior authorization procedures described by Section 533.00282 and the timeline for reconsidering an adverse determination on a prior authorization described by Section 533.00284 together may not exceed the time frame for a decision under federally prescribed time frames. It is the intent of the legislature that these provisions allow sufficient time to provide necessary documentation and avoid unnecessary denials without delaying access to care.

(43) On page 18, line 1, between "organizations" and the underlined comma, insert "and in consultation with the STAR Kids Managed Care Advisory Committee described by Section 533.00254".

(44) On page 18, strike lines 12-27 and reletter subsequent subsections and any cross-references to those subsections accordingly.

(45) On page 21, line 24, strike "The" and substitute "As soon as practicable after the effective date of this Act but not later than September 1, 2020, the".

(____) Insert new "Sec.____. ELIGIBLITY OF CERTAIN CHILDREN FOR MEDICALLY DEPENDENT CHILDREN PROGRAM AND DEAF BLIND MULTIPLE DISABILITIES. (a) Notwithstanding any other law and to the extent allowed by federal law, when determining eligibility for the medically dependent children (MDCP) and deaf blind multiple disabilities (DBMD) waiver programs or a "Money Follows the Person" demonstration project, the commission shall consider if a child:

(1) is diagnosed as having a condition included in the list of compassionate allowances conditions published by the United States Social Security Administration; or

(2) receives Medicaid hospice or palliative care services.

(b) If a child is determined eligible for the MDCP or DBMD waiver programs under Subsection (a), enrollment in the MDCP or DBMD waiver programs is contingent on the availability of a waiver slot. If a slot is not immediately available, the commission shall place the child on the interest list for the MDCP or DBMD waiver programs in the first position on the list."

(____) Section 533.00253 is amended by amending Subsection (c)(4) to read as follows: (4) provide a care needs assessment for a recipient [that is comprehensive, holistic, consumer-directed, evidence-based, and takes into consideration social and medical issues, for purposes of prioritizing the recipient's needs that threaten independent living]