86R13476 KLA-D

By: Muñoz, Jr. H.B. No. 2357

A BILL TO BE ENTITLED

AN ACT

relating to utilization reviews and care coordination under the Medicaid managed care program.

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

SECTION 1. Section 533.00281, Government Code, is amended by adding Subsection (f) to read as follows:

(f) Nothing in this section precludes the commission from conducting a utilization review for managed care organizations participating in another Medicaid managed care program or with respect to other service types within a Medicaid managed care program.

SECTION 2. Subchapter A, Chapter 533, Government Code, is amended by adding Section 533.00294 to read as follows:

Sec. 533.00294. CARE COORDINATION BENEFITS. (a) In this section:

(1) "Care coordination" means assisting recipients to develop a plan of care, including a service plan, that meets the recipient's needs and coordinating the provision of Medicaid benefits in a manner that is consistent with the plan of care. The term is synonymous with "case management," "service coordination," and "service management."

(2) "Medicaid managed care organization" means a managed care organization that contracts with the commission under this chapter to provide health care services to recipients.

(b) The commission shall streamline and clarify the provision of care coordination benefits across Medicaid programs and services for recipients receiving benefits under a managed care delivery model. In streamlining and clarifying the provision of care coordination benefits, the commission shall, at a minimum, include requirements in Medicaid managed care contracts that are designed to:

(1) subject to Subsection (c), establish a process for determining and designating a single person as the primary person responsible for a recipient's care coordination;

(2) evaluate and eliminate duplicative services intended to achieve recipient care coordination, including care coordination or related benefits provided:

(A) by a Medicaid managed care organization;

(B) by a recipient's medical or health home;

(C) through a disease management program provided by a Medicaid managed care organization;

(D) by a provider of targeted case management and psychiatric rehabilitation services; or

(E) through a program of case management for high-risk pregnant women and high-risk children established under Section 22.0031, Human Resources Code;

(3) evaluate and, if the commission determines it appropriate, modify the capitation rate paid to Medicaid managed care organizations to account for the provision of care coordination benefits by a person not affiliated with the organization; and

(4) establish and use a consistent set of terms for care coordination provided under a managed care delivery model.

(c) In establishing a process under Subsection (b)(1), the commission shall ensure that:

(1) for a recipient who receives targeted case management and psychiatric rehabilitation services through a local mental health authority, the default entity to act as the primary entity responsible for the recipient's care coordination under Subsection (b)(1) is the local mental health authority;

(2) for a recipient who receives targeted case management and psychiatric rehabilitation services through a Medicaid managed care organization network provider, the default person to act as the primary person responsible for the recipient's care coordination under Subsection (b)(1) is the network provider; and

(3) for recipients other than those described by Subdivision (1) or (2), the process includes an evaluation designed to identify the provider that would best and most cost-effectively meet the care coordination needs of a recipient.

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, 2019.