86R7735 LED-D

By: Rose H.B. No. 3548

A BILL TO BE ENTITLED

AN ACT

relating to managing Medicaid recipient and provider complaints and appeals.

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 COMPLAINTS AND APPEALS MANAGEMENT SYSTEM. (a) In this section:

(1) "Appeal" includes all types of protests and objections, including a request for a fair hearing and an appeal through a Medicaid managed care organization's internal appeals process.

(2) "Complaint" includes a telephone call, request for assistance, inquiry, concern, grievance, and other requests for information related to Medicaid from a recipient or provider.

(3) "Office" means the commission's office of inspector general.

(b) The commission shall operate a system to manage Medicaid recipient and provider complaints and appeals submitted to the commission, the office, or a managed care organization that contracts with the commission to provide health care services to Medicaid recipients. The system must:

(1) provide the commission and the office with immediate access to the complaint or appeal and, if applicable, a denial of the complaint or appeal; and

(2) associate each complaint and appeal with the recipient's or provider's Medicaid identification number.

(c) The commission shall ensure any Medicaid provider may submit a complaint or appeal through the system, including a provider that does not contract with a managed care organization but treats a recipient enrolled in a managed care plan offered by the managed care organization.

(d) A managed care organization shall regularly update the system with:

(1) the status of a complaint or appeal;

(2) whether the organization determined a complaint was valid or invalid and an explanation of that determination;

(3) steps the organization is taking to resolve the complaint or appeal;

(4) the final resolution of the complaint or appeal; and

(5) if the organization denies a complaint or appeal:

(A) the justification for denying the complaint or appeal; and

(B) instructions for requesting an appeal of the denial.

(e) The commission and the office shall develop a policy to determine, with regard to a complaint or appeal submitted to the commission or the office, whether to:

(1) direct the complaint or appeal to a managed care organization to be resolved; or

(2) investigate the complaint or appeal internally.

(f) The policy described by Subsection (e) must require the commission and the office to consider whether a recipient or provider wishes to remain anonymous.

(g) To ensure complaints and appeals are managed consistently, the commission shall ensure the definitions of a complaint and an appeal are consistent among:

(1) commission employees and divisions within the commission;

(2) managed care organizations that contract with the commission to provide health care services to recipients;

(3) the office; and

(4) the commission's office of the ombudsman.

SECTION 2. Not later than January 1, 2020, the Health and Human Services Commission shall develop the complaint and appeal management system as required by 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, 2019.