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A BILL TO BE ENTITLED
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AN ACT
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relating to the administration and operation of Medicaid, including |
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Medicaid managed care. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 531.001, Government Code, is amended by |
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adding Subdivision (4-c) to read as follows: |
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(4-c) "Medicaid managed care organization" means a |
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managed care organization as defined by Section 533.001 that |
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contracts with the commission under Chapter 533 to provide health |
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care services to Medicaid recipients. |
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SECTION 2. Subchapter B, Chapter 531, Government Code, is |
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amended by adding Sections 531.02112, 531.021182, 531.02131, |
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531.02142, 531.024162, 531.024163, 531.0319, and 531.0511 to read |
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as follows: |
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Sec. 531.02112. POLICIES FOR IMPLEMENTING CHANGES TO |
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PAYMENT RATES UNDER MEDICAID. (a) The commission shall adopt |
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policies related to the determination of fees, charges, and rates |
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for payments under Medicaid to ensure, to the greatest extent |
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possible, that changes to a fee schedule are implemented in a way |
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that minimizes administrative complexity, financial uncertainty, |
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and retroactive adjustments for providers. |
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(b) In adopting policies under Subsection (a), the |
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commission shall: |
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(1) develop a process for individuals and entities |
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that deliver services under the Medicaid managed care program to |
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provide oral or written input on the proposed policies; and |
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(2) ensure that managed care organizations and the |
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entity serving as the state's Medicaid claims administrator under |
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the Medicaid fee-for-service delivery model are provided a period |
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of not less than 45 days before the effective date of a final fee |
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schedule change to make any necessary administrative or systems |
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adjustments to implement the change. |
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(c) This section does not apply to changes to the fees, |
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charges, or rates for payments made to a nursing facility or to |
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capitation rates paid to a Medicaid managed care organization. |
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Sec. 531.021182. USE OF NATIONAL PROVIDER IDENTIFIER |
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NUMBER. (a) In this section, "national provider identifier |
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number" means the national provider identifier number required |
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under Section 1128J(e), Social Security Act (42 U.S.C. Section |
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1320a-7k(e)). |
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(b) The commission shall transition from using a |
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state-issued provider identifier number to using only a national |
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provider identifier number in accordance with this section. |
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(c) The commission shall implement a Medicaid provider |
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management and enrollment system and, following that |
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implementation, use only a national provider identifier number to |
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enroll a provider in Medicaid. |
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(d) The commission shall implement a modernized claims |
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processing system and, following that implementation, use only a |
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national provider identifier number to process claims for and |
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authorize Medicaid services. |
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Sec. 531.02131. GRIEVANCES RELATED TO MEDICAID. (a) The |
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commission shall adopt a definition of "grievance" related to |
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Medicaid and ensure the definition is consistent among divisions |
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within the commission to ensure all grievances are managed |
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consistently. |
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(b) The commission shall standardize Medicaid grievance |
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data reporting and tracking among divisions within the commission. |
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(c) The commission shall implement a no-wrong-door system |
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for Medicaid grievances reported to the commission. |
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(d) The commission shall establish a procedure for |
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expedited resolution of a grievance related to Medicaid that allows |
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the commission to: |
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(1) identify a grievance related to a Medicaid access |
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to care issue that is urgent and requires an expedited resolution; |
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and |
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(2) resolve the grievance within a specified period. |
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(e) The commission shall verify grievance data reported by a |
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Medicaid managed care organization. |
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(f) The commission shall: |
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(1) aggregate Medicaid recipient and provider |
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grievance data to provide a comprehensive data set of grievances; |
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and |
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(2) make the aggregated data available to the |
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legislature and the public in a manner that does not allow for the |
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identification of a particular recipient or provider. |
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Sec. 531.02142. PUBLIC ACCESS TO CERTAIN MEDICAID DATA. |
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(a) To the extent permitted by federal law, the commission in |
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consultation and collaboration with the appropriate advisory |
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committees related to Medicaid shall make available to the public |
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on the commission's Internet website in an easy-to-read format data |
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relating to the quality of health care received by Medicaid |
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recipients and the health outcomes of those recipients. Data made |
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available to the public under this section must be made available in |
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a manner that does not identify or allow for the identification of |
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individual recipients. |
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(b) In performing its duties under this section, the |
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commission may collaborate with an institution of higher education |
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or another state agency with experience in analyzing and producing |
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public use data. |
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Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID |
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COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS. |
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(a) The commission shall ensure that notice sent by the commission |
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or a Medicaid managed care organization to a Medicaid recipient or |
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provider regarding the denial of coverage or prior authorization |
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for a service includes: |
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(1) information required by federal and state law and |
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applicable regulations; |
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(2) for the recipient, a clear and easy-to-understand |
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explanation of the reason for the denial; and |
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(3) for the provider, a thorough and detailed clinical |
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explanation of the reason for the denial, including, as applicable, |
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information required under Subsection (b). |
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(b) The commission or a Medicaid managed care organization |
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that receives from a provider a coverage or prior authorization |
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request that contains insufficient or inadequate documentation to |
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approve the request shall issue a notice to the provider and the |
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Medicaid recipient on whose behalf the request was submitted. The |
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notice issued under this subsection must: |
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(1) include a section specifically for the provider |
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that contains: |
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(A) a clear and specific list and description of |
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the documentation necessary for the commission or organization to |
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make a final determination on the request; |
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(B) the applicable timeline, based on the |
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requested service, for the provider to submit the documentation and |
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a description of the reconsideration process described by Section |
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533.00284, if applicable; and |
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(C) information on the manner through which a |
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provider may contact a Medicaid managed care organization or other |
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entity as required by Section 531.024163; and |
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(2) be sent to the provider: |
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(A) using the provider's preferred method of |
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contact most recently provided to the commission or the Medicaid |
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managed care organization and using any alternative and known |
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methods of contact; and |
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(B) as applicable, through an electronic |
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notification on an Internet portal. |
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Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING |
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MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive |
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commissioner by rule shall require each Medicaid managed care |
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organization or other entity responsible for authorizing coverage |
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for health care services under Medicaid to ensure that the |
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organization or entity maintains on the organization's or entity's |
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Internet website in an easily searchable and accessible format: |
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(1) the applicable timelines for prior authorization |
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requirements, including: |
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(A) the time within which the organization or |
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entity must make a determination on a prior authorization request; |
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(B) a description of the notice the organization |
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or entity provides to a provider and Medicaid recipient on whose |
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behalf the request was submitted regarding the documentation |
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required to complete a determination on a prior authorization |
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request; and |
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(C) the deadline by which the organization or |
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entity is required to submit the notice described by Paragraph (B); |
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and |
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(2) an accurate and up-to-date catalogue of coverage |
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criteria and prior authorization requirements, including: |
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(A) for a prior authorization requirement first |
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imposed on or after September 1, 2019, the effective date of the |
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requirement; |
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(B) a list or description of any necessary or |
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supporting documentation necessary to obtain prior authorization |
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for a specified service; and |
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(C) the date and results of each review of the |
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prior authorization requirement conducted under Section 533.00283, |
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if applicable. |
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(b) The executive commissioner by rule shall require each |
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Medicaid managed care organization or other entity responsible for |
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authorizing coverage for health care services under Medicaid to: |
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(1) adopt and maintain a process for a provider or |
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Medicaid recipient to contact the organization or entity to clarify |
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prior authorization requirements or assist the provider or |
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recipient in submitting a prior authorization request; and |
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(2) ensure that the process described by Subdivision |
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(1) is not arduous or overly burdensome to a provider or recipient. |
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Sec. 531.0319. MEDICAID MEDICAL BENEFITS POLICY MANUAL. |
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(a) To the greatest extent possible, the commission shall |
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consolidate policy manuals, handbooks, and other informational |
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documents into one Medicaid medical benefits policy manual to |
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clarify and provide guidance on the policies under the Medicaid |
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managed care delivery model. |
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(b) The commission shall periodically update the Medicaid |
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medical benefits policy manual described by this section to reflect |
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policies adopted or amended by the commission. |
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Sec. 531.0511. MEDICALLY DEPENDENT CHILDREN WAIVER |
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PROGRAM: CONSUMER DIRECTION OF SERVICES. Notwithstanding Sections |
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531.051(c)(1) and (d), a consumer direction model implemented under |
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Section 531.051, including the consumer-directed service option, |
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for the delivery of services under the medically dependent children |
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(MDCP) waiver program must allow for the delivery of all services |
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and supports available under that program through consumer |
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direction. |
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SECTION 3. Section 533.00253(a)(1), Government Code, is |
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amended to read as follows: |
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(1) "Advisory committee" means the STAR Kids Managed |
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Care Advisory Committee established by the executive commissioner |
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under Section 531.012 [533.00254]. |
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SECTION 4. Section 533.00253, Government Code, is amended |
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by adding Subsections (f), (g), and (h) to read as follows: |
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(f) Using existing resources, the executive commissioner in |
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consultation and collaboration with the advisory committee shall |
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determine the feasibility of providing Medicaid benefits to |
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children enrolled in the STAR Kids managed care program under: |
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(1) an accountable care organization model in |
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accordance with guidelines established by the Centers for Medicare |
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and Medicaid Services; or |
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(2) an alternative model developed by or in |
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collaboration with the Centers for Medicare and Medicaid Services |
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Innovation Center. |
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(g) Not later than December 1, 2022, the commission shall |
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prepare and submit a written report to the legislature of the |
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executive commissioner's determination under Subsection (f). |
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(h) Subsections (f) and (g) and this subsection expire |
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September 1, 2023. |
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SECTION 5. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Sections 533.00282, 533.00283, 533.00284, and |
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533.0031 to read as follows: |
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Sec. 533.00282. UTILIZATION REVIEW PROCEDURES. Section |
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4201.304, Insurance Code, does not apply to a Medicaid managed care |
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organization or a utilization review agent who conducts utilization |
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reviews for a Medicaid managed care organization. |
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Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION |
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REQUIREMENTS. (a) Each Medicaid managed care organization shall |
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develop and implement a process to conduct an annual review of the |
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organization's prior authorization requirements, other than a |
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prior authorization requirement prescribed by or implemented under |
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Section 531.073 for the vendor drug program. In conducting a |
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review, the organization must: |
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(1) solicit, receive, and consider input from |
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providers in the organization's provider network; and |
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(2) ensure that each prior authorization requirement |
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is based on accurate, up-to-date, evidence-based, and |
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peer-reviewed clinical criteria that distinguish, as appropriate, |
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between categories, including age, of recipients for whom prior |
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authorization requests are submitted. |
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(b) A Medicaid managed care organization may not impose a |
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prior authorization requirement, other than a prior authorization |
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requirement prescribed by or implemented under Section 531.073 for |
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the vendor drug program, unless the organization has reviewed the |
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requirement during the most recent annual review required under |
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this section. |
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Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE |
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DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In |
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addition to the requirements of Section 533.005, a contract between |
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a Medicaid managed care organization and the commission must |
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include a requirement that the organization establish a process for |
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reconsidering an adverse determination on a prior authorization |
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request that resulted solely from the submission of insufficient or |
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inadequate documentation. |
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(b) The process for reconsidering an adverse determination |
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on a prior authorization request under this section must: |
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(1) allow a provider to, not later than the seventh |
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business day following the date of the determination, submit any |
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documentation that was identified as insufficient or inadequate in |
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the notice provided under Section 531.024162; |
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(2) allow the provider requesting the prior |
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authorization to discuss the request with another provider who |
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practices in the same or a similar specialty, but not necessarily |
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the same subspecialty, and has experience in treating the same |
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category of population as the recipient on whose behalf the request |
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is submitted; |
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(3) require the Medicaid managed care organization to, |
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not later than the first business day following the date the |
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provider submits sufficient and adequate documentation under |
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Subdivision (1), amend the determination on the prior authorization |
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request, as necessary, considering the additional documentation; |
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and |
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(4) comply with 42 C.F.R. Section 438.210. |
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(c) An adverse determination on a prior authorization |
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request is considered a denial of services in an evaluation of the |
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Medicaid managed care organization only if the determination is not |
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amended under Subsection (b)(3). |
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(d) The process for reconsidering an adverse determination |
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on a prior authorization request under this section does not |
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affect: |
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(1) any related timelines, including the timeline for |
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an internal appeal or a Medicaid fair hearing; or |
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(2) any rights of a recipient to appeal a |
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determination on a prior authorization request. |
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Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION. |
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(a) A managed care plan offered by a Medicaid managed care |
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organization must be accredited by a nationally recognized |
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accreditation organization. The commission may choose whether to |
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require all managed care plans offered by Medicaid managed care |
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organizations to be accredited by the same organization or to allow |
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for accreditation by different organizations. |
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(b) The commission may use the data, scoring, and other |
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information provided to or received from an accreditation |
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organization in the commission's contract oversight processes. |
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SECTION 6. The Health and Human Services Commission shall |
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issue a request for information to seek information and comments |
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regarding contracting with a managed care organization to arrange |
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for or provide a managed care plan under the STAR Kids managed care |
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program established under Section 533.00253, Government Code, |
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throughout the state instead of on a regional basis. |
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SECTION 7. (a) Using available resources, the Health and |
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Human Services Commission shall report available data on the 30-day |
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limitation on reimbursement for inpatient hospital care provided to |
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Medicaid recipients enrolled in the STAR+PLUS Medicaid managed care |
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program under 1 T.A.C. Section 354.1072(a)(1) and other applicable |
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law. To the extent data is available on the subject, the commission |
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shall also report on: |
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(1) the number of Medicaid recipients affected by the |
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limitation and their clinical outcomes; and |
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(2) the impact of the limitation on reducing |
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unnecessary Medicaid inpatient hospital days and any cost savings |
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achieved by the limitation under Medicaid. |
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(b) Not later than December 1, 2020, the Health and Human |
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Services Commission shall submit the report containing the data |
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described by Subsection (a) of this section to the governor, the |
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legislature, and the Legislative Budget Board. The report required |
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under this subsection may be combined with any other report |
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required by this Act or other law. |
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SECTION 8. The policies for implementing changes to payment |
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rates required by Section 531.02112, Government Code, as added by |
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this Act, apply only to a change to a fee, charge, or rate that takes |
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effect on or after January 1, 2021. |
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SECTION 9. The Health and Human Services Commission shall |
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implement: |
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(1) the Medicaid provider management and enrollment |
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system required by Section 531.021182(c), Government Code, as added |
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by this Act, not later than September 1, 2020; and |
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(2) the modernized claims processing system required |
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by Section 531.021182(d), Government Code, as added by this Act, |
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not later than September 1, 2023. |
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SECTION 10. As soon as practicable after the effective date |
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of this Act, the executive commissioner of the Health and Human |
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Services Commission shall adopt rules necessary to implement the |
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changes in law made by this Act. |
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SECTION 11. (a) Section 533.00284, Government Code, as |
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added by this Act, applies only to a contract between the Health and |
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Human Services Commission and a Medicaid managed care organization |
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under Chapter 533, Government Code, that is entered into or renewed |
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on or after the effective date of this Act. |
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(b) The Health and Human Services Commission shall seek to |
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amend contracts entered into with Medicaid managed care |
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organizations under Chapter 533, Government Code, before the |
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effective date of this Act to include the provisions required by |
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Section 533.00284, Government Code, as added by this Act. |
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SECTION 12. The Health and Human Services Commission shall |
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require that a managed care plan offered by a managed care |
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organization with which the commission enters into or renews a |
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contract under Chapter 533, Government Code, on or after the |
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effective date of this Act comply with Section 533.0031, Government |
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Code, as added by this Act, not later than September 1, 2022. |
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SECTION 13. If before implementing any provision of this |
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Act a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 14. The Health and Human Services Commission is |
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required to implement a provision of this Act only if the |
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legislature appropriates money specifically for that purpose. If |
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the legislature does not appropriate money specifically for that |
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purpose, the commission may, but is not required to, implement a |
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provision of this Act using other appropriations available for that |
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purpose. |
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SECTION 15. This Act takes effect September 1, 2019. |