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A BILL TO BE ENTITLED
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AN ACT
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relating to an independent medical review of certain determinations |
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by the Health and Human Services Commission or a Medicaid managed |
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care organization. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Section 533.00715 to read as follows: |
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Sec. 533.00715. INDEPENDENT APPEALS PROCEDURE. (a) In |
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this section, "third-party arbiter" means a third-party medical |
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review organization that provides objective, unbiased medical |
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necessity determinations conducted by clinical staff with |
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education and practice in the same or similar practice area as the |
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procedure for which an independent determination of medical |
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necessity is sought. |
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(b) The commission, using money appropriated for the |
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purpose, shall contract with at least three independent, |
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third-party arbiters to resolve recipient appeals of any commission |
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or a Medicaid managed care organization adverse benefit |
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determination or reduction in or denial of health care services on |
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the basis of medical necessity. |
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(c) The commission shall establish a common procedure for |
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appeals. The procedure must provide that a health care service |
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ordered by a health care provider is presumed medically necessary |
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and the commission or Medicaid managed care organization bears the |
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burden of proof to show the health care service is not medically |
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necessary. The commission shall also establish a procedure for |
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expedited appeals that allows a third-party arbiter to: |
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(1) identify an appeal that requires an expedited |
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resolution; and |
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(2) resolve the appeal within a specified period. |
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(d) Subject to Subsection (e), the commission shall ensure |
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an appeal is randomly assigned to a third-party arbiter. |
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(e) The commission shall ensure each third-party arbiter |
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has the necessary medical expertise to resolve an appeal. |
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(f) A third-party arbiter shall establish and maintain an |
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Internet portal through which a recipient may track the status and |
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final disposition of an appeal. |
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(g) A third-party arbiter shall educate recipients |
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regarding: |
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(1) appeals processes and options; |
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(2) proper and improper denials of health care |
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services on the basis of medical necessity; and |
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(3) information available through the commission's |
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office of the ombudsman. |
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(h) A third-party arbiter may share with Medicaid managed |
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care organizations information regarding: |
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(1) appeals processes; and |
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(2) the types of documents the arbiter may require |
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from the organization to resolve appeals. |
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(i) A third-party arbiter shall notify the commission of the |
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final disposition of each appeal. The commission shall review |
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aggregate denial data categorized by Medicaid managed care plan to |
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identify trends and determine whether a Medicaid managed care |
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organization is disproportionately denying prior authorization |
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requests from a single provider or set of providers. |
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SECTION 2. 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 the rules necessary to implement |
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this Act. |
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SECTION 3. If before implementing any provision of this Act |
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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 4. This Act takes effect September 1, 2019. |
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