Amend SB 1648 (house committee printing) by adding the following appropriately numbered SECTION and renumbering subsequent SECTIONS accordingly:

SECTION ____. Sections 531.024164(b) and (f), Government Code, are amended to read as follows:

(b)  The commission, as soon as practicable following a competitive request for proposal process, shall contract with one [an] independent external medical reviewer to conduct external medical reviews and review:

(1)  the resolution of a Medicaid recipient appeal related to a reduction in or denial of services on the basis of medical necessity in the Medicaid managed care program; or

(2)  a denial by the commission of eligibility for a Medicaid program in which eligibility is based on a Medicaid recipient's medical and functional needs.

(f)  A Medicaid recipient or applicant, or the recipient's or applicant's parent or legally authorized representative, must affirmatively request an external medical review, except that the Medicaid managed care organization shall promptly forward to the external medical reviewer for external medical review any appeal determination that is adverse to the recipient or applicant in the STAR Health program. If requested or forwarded:

(1)  an external medical review described by Subsection (b)(1) occurs after the internal Medicaid managed care organization appeal and before the Medicaid fair hearing and is granted when a Medicaid recipient contests the internal appeal decision of the Medicaid managed care organization; and

(2)  an external medical review described by Subsection (b)(2) occurs after the eligibility denial and before the Medicaid fair hearing.