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A BILL TO BE ENTITLED
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AN ACT
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relating to requirements applicable to certain third-party health |
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insurers in relation to Medicaid. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 531.024131(a), Government Code, is |
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amended to read as follows: |
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(a) If cost-effective, the commission may: |
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(1) contract to expand all or part of the billing |
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coordination system established under Section 531.02413 to process |
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claims for services provided through other benefits programs |
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administered by the commission or a health and human services |
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agency; |
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(2) expand any other billing coordination tools and |
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resources used to process claims for health care services provided |
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through Medicaid to process claims for services provided through |
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other benefits programs administered by the commission or a health |
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and human services agency; and |
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(3) expand the scope of persons about whom information |
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is collected under Section 32.0424(a) [32.042], Human Resources |
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Code, to include recipients of services provided through other |
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benefits programs administered by the commission or a health and |
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human services agency. |
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SECTION 2. Section 32.0421(a), Human Resources Code, is |
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amended to read as follows: |
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(a) The commission may impose an administrative penalty on a |
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person who does not comply with a request for information made under |
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Section 32.0424(a) [32.042(b)]. |
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SECTION 3. Section 32.0424, Human Resources Code, is |
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amended to read as follows: |
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Sec. 32.0424. REQUIREMENTS OF THIRD-PARTY HEALTH INSURERS. |
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(a) A third-party health insurer shall [is required to] provide to |
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the commission or the commission's designee, on the commission's or |
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the commission's designee's request, information in a form |
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prescribed by the executive commissioner necessary to determine: |
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(1) the period during which an individual entitled to |
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medical assistance, the individual's spouse, or the individual's |
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dependents may be, or may have been, covered by coverage issued by |
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the health insurer; |
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(2) the nature of the coverage; and |
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(3) the name, address, and identifying number of the |
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health plan under which the person may be, or may have been, |
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covered. |
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(b) A third-party health insurer shall accept the state's |
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right of recovery and the assignment under Section 32.033 to the |
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state of any right of an individual or other entity to payment from |
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the third-party health insurer for an item or service for which |
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payment was made under the medical assistance program, including a |
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waiver program established under the medical assistance program. |
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(b-1) Except as provided by Subsection (b-2), for an item or |
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service provided to an individual entitled to medical assistance |
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that was previously paid for by the commission or the commission's |
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designee and for which a third-party health insurer is responsible |
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for payment, the third-party health insurer shall accept |
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authorization provided by the commission or the commission's |
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designee that the item or service is covered under the medical |
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assistance program as if that authorization is a prior |
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authorization made by the third-party health insurer for the item |
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or service. |
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(b-2) Subsection (b-1) does not apply to a third-party |
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health insurer with respect to providing: |
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(1) hospital insurance benefits or supplementary |
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insurance benefits under Part A or B of Title XVIII of the Social |
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Security Act (42 U.S.C. Section 1395c et seq. or 1395j et seq.); |
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(2) a health care prepayment plan under Section |
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1833(a)(1)(A), Social Security Act (42 U.S.C. Section |
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1395l(a)(1)(A)); |
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(3) a Medicare Advantage plan under Part C of Title |
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XVIII of the Social Security Act (42 U.S.C. Section 1395w-21 et |
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seq.); |
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(4) a prescription drug plan as a prescription drug |
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plan sponsor under Part D of Title XVIII of the Social Security Act |
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(42 U.S.C. Section 1395w-101 et seq.); or |
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(5) a reasonable cost reimbursement plan under Section |
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1876, Social Security Act (42 U.S.C. Section 1395mm). |
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(c) Not later than the 60th day after the date a [A] |
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third-party health insurer receives an [shall respond to any] |
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inquiry from [by] the commission or the commission's designee |
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regarding a claim for payment for any health care item or service |
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submitted to the insurer [reimbursed by the commission under the |
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medical assistance program] not later than the third year after |
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[anniversary of] the date the health care item or service was |
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provided, the insurer shall respond to the inquiry. |
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(d) A third-party health insurer may not deny a claim |
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submitted by the commission or the commission's designee for which |
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payment was made under the medical assistance program solely on the |
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basis of the date of submission of the claim, the type or format of |
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the claim form, [or] a failure to present proper documentation at |
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the point of service that is the basis of the claim, or, for a |
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responsible third-party health insurer, other than an insurer |
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described by Subsection (b-2), a failure to obtain prior |
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authorization for the item or service for which the claim is being |
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submitted, if: |
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(1) the claim is submitted by the commission or the |
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commission's designee not later than the third anniversary of the |
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date the item or service was provided; and |
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(2) any action by the commission or the commission's |
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designee to enforce the state's rights with respect to the claim is |
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commenced not later than the sixth anniversary of the date the |
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commission or the commission's designee submits the claim. |
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(e) In this section, "third-party health insurer" means a |
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health insurer or other person or arrangement that is legally |
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responsible by state or federal law or private agreement to pay some |
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or all claims for health care items or services provided to an |
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individual. The term includes: |
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(1) a self-insured plan; |
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(2) a group health plan as defined by Section 607 of |
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the Employee Retirement Income Security Act of 1974 (29 U.S.C. |
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Section 1167); |
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(3) a service benefit plan; |
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(4) a managed care organization; and |
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(5) a pharmacy benefit manager [This section does not |
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limit the scope or amount of information required by Section |
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32.042]. |
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SECTION 4. Section 32.042, Human Resources Code, is |
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repealed. |
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SECTION 5. 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 6. This Act takes effect September 1, 2023. |
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