By: Perry  S.B. No. 1342
         (In the Senate - Filed March 1, 2023; March 16, 2023, read
  first time and referred to Committee on Health & Human Services;
  May 8, 2023, reported adversely, with favorable Committee
  Substitute by the following vote:  Yeas 7, Nays 0; May 8, 2023, sent
  to printer.)
 
  COMMITTEE SUBSTITUTE FOR S.B. No. 1342 By:  Perry
 
 
A BILL TO BE ENTITLED
 
AN ACT
 
  relating to requirements applicable to certain third-party health
  insurers in relation to Medicaid.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 531.024131(a), Government Code, is
  amended to read as follows:
         (a)  If cost-effective, the commission may:
               (1)  contract to expand all or part of the billing
  coordination system established under Section 531.02413 to process
  claims for services provided through other benefits programs
  administered by the commission or a health and human services
  agency;
               (2)  expand any other billing coordination tools and
  resources used to process claims for health care services provided
  through Medicaid to process claims for services provided through
  other benefits programs administered by the commission or a health
  and human services agency; and
               (3)  expand the scope of persons about whom information
  is collected under Section 32.0424(a) [32.042], Human Resources
  Code, to include recipients of services provided through other
  benefits programs administered by the commission or a health and
  human services agency.
         SECTION 2.  Section 32.0421(a), Human Resources Code, is
  amended to read as follows:
         (a)  The commission may impose an administrative penalty on a
  person who does not comply with a request for information made under
  Section 32.0424(a) [32.042(b)].
         SECTION 3.  Section 32.0424, Human Resources Code, is
  amended to read as follows:
         Sec. 32.0424.  REQUIREMENTS OF THIRD-PARTY HEALTH INSURERS.  
  (a)  A third-party health insurer shall [is required to] provide to
  the commission or the commission's designee, on the commission's or
  the commission's designee's request, information in a form
  prescribed by the executive commissioner necessary to determine:
               (1)  the period during which an individual entitled to
  medical assistance, the individual's spouse, or the individual's
  dependents may be, or may have been, covered by coverage issued by
  the health insurer;
               (2)  the nature of the coverage; and
               (3)  the name, address, and identifying number of the
  health plan under which the person may be, or may have been,
  covered.
         (b)  A third-party health insurer shall accept the state's
  right of recovery and the assignment under Section 32.033 to the
  state of any right of an individual or other entity to payment from
  the third-party health insurer for an item or service for which
  payment was made under the medical assistance program, including a
  waiver program established under the medical assistance program.
         (b-1)  Except as provided by Subsection (b-2), for an item or
  service provided to an individual entitled to medical assistance
  that was previously paid for by the commission or the commission's
  designee and for which a third-party health insurer is responsible
  for payment, the third-party health insurer shall accept
  authorization provided by the commission or the commission's
  designee that the item or service is covered under the medical
  assistance program as if that authorization is a prior
  authorization made by the third-party health insurer for the item
  or service.
         (b-2)  Subsection (b-1) does not apply to a third-party
  health insurer with respect to providing:
               (1)  hospital insurance benefits or supplementary
  insurance benefits under Part A or B of Title XVIII of the Social
  Security Act (42 U.S.C. Section 1395c et seq. or 1395j et seq.);
               (2)  a health care prepayment plan under Section
  1833(a)(1)(A), Social Security Act (42 U.S.C. Section
  1395l(a)(1)(A));
               (3)  a Medicare Advantage plan under Part C of Title
  XVIII of the Social Security Act (42 U.S.C. Section 1395w-21 et
  seq.);
               (4)  a prescription drug plan as a prescription drug
  plan sponsor under Part D of Title XVIII of the Social Security Act
  (42 U.S.C. Section 1395w-101 et seq.); or
               (5)  a reasonable cost reimbursement plan under Section
  1876, Social Security Act (42 U.S.C. Section 1395mm).
         (c)  Not later than the 60th day after the date a [A]
  third-party health insurer receives an [shall respond to any]
  inquiry from [by] the commission or the commission's designee
  regarding a claim for payment for any health care item or service
  submitted to the insurer [reimbursed by the commission under the
  medical assistance program] not later than the third year after 
  [anniversary of] the date the health care item or service was
  provided, the insurer shall respond to the inquiry.
         (d)  A third-party health insurer may not deny a claim
  submitted by the commission or the commission's designee for which
  payment was made under the medical assistance program solely on the
  basis of the date of submission of the claim, the type or format of
  the claim form, [or] a failure to present proper documentation at
  the point of service that is the basis of the claim, or, for a
  responsible third-party health insurer, other than an insurer
  described by Subsection (b-2), a failure to obtain prior
  authorization for the item or service for which the claim is being
  submitted, if:
               (1)  the claim is submitted by the commission or the
  commission's designee not later than the third anniversary of the
  date the item or service was provided; and
               (2)  any action by the commission or the commission's
  designee to enforce the state's rights with respect to the claim is
  commenced not later than the sixth anniversary of the date the
  commission or the commission's designee submits the claim.
         (e)  In this section, "third-party health insurer" means a
  health insurer or other person or arrangement that is legally
  responsible by state or federal law or private agreement to pay some
  or all claims for health care items or services provided to an
  individual.  The term includes:
               (1)  a self-insured plan;
               (2)  a group health plan as defined by Section 607 of
  the Employee Retirement Income Security Act of 1974 (29 U.S.C.
  Section 1167);
               (3)  a service benefit plan;
               (4)  a managed care organization; and
               (5)  a pharmacy benefit manager [This section does not
  limit the scope or amount of information required by Section
  32.042].
         SECTION 4.  Section 32.042, Human Resources Code, is
  repealed.
         SECTION 5.  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 6.  This Act takes effect September 1, 2023.
 
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