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A BILL TO BE ENTITLED
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AN ACT
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relating to certain payment recovery and recoupment efforts under |
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Medicaid and the child health plan program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 544.0502, Government Code, as effective |
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April 1, 2025, is amended by amending Subsection (i) and adding |
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Subsection (j) to read as follows: |
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(i) The executive commissioner shall adopt rules necessary |
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to implement this section, including rules establishing due process |
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procedures that a managed care organization must follow when |
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engaging in payment recovery efforts as provided by this section. |
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In adopting the rules establishing due process procedures, the |
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executive commissioner shall require that a managed care |
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organization or an organization's contracted entity that engages in |
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payment recovery efforts as provided by this section and Section |
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544.0503 provide to [a provider required to use electronic visit |
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verification]: |
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(1) a provider required to use electronic visit |
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verification written notice of the organization's intent to recoup |
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overpayments in accordance with Section 544.0503; and |
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(2) a provider, regardless of whether the provider is |
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required to use electronic visit verification, a minimum of [at |
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least] 60 days after the provider has exhausted all rights to an |
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appeal to cure any defect in a claim, including by submitting |
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necessary documentation for the claim or resubmitting the claim, |
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before the organization may begin efforts to collect overpayments. |
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(j) A managed care organization or the organization's |
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contracted entity that engages in payment recovery efforts under |
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this section or Section 544.0503, in conducting an audit or other |
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review of a claim for equipment, supplies, or services for which the |
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organization granted prior authorization, may not review: |
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(1) the medical necessity determination; or |
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(2) an error in the claim documentation for the |
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previously approved equipment, supplies, or services, if the error |
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was not made by the provider. |
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SECTION 2. Section 544.0504, Government Code, as effective |
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April 1, 2025, is amended to read as follows: |
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Sec. 544.0504. RECOVERY AUDIT CONTRACTORS. To the extent |
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required under Section 1902(a)(42), Social Security Act (42 U.S.C. |
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Section 1396a(a)(42)), the commission shall establish a program |
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under which the commission contracts with one or more recovery |
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audit contractors to identify [Medicaid] underpayments and |
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overpayments under Medicaid, including under the Medicaid managed |
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care program, and recover the overpayments. |
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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, 2025. |