89R16086 KKR-F

By: Buckley H.B. No. 5512

A BILL TO BE ENTITLED

AN ACT

relating to the participation and reimbursement of and requirements affecting certain providers, including providers of eye health care and vision care services, under Medicaid.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subchapter D, Chapter 532, Government Code, as effective April 1, 2025, is amended by adding Sections 532.01511 and 532.01512 to read as follows:

Sec. 532.01511. PROVIDER ENROLLMENT AND CREDENTIALING PROCESSES: PROVIDER SUPPORT; COMPLAINTS. (a) The commission shall ensure that providers have access to a dedicated support team for the Internet portal established under Section 532.0151 that:

(1) assists current and prospective Medicaid providers in completing the Medicaid provider enrollment and credentialing processes; and

(2) reduces the administrative burdens associated with those processes.

(b) The commission shall:

(1) annually evaluate the performance of the support team described by Subsection (a), including the timeliness of assistance the support team provides; and

(2) not later than September 1 of each year, post on the commission's Internet website a report summarizing the results of the evaluation conducted under Subdivision (1).

(c) For purposes of improving the commission's Medicaid provider enrollment and credentialing processes, the commission shall develop a procedure by which a provider may electronically submit complaints and feedback about those processes and the support provided by the support team described by Subsection (a). Information about the procedure must:

(1) be prominently posted on the commission's or the commission's designee's Internet website in the same location that instructions and resources for using the Internet portal established under Section 532.0151 are posted; and

(2) allow a provider to submit a complaint or provide feedback through an electronic form from that location.

Sec. 532.01512. NOTICE OF PROVIDER DISENROLLMENT. Before the commission may disenroll a Medicaid provider during the provider's enrollment revalidation period, the commission must:

(1) not later than the 30th day before the date of disenrollment provide electronically and by mail to the provider written notice of the commission's disenrollment determination; and

(2) allow the provider to address any deficiencies in the provider's application for revalidation of enrollment before the date the provider is disenrolled.

SECTION 2. Subchapter F, Chapter 540, Government Code, as effective April 1, 2025, is amended by adding Sections 540.0281 and 540.0282 to read as follows:

Sec. 540.0281. ADMINISTRATION OF EYE HEALTH CARE AND VISION CARE SERVICES. (a) A contract to which this subchapter applies must prohibit the contracting Medicaid managed care organization from using a different insurer, health maintenance organization, third-party administrator, managed care plan, vision plan, or other plan or entity the organization contracts with, offers, owns, or otherwise engages to provide or arrange for the provision of eye health care or vision care services under the managed care plan the Medicaid managed care organization offers to:

(1) establish an eye health care services provider's inclusion in the organization's provider network;

(2) contract with an eye health care services provider to provide or arrange for the provision of eye health care or vision care services under the organization's Medicaid managed care plan;

(3) reduce, restrict, or limit eye health care or vision care services that are required to be provided to recipients and are within the eye health care services provider's scope of practice; or

(4) deny participation of an eye health care services provider in the organization's Medicaid managed care plan if the provider:

(A) seeks to participate in that plan; and

(B) meets the organization's requirements for participation in the plan.

(b) Notwithstanding Section 1451.152, Insurance Code, an insurer, health maintenance organization, third-party administrator, managed care plan, vision plan, or other plan or entity that a Medicaid managed care organization contracts with, offers, owns, or otherwise engages to provide or arrange for the provision of eye health care or vision care services under the organization's Medicaid managed care plan shall comply with the requirements of Subchapter D, Chapter 1451, Insurance Code.

Sec. 540.0282. REIMBURSEMENT OF EYE HEALTH CARE SERVICES PROVIDERS. A contract to which this subchapter applies must require that the contracting Medicaid managed care organization require any insurer, health maintenance organization, third-party administrator, managed care plan, vision plan, or other plan or entity the organization contracts with, offers, owns, or otherwise engages to provide or arrange for the provision of eye health care or vision care services under the managed care plan the Medicaid managed care organization offers to reimburse an eye health care services provider who provides services to a recipient under the organization's managed care plan at a rate that is at least equal to the Medicaid fee-for-service rate for the provision of the same or similar services.

SECTION 3. Section 540.0651(a), Government Code, as effective April 1, 2025, is amended to read as follows:

(a) The commission shall require that each managed care organization that contracts with the commission under any managed care model or arrangement to provide health care services to recipients in a region:

(1) seek participation in the organization's provider network from:

(A) each health care provider in the region who has traditionally provided care to recipients;

(B) each hospital in the region that has been designated as a disproportionate share hospital under Medicaid; and

(C) each specialized pediatric laboratory in the region, including a laboratory located in a children's hospital;

(2) include in the organization's provider network for at least three years:

(A) each health care provider in the region who:

(i) previously provided care to Medicaid and charity care recipients at a significant level as the commission prescribes;

(ii) agrees to accept the organization's prevailing provider contract rate; and

(iii) has the credentials the organization requires, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network;

(B) each accredited primary care residency program in the region; and

(C) each disproportionate share hospital the commission designates as a statewide significant traditional provider; [and]

(3) subject to Section 32.047, Human Resources Code, and notwithstanding any other law, include in the organization's provider network each optometrist, therapeutic optometrist, and ophthalmologist described by Section 532.0153(b)(1)(A) or (B) who, and an institution of higher education described by Section 532.0153(a)(4) in the region that:

(A) seeks participation in the organization's provider network;

(B) agrees to comply with the organization's terms;

(C) [(B)] agrees to accept the [organization's prevailing provider contract] rate specified in the contract between the provider and the organization;

(D) [(C)] agrees to abide by the organization's required standards of care; and

(E) [(D)] is an enrolled Medicaid provider; and

(4) contract directly with each provider described by Subdivision (3) to participate in the organization's provider network.

SECTION 4. Notwithstanding Section 532.01511, Government Code, as added by this Act, the Health and Human Services Commission shall conduct the initial evaluation and post the report summarizing the results of the evaluation as required by that section not later than September 1, 2026.

SECTION 5. As soon as possible after the effective date of this Act, the Health and Human Services Commission shall:

(1) ensure the Internet portal support team required by Section 532.01511(a), Government Code, as added by this Act, is established; and

(2) adopt rules necessary to implement the changes in law made by this Act.

SECTION 6. (a) The Health and Human Services Commission shall, in a contract between the commission and a managed care organization under Chapter 540, Government Code, as effective April 1, 2025, that is entered into or renewed on or after the effective date of this Act, require that the managed care organization comply with Sections 540.0281 and 540.0282, Government Code, as added by this Act, and Section 540.0651, Government Code, as effective April 1, 2025, and amended by this Act.

(b) The Health and Human Services Commission shall seek to amend contracts entered into with managed care organizations under Chapter 533, Government Code, or under Chapter 540, Government Code, as effective April 1, 2025, before the effective date of this Act to require those managed care organizations to comply with Sections 540.0281 and 540.0282, Government Code, as added by this Act, and Section 540.0651, Government Code, as effective April 1, 2025, and amended by this Act. To the extent of a conflict between those provisions of law and a provision of a contract with a managed care organization entered into before the effective date of this Act, the contract provision prevails.

SECTION 7. 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 8. This Act takes effect September 1, 2025.