reglab/housing_qa huggingface dataset:
TX Govt Code § 533.0131 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.0131. Use of Encounter Data in Determining Premium Payment Rates

Sec. 533.0131.  USE OF ENCOUNTER DATA IN DETERMINING PREMIUM PAYMENT RATES.  (a)  In determining premium payment rates and other amounts paid to managed care organizations under a managed care plan, the commission may not base or derive the rates or amounts on or from encounter data, or incorporate in the determination an analysis of encounter data, unless a certifier of encounter data certifies that:(1)  the encounter data for the most recent state fiscal year is complete, accurate, and reliable;  and(2)  there is no statistically significant variability in the encounter data attributable to incompleteness, inaccuracy, or another deficiency as compared to equivalent data for similar populations and when evaluated against professionally accepted standards.(b)  For purposes of determining whether data is equivalent data for similar populations under Subsection (a)(2), a certifier of encounter data shall, at a minimum, consider:(1)  the regional variation in utilization patterns of recipients and costs of health care services;(2)  the range and type of health care services to be covered by premium payment rates;(3)  the number of managed care plans in the region;  and(4)  the current number of recipients in each region, including the number for each category of recipient.|Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.|
TX Govt Code § 533.01315 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.01315. Reimbursement for Services Provided Outside of Regular Business Hours

Sec. 533.01315.  REIMBURSEMENT FOR SERVICES PROVIDED OUTSIDE OF REGULAR BUSINESS HOURS.  (a)  This section applies only to a recipient receiving benefits through any Medicaid managed care model or arrangement.(b)  The commission shall ensure that a federally qualified health center, rural health clinic, or municipal health department's public clinic is reimbursed for health care services provided to a recipient outside of regular business hours, including on a weekend or holiday, at a rate that is equal to the allowable rate for those services as determined under Section 32.028, Human Resources Code, regardless of whether the recipient has a referral from the recipient's primary care provider.(c)  The executive commissioner shall adopt rules regarding the days, times of days, and holidays that are considered to be outside of regular business hours for purposes of Subsection (b).|Added by Acts 2007, 80th Leg., R.S., Ch. 298 (H.B. 1579), Sec. 1, eff. September 1, 2007.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.231, eff. April 2, 2015.|
TX Govt Code § 533.0132 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.0132. State Taxes

Sec. 533.0132.  STATE TAXES.  The commission shall ensure that any experience rebate or profit sharing for managed care organizations is calculated by treating premium, maintenance, and other taxes under the Insurance Code and any other taxes payable to this state as allowable expenses for purposes of determining the amount of the experience rebate or profit sharing.|Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.30, eff. Sept. 1, 2003.|
TX Govt Code § 533.014 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.014. Profit Sharing

Sec. 533.014.  PROFIT SHARING.  (a)  The executive commissioner shall adopt rules regarding the sharing of profits earned by a managed care organization through a managed care plan providing health care services under a contract with the commission under this chapter.(b)  Except as provided by Subsection (c), any amount received by the state under this section shall be deposited in the general revenue fund.(c)  If cost-effective, the commission may use amounts received by the state under this section to provide incentives to specific managed care organizations to promote quality of care, encourage payment reform, reward local service delivery reform, increase efficiency, and reduce inappropriate or preventable service utilization.|Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1, 1999.Amended by: Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 4.05, eff. September 1, 2013.Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.232, eff. April 2, 2015.|
TX Govt Code § 533.015 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.015. Coordination of External Oversight Activities

Sec. 533.015.  COORDINATION OF EXTERNAL OVERSIGHT ACTIVITIES.  (a)  To the extent possible, the commission shall coordinate all external oversight activities to minimize duplication of oversight of managed care plans under Medicaid and disruption of operations under those plans.(b)  The executive commissioner, after consulting with the commission's office of inspector general, shall by rule define the commission's and office's roles in and jurisdiction over, and frequency of, audits of managed care organizations participating in Medicaid that are conducted by the commission and the commission's office of inspector general. Text of subsection as amended by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.23(a) (c)  In accordance with Section 531.102(q), the commission shall share with the commission's office of inspector general, at the request of the office, the results of any informal audit or onsite visit that could inform that office's risk assessment when determining whether to conduct, or the scope of, an audit of a managed care organization participating in Medicaid. Text of subsection as amended by Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 12 (c)  In accordance with Section 531.102(w), the commission shall share with the commission's office of inspector general, at the request of the office, the results of any informal audit or on-site visit that could inform that office's risk assessment when determining whether to conduct, or the scope of, an audit of a managed care organization participating in Medicaid.|Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1, 1999.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.233, eff. April 2, 2015.Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.23(a), eff. September 1, 2015.Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 12, eff. September 1, 2015.|
TX Govt Code § 533.016 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.016. Provider Reporting of Encounter Data

Sec. 533.016.  PROVIDER REPORTING OF ENCOUNTER DATA.  The commission shall collaborate with managed care organizations that contract with the commission and health care providers under the organizations' provider networks to develop incentives and mechanisms to encourage providers to report complete and accurate encounter data to managed care organizations in a timely manner.|Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.|
TX Govt Code § 533.0161 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.0161. Monitoring of Psychotropic Drug Prescriptions for Certain Children

Sec. 533.0161.  MONITORING OF PSYCHOTROPIC DRUG PRESCRIPTIONS FOR CERTAIN CHILDREN.  (a)  In this section, "psychotropic drug" has the meaning assigned by Section 261.111, Family Code.(b)  The commission shall implement a system under which the commission will use Medicaid prescription drug data to monitor the prescribing of psychotropic drugs for:(1)  children who are in the conservatorship of the Department of Family and Protective Services and enrolled in the STAR Health Medicaid managed care program or eligible for both Medicaid and Medicare; and(2)  children who are under the supervision of the Department of Family and Protective Services through an agreement under the Interstate Compact on the Placement of Children under Subchapter B, Chapter 162, Family Code.(c)  The commission shall include as a component of the monitoring system required by this section a medical review of a prescription to which Subsection (b) applies when that review is appropriate.|Added by Acts 2011, 82nd Leg., R.S., Ch. 843 (H.B. 3531), Sec. 1, eff. September 1, 2011.Amended by: Acts 2013, 83rd Leg., R.S., Ch. 204 (H.B. 915), Sec. 14, eff. September 1, 2013.|
TX Govt Code § 533.017 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.017. Qualifications of Certifier of Encounter Data

Sec. 533.017.  QUALIFICATIONS OF CERTIFIER OF ENCOUNTER DATA.  (a)  The person acting as the state Medicaid director shall appoint a person as the certifier of encounter data.(b)  The certifier of encounter data must have:(1)  demonstrated expertise in estimating premium payment rates paid to a managed care organization under a managed care plan;  and(2)  access to actuarial expertise, including expertise in estimating premium payment rates paid to a managed care organization under a managed care plan.(c)  A person may not be appointed under this section as the certifier of encounter data if the person participated with the commission in developing premium payment rates for managed care organizations under managed care plans in this state during the three-year period before the date the certifier is appointed.|Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.|
TX Govt Code § 533.018 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.018. Certification of Encounter Data

Sec. 533.018.  CERTIFICATION OF ENCOUNTER DATA.  (a)  The certifier of encounter data shall certify the completeness, accuracy, and reliability of encounter data for each state fiscal year.(b)  The commission shall make available to the certifier all records and data the certifier considers appropriate for evaluating whether to certify the encounter data.  The commission shall provide to the certifier selected resources and assistance in obtaining, compiling, and interpreting the records and data.|Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.|
TX Govt Code § 533.019 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.019. Value-Added Services

Sec. 533.019.  VALUE-ADDED SERVICES.  The commission shall actively encourage managed care organizations that contract with the commission to offer benefits, including health care services or benefits or other types of services, that:(1)  are in addition to the services ordinarily covered by the managed care plan offered by the managed care organization; and(2)  have the potential to improve the health status of enrollees in the plan.|Added by Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 12(a), eff. September 1, 2007.|
TX Govt Code § 533.020 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter A. General Provisions|Section 533.020. Managed Care Organizations: Fiscal Solvency and Complaint System Guidelines

Sec. 533.020.  MANAGED CARE ORGANIZATIONS:  FISCAL SOLVENCY AND COMPLAINT SYSTEM GUIDELINES.  (a)  The Texas Department of Insurance, in conjunction with the commission, shall establish fiscal solvency standards and complaint system guidelines for managed care organizations that serve recipients.(b)  The guidelines must require that information regarding a managed care organization's complaint process be made available to a recipient in an appropriate communication format when the recipient enrolls in the Medicaid managed care program.|Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1K.001, eff. April 1, 2009.Renumbered from Government Code, Section 533.019 by Acts 2009, 81st Leg., R.S., Ch. 87 (S.B. 1969), Sec. 27.001(38), eff. September 1, 2009.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.234, eff. April 2, 2015.|
TX Govt Code § 533.051 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.051. Definitions

Sec. 533.051.  DEFINITIONS.  In this subchapter:(1)  "Accounts receivable tracking system" means the system the commission uses to track experience rebates and other payments collected from managed care organizations.(2)  "Agreed-upon procedures engagement" means an evaluation of a managed care organization's financial statistical reports or other data conducted by an independent auditing firm engaged by the commission as agreed in the managed care organization's contract with the commission.(3)  "Experience rebate" means the amount a managed care organization is required to pay the state according to the graduated rebate method described in the managed care organization's contract with the commission.(4)  "External quality review organization" means an organization that performs an external quality review of a managed care organization in accordance with 42 C.F.R. Section 438.350.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.052 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.052. Applicability and Construction of Subchapter

Sec. 533.052.  APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER.  This subchapter does not apply to and may not be construed as affecting the conduct of audits by the commission's office of inspector general under the authority provided by Subchapter C, Chapter 531, including an audit of a managed care organization conducted by the office after coordinating the office's audit and oversight activities with the commission as required by Section 531.102(q), as added by Chapter 837 (S.B. 200), Acts of the 84th Legislature, Regular Session, 2015.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.053 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.053. Overall Strategy for Managing Audit Resources

Sec. 533.053.  OVERALL STRATEGY FOR MANAGING AUDIT RESOURCES.  The commission shall develop and implement an overall strategy for planning, managing, and coordinating audit resources that the commission uses to verify the accuracy and reliability of program and financial information reported by managed care organizations.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.054 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.054. Performance Audit Selection Process and Follow-Up

Sec. 533.054.  PERFORMANCE AUDIT SELECTION PROCESS AND FOLLOW-UP.  (a)  To improve the commission's processes for performance audits of managed care organizations, the commission shall:(1)  document the process by which the commission selects managed care organizations to audit;(2)  include previous audit coverage as a risk factor in selecting managed care organizations to audit; and(3)  prioritize the highest risk managed care organizations to audit.(b)  To verify that managed care organizations correct negative performance audit findings, the commission shall:(1)  establish a process to:(A)  document how the commission follows up on negative performance audit findings; and(B)  verify that managed care organizations implement performance audit recommendations; and(2)  establish and implement policies and procedures to:(A)  determine under what circumstances the commission must issue a corrective action plan to a managed care organization based on a performance audit; and(B)  follow up on the managed care organization's implementation of the corrective action plan.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.055 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.055. Agreed-Upon Procedures Engagements and Corrective Action Plans

Sec. 533.055.  AGREED-UPON PROCEDURES ENGAGEMENTS AND CORRECTIVE ACTION PLANS.  To enhance the commission's use of agreed-upon procedures engagements to identify managed care organizations' performance and compliance issues, the commission shall:(1)  ensure that financial risks identified in agreed-upon procedures engagements are adequately and consistently addressed; and(2)  establish policies and procedures to determine under what circumstances the commission must issue a corrective action plan based on an agreed-upon procedures engagement.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.056 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.056. Audits of Pharmacy Benefit Managers

Sec. 533.056.  AUDITS OF PHARMACY BENEFIT MANAGERS.  To obtain greater assurance about the effectiveness of pharmacy benefit managers' internal controls and compliance with state requirements, the commission shall:(1)  periodically audit each pharmacy benefit manager that contracts with a managed care organization; and(2)  develop, document, and implement a monitoring process to ensure that managed care organizations correct and resolve negative findings reported in performance audits or agreed-upon procedures engagements of pharmacy benefit managers.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.057 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.057. Collection of Costs for Audit-Related Services

Sec. 533.057.  COLLECTION OF COSTS FOR AUDIT-RELATED SERVICES.  The commission shall develop, document, and implement billing processes in the Medicaid and CHIP services department of the commission to ensure that managed care organizations reimburse the commission for audit-related services as required by contract.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.058 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.058. Collection Activities Related to Profit Sharing

Sec. 533.058.  COLLECTION ACTIVITIES RELATED TO PROFIT SHARING.  To strengthen the commission's process for collecting shared profits from managed care organizations, the commission shall develop, document, and implement monitoring processes in the Medicaid and CHIP services department of the commission to ensure that the commission:(1)  identifies experience rebates deposited in the commission's suspense account and timely transfers those rebates to the appropriate accounts; and(2)  timely follows up on and resolves disputes over experience rebates claimed by managed care organizations.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.059 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.059. Use of Information From External Quality Reviews

Sec. 533.059.  USE OF INFORMATION FROM EXTERNAL QUALITY REVIEWS.  (a)  To enhance the commission's monitoring of managed care organizations, the commission shall use the information provided by the external quality review organization, including:(1)  detailed data from results of surveys of Medicaid recipients and, if applicable, child health plan program enrollees, caregivers of those recipients and enrollees, and Medicaid and, as applicable, child health plan program providers; and(2)  the validation results of matching paid claims data with medical records.(b)  The commission shall document how the commission uses the information described by Subsection (a) to monitor managed care organizations.|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.060 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter B. Strategy for Managing Audit Resources|Section 533.060. Security and Processing Controls Over Information Technology Systems

Sec. 533.060.  SECURITY AND PROCESSING CONTROLS OVER INFORMATION TECHNOLOGY SYSTEMS.  The commission shall:(1)  strengthen user access controls for the commission's accounts receivable tracking system and network folders that the commission uses to manage the collection of experience rebates;(2)  document daily reconciliations of deposits recorded in the accounts receivable tracking system to the transactions processed in:(A)  the commission's cost accounting system for all health and human services agencies; and(B)  the uniform statewide accounting system; and(3)  develop, document, and implement a process to ensure that the commission formally documents:(A)  all programming changes made to the accounts receivable tracking system; and(B)  the authorization and testing of the changes described by Paragraph (A).|Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.|
TX Govt Code § 533.081 (2021)
2021 Texas Statutes|Government Code|Title 4 - Executive Branch|Subtitle I - Health and Human Services|Chapter 533 - Medicaid Managed Care Program|Subchapter E. Pilot Program to Increase Incentive-Based Provider Payments|Section 533.081. Definition

Sec. 533.081.  DEFINITION.  In this subchapter, "pilot program" means the pilot program to increase incentive-based provider payments established under Section 533.082.|Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.25(a), eff. September 1, 2015.|For expiration of this section, see Section 533.084.