reglab/housing_qa huggingface dataset:
TX Govt Code § 533.00254 (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 533.00254. Star Kids Managed Care Advisory Committee

Sec. 533.00254.  STAR KIDS MANAGED CARE ADVISORY COMMITTEE.  (a)  The STAR Kids Managed Care Advisory Committee established by the executive commissioner under Section 531.012 shall:(1)  advise the commission on the operation of the STAR Kids managed care program under Section 533.00253; and(2)  make recommendations for improvements to that program.(b)  On December 31, 2023:(1)  the advisory committee is abolished; and(2)  this section expires.|Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.Added by Acts 2019, 86th Leg., R.S., Ch. 1330 (H.B. 4533), Sec. 5, eff. September 1, 2019.|
TX Govt Code § 533.002551 (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 533.002551. Monitoring of Compliance With Behavioral Health Integration

Sec. 533.002551.  MONITORING OF COMPLIANCE WITH BEHAVIORAL HEALTH INTEGRATION.  (a)  In this section, "behavioral health services" has the meaning assigned by Section 533.00255.(b)  In monitoring contracts the commission enters into with managed care organizations under this chapter, the commission shall:(1)  ensure managed care organizations fully integrate behavioral health services into a recipient's primary care coordination;(2)  use performance audits and other oversight tools to improve monitoring of the provision and coordination of behavioral health services; and(3)  establish performance measures that may be used to determine the effectiveness of the integration of behavioral health services.(c)  In monitoring a managed care organization's compliance with behavioral health services integration requirements under this section, the commission shall give particular attention to a managed care organization that provides behavioral health services through a contract with a third party.|Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.20, eff. September 1, 2015.|
TX Govt Code § 533.002552 (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 533.002552. Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families

Sec. 533.002552.  TARGETED CASE MANAGEMENT AND PSYCHIATRIC REHABILITATIVE SERVICES FOR CHILDREN, ADOLESCENTS, AND FAMILIES.  (a)  A provider in the provider network of a managed care organization that contracts with the commission to provide behavioral health services under Section 533.00255 may contract with the managed care organization to provide targeted case management and psychiatric rehabilitative services to children, adolescents, and their families.(b)  Commission rules and guidelines concerning contract and training requirements applicable to the provision of behavioral health services may apply to a provider that contracts with a managed care organization under Subsection (a) only to the extent those contract and training requirements are specific to the provision of targeted case management and psychiatric rehabilitative services to children, adolescents, and their families. (c)  Commission rules and guidelines applicable to a provider that contracts with a managed care organization under Subsection (a) may not require the provider to provide a behavioral health crisis hotline or a mobile crisis team that operates 24 hours per day and seven days per week.  This subsection does not prohibit a managed care organization that contracts with the commission to provide behavioral health services under Section 533.00255 from specifically contracting with a provider for the provision of a behavioral health crisis hotline or a mobile crisis team that operates 24 hours per day and seven days per week. (d)  Commission rules and guidelines applicable to a provider that contracts with a managed care organization to provide targeted case management and psychiatric rehabilitative services specific to children and adolescents who are at risk of juvenile justice involvement, expulsion from school, displacement from the home, hospitalization, residential treatment, or serious injury to self, others, or animals may not require the provider to also provide less intensive psychiatric rehabilitative services specified by commission rules and guidelines as applicable to the provision of targeted case management and psychiatric rehabilitative services to children, adolescents, and their families, if that provider has a referral arrangement to provide access to those less intensive psychiatric rehabilitative services.(e)  Commission rules and guidelines applicable to a provider that contracts with a managed care organization under Subsection (a) may not require the provider to provide services not covered under Medicaid.|Added by Acts 2017, 85th Leg., R.S., Ch. 519 (S.B. 74), Sec. 1, eff. June 9, 2017.|
TX Govt Code § 533.002553 (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 533.002553. Behavioral Health Services Provided Through Third Party or Subsidiary

Sec. 533.002553.  BEHAVIORAL HEALTH SERVICES PROVIDED THROUGH THIRD PARTY OR SUBSIDIARY.  (a)  In this section, "behavioral health services" has the meaning assigned by Section 533.00255.(b)  For a managed care organization that contracts with the commission under this chapter and that provides behavioral health services through a contract with a third party or an arrangement with a subsidiary of the managed care organization, the commission shall:(1)  require the effective sharing and integration of care coordination, service authorization, and utilization management data between the managed care organization and the third party or subsidiary;(2)  encourage, to the extent feasible, the colocation of physical health and behavioral health care coordination staff;(3)  require warm call transfers between physical health and behavioral health care coordination staff;(4)  require the managed care organization and the third party or subsidiary to implement joint rounds for physical health and behavioral health services network providers or some other effective means for sharing clinical information; and (5)  ensure that the managed care organization makes available a seamless provider portal for both physical health and behavioral health services network providers, to the extent allowed by federal law. |Added by Acts 2017, 85th Leg., R.S., Ch. 519 (S.B. 74), Sec. 1, eff. June 9, 2017.|
TX Govt Code § 533.002555 (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 533.002555. Transition of Case Management for Children and Pregnant Women Program Recipients to Managed Care Program

Sec. 533.002555.  TRANSITION OF CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN PROGRAM RECIPIENTS TO MANAGED CARE PROGRAM.  (a)  In this section, "children and pregnant women program" means the benefits program provided under Medicaid and administered by the Department of State Health Services that provides case management services to children who have a health condition or health risk and pregnant women who have a high-risk condition.(b)  The commission shall transition to a Medicaid managed care model all case management services provided to recipients under the children and pregnant women program.  In transitioning services under this section, the commission shall ensure a recipient is provided case management services through the managed care plan in which the recipient is enrolled.(c)  In implementing this section, the commission shall ensure:(1)  a seamless transition in case management for recipients receiving benefits under the children and pregnant women program; and(2)  case management services provided under the program are not interrupted.|Added by Acts 2021, 87th Leg., R.S., Ch. 629 (H.B. 133), Sec. 1, eff. September 1, 2021.|
TX Govt Code § 533.00256 (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 533.00256. Managed Care Clinical Improvement Program

Sec. 533.00256.  MANAGED CARE CLINICAL IMPROVEMENT PROGRAM.  (a)  In consultation with appropriate stakeholders with an interest in the provision of acute care services and long-term services and supports under the Medicaid managed care program, the commission shall:(1)  establish a clinical improvement program to identify goals designed to improve quality of care and care management and to reduce potentially preventable events, as defined by Section 536.001; and(2)  require managed care organizations to develop and implement collaborative program improvement strategies to address the goals.(b)  Goals established under this section may be set by geographic region and program type.|Added by Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 4.01, eff. September 1, 2013.Amended by: Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.16, eff. January 1, 2016.Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.16, eff. January 1, 2016.|
TX Govt Code § 533.0026 (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 533.0026. Direct Access to Eye Health Care Services Under Medicaid Managed Care Model or Arrangement

Sec. 533.0026.  DIRECT ACCESS TO EYE HEALTH CARE SERVICES UNDER MEDICAID MANAGED CARE MODEL OR ARRANGEMENT.  (a)  Notwithstanding any other law, the commission shall ensure that a managed care plan offered by a managed care organization that contracts with the commission under this chapter and any other Medicaid managed care model or arrangement implemented under this chapter allow a recipient who receives services through the plan or other model or arrangement to, in the manner and to the extent required by Section 32.072, Human Resources Code:(1)  select an in-network ophthalmologist or therapeutic optometrist in the managed care network to provide eye health care services, other than surgery; and(2)  have direct access to the selected in-network ophthalmologist or therapeutic optometrist for the provision of the nonsurgical services.(b)  This section does not affect the obligation of an ophthalmologist or therapeutic optometrist in a managed care network to comply with the terms and conditions of the managed care plan.|Added by Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 21(b), eff. September 1, 2007.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.218, eff. April 2, 2015.|
TX Govt Code § 533.0027 (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 533.0027. Procedures to Ensure Certain Recipients Are Enrolled in Same Managed Care Plan

Sec. 533.0027.  PROCEDURES TO ENSURE CERTAIN RECIPIENTS ARE ENROLLED IN SAME MANAGED CARE PLAN.  The commission shall ensure that all recipients who are children and who reside in the same household may, at the family's election, be enrolled in the same managed care plan.|Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(b), eff. September 28, 2011.|
TX Govt Code § 533.0028 (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 533.0028. Evaluation of Certain Star + Plus Medicaid Managed Care Program Services

Sec. 533.0028.  EVALUATION OF CERTAIN STAR + PLUS MEDICAID MANAGED CARE PROGRAM SERVICES.  The external quality review organization shall periodically conduct studies and surveys to assess the quality of care and satisfaction with health care services provided to enrollees in the STAR + PLUS Medicaid managed care program who are eligible to receive health care benefits under both Medicaid and the Medicare program.|Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(b), eff. September 28, 2011.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.219, eff. April 2, 2015.|
TX Govt Code § 533.00281 (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 533.00281. Utilization Review for Star + Plus Medicaid Managed Care Organizations

Sec. 533.00281.  UTILIZATION REVIEW FOR STAR + PLUS MEDICAID MANAGED CARE ORGANIZATIONS.  (a)  The commission's office of contract management shall establish an annual utilization review process for managed care organizations participating in the STAR + PLUS Medicaid managed care program.  The commission shall determine the topics to be examined in the review process, except that the review process must include a thorough investigation of each managed care organization's procedures for determining whether a recipient should be enrolled in the STAR + PLUS home and community-based services and supports (HCBS) program, including the conduct of functional assessments for that purpose and records relating to those assessments.(b)  The office of contract management shall use the utilization review process to review each fiscal year:(1)  every managed care organization participating in the STAR + PLUS Medicaid managed care program; or(2)  only the managed care organizations that, using a risk-based assessment process, the office determines have a higher likelihood of inappropriate client placement in the STAR + PLUS home and community-based services and supports (HCBS) program.(c)  Expired.(d)  In conjunction with the commission's office of contract management, the commission shall provide a report to the standing committees of the senate and house of representatives with jurisdiction over Medicaid not later than December 1 of each year.  The report must:(1)  summarize the results of the utilization reviews conducted under this section during the preceding fiscal year;(2)  provide analysis of errors committed by each reviewed managed care organization; and(3)  extrapolate those findings and make recommendations for improving the efficiency of the program.(e)  If a utilization review conducted under this section results in a determination to recoup money from a managed care organization, a service provider who contracts with the managed care organization may not be held liable for the good faith provision of services based on an authorization from the managed care organization.|Added by Acts 2013, 83rd Leg., R.S., Ch. 76 (S.B. 348), Sec. 1, eff. May 18, 2013.Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.220, eff. April 2, 2015.|
TX Govt Code § 533.00282 (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 533.00282. Utilization Review and Prior Authorization Procedures

Sec. 533.00282.  UTILIZATION REVIEW AND PRIOR AUTHORIZATION PROCEDURES.  (a)  Section 4201.304(a)(2), Insurance Code, does not apply to a Medicaid managed care organization or a utilization review agent who conducts utilization reviews for a Medicaid managed care organization.(b)  In addition to the requirements of Section 533.005, a contract between a Medicaid managed care organization and the commission must require that:(1)  before issuing an adverse determination on a prior authorization request, the organization provide the physician requesting the prior authorization with a reasonable opportunity to discuss the request with another physician who practices in the same or a similar specialty, but not necessarily the same subspecialty, and has experience in treating the same category of population as the recipient on whose behalf the request is submitted; and(2)  the organization review and issue determinations on prior authorization requests with respect to a recipient who is not hospitalized at the time of the request according to the following time frames:(A)  within three business days after receiving the request; or(B)  within the time frame and following the process established by the commission if the organization receives a request for prior authorization that does not include sufficient or adequate documentation.(c)  In consultation with the state Medicaid managed care advisory committee, the commission shall establish a process for use by a Medicaid managed care organization that receives a prior authorization request, with respect to a recipient who is not hospitalized at the time of the request, that does not include sufficient or adequate documentation.  The process must provide a time frame within which a provider may submit the necessary documentation.  The time frame must be longer than the time frame specified by Subsection (b)(2)(A) within which a Medicaid managed care organization must issue a determination on a prior authorization request.|Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.|
TX Govt Code § 533.002821 (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 533.002821. Prior Authorization Procedures for Hospitalized Recipient

Sec. 533.002821.  PRIOR AUTHORIZATION PROCEDURES FOR HOSPITALIZED RECIPIENT.  In addition to the requirements of Section 533.005, a contract between a managed care organization and the commission described by that section must require that, notwithstanding any other law, the organization review and issue determinations on prior authorization requests with respect to a recipient who is hospitalized at the time of the request according to the following time frames:(1)  within one business day after receiving the request, except as provided by Subdivisions (2) and (3);(2)  within 72 hours after receiving the request if the request is submitted by a provider of acute care inpatient services for services or equipment necessary to discharge the recipient from an inpatient facility; or(3)  within one hour after receiving the request if the request is related to poststabilization care or a life-threatening condition.|Added by Acts 2019, 86th Leg., R.S., Ch. 619 (S.B. 1096), Sec. 2, eff. September 1, 2019.|
TX Govt Code § 533.00283 (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 533.00283. Annual Review of Prior Authorization Requirements

Sec. 533.00283.  ANNUAL REVIEW OF PRIOR AUTHORIZATION REQUIREMENTS.  (a)  Each Medicaid managed care organization, in consultation with the organization's provider advisory group required by contract, shall develop and implement a process to conduct an annual review of the organization's prior authorization requirements, other than a prior authorization requirement prescribed by or implemented under Section 531.073 for the vendor drug program.  In conducting a review, the organization must:(1)  solicit, receive, and consider input from providers in the organization's provider network; and(2)  ensure that each prior authorization requirement is based on accurate, up-to-date, evidence-based, and peer-reviewed clinical criteria that distinguish, as appropriate, between categories, including age, of recipients for whom prior authorization requests are submitted.(b)  A Medicaid managed care organization may not impose a prior authorization requirement, other than a prior authorization requirement prescribed by or implemented under Section 531.073 for the vendor drug program, unless the organization has reviewed the requirement during the most recent annual review required under this section.(c)  The commission shall periodically review each Medicaid managed care organization to ensure the organization's compliance with this section.|Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.|
TX Govt Code § 533.00284 (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 533.00284. Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests

Sec. 533.00284.  RECONSIDERATION FOLLOWING ADVERSE DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS.  (a)  In consultation with the state Medicaid managed care advisory committee, the commission shall establish a uniform process and timeline for Medicaid managed care organizations to reconsider an adverse determination on a prior authorization request that resulted solely from the submission of insufficient or inadequate documentation.  In addition to the requirements of Section 533.005, a contract between a Medicaid managed care organization and the commission must include a requirement that the organization implement the process and timeline.(b)  The process and timeline must:(1)  allow a provider to submit any documentation that was identified as insufficient or inadequate in the notice provided under Section 531.024162;(2)  allow the provider requesting the prior authorization to discuss the request with another provider who practices in the same or a similar specialty, but not necessarily the same subspecialty, and has experience in treating the same category of population as the recipient on whose behalf the request is submitted; and(3)  require the Medicaid managed care organization to amend the determination on the prior authorization request as necessary, considering the additional documentation.(c)  An adverse determination on a prior authorization request is considered a denial of services in an evaluation of the Medicaid managed care organization only if the determination is not amended under Subsection (b)(3) to approve the request.(d)  The process and timeline for reconsidering an adverse determination on a prior authorization request under this section do not affect:(1)  any related timelines, including the timeline for an internal appeal, a Medicaid fair hearing, or a review conducted by an external medical reviewer; or(2)  any rights of a recipient to appeal a determination on a prior authorization request.|Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.|
TX Govt Code § 533.002841 (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 533.002841. Maximum Period for Prior Authorization Decision; Access to Care

Sec. 533.002841.  MAXIMUM PERIOD FOR PRIOR AUTHORIZATION DECISION; ACCESS TO CARE.  The time frames prescribed by the utilization review and prior authorization procedures described by Section 533.00282 and the timeline for reconsidering an adverse determination on a prior authorization described by Section 533.00284 together may not exceed the time frame for a decision under federally prescribed time frames.  It is the intent of the legislature that these provisions allow sufficient time to provide necessary documentation and avoid unnecessary denials without delaying access to care.|Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.|