reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0272. Certain Services Permitted in Lieu of Other Mental Health or Substance Use Disorder Services; Annual Report

Text of section effective on April 01, 2025
Sec. 540.0272.  CERTAIN SERVICES PERMITTED IN LIEU OF OTHER MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICES; ANNUAL REPORT.  A contract to which this subchapter applies must contain language permitting the contracting Medicaid managed care organization to offer medically appropriate, cost-effective, evidence-based services from a list approved by the state Medicaid managed care advisory committee and included in the contract in lieu of mental health or substance use disorder services specified in the state Medicaid plan. A recipient is not required to use a service from the list included in the contract in lieu of another mental health or substance use disorder service specified in the state Medicaid plan. The commission shall:
(1)  prepare and submit to the legislature an annual report on the number of times during the preceding year a service from the list included in the contract is used; and
(2)  consider the actual cost and use of any services from the list included in the contract that are offered by a Medicaid managed care organization when setting the capitation rates for that organization under the contract.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0273. Outpatient Pharmacy Benefit Plan

Text of section effective on April 01, 2025
Sec. 540.0273.  OUTPATIENT PHARMACY BENEFIT PLAN.  (a)  Subject to Subsection (b), a contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop, implement, and maintain an outpatient pharmacy benefit plan for the organization's enrolled recipients that:
(1)  except as provided by Section 540.0280(2), exclusively employs the vendor drug program formulary and preserves this state's ability to reduce Medicaid fraud, waste, and abuse;
(2)  adheres to the applicable preferred drug list the commission adopts under Subchapter E, Chapter 549;
(3)  except as provided by Section 540.0280(1), includes the prior authorization procedures and requirements prescribed by or implemented under Sections 549.0257(a) and (c) and 549.0259 for the vendor drug program;
(4)  does not require a clinical, nonpreferred, or other prior authorization for any antiretroviral drug, as defined by Section 549.0252, or a step therapy or other protocol, that could restrict or delay the dispensing of the drug except to minimize fraud, waste, or abuse; and
(5)  does not require prior authorization for a nonpreferred antipsychotic drug prescribed to an adult recipient if the requirements of Section 549.0253(a) are met.
(b)  The requirements imposed by Subsections (a)(1)-(3) do not apply, and may not be enforced, on and after August 31, 2023.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0274. Pharmacy Benefit Plan: Rebates and Receipt of Confidential Information Prohibited

Text of section effective on April 01, 2025
Sec. 540.0274.  PHARMACY BENEFIT PLAN: REBATES AND RECEIPT OF CONFIDENTIAL INFORMATION PROHIBITED.  A Medicaid managed care organization, for purposes of the organization's outpatient pharmacy benefit plan required by Section 540.0273 in a contract to which this subchapter applies, may not:
(1)  negotiate or collect rebates associated with pharmacy products on the vendor drug program formulary; or
(2)  receive drug rebate or pricing information that is confidential under Subchapter D, Chapter 549.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0275. Pharmacy Benefit Plan: Certain Pharmacy Benefits for Sex Offenders Prohibited

Text of section effective on April 01, 2025
Sec. 540.0275.  PHARMACY BENEFIT PLAN: CERTAIN PHARMACY BENEFITS FOR SEX OFFENDERS PROHIBITED.  A Medicaid managed care organization's pharmacy benefit plan required by Section 540.0273 in a contract to which this subchapter applies must comply with the prohibition under Section 549.0004.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0276. Pharmacy Benefit Plan: Recipient Selection of Pharmaceutical Services Provider

Text of section effective on April 01, 2025
Sec. 540.0276.  PHARMACY BENEFIT PLAN: RECIPIENT SELECTION OF PHARMACEUTICAL SERVICES PROVIDER.  A Medicaid managed care organization, under the organization's pharmacy benefit plan required by Section 540.0273 in a contract to which this subchapter applies, may not prohibit, limit, or interfere with a recipient's selection of a pharmacy or pharmacist of the recipient's choice to provide pharmaceutical services under the plan by imposing different copayments.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0277. Pharmacy Benefit Plan: Pharmacy Benefit Providers

Text of section effective on April 01, 2025
Sec. 540.0277.  PHARMACY BENEFIT PLAN: PHARMACY BENEFIT PROVIDERS.  (a)  A Medicaid managed care organization's pharmacy benefit plan required by Section 540.0273 in a contract to which this subchapter applies must allow the organization or any subcontracted pharmacy benefit manager to contract with a pharmacist or pharmacy providers separately for specialty pharmacy services, except that:
(1)  the organization and pharmacy benefit manager are prohibited from allowing exclusive contracts with a specialty pharmacy owned wholly or partly by the pharmacy benefit manager responsible for administering the pharmacy benefit program; and
(2)  the organization and pharmacy benefit manager must adopt policies and procedures for reclassifying prescription drugs from retail to specialty drugs that:
(A)  are consistent with rules the executive commissioner adopts; and
(B)  include notice to network pharmacy providers from the organization.
(b)  A Medicaid managed care organization, under the organization's pharmacy benefit plan required by Section 540.0273 in a contract to which this subchapter applies:
(1)  may not prevent a pharmacy or pharmacist from participating as a provider if the pharmacy or pharmacist agrees to comply with the financial terms, as well as other reasonable administrative and professional terms, of the contract;
(2)  may include mail-order pharmacies in the organization's networks, but may not require enrolled recipients to use those pharmacies; and
(3)  may not charge an enrolled recipient who opts to use a mail-order pharmacy a fee, including a postage or handling fee.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0278. Pharmacy Benefit Plan: Prompt Payment of Pharmacy Benefit Claims

Text of section effective on April 01, 2025
Sec. 540.0278.  PHARMACY BENEFIT PLAN: PROMPT PAYMENT OF PHARMACY BENEFIT CLAIMS.  A Medicaid managed care organization or pharmacy benefit manager, as applicable, under the organization's pharmacy benefit plan required by Section 540.0273 in a contract to which this subchapter applies, must pay claims in accordance with Section 843.339, Insurance Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0280. Pharmacy Benefit Plan: Pharmacy Benefits for Child Enrolled in Star Kids Managed Care Program

Text of section effective on April 01, 2025
Sec. 540.0280.  PHARMACY BENEFIT PLAN: PHARMACY BENEFITS FOR CHILD ENROLLED IN STAR KIDS MANAGED CARE PROGRAM.  A Medicaid managed care organization or pharmacy benefit manager, as applicable, under the organization's pharmacy benefit plan required by Section 540.0273 in a contract to which this subchapter applies:
(1)  may not require a prior authorization, other than a clinical prior authorization or a prior authorization the commission imposes to minimize the opportunity for fraud, waste, or abuse, for or impose any other barriers to a drug that is prescribed to a child enrolled in the STAR Kids managed care program for a particular disease or treatment and that is on the vendor drug program formulary or require additional prior authorization for a drug included in the preferred drug list the commission adopts under Subchapter E, Chapter 549;
(2)  must provide continued access to a drug prescribed to a child enrolled in the STAR Kids managed care program, regardless of whether the drug is on the vendor drug program formulary or, if applicable on or after August 31, 2023, the organization's formulary;
(3)  may not use a protocol that requires a child enrolled in the STAR Kids managed care program to use a prescription drug or sequence of prescription drugs other than the drug the child's physician recommends for the child's treatment before the organization will cover the recommended drug; and
(4)  must pay liquidated damages to the commission for each failure, as the commission determines, to comply with this section in an amount that is a reasonable forecast of the damages caused by the noncompliance.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter G. Prior Authorization and Utilization Review Procedures › Section 540.0301. Inapplicability of Certain Other Law to Medicaid Managed Care Utilization Reviews

Text of section effective on April 01, 2025
Sec. 540.0301.  INAPPLICABILITY OF CERTAIN OTHER LAW TO MEDICAID MANAGED CARE UTILIZATION REVIEWS.  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.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter G. Prior Authorization and Utilization Review Procedures › Section 540.0302. Prior Authorization Procedures for Hospitalized Recipient

Text of section effective on April 01, 2025
Sec. 540.0302.  PRIOR AUTHORIZATION PROCEDURES FOR HOSPITALIZED RECIPIENT.  (a)  This section applies only to a prior authorization request submitted with respect to a recipient who is hospitalized at the time of the request.
(b)  In addition to the requirements of Subchapter F, a contract between a Medicaid managed care organization and the commission to which that subchapter applies must require that, notwithstanding any other law, the organization review and issue a determination on a prior authorization request to which this section applies according to the following time frames:
(1)  within one business day after the organization receives the request, except as provided by Subdivisions (2) and (3);
(2)  within 72 hours after the organization receives the request if a provider of acute care inpatient services submits the request and the request is for services or equipment necessary to discharge the recipient from an inpatient facility; or
(3)  within one hour after the organization receives the request if the request is related to poststabilization care or a life-threatening condition.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter G. Prior Authorization and Utilization Review Procedures › Section 540.0303. Prior Authorization Procedures for Nonhospitalized Recipient

Text of section effective on April 01, 2025
Sec. 540.0303.  PRIOR AUTHORIZATION PROCEDURES FOR NONHOSPITALIZED RECIPIENT.  (a)  This section applies only to a prior authorization request submitted with respect to a recipient who is not hospitalized at the time of the request.
(b)  In addition to the requirements of Subchapter F, a contract between a Medicaid managed care organization and the commission to which that subchapter applies must require that the organization review and issue a determination on a prior authorization request to which this section applies according to the following time frames:
(1)  within three business days after the organization receives the request; or
(2)  within the time frame and following the process the commission establishes if the organization receives a prior authorization request 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 to which this section applies 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)(1).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter G. Prior Authorization and Utilization Review Procedures › Section 540.0304. Annual Review of Prior Authorization Requirements

Text of section effective on April 01, 2025
Sec. 540.0304.  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 for conducting an annual review of the organization's prior authorization requirements. The annual review process does not apply to a prior authorization requirement prescribed by or implemented under Subchapter F, Chapter 549, for the vendor drug program.
(b)  In conducting an annual review, a Medicaid managed care 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, as appropriate, distinguish between categories of recipients for whom prior authorization requests are submitted, including age categories.
(c)  A Medicaid managed care organization may not impose a prior authorization requirement, other than a prior authorization requirement prescribed by or implemented under Subchapter F, Chapter 549, for the vendor drug program, unless the organization reviewed the requirement during the most recent annual review.
(d)  The commission shall periodically review each Medicaid managed care organization to ensure the organization's compliance with this section.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter G. Prior Authorization and Utilization Review Procedures › Section 540.0305. Physician Consultation Before Adverse Prior Authorization Determination

Text of section effective on April 01, 2025
Sec. 540.0305.  PHYSICIAN CONSULTATION BEFORE ADVERSE PRIOR AUTHORIZATION DETERMINATION.  In addition to the requirements of Subchapter F, a contract between a Medicaid managed care organization and the commission to which that subchapter applies must require that, 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:
(1)  practices in the same or a similar specialty, but not necessarily the same subspecialty; and
(2)  has experience in treating the same category of population as the recipient on whose behalf the physician submitted the request.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter G. Prior Authorization and Utilization Review Procedures › Section 540.0306. Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests

Text of section effective on April 01, 2025
Sec. 540.0306.  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 a Medicaid managed care organization 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 Subchapter F, a contract between a Medicaid managed care organization and the commission to which that subchapter applies 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 identified as insufficient or inadequate in the notice provided under Section 532.0403;
(2)  allow the provider requesting the prior authorization to discuss the request with another provider who:
(A)  practices in the same or a similar specialty, but not necessarily the same subspecialty; and
(B)  has experience in treating the same category of population as the recipient on whose behalf the provider submitted the request; 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 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter G. Prior Authorization and Utilization Review Procedures › Section 540.0307. Maximum Period for Prior Authorization Decision; Access to Care

Text of section effective on April 01, 2025
Sec. 540.0307.  MAXIMUM PERIOD FOR PRIOR AUTHORIZATION DECISION; ACCESS TO CARE. The combined amount of time provided for the time frames prescribed by the utilization review and prior authorization procedures described by Sections 540.0301, 540.0303, and 540.0305 and the timeline for reconsidering an adverse determination on a prior authorization described by Section 540.0306 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 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter H. Premium Payment Rates › Section 540.0351. Premium Payment Rate Determination

Text of section effective on April 01, 2025
Sec. 540.0351.  PREMIUM PAYMENT RATE DETERMINATION.  (a)  In determining premium payment rates paid to a managed care organization under a managed care plan, the commission shall consider:
(1)  the regional variation in health care service costs;
(2)  the range and type of health care services that premium payment rates are to cover;
(3)  the number of managed care plans in a region;
(4)  the current and projected number of recipients in each region, including the current and projected number for each category of recipient;
(5)  the managed care plan's ability to meet operating costs under the proposed premium payment rates;
(6)  the requirements of the Balanced Budget Act of 1997 (Pub. L. No. 105-33) and implementing regulations that require adequacy of premium payments to Medicaid managed care organizations;
(7)  the adequacy of the management fee paid for assisting enrollees of Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.) who are voluntarily enrolled in the managed care plan;
(8)  the impact of reducing premium payment rates for the category of pregnant recipients; and
(9)  the managed care plan's ability under the proposed premium payment rates to pay inpatient and outpatient hospital provider payment rates that are comparable to the inpatient and outpatient hospital provider payment rates the commission pays under a primary care case management model or a partially capitated model.
(b)  The premium payment rates paid to a managed care organization that holds a certificate of authority issued under Chapter 843, Insurance Code, must be established by a competitive bid process but may not exceed the maximum premium payment rates the commission establishes under Section 540.0352(b).
(c)  The commission shall pursue and, if appropriate, implement premium rate-setting strategies that encourage provider payment reform and more efficient service delivery and provider practices.  In pursuing the strategies, the commission shall review and consider strategies employed or under consideration by other states.  If necessary, the commission may request a waiver or other authorization from a federal agency to implement strategies the commission identifies under this subsection.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter H. Premium Payment Rates › Section 540.0352. Maximum Premium Payment Rates for Certain Programs

Text of section effective on April 01, 2025
Sec. 540.0352.  MAXIMUM PREMIUM PAYMENT RATES FOR CERTAIN PROGRAMS.  (a)  This section applies only to a Medicaid managed care organization that holds a certificate of authority issued under Chapter 843, Insurance Code, and with respect to Medicaid managed care pilot programs, Medicaid behavioral health pilot programs, and Medicaid STAR+PLUS pilot programs implemented in a health care service region after June 1, 1999.
(b)  In determining the maximum premium payment rates paid to a Medicaid managed care organization to which this section applies, the commission shall consider and adjust for the regional variation in costs of services under the traditional fee-for-service component of Medicaid, utilization patterns, and other factors that influence the potential for cost savings. For a service area with a service area factor of.93 or less, or another appropriate service area factor, as the commission determines, the commission may not discount premium payment rates in an amount that is more than the amount necessary to meet federal budget neutrality requirements for projected fee-for-service costs unless:
(1)  a historical review of managed care financial results among managed care organizations in the service area the organization serves demonstrates that additional savings are warranted; or
(2)  a review of Medicaid fee-for-service delivery in the service area the organization serves has historically shown:
(A)  significant recipient overutilization of certain services covered by the premium payment rates in comparison to utilization patterns throughout the rest of this state; or
(B)  an above-market cost for services for which there is substantial evidence that Medicaid managed care delivery will reduce the cost of those services.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter H. Premium Payment Rates › Section 540.0353. Use of Encounter Data in Determining Premium Payment Rates and Other Payment Amounts

Text of section effective on April 01, 2025
Sec. 540.0353.  USE OF ENCOUNTER DATA IN DETERMINING PREMIUM PAYMENT RATES AND OTHER PAYMENT AMOUNTS.  (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)  In 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 recipient utilization patterns and health care service costs;
(2)  the range and type of health care services premium payment rates are to cover;
(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 recipient category.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter I. Encounter Data › Section 540.0401. Provider Reporting of Encounter Data

Text of section effective on April 01, 2025
Sec. 540.0401.  PROVIDER REPORTING OF ENCOUNTER DATA.  The commission shall collaborate with Medicaid managed care organizations and health care providers in the organizations' provider networks to develop incentives and mechanisms to encourage providers to report complete and accurate encounter data to the organizations in a timely manner.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter I. Encounter Data › Section 540.0402. Certifier of Encounter Data Qualifications

Text of section effective on April 01, 2025
Sec. 540.0402.  CERTIFIER OF ENCOUNTER DATA QUALIFICATIONS.  (a)  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 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 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter I. Encounter Data › Section 540.0403. Encounter Data Certification

Text of section effective on April 01, 2025
Sec. 540.0403.  ENCOUNTER DATA CERTIFICATION.  (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 of encounter data 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 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter J. Managed Care Plan Requirements › Section 540.0451. Medicaid Managed Care Plan Accreditation

Text of section effective on April 01, 2025
Sec. 540.0451.  MEDICAID MANAGED CARE PLAN ACCREDITATION.  (a)  A Medicaid managed care plan must be accredited by a nationally recognized accreditation organization. The commission may:
(1)  require all Medicaid managed care plans to be accredited by the same organization; or
(2)  allow for accreditation by different organizations.
(b)  The commission may use the data, scoring, and other information provided to or received from an accreditation organization in the commission's contract oversight process.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter J. Managed Care Plan Requirements › Section 540.0452. Medical Director Qualifications

Text of section effective on April 01, 2025
Sec. 540.0452.  MEDICAL DIRECTOR QUALIFICATIONS.  An individual who serves as a medical director for a managed care plan must be a physician licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter K. Medicaid Managed Care Plan Enrollment and Disenrollment › Section 540.0501. Recipient Enrollment in and Disenrollment From Medicaid Managed Care Plan

Text of section effective on April 01, 2025
Sec. 540.0501.  RECIPIENT ENROLLMENT IN AND DISENROLLMENT FROM MEDICAID MANAGED CARE PLAN.  The commission shall:
(1)  encourage recipients to choose appropriate Medicaid managed care plans and primary health care providers by:
(A)  providing initial information to recipients and providers in a region about the need for recipients to choose plans and providers not later than the 90th day before the date a Medicaid managed care organization plans to begin providing health care services to recipients in that region through managed care;
(B)  providing follow-up information before assignment of plans and providers and after assignment, if necessary, to recipients who delay in choosing plans and providers; and
(C)  allowing plans and providers to provide information to recipients or engage in marketing activities under marketing guidelines the commission establishes under Section 540.0055(a) after the commission approves the information or activities;
(2)  in assigning plans and providers to recipients who fail to choose plans and providers, consider:
(A)  the importance of maintaining existing provider-patient and physician-patient relationships, including relationships with specialists, public health clinics, and community health centers;
(B)  to the extent possible, the need to assign family members to the same providers and plans; and
(C)  geographic convenience of plans and providers for recipients;
(3)  retain responsibility for enrolling recipients in and disenrolling recipients from plans, except that the commission may delegate the responsibility to an independent contractor who receives no form of payment from, and has no financial ties to, any managed care organization;
(4)  develop and implement an expedited process for determining eligibility for and enrolling pregnant women and newborn infants in plans; and
(5)  ensure immediate access to prenatal services and newborn care for pregnant women and newborn infants enrolled in plans, including ensuring that a pregnant woman may obtain an appointment with an obstetrical care provider for an initial maternity evaluation not later than the 30th day after the date the woman applies for Medicaid.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter K. Medicaid Managed Care Plan Enrollment and Disenrollment › Section 540.0502. Automatic Enrollment in Medicaid Managed Care Plan

Text of section effective on April 01, 2025
Sec. 540.0502.  AUTOMATIC ENROLLMENT IN MEDICAID MANAGED CARE PLAN.  (a)  If the commission determines that it is feasible and notwithstanding any other law, the commission may implement an automatic enrollment process under which an applicant determined eligible for Medicaid is automatically enrolled in a Medicaid managed care plan the applicant chooses.
(b)  The commission may elect to implement the automatic enrollment process for certain recipient populations.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter K. Medicaid Managed Care Plan Enrollment and Disenrollment › Section 540.0503. Enrollment of Certain Recipients in Same Medicaid Managed Care Plan

Text of section effective on April 01, 2025
Sec. 540.0503.  ENROLLMENT OF CERTAIN RECIPIENTS IN SAME MEDICAID 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 Medicaid managed care plan.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter K. Medicaid Managed Care Plan Enrollment and Disenrollment › Section 540.0504. Quality-Based Enrollment Incentive Program for Medicaid Managed Care Organizations

Text of section effective on April 01, 2025
Sec. 540.0504.  QUALITY-BASED ENROLLMENT INCENTIVE PROGRAM FOR MEDICAID MANAGED CARE ORGANIZATIONS.  The commission shall create an incentive program that automatically enrolls in a Medicaid managed care plan a greater percentage of recipients who did not actively choose a plan, based on:
(1)  the quality of care provided through the Medicaid managed care organization offering the plan;
(2)  the organization's ability to efficiently and effectively provide services, considering the acuity of populations the organization primarily serves; and
(3)  the organization's performance with respect to exceeding or failing to achieve appropriate outcome and process measures the commission develops, including measures based on potentially preventable events.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter K. Medicaid Managed Care Plan Enrollment and Disenrollment › Section 540.0505. Limitations on Recipient Disenrollment From Medicaid Managed Care Plan

Text of section effective on April 01, 2025
Sec. 540.0505.  LIMITATIONS ON RECIPIENT DISENROLLMENT FROM MEDICAID MANAGED CARE PLAN.  (a)  Except as provided by Subsections (b) and (c) and to the extent permitted by federal law, a recipient enrolled in a Medicaid managed care plan may not disenroll from that plan and enroll in another Medicaid managed care plan during the 12-month period after the date the recipient initially enrolls in a plan.
(b)  At any time before the 91st day after the date of a recipient's initial enrollment in a Medicaid managed care plan, the recipient may disenroll from that plan for any reason and enroll in another Medicaid managed care plan.
(c)  The commission shall allow a recipient who is enrolled in a Medicaid managed care plan to disenroll from that plan and enroll in another Medicaid managed care plan:
(1)  at any time for cause in accordance with federal law; and
(2)  once for any reason after the periods described by Subsections (a) and (b).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter L. Continuity of Care and Coordination of Benefits › Section 540.0551. Guidance Regarding Continuation of Services Under Certain Circumstances

Text of section effective on April 01, 2025
Sec. 540.0551.  GUIDANCE REGARDING CONTINUATION OF SERVICES UNDER CERTAIN CIRCUMSTANCES.  The commission shall provide guidance and additional education to Medicaid managed care organizations regarding federal law requirements to continue providing services during an internal appeal, a Medicaid fair hearing, or any other review.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter M. Provider Network Adequacy › Section 540.0601. Monitoring of Provider Networks

Text of section effective on April 01, 2025
Sec. 540.0601.  MONITORING OF PROVIDER NETWORKS.  The commission shall establish and implement a process for the direct monitoring of a Medicaid managed care organization's provider network and providers in the network.  The process:
(1)  must be used to ensure compliance with contractual obligations related to:
(A)  the number of providers accepting new patients under the Medicaid managed care program; and
(B)  the length of time a recipient must wait between scheduling an appointment with a provider and receiving treatment from the provider;
(2)  may use reasonable methods to ensure compliance with contractual obligations, including telephone calls made at random times without notice to assess the availability of providers and services to new and existing recipients; and
(3)  may be implemented directly by the commission or through a contractor.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter M. Provider Network Adequacy › Section 540.0602. Report on Out-of-Network Provider Services

Text of section effective on April 01, 2025
Sec. 540.0602.  REPORT ON OUT-OF-NETWORK PROVIDER SERVICES.  To ensure appropriate access to an adequate provider network, each Medicaid managed care organization providing health care services to recipients in a health care service region shall submit to the commission, in the format and manner the commission prescribes, a report detailing the number, type, and scope of services out-of-network providers provide to recipients enrolled in a Medicaid managed care plan the organization provides.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter M. Provider Network Adequacy › Section 540.0603. Report on Commission Investigation of Provider Complaint

Text of section effective on April 01, 2025
Sec. 540.0603.  REPORT ON COMMISSION INVESTIGATION OF PROVIDER COMPLAINT.  Not later than the 60th day after the date a provider files a complaint with the commission regarding reimbursement for or overuse of out-of-network providers by a Medicaid managed care organization, the commission shall provide to the provider a report regarding the conclusions of the commission's investigation.  The report must include:
(1)  a description of any corrective action required of the organization that was the subject of the complaint; and
(2)  if applicable, a conclusion regarding the amount of reimbursement owed to an out-of-network provider.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter M. Provider Network Adequacy › Section 540.0604. Additional Reimbursement Following Provider Complaint

Text of section effective on April 01, 2025
Sec. 540.0604.  ADDITIONAL REIMBURSEMENT FOLLOWING PROVIDER COMPLAINT.  (a)  If, after an investigation, the commission determines that a Medicaid managed care organization owes additional reimbursement to a provider, the organization shall, not later than the 90th day after the date the provider filed the complaint, pay the additional reimbursement or provide to the provider a reimbursement payment plan under which the organization must pay the entire amount of the additional reimbursement not later than the 120th day after the date the provider filed the complaint.
(b)  The commission may require a Medicaid managed care organization to pay interest on any amount of the additional reimbursement that is not paid on or before the 90th day after the date the provider to whom the amount is owed filed the complaint.  If the commission requires the organization to pay interest, interest accrues at a rate of 18 percent simple interest per year on the unpaid amount beginning on the 90th day after the date the provider to whom the amount is owed filed the complaint and accrues until the date the organization pays the entire reimbursement amount.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter M. Provider Network Adequacy › Section 540.0605. Corrective Action Plan for Inadequate Network and Provider Reimbursement

Text of section effective on April 01, 2025
Sec. 540.0605.  CORRECTIVE ACTION PLAN FOR INADEQUATE NETWORK AND PROVIDER REIMBURSEMENT.  (a)  The commission shall initiate a corrective action plan requiring a Medicaid managed care organization to maintain an adequate provider network, provide reimbursement to support that network, and educate recipients enrolled in Medicaid managed care plans provided by the organization regarding the proper use of the plan's provider network, if:
(1)  as the commission determines, the organization exceeds maximum limits the commission established for out-of-network access to health care services; or
(2)  based on the commission's investigation of a provider complaint regarding reimbursement, the commission determines that the organization did not reimburse an out-of-network provider based on a reasonable reimbursement methodology.
(b)  The corrective action plan required by Subsection (a) must include at least one of the following elements:
(1)  a requirement that reimbursements the Medicaid managed care organization pays to out-of-network providers for a health care service provided to a recipient enrolled in a Medicaid managed care plan provided by the organization equal the allowable rate for the service, as determined under Sections 32.028 and 32.0281, Human Resources Code, for all health care services provided during the period the organization:
(A)  is not in compliance with the utilization benchmarks the commission determines; or
(B)  is not reimbursing out-of-network providers based on a reasonable methodology, as the commission determines;
(2)  an immediate freeze on the enrollment of additional recipients in a Medicaid managed care plan the organization provides that continues until the commission determines that the provider network under the plan can adequately meet the needs of additional recipients; and
(3)  other actions the commission determines are necessary to ensure that recipients enrolled in a Medicaid managed care plan the organization provides have access to appropriate health care services and that providers are properly reimbursed for providing medically necessary health care services to those recipients.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter M. Provider Network Adequacy › Section 540.0606. Remedies for Noncompliance With Corrective Action Plan

Text of section effective on April 01, 2025
Sec. 540.0606.  REMEDIES FOR NONCOMPLIANCE WITH CORRECTIVE ACTION PLAN.  The commission shall pursue any appropriate remedy authorized in the contract between the Medicaid managed care organization and the commission if the organization fails to comply with a corrective action plan under Section 540.0605(a).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.