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 N. Providers › Section 540.0652. Provider Access Standards; Biennial Report

Text of section effective on April 01, 2025
Sec. 540.0652.  PROVIDER ACCESS STANDARDS; BIENNIAL REPORT.  (a)  The commission shall establish minimum provider access standards for a Medicaid managed care organization's provider network.  The provider access standards must ensure that a Medicaid managed care organization provides recipients sufficient access to:
(1)  preventive care;
(2)  primary care;
(3)  specialty care;
(4)  after-hours urgent care;
(5)  chronic care;
(6)  long-term services and supports;
(7)  nursing services;
(8)  therapy services, including services provided in a clinical setting or in a home or community-based setting; and
(9)  any other services the commission identifies.
(b)  To the extent feasible, the provider access standards must:
(1)  distinguish between access to providers in urban and rural settings;
(2)  consider the number and geographic distribution of Medicaid-enrolled providers in a particular service delivery area; and
(3)  subject to Section 548.0054(a) and consistent with Section 111.007, Occupations Code, consider and include the availability of telehealth services and telemedicine medical services in a Medicaid managed care organization's provider network.
(c)  The commission shall biennially submit to the legislature and make available to the public a report that contains:
(1)  information and statistics on:
(A)  recipient access to providers through Medicaid managed care organizations' provider networks; and
(B)  Medicaid managed care organization compliance with contractual obligations related to provider access standards;
(2)  a compilation and analysis of information Medicaid managed care organizations submit to the commission under Section 540.0260(4);
(3)  for both primary care providers and specialty providers, information on provider-to-recipient ratios in a Medicaid managed care organization's provider network and benchmark ratios to indicate whether deficiencies exist in a given network; and
(4)  a description of, and analysis of the results from, the commission's monitoring process established under Section 540.0601.
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 N. Providers › Section 540.0653. Penalties and Other Remedies for Failure to Comply With Provider Access Standards

Text of section effective on April 01, 2025
Sec. 540.0653.  PENALTIES AND OTHER REMEDIES FOR FAILURE TO COMPLY WITH PROVIDER ACCESS STANDARDS.  If a Medicaid managed care organization fails to comply with one or more provider access standards the commission establishes under Section 540.0652 and the commission determines the organization has not made substantial efforts to mitigate or remedy the noncompliance, the commission:
(1)  may:
(A)  elect to not retain or renew the commission's contract with the organization; or
(B)  require the organization to pay liquidated damages in accordance with Section 540.0260(3); and
(2)  if the organization's noncompliance occurs in a given service delivery area for two consecutive calendar quarters, shall suspend default enrollment to the organization in that service delivery area for at least one calendar quarter.
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 N. Providers › Section 540.0654. Provider Network Directories

Text of section effective on April 01, 2025
Sec. 540.0654.  PROVIDER NETWORK DIRECTORIES.  (a)  The commission shall ensure that a Medicaid managed care organization:
(1)  posts on the organization's Internet website:
(A)  the organization's provider network directory; and
(B)  a direct telephone number and e-mail address through which a recipient enrolled in the organization's managed care plan or the recipient's provider may contact the organization to receive assistance with:
(i)  identifying in-network providers and services available to the recipient; and
(ii)  scheduling an appointment for the recipient with an available in-network provider or to access available in-network services; and
(2)  updates the online directory required under Subdivision (1)(A) at least monthly.
(b)  A Medicaid managed care organization is required to send a paper form of the organization's provider network directory for the program only to a recipient who requests to receive the directory in paper form.
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 N. Providers › Section 540.0656. Expedited Credentialing Process for Certain Providers

Text of section effective on April 01, 2025
Sec. 540.0656.  EXPEDITED CREDENTIALING PROCESS FOR CERTAIN PROVIDERS.  (a)  In this section, "applicant provider" means a physician or other health care provider applying for expedited credentialing.
(b)  Notwithstanding any other law and subject to Subsection (c), a Medicaid managed care organization shall establish and implement an expedited credentialing process that allows an applicant provider to provide services to recipients on a provisional basis.
(c)  The commission shall identify the types of providers for which a Medicaid managed care organization must establish and implement an expedited credentialing process.
(d)  To qualify for expedited credentialing and payment under Subsection (e), an applicant provider must:
(1)  be a member of an established health care provider group that has a current contract with a Medicaid managed care organization;
(2)  be a Medicaid-enrolled provider;
(3)  agree to comply with the terms of the contract described by Subdivision (1); and
(4)  submit all documentation and other information the Medicaid managed care organization requires as necessary to enable the organization to begin the credentialing process the organization requires to include a provider in the organization's provider network.
(e)  On an applicant provider's submission of the information the Medicaid managed care organization requires under Subsection (d), and for Medicaid reimbursement purposes only, the organization shall treat the provider as if the provider were in the organization's provider network when the provider provides services to recipients, subject to Subsections (f) and (g).
(f)  Except as provided by Subsection (g), a Medicaid managed care organization that determines on completion of the credentialing process that an applicant provider does not meet the organization's credentialing requirements may recover from the provider the difference between payments for in-network benefits and out-of-network benefits.
(g)  A Medicaid managed care organization that determines on completion of the credentialing process that an applicant provider does not meet the organization's credentialing requirements and that the provider made fraudulent claims in the provider's application for credentialing may recover from the provider the entire amount the organization paid the 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 N. Providers › Section 540.0657. Frequency of Provider Recredentialing

Text of section effective on April 01, 2025
Sec. 540.0657.  FREQUENCY OF PROVIDER RECREDENTIALING.  (a)  A Medicaid managed care organization shall formally recredential a physician or other provider with the frequency required by the single, consolidated Medicaid provider enrollment and credentialing process, if that process is created under Section 532.0151.
(b)  Notwithstanding any other law, the required frequency of recredentialing may be less frequent than once in any three-year period.
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 N. Providers › Section 540.0658. Provider Incentives for Promoting Preventive Services

Text of section effective on April 01, 2025
Sec. 540.0658.  PROVIDER INCENTIVES FOR PROMOTING PREVENTIVE SERVICES.  To the extent possible, the commission shall work to ensure that a Medicaid managed care organization provides payment incentives to a health care provider in the organization's provider network whose performance in promoting recipient use of preventive services exceeds minimum established standards.
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 N. Providers › Section 540.0659. Reimbursement Rate for Certain Services Provided by Certain Health Centers and Clinics Outside Regular Business Hours

Text of section effective on April 01, 2025
Sec. 540.0659.  REIMBURSEMENT RATE FOR CERTAIN SERVICES PROVIDED BY CERTAIN HEALTH CENTERS AND CLINICS OUTSIDE REGULAR BUSINESS HOURS.  (a)  This section applies only to a recipient receiving benefits through a 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 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 O. Delivery of Services: General Provisions › Section 540.0701. Acute Care Service Delivery Through Most Cost-Effective Model; Managed Care Service Delivery Areas

Text of section effective on April 01, 2025
Sec. 540.0701.  ACUTE CARE SERVICE DELIVERY THROUGH MOST COST-EFFECTIVE MODEL; MANAGED CARE SERVICE DELIVERY AREAS.  (a)  Except as otherwise provided by this section and notwithstanding any other law, the commission shall provide Medicaid acute care services through the most cost-effective model of Medicaid capitated managed care as the commission determines.  The commission shall require mandatory participation in a Medicaid capitated managed care program for all individuals eligible for Medicaid acute care benefits, but may implement alternative models or arrangements, including a traditional fee-for-service arrangement, if the commission determines the alternative would be more cost-effective or efficient.
(b)  In determining whether a model or arrangement described by Subsection (a) is more cost-effective, the executive commissioner must consider:
(1)  the scope, duration, and types of health benefits or services to be provided in a certain part of this state or to a certain recipient population;
(2)  administrative costs necessary to meet federal and state statutory and regulatory requirements;
(3)  the anticipated effect of market competition associated with the configuration of Medicaid service delivery models the commission determines; and
(4)  the gain or loss to this state of a tax collected under Chapter 222, Insurance Code.
(c)  If the commission determines that it is not more cost-effective to use a Medicaid managed care model to provide certain types of Medicaid acute care in a certain area or to certain recipients as prescribed by this section, the commission shall provide Medicaid acute care through a traditional fee-for-service arrangement.
(d)  The commission shall determine the most cost-effective alignment of managed care service delivery areas.  The executive commissioner may consider:
(1)  the number of lives impacted;
(2)  the usual source of health care services for residents in an area; and
(3)  other factors that impact health care service delivery in the area.
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 O. Delivery of Services: General Provisions › Section 540.0702. Transition of Case Management for Children and Pregnant Women Program Recipients to Medicaid Managed Care Program

Text of section effective on April 01, 2025
Sec. 540.0702.  TRANSITION OF CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN PROGRAM RECIPIENTS TO MEDICAID MANAGED CARE PROGRAM.  (a)  In this section, "children and pregnant women program" means the Medicaid benefits program 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 children and pregnant women program recipients.  In transitioning the services, the commission shall ensure a recipient is provided case management services through the Medicaid managed care plan in which the recipient is enrolled.
(c)  In implementing this section, the commission shall ensure that:
(1)  there is a seamless transition in case management services for children and pregnant women program recipients; and
(2)  case management services provided under the program are not interrupted.
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 O. Delivery of Services: General Provisions › Section 540.0703. Behavioral Health and Physical Health Services

Text of section effective on April 01, 2025
Sec. 540.0703.  BEHAVIORAL HEALTH AND PHYSICAL HEALTH SERVICES.  (a)  In this section, "behavioral health services" means mental health and substance use disorder services.
(b)  To the greatest extent possible, the commission shall integrate the following services into the Medicaid managed care program:
(1)  behavioral health services, including targeted case management and psychiatric rehabilitation services; and
(2)  physical health services.
(c)  A Medicaid managed care organization shall:
(1)  develop a network of public and private behavioral health services providers; and
(2)  ensure adults with serious mental illness and children with serious emotional disturbance have access to a comprehensive array of services.
(d)  In implementing this section, the commission shall ensure that:
(1)  an appropriate assessment tool is used to authorize services;
(2)  providers are well-qualified and able to provide an appropriate array of services;
(3)  appropriate performance and quality outcomes are measured;
(4)  two health home pilot programs are established in two health service areas, representing two distinct regions of this state, for individuals who are diagnosed with:
(A)  a serious mental illness; and
(B)  at least one other chronic health condition;
(5)  a health home established under a pilot program under Subdivision (4) complies with the principles for patient-centered medical homes described in Section 540.0712; and
(6)  all behavioral health services provided under this section are based on an approach to treatment in which the expected outcome of treatment is recovery.
(e)  If the commission determines that it is cost-effective and beneficial to recipients, the commission shall include a peer specialist as a benefit to recipients or as a provider type.
(f)  To the extent of any conflict between this section and any other law relating to behavioral health services, this section prevails.
(g)  The executive commissioner shall adopt rules necessary to implement 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 O. Delivery of Services: General Provisions › Section 540.0704. Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families

Text of section effective on April 01, 2025
Sec. 540.0704.  TARGETED CASE MANAGEMENT AND PSYCHIATRIC REHABILITATIVE SERVICES FOR CHILDREN, ADOLESCENTS, AND FAMILIES.  (a)  A provider in the provider network of a Medicaid managed care organization that contracts with the commission to provide behavioral health services under Section 540.0703 may contract with the 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 Medicaid 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 Medicaid 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 Medicaid managed care organization that contracts with the commission to provide behavioral health services under Section 540.0703 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 Medicaid 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 Medicaid managed care organization under Subsection (a) may not require the provider to provide services not covered under 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 O. Delivery of Services: General Provisions › Section 540.0705. Behavioral Health Services Provided Through Third Party or Subsidiary

Text of section effective on April 01, 2025
Sec. 540.0705.  BEHAVIORAL HEALTH SERVICES PROVIDED THROUGH THIRD PARTY OR SUBSIDIARY.  (a)  In this section, "behavioral health services" has the meaning assigned by Section 540.0703.
(b)  For a Medicaid managed care organization that provides behavioral health services through a contract with a third party or an arrangement with a subsidiary of the organization, the commission shall:
(1)  require the effective sharing and integration of care coordination, service authorization, and utilization management data between the organization and the third party or subsidiary;
(2)  encourage the colocation of physical health and behavioral health care coordination staff, to the extent feasible;
(3)  require warm call transfers between physical health and behavioral health care coordination staff;
(4)  require the 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 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 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 O. Delivery of Services: General Provisions › Section 540.0706. Psychotropic Medication Monitoring System for Certain Children

Text of section effective on April 01, 2025
Sec. 540.0706.  PSYCHOTROPIC MEDICATION MONITORING SYSTEM FOR CERTAIN CHILDREN.  (a)  In this section, "psychotropic medication" has the meaning assigned by Section 266.001, 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 medications for:
(1)  children who are in the conservatorship of the Department of Family and Protective Services and enrolled in the STAR Health 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 a medical review of a prescription to which Subsection (b) applies when that review is appropriate.
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 O. Delivery of Services: General Provisions › Section 540.0707. Medication Therapy Management

Text of section effective on April 01, 2025
Sec. 540.0707.  MEDICATION THERAPY MANAGEMENT.  The executive commissioner shall collaborate with Medicaid managed care organizations to implement medication therapy management services to lower costs and improve quality outcomes for recipients by reducing adverse drug 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 O. Delivery of Services: General Provisions › Section 540.0708. Special Disease Management

Text of section effective on April 01, 2025
Sec. 540.0708.  SPECIAL DISEASE MANAGEMENT.  (a)  The commission shall ensure that a Medicaid managed care organization develops and implements special disease management programs to manage a disease or other chronic health condition with respect to which disease management would be cost-effective for populations the commission identifies.  The special disease management programs may manage a disease or other chronic health condition such as:
(1)  heart disease;
(2)  chronic kidney disease and related medical complications;
(3)  respiratory illness, including asthma;
(4)  diabetes;
(5)  end-stage renal disease;
(6)  HIV infection; or
(7)  AIDS.
(b)  A Medicaid managed care plan must provide, in the manner the commission requires, disease management services including:
(1)  patient self-management education;
(2)  provider education;
(3)  evidence-based models and minimum standards of care;
(4)  standardized protocols and participation criteria; and
(5)  physician-directed or physician-supervised care.
(c)  The executive commissioner by rule shall prescribe the minimum requirements that a Medicaid managed care organization must meet in providing a special disease management program to be eligible to receive a contract under this section.  The organization must at a minimum be required to:
(1)  provide disease management services that have performance measures for particular diseases that are comparable to the relevant performance measures applicable to a provider of disease management services under Section 32.057, Human Resources Code;
(2)  show evidence of ability to manage complex diseases in the Medicaid population; and
(3)  if a special disease management program the organization provides has low active participation rates, identify the reason for the low rates and develop an approach to increase active participation in special disease management programs for high-risk recipients.
(d)  If a Medicaid managed care organization implements a special disease management program to manage chronic kidney disease and related medical complications as provided by Subsection (a) and the organization develops a program to provide screening for and diagnosis and treatment of chronic kidney disease and related medical complications to recipients under the organization's Medicaid managed care plan, the program for screening, diagnosis, and treatment must use generally recognized clinical practice guidelines and laboratory assessments that identify chronic kidney disease on the basis of impaired kidney function or the presence of kidney damage.
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 O. Delivery of Services: General Provisions › Section 540.0709. Special Protocols for Indigent Populations

Text of section effective on April 01, 2025
Sec. 540.0709.  SPECIAL PROTOCOLS FOR INDIGENT POPULATIONS.  In conjunction with an academic center, the commission may study the treatment of indigent populations to develop special protocols for use by Medicaid managed care organizations in providing health care services to 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 O. Delivery of Services: General Provisions › Section 540.0710. Direct Access to Eye Health Care Services

Text of section effective on April 01, 2025
Sec. 540.0710.  DIRECT ACCESS TO EYE HEALTH CARE SERVICES.  (a)  Notwithstanding any other law, the commission shall ensure that a Medicaid managed care plan offered by a Medicaid managed care organization and any other Medicaid managed care model or arrangement implemented under this chapter allow a recipient receiving 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 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 of the 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 O. Delivery of Services: General Provisions › Section 540.0712. Promotion and Principles of Patient-Centered Medical Home

Text of section effective on April 01, 2025
Sec. 540.0712.  PROMOTION AND PRINCIPLES OF PATIENT-CENTERED MEDICAL HOME.  (a)  In this section, "patient-centered medical home" means a medical relationship:
(1)  between a primary care physician and a patient in which the physician:
(A)  provides comprehensive primary care to the patient; and
(B)  facilitates partnerships between the physician, the patient, any acute care and other care providers, and, when appropriate, the patient's family; and
(2)  that encompasses the following primary principles:
(A)  the patient has an ongoing relationship with the physician, who is trained to be the first contact for and to provide continuous and comprehensive care to the patient;
(B)  the physician leads a team of individuals at the practice level who are collectively responsible for the patient's ongoing care;
(C)  the physician is responsible for providing all of the care the patient needs or for coordinating with other qualified providers to provide care to the patient throughout the patient's life, including preventive care, acute care, chronic care, and end-of-life care;
(D)  the patient's care is coordinated across health care facilities and the patient's community and is facilitated by registries, information technology, and health information exchange systems to ensure that the patient receives care when and where the patient wants and needs the care and in a culturally and linguistically appropriate manner; and
(E)  quality and safe care is provided.
(b)  The commission shall, to the extent possible, work to ensure that Medicaid managed care organizations:
(1)  promote the development of patient-centered medical homes for recipients; and
(2)  provide payment incentives for providers that meet the requirements of a patient-centered medical home.
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 O. Delivery of Services: General Provisions › Section 540.0713. Value-Added Services

Text of section effective on April 01, 2025
Sec. 540.0713.  VALUE-ADDED SERVICES.  The commission shall actively encourage Medicaid managed care organizations 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 Medicaid managed care plan the organization offers; and
(2)  have the potential to improve the health status of recipients enrolled in the 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 P. Delivery of Services: Star+plus Medicaid Managed Care Program › Section 540.0751. Delivery of Acute Care Services and Long-Term Services and Supports

Text of section effective on April 01, 2025
Sec. 540.0751.  DELIVERY OF ACUTE CARE SERVICES AND LONG-TERM SERVICES AND SUPPORTS.  Subject to Sections 540.0701 and 540.0753, the commission shall expand the STAR+PLUS Medicaid managed care program to all areas of this state to serve individuals eligible for Medicaid acute care services and long-term services and supports.
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 P. Delivery of Services: Star+plus Medicaid Managed Care Program › Section 540.0753. Delivery of Basic Attendant and Habilitation Services

Text of section effective on April 01, 2025
Sec. 540.0753.  DELIVERY OF BASIC ATTENDANT AND HABILITATION SERVICES.  Subject to Section 542.0152, the commission shall:
(1)  implement the option for the delivery of basic attendant and habilitation services to individuals with disabilities under the STAR+PLUS Medicaid managed care program that:
(A)  is the most cost-effective; and
(B)  maximizes federal funding for the delivery of services for that program and other similar programs; and
(2)  provide voluntary training to individuals receiving services under the STAR+PLUS Medicaid managed care program or their legally authorized representatives regarding how to select, manage, and dismiss a personal attendant providing basic attendant and habilitation services under the program.
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 P. Delivery of Services: Star+plus Medicaid Managed Care Program › Section 540.0754. Evaluation of Certain Program Services

Text of section effective on April 01, 2025
Sec. 540.0754.  EVALUATION OF CERTAIN 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 recipients who are:
(1)  enrolled in the STAR+PLUS Medicaid managed care program; and
(2)  eligible to receive health care benefits under both Medicaid and the Medicare program.
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 P. Delivery of Services: Star+plus Medicaid Managed Care Program › Section 540.0755. Utilization Review; Annual Report

Text of section effective on April 01, 2025
Sec. 540.0755.  UTILIZATION REVIEW; ANNUAL REPORT.  (a)  The commission's office of contract management shall establish an annual utilization review process for Medicaid 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.  The review process must include a thorough investigation of each Medicaid managed care organization's procedures for determining whether a recipient should be enrolled in the STAR+PLUS home and community-based services (HCBS) waiver 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 Medicaid managed care organization participating in the STAR+PLUS Medicaid managed care program; or
(2)  only the Medicaid managed care organizations that, using a risk-based assessment process, the office determines have a higher likelihood of inappropriate recipient placement in the STAR+PLUS home and community-based services (HCBS) waiver program.
(c)  Not later than December 1 of each year and 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.  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 Medicaid managed care organization; and
(3)  extrapolate those findings and make recommendations for improving the STAR+PLUS Medicaid managed care program's efficiency.
(d)  If a utilization review conducted under this section results in a determination to recoup money from a Medicaid managed care organization, a service provider who contracts with the organization may not be held liable for providing services in good faith based on the organization's authorization.
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 Q. Delivery of Services: Star Health Program › Section 540.0801. Trauma-Informed Care Training

Text of section effective on April 01, 2025
Sec. 540.0801.  TRAUMA-INFORMED CARE TRAINING.  (a)  A STAR Health program managed care contract between a Medicaid managed care organization and the commission must require that trauma-informed care training be offered to each contracted physician or provider.
(b)  The commission shall encourage each Medicaid managed care organization providing health care services to recipients under the STAR Health program to make training in post-traumatic stress disorder and attention-deficit/hyperactivity disorder available to a contracted physician or provider within a reasonable time after the date the physician or provider begins providing services under the Medicaid managed care plan the organization offers.
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 Q. Delivery of Services: Star Health Program › Section 540.0802. Mental Health Providers

Text of section effective on April 01, 2025
Sec. 540.0802.  MENTAL HEALTH PROVIDERS.  A STAR Health program managed care contract between a Medicaid managed care organization and the commission must require the organization to ensure that the organization maintains a network of mental and behavioral health providers, including child psychiatrists and other appropriate providers, in all Department of Family and Protective Services regions in this state, regardless of whether community-based care has been implemented in any region.
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 Q. Delivery of Services: Star Health Program › Section 540.0803. Health Screening Requirements and Compliance With Texas Health Steps

Text of section effective on April 01, 2025
Sec. 540.0803.  HEALTH SCREENING REQUIREMENTS AND COMPLIANCE WITH TEXAS HEALTH STEPS.  (a)  A Medicaid managed care organization providing health care services to a recipient under the STAR Health program must ensure that the recipient receives a complete early and periodic screening, diagnosis, and treatment checkup in accordance with the requirements specified in the managed care contract between the organization and the commission.
(b)  The commission shall encourage each Medicaid managed care organization providing health care services to a recipient under the STAR Health program to ensure that the organization's network providers comply with the regimen of care prescribed by the Texas Health Steps program under Section 32.056, Human Resources Code, if applicable, including the requirement to provide a mental health screening during each of the recipient's Texas Health Steps medical exams a network provider conducts.
(c)  The commission shall include a provision in a STAR Health program managed care contract between a Medicaid managed care organization and the commission specifying progressive monetary penalties for the organization's failure to comply with Subsection (a).
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 Q. Delivery of Services: Star Health Program › Section 540.0804. Health Care and Other Services for Children in Substitute Care

Text of section effective on April 01, 2025
Sec. 540.0804.  HEALTH CARE AND OTHER SERVICES FOR CHILDREN IN SUBSTITUTE CARE.  (a) The commission shall annually evaluate the use of benefits offered to children in foster care under the STAR Health program and provide recommendations to the Department of Family and Protective Services and each single source continuum contractor in this state to better coordinate the provision of health care and use of those benefits for those children.
(b)  In conducting the evaluation, the commission shall:
(1)  collaborate with residential child-care providers regarding any unmet needs of children in foster care and the development of capacity for providing quality medical, behavioral health, and other services for those children; and
(2)  identify options to obtain federal matching funds under Medicaid to pay for a safe home-like or community-based residential setting for a child in the conservatorship of the Department of Family and Protective Services:
(A)  who is identified or diagnosed as having a serious behavioral or mental health condition that requires intensive treatment;
(B)  who is identified as a victim of serious abuse or serious neglect;
(C)  for whom a traditional substitute care placement contracted for or purchased by the department is not available or would further denigrate the child's behavioral or mental health condition; or
(D)  for whom the department determines a safe home-like or community-based residential placement could stabilize the child's behavioral or mental health condition in order to return the child to a traditional substitute care placement.
(c)  The commission shall report the commission's findings to the standing committees of the senate and house of representatives having jurisdiction over the Department of Family and Protective 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 Q. Delivery of Services: Star Health Program › Section 540.0805. Placement Change Notice and Care Coordination

Text of section effective on April 01, 2025
Sec. 540.0805.  PLACEMENT CHANGE NOTICE AND CARE COORDINATION.  A STAR Health program managed care contract between a Medicaid managed care organization and the commission must require the organization to ensure continuity of care for a child whose placement has changed by:
(1)  notifying each specialist treating the child of the placement change; and
(2)  coordinating the transition of care from the child's previous treating primary care physician and specialists to the child's new treating primary care physician and specialists, if any.
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 Q. Delivery of Services: Star Health Program › Section 540.0806. Medicaid Benefits for Certain Children Formerly in Foster Care

Text of section effective on April 01, 2025
Sec. 540.0806.  MEDICAID BENEFITS FOR CERTAIN CHILDREN FORMERLY IN FOSTER CARE.  (a)  This section applies only with respect to a child who:
(1)  resides in this state; and
(2)  is eligible for assistance or services under:
(A)  Subchapter D, Chapter 162, Family Code; or
(B)  Subchapter K, Chapter 264, Family Code.
(b)  Except as provided by Subsection (c), the commission shall ensure that each child to whom this section applies remains or is enrolled in the STAR Health program until the child is enrolled in another Medicaid managed care program.
(c)  A child to whom this section applies who received Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.) or was receiving Supplemental Security Income before becoming eligible for assistance or services under Subchapter D, Chapter 162, Family Code, or Subchapter K, Chapter 264, Family Code, may receive Medicaid benefits in accordance with the program established under this subsection. To the extent allowed by federal law, the commission, in consultation with the Department of Family and Protective Services, shall develop and implement a program that allows the adoptive parent or permanent managing conservator of a child described by this subsection to elect on behalf of the child to receive or continue receiving Medicaid benefits under the:
(1)  STAR Health program; or
(2)  STAR Kids managed care program.
(d)  The commission shall protect the continuity of care for each child to whom this section applies and ensure coordination between the STAR Health program and any other Medicaid managed care program for each child who is transitioning between Medicaid managed care programs.
(e)  The executive commissioner shall adopt rules necessary to implement 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 R. Delivery of Services: Star Kids Managed Care Program › Section 540.0851. Star Kids Managed Care Program

Text of section effective on April 01, 2025
Sec. 540.0851.  STAR KIDS MANAGED CARE PROGRAM.  (a)  In this section, "health home" means a primary care provider practice or specialty care provider practice that incorporates several features, including comprehensive care coordination, family-centered care, and data management, that are focused on improving outcome-based quality of care and increasing patient and provider satisfaction under Medicaid.
(b)  Subject to Sections 540.0701 and 540.0753, the commission shall establish a mandatory STAR Kids capitated managed care program tailored to provide Medicaid benefits to children with disabilities.  The program must:
(1)  provide Medicaid benefits customized to meet the health care needs of program recipients through a defined system of care;
(2)  better coordinate recipient care under the program;
(3)  improve recipient:
(A)  access to health care services; and
(B)  health outcomes;
(4)  achieve cost containment and cost efficiency;
(5)  reduce:
(A)  the administrative complexity of delivering Medicaid benefits; and
(B)  the incidence of unnecessary institutionalizations and potentially preventable events by ensuring the availability of appropriate services and care management;
(6)  require a health home; and
(7)  for recipients who receive long-term services and supports outside of the Medicaid managed care organization, coordinate and collaborate with long-term care service providers and long-term care management providers.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.