reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.002553. Behavioral Health Services Provided Through Third Party or Subsidiary

Text of section effective until April 01, 2025
Sec. 533.002553.  BEHAVIORAL HEALTH SERVICES PROVIDED THROUGH THIRD PARTY OR SUBSIDIARY.  (a)  In this section, "behavioral health services" has the meaning assigned by Section 533.00255.
(b)  For a managed care organization that contracts with the commission under this chapter and that provides behavioral health services through a contract with a third party or an arrangement with a subsidiary of the managed care organization, the commission shall:
(1)  require the effective sharing and integration of care coordination, service authorization, and utilization management data between the managed care organization and the third party or subsidiary;
(2)  encourage, to the extent feasible, the colocation of physical health and behavioral health care coordination staff;
(3)  require warm call transfers between physical health and behavioral health care coordination staff;
(4)  require the managed care organization and the third party or subsidiary to implement joint rounds for physical health and behavioral health services network providers or some other effective means for sharing clinical information; and
(5)  ensure that the managed care organization makes available a seamless provider portal for both physical health and behavioral health services network providers, to the extent allowed by federal law.
Added by Acts 2017, 85th Leg., R.S., Ch. 519 (S.B. 74), Sec. 1, eff. June 9, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.002555. Transition of Case Management for Children and Pregnant Women Program Recipients to Managed Care Program

Text of section effective until April 01, 2025
Sec. 533.002555.  TRANSITION OF CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN PROGRAM RECIPIENTS TO MANAGED CARE PROGRAM.  (a)  In this section, "children and pregnant women program" means the benefits program provided under Medicaid and administered by the Department of State Health Services that provides case management services to children who have a health condition or health risk and pregnant women who have a high-risk condition.
(b)  The commission shall transition to a Medicaid managed care model all case management services provided to recipients under the children and pregnant women program.  In transitioning services under this section, the commission shall ensure a recipient is provided case management services through the managed care plan in which the recipient is enrolled.
(c)  In implementing this section, the commission shall ensure:
(1)  a seamless transition in case management for recipients receiving benefits under the children and pregnant women program; and
(2)  case management services provided under the program are not interrupted.
Added by Acts 2021, 87th Leg., R.S., Ch. 629 (H.B. 133), Sec. 1, eff. September 1, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00256. Managed Care Clinical Improvement Program

Text of section effective until April 01, 2025
Sec. 533.00256.  MANAGED CARE CLINICAL IMPROVEMENT PROGRAM.  (a)  In consultation with appropriate stakeholders with an interest in the provision of acute care services and long-term services and supports under the Medicaid managed care program, the commission shall:
(1)  establish a clinical improvement program to identify goals designed to improve quality of care and care management and to reduce potentially preventable events, as defined by Section 536.001; and
(2)  require managed care organizations to develop and implement collaborative program improvement strategies to address the goals.
(b)  Goals established under this section may be set by geographic region and program type.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 4.01, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.16, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.16, eff. January 1, 2016.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
Without reference to the amendment of this section, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.002581. Delivery of Nonmedical Transportation Services Under Medicaid Managed Care Program

Text of section effective until April 01, 2025
Sec. 533.002581.  DELIVERY OF NONMEDICAL TRANSPORTATION SERVICES UNDER MEDICAID MANAGED CARE PROGRAM.  (a)  In this section, "nonmedical transportation service" and "transportation vendor" have the meanings assigned by Section 533.00258.
(b)  Expired.
(c)  Beginning not later than September 1, 2020, the commission shall require each Medicaid managed care organization to arrange for the provision of nonmedical transportation services to recipients enrolled in a managed care plan offered by the organization.
(d)  A Medicaid managed care organization may contract with a transportation vendor or other third party to arrange for the provision of nonmedical transportation services.  If a Medicaid managed care organization contracts with a third party that is not a transportation vendor to arrange for the provision of nonmedical transportation services, the third party shall contract with a transportation vendor to deliver the nonmedical transportation services.
(e)  A Medicaid managed care organization that contracts with a transportation vendor or other third party to arrange for the provision of nonmedical transportation services shall ensure the effective sharing and integration of service coordination, service authorization, and utilization management data between the managed care organization and the transportation vendor or third party.
(f)  A Medicaid managed care organization may not require:
(1)  a motor vehicle operator to enroll as a Medicaid provider to provide nonmedical transportation services; or
(2)  the credentialing of a motor vehicle operator to provide nonmedical transportation services.
(g)  For purposes of this section and notwithstanding Section 2402.111(a)(2)(A), Occupations Code, a motor vehicle operator who provides services under this section may use a wheelchair-accessible vehicle equipped with a lift or ramp that is capable of transporting passengers using a fixed-frame wheelchair in the cabin of the vehicle if the vehicle otherwise meets the requirements of Section 2402.111, Occupations Code.
(h)  The commission may waive the applicability of Subsection (c) to a Medicaid managed care organization for not more than three months as necessary based on the results of a review conducted under Section 533.007 and until enrollment of recipients in a managed care plan offered by the organization is permitted under that section.
Added by Acts 2019, 86th Leg., R.S., Ch. 1235 (H.B. 1576), Sec. 8, eff. June 14, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0026. Direct Access to Eye Health Care Services Under Medicaid Managed Care Model or Arrangement

Text of section effective until April 01, 2025
Sec. 533.0026.  DIRECT ACCESS TO EYE HEALTH CARE SERVICES UNDER MEDICAID MANAGED CARE MODEL OR ARRANGEMENT.  (a)  Notwithstanding any other law, the commission shall ensure that a managed care plan offered by a managed care organization that contracts with the commission under this chapter and any other Medicaid managed care model or arrangement implemented under this chapter allow a recipient who receives services through the plan or other model or arrangement to, in the manner and to the extent required by Section 32.072, Human Resources Code:
(1)  select an in-network ophthalmologist or therapeutic optometrist in the managed care network to provide eye health care services, other than surgery; and
(2)  have direct access to the selected in-network ophthalmologist or therapeutic optometrist for the provision of the nonsurgical services.
(b)  This section does not affect the obligation of an ophthalmologist or therapeutic optometrist in a managed care network to comply with the terms and conditions of the managed care plan.
Added by Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 21(b), eff. September 1, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.218, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0027. Procedures to Ensure Certain Recipients Are Enrolled in Same Managed Care Plan

Text of section effective until April 01, 2025
Sec. 533.0027.  PROCEDURES TO ENSURE CERTAIN RECIPIENTS ARE ENROLLED IN SAME MANAGED CARE PLAN.  The commission shall ensure that all recipients who are children and who reside in the same household may, at the family's election, be enrolled in the same managed care plan.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(b), eff. September 28, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0028. Evaluation of Certain Star + Plus Medicaid Managed Care Program Services

Text of section effective until April 01, 2025
Sec. 533.0028.  EVALUATION OF CERTAIN STAR + PLUS MEDICAID MANAGED CARE PROGRAM SERVICES.  The external quality review organization shall periodically conduct studies and surveys to assess the quality of care and satisfaction with health care services provided to enrollees in the STAR + PLUS Medicaid managed care program who are eligible to receive health care benefits under both Medicaid and the Medicare program.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(b), eff. September 28, 2011.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.219, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00281. Utilization Review for Star + Plus Medicaid Managed Care Organizations

Text of section effective until April 01, 2025
Sec. 533.00281.  UTILIZATION REVIEW FOR STAR + PLUS MEDICAID MANAGED CARE ORGANIZATIONS.  (a)  The commission's office of contract management shall establish an annual utilization review process for managed care organizations participating in the STAR + PLUS Medicaid managed care program.  The commission shall determine the topics to be examined in the review process, except that the review process must include a thorough investigation of each managed care organization's procedures for determining whether a recipient should be enrolled in the STAR + PLUS home and community-based services and supports (HCBS) program, including the conduct of functional assessments for that purpose and records relating to those assessments.
(b)  The office of contract management shall use the utilization review process to review each fiscal year:
(1)  every managed care organization participating in the STAR + PLUS Medicaid managed care program; or
(2)  only the managed care organizations that, using a risk-based assessment process, the office determines have a higher likelihood of inappropriate client placement in the STAR + PLUS home and community-based services and supports (HCBS) program.
(c)  Expired.
(d)  In conjunction with the commission's office of contract management, the commission shall provide a report to the standing committees of the senate and house of representatives with jurisdiction over Medicaid not later than December 1 of each year.  The report must:
(1)  summarize the results of the utilization reviews conducted under this section during the preceding fiscal year;
(2)  provide analysis of errors committed by each reviewed managed care organization; and
(3)  extrapolate those findings and make recommendations for improving the efficiency of the program.
(e)  If a utilization review conducted under this section results in a determination to recoup money from a managed care organization, a service provider who contracts with the managed care organization may not be held liable for the good faith provision of services based on an authorization from the managed care organization.
Added by Acts 2013, 83rd Leg., R.S., Ch. 76 (S.B. 348), Sec. 1, eff. May 18, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.220, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00282. Utilization Review and Prior Authorization Procedures

Text of section effective until April 01, 2025
Sec. 533.00282.  UTILIZATION REVIEW AND PRIOR AUTHORIZATION PROCEDURES.  (a)  Section 4201.304(a)(2), Insurance Code, does not apply to a Medicaid managed care organization or a utilization review agent who conducts utilization reviews for a Medicaid managed care organization.
(b)  In addition to the requirements of Section 533.005, a contract between a Medicaid managed care organization and the commission must require that:
(1)  before issuing an adverse determination on a prior authorization request, the organization provide the physician requesting the prior authorization with a reasonable opportunity to discuss the request with another physician who practices in the same or a similar specialty, but not necessarily the same subspecialty, and has experience in treating the same category of population as the recipient on whose behalf the request is submitted; and
(2)  the organization review and issue determinations on prior authorization requests with respect to a recipient who is not hospitalized at the time of the request according to the following time frames:
(A)  within three business days after receiving the request; or
(B)  within the time frame and following the process established by the commission if the organization receives a request for prior authorization that does not include sufficient or adequate documentation.
(c)  In consultation with the state Medicaid managed care advisory committee, the commission shall establish a process for use by a Medicaid managed care organization that receives a prior authorization request, with respect to a recipient who is not hospitalized at the time of the request, that does not include sufficient or adequate documentation.  The process must provide a time frame within which a provider may submit the necessary documentation.  The time frame must be longer than the time frame specified by Subsection (b)(2)(A) within which a Medicaid managed care organization must issue a determination on a prior authorization request.
Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.002821. Prior Authorization Procedures for Hospitalized Recipient

Text of section effective until April 01, 2025
Sec. 533.002821.  PRIOR AUTHORIZATION PROCEDURES FOR HOSPITALIZED RECIPIENT.  In addition to the requirements of Section 533.005, a contract between a managed care organization and the commission described by that section must require that, notwithstanding any other law, the organization review and issue determinations on prior authorization requests with respect to a recipient who is hospitalized at the time of the request according to the following time frames:
(1)  within one business day after receiving the request, except as provided by Subdivisions (2) and (3);
(2)  within 72 hours after receiving the request if the request is submitted by a provider of acute care inpatient services for services or equipment necessary to discharge the recipient from an inpatient facility; or
(3)  within one hour after receiving the request if the request is related to poststabilization care or a life-threatening condition.
Added by Acts 2019, 86th Leg., R.S., Ch. 619 (S.B. 1096), Sec. 2, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00283. Annual Review of Prior Authorization Requirements

Text of section effective until April 01, 2025
Sec. 533.00283.  ANNUAL REVIEW OF PRIOR AUTHORIZATION REQUIREMENTS.  (a)  Each Medicaid managed care organization, in consultation with the organization's provider advisory group required by contract, shall develop and implement a process to conduct an annual review of the organization's prior authorization requirements, other than a prior authorization requirement prescribed by or implemented under Section 531.073 for the vendor drug program.  In conducting a review, the organization must:
(1)  solicit, receive, and consider input from providers in the organization's provider network; and
(2)  ensure that each prior authorization requirement is based on accurate, up-to-date, evidence-based, and peer-reviewed clinical criteria that distinguish, as appropriate, between categories, including age, of recipients for whom prior authorization requests are submitted.
(b)  A Medicaid managed care organization may not impose a prior authorization requirement, other than a prior authorization requirement prescribed by or implemented under Section 531.073 for the vendor drug program, unless the organization has reviewed the requirement during the most recent annual review required under this section.
(c)  The commission shall periodically review each Medicaid managed care organization to ensure the organization's compliance with this section.
Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00284. Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests

Text of section effective until April 01, 2025
Sec. 533.00284.  RECONSIDERATION FOLLOWING ADVERSE DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS.  (a)  In consultation with the state Medicaid managed care advisory committee, the commission shall establish a uniform process and timeline for Medicaid managed care organizations to reconsider an adverse determination on a prior authorization request that resulted solely from the submission of insufficient or inadequate documentation.  In addition to the requirements of Section 533.005, a contract between a Medicaid managed care organization and the commission must include a requirement that the organization implement the process and timeline.
(b)  The process and timeline must:
(1)  allow a provider to submit any documentation that was identified as insufficient or inadequate in the notice provided under Section 531.024162;
(2)  allow the provider requesting the prior authorization to discuss the request with another provider who practices in the same or a similar specialty, but not necessarily the same subspecialty, and has experience in treating the same category of population as the recipient on whose behalf the request is submitted; and
(3)  require the Medicaid managed care organization to amend the determination on the prior authorization request as necessary, considering the additional documentation.
(c)  An adverse determination on a prior authorization request is considered a denial of services in an evaluation of the Medicaid managed care organization only if the determination is not amended under Subsection (b)(3) to approve the request.
(d)  The process and timeline for reconsidering an adverse determination on a prior authorization request under this section do not affect:
(1)  any related timelines, including the timeline for an internal appeal, a Medicaid fair hearing, or a review conducted by an external medical reviewer; or
(2)  any rights of a recipient to appeal a determination on a prior authorization request.
Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.002841. Maximum Period for Prior Authorization Decision; Access to Care

Text of section effective until April 01, 2025
Sec. 533.002841.  MAXIMUM PERIOD FOR PRIOR AUTHORIZATION DECISION; ACCESS TO CARE.  The time frames prescribed by the utilization review and prior authorization procedures described by Section 533.00282 and the timeline for reconsidering an adverse determination on a prior authorization described by Section 533.00284 together may not exceed the time frame for a decision under federally prescribed time frames.  It is the intent of the legislature that these provisions allow sufficient time to provide necessary documentation and avoid unnecessary denials without delaying access to care.
Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0029. Promotion and Principles of Patient-Centered Medical Homes for Recipients

Text of section effective until April 01, 2025
Sec. 533.0029.  PROMOTION AND PRINCIPLES OF PATIENT-CENTERED MEDICAL HOMES FOR RECIPIENTS.  (a)  For purposes of this section, a "patient-centered medical home" means a medical relationship:
(1)  between a primary care physician and a child or adult patient in which the physician:
(A)  provides comprehensive primary care to the patient; and
(B)  facilitates partnerships between the physician, the patient, 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 the patient 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 ongoing care of the patient;
(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 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 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(b), eff. September 28, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.003. Considerations in Awarding Contracts

Text of section effective until April 01, 2025
Sec. 533.003.  CONSIDERATIONS IN AWARDING CONTRACTS.  (a)  In awarding contracts to managed care organizations, the commission shall:
(1)  give preference to organizations that have significant participation in the organization's provider network from each health care provider in the region who has traditionally provided care to Medicaid and charity care patients;
(2)  give extra consideration to organizations that agree to assure continuity of care for at least three months beyond the period of Medicaid eligibility for recipients;
(3)  consider the need to use different managed care plans to meet the needs of different populations;
(4)  consider the ability of organizations to process Medicaid claims electronically; and
(5)  in the initial implementation of managed care in the South Texas service region, give extra consideration to an organization that either:
(A)  is locally owned, managed, and operated, if one exists; or
(B)  is in compliance with the requirements of Section 533.004.
(b)  The commission, in considering approval of a subcontract between a managed care organization and a pharmacy benefit manager for the provision of prescription drug benefits under Medicaid, shall review and consider whether the pharmacy benefit manager has been in the preceding three years:
(1)  convicted of an offense involving a material misrepresentation or an act of fraud or of another violation of state or federal criminal law;
(2)  adjudicated to have committed a breach of contract; or
(3)  assessed a penalty or fine in the amount of $500,000 or more in a state or federal administrative proceeding.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.  Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 2, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.02, eff. Sept. 1, 1999.
Amended by:
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(c), eff. September 28, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.221, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0031. Medicaid Managed Care Plan Accreditation

Text of section effective until April 01, 2025
Sec. 533.0031.  MEDICAID MANAGED CARE PLAN ACCREDITATION.  (a)  A managed care plan offered by a Medicaid managed care organization must be accredited by a nationally recognized accreditation organization.  The commission may choose whether to require all managed care plans offered by Medicaid managed care organizations to be accredited by the same organization or to 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 processes.
Added by Acts 2019, 86th Leg., R.S., Ch. 680 (S.B. 2138), Sec. 3, eff. June 10, 2019.
Added by Acts 2019, 86th Leg., R.S., Ch. 1330 (H.B. 4533), Sec. 5, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0035. Certification by Commission

Text of section effective until April 01, 2025
Sec. 533.0035.  CERTIFICATION BY COMMISSION.  (a)  Before the commission may award a contract under this chapter to a managed care organization, the commission shall evaluate and certify that the organization is reasonably able to fulfill the terms of the contract, including all requirements of applicable federal and state law.
(b)  Notwithstanding any other law, the commission may not award a contract under this chapter to a managed care organization that does not receive the certification required under this section.
(c)  A managed care organization may appeal a denial of certification by the commission under this section.
Added by Acts 2021, 87th Leg., R.S., Ch. 609 (S.B. 1244), Sec. 1, eff. September 1, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00511. Quality-Based Enrollment Incentive Program for Managed Care Organizations

Text of section effective until April 01, 2025
Sec. 533.00511.  QUALITY-BASED ENROLLMENT INCENTIVE PROGRAM FOR MANAGED CARE ORGANIZATIONS.  (a)  In this section, "potentially preventable event" has the meaning assigned by Section 536.001.
(b)  The commission shall create an incentive program that automatically enrolls a greater percentage of recipients who did not actively choose their managed care plan in a managed care plan, based on:
(1)  the quality of care provided through the managed care organization offering that managed care plan;
(2)  the organization's ability to efficiently and effectively provide services, taking into consideration the acuity of populations primarily served by the organization; and
(3)  the organization's performance with respect to exceeding, or failing to achieve, appropriate outcome and process measures developed by the commission, including measures based on potentially preventable events.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 4.03, eff. September 1, 2013.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00515. Medication Therapy Management

Text of section effective until April 01, 2025
Sec. 533.00515.  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 2021, 87th Leg., R.S., Ch. 820 (H.B. 2658), Sec. 4, eff. September 1, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0052. Star Health Program: Trauma-Informed Care Training

Text of section effective until April 01, 2025
Sec. 533.0052.  STAR HEALTH PROGRAM:  TRAUMA-INFORMED CARE TRAINING.  (a)  A contract between a managed care organization and the commission for the organization to provide health care services to recipients under the STAR Health program must include a requirement that trauma-informed care training be offered to each contracted physician or provider.
(b)  The commission shall encourage each 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 managed care plan.
Added by Acts 2011, 82nd Leg., R.S., Ch. 371 (S.B. 219), Sec. 3, eff. September 1, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00521. Star Health Program: Health Care for Foster Children

Text of section effective until April 01, 2025
Sec. 533.00521.  STAR HEALTH PROGRAM:  HEALTH CARE FOR FOSTER CHILDREN.  (a)  The commission shall annually evaluate the use of benefits under the Medicaid program in the STAR Health program offered to children in foster care 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 children in foster care.
(b)  In conducting the evaluation required under Subsection (a), 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 children in foster care; and
(2)  identify options to obtain federal matching funds under the Medical Assistance Program 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 its 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 2021, 87th Leg., R.S., Ch. 621 (S.B. 1896), Sec. 13(a), eff. June 14, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00522. Star Health Program: Mental Health Providers

Text of section effective until April 01, 2025
Sec. 533.00522.  STAR HEALTH PROGRAM:  MENTAL HEALTH PROVIDERS.  A contract between a Medicaid managed care organization and the commission for the organization to provide health care services to recipients under the STAR Health program must require the organization to ensure 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 2021, 87th Leg., R.S., Ch. 621 (S.B. 1896), Sec. 13(b), eff. June 14, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0053. Compliance With Texas Health Steps

Text of section effective until April 01, 2025
Sec. 533.0053.  COMPLIANCE WITH TEXAS HEALTH STEPS.  The commission shall encourage each 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 conducted by a network provider.
Added by Acts 2011, 82nd Leg., R.S., Ch. 371 (S.B. 219), Sec. 3, eff. September 1, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.00531. Medicaid Benefits for Certain Children Formerly in Foster Care

Text of section effective until April 01, 2025
Sec. 533.00531.  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 described by Subsection (a) remains or is enrolled in the STAR Health program unless or until the child is enrolled in another Medicaid managed care program.
(c)  If a child described by Subsection (a) 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, as applicable, the child may receive Medicaid benefits in accordance with the program established under this subsection.  To the extent permitted 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, if applicable, 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 described under this section and, if applicable, 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 2019, 86th Leg., R.S., Ch. 1022 (H.B. 72), Sec. 2, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0054. Health Screening Requirements for Enrollee Under Star Health Program

Text of section effective until April 01, 2025
Sec. 533.0054.  HEALTH SCREENING REQUIREMENTS FOR ENROLLEE UNDER STAR HEALTH PROGRAM.  (a)  A managed care organization that contracts with the commission to provide health care services to recipients under the STAR Health program must ensure that enrollees receive a complete early and periodic screening, diagnosis, and treatment checkup in accordance with the requirements specified in the contract between the managed care organization and the commission.
(b)  The commission shall include a provision in a contract with a managed care organization to provide health care services to recipients under the STAR Health program specifying progressive monetary penalties for the organization's failure to comply with Subsection (a).
Added by Acts 2017, 85th Leg., R.S., Ch. 319 (S.B. 11), Sec. 24(a), eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0056. Star Health Program: Notification of Placement Change

Text of section effective until April 01, 2025
Sec. 533.0056.  STAR HEALTH PROGRAM:  NOTIFICATION OF PLACEMENT CHANGE.  A contract between a managed care organization and the commission for the organization to provide health care services to recipients under the STAR Health program 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 treating specialists to the child's new treating primary care physician and treating specialists, if any.
Added by Acts 2017, 85th Leg., R.S., Ch. 317 (H.B. 7), Sec. 40(a), eff. September 1, 2017.
Added by Acts 2017, 85th Leg., R.S., Ch. 319 (S.B. 11), Sec. 25(a), eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.006. Provider Networks

Text of section effective until April 01, 2025
Sec. 533.006.  PROVIDER NETWORKS.  (a)  The commission shall require that each managed care organization that contracts with the commission to provide health care services to recipients in a region:
(1)  seek participation in the organization's provider network from:
(A)  each health care provider in the region who has traditionally provided care to recipients;
(B)  each hospital in the region that has been designated as a disproportionate share hospital under Medicaid; and
(C)  each specialized pediatric laboratory in the region, including those laboratories located in children's hospitals; and
(2)  include in its provider network for not less than three years:
(A)  each health care provider in the region who:
(i)  previously provided care to Medicaid and charity care recipients at a significant level as prescribed by the commission;
(ii)  agrees to accept the prevailing provider contract rate of the managed care organization; and
(iii)  has the credentials required by the managed care organization, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network;
(B)  each accredited primary care residency program in the region; and
(C)  each disproportionate share hospital designated by the commission as a statewide significant traditional provider.
(b)  A contract between a managed care organization and the commission for the organization to provide health care services to recipients in a health care service region that includes a rural area must require that the organization include in its provider network rural hospitals, physicians, home and community support services agencies, and other rural health care providers who:
(1)  are sole community providers;
(2)  provide care to Medicaid and charity care recipients at a significant level as prescribed by the commission;
(3)  agree to accept the prevailing provider contract rate of the managed care organization; and
(4)  have the credentials required by the managed care organization, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.  Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 5, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.05, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.225, eff. April 2, 2015.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0061. Provider Access Standards; Report

Text of section effective until April 01, 2025
Sec. 533.0061.  PROVIDER ACCESS STANDARDS; REPORT.  (a)  The commission shall establish minimum provider access standards for the provider network of a managed care organization that contracts with the commission to provide health care services to recipients.  The access standards must ensure that a 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 identified by the commission.
(b)  To the extent it is feasible, the provider access standards established under this section 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 531.0216(c) and consistent with Section 111.007, Occupations Code, consider and include the availability of telehealth services and telemedicine medical services within the provider network of a Medicaid managed care organization.
(c)  The commission shall biennially submit to the legislature and make available to the public a report containing information and statistics about recipient access to providers through the provider networks of the managed care organizations and managed care organization compliance with contractual obligations related to provider access standards established under this section.  The report must contain:
(1)  a compilation and analysis of information submitted to the commission under Section 533.005(a)(20)(D);
(2)  for both primary care providers and specialty providers, information on provider-to-recipient ratios in an organization's provider network, as well as benchmark ratios to indicate whether deficiencies exist in a given network; and
(3)  a description of, and analysis of the results from, the commission's monitoring process established under Section 533.007(l).
Added by Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 5, eff. September 1, 2015.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 624 (H.B. 4), Sec. 4, eff. June 15, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.