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 D. Strategy for Managing Audit Resources › Section 540.0154. Performance Audit Selection Process and Follow-Up

Text of section effective on April 01, 2025
Sec. 540.0154.  PERFORMANCE AUDIT SELECTION PROCESS AND FOLLOW-UP.  (a)  To improve the commission's processes for performance audits of managed care organizations, the commission shall:
(1)  document the process by which the commission selects organizations to audit;
(2)  include previous audit coverage as a risk factor in selecting organizations to audit; and
(3)  prioritize the highest risk organizations to audit.
(b)  To verify that managed care organizations correct negative performance audit findings, the commission shall:
(1)  establish a process to:
(A)  document how the commission follows up on those findings; and
(B)  verify that organizations implement performance audit recommendations; and
(2)  establish and implement policies and procedures to:
(A)  determine under what circumstances the commission must issue a corrective action plan to an organization based on a performance audit; and
(B)  follow up on the organization's implementation of 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 D. Strategy for Managing Audit Resources › Section 540.0155. Agreed-Upon Procedures Engagements and Corrective Action Plans

Text of section effective on April 01, 2025
Sec. 540.0155.  AGREED-UPON PROCEDURES ENGAGEMENTS AND CORRECTIVE ACTION PLANS.  To enhance the commission's use of agreed-upon procedures engagements to identify managed care organizations' performance and compliance issues, the commission shall:
(1)  ensure that financial risks identified in agreed-upon procedures engagements are adequately and consistently addressed; and
(2)  establish policies and procedures to determine under what circumstances the commission must issue a corrective action plan based on an agreed-upon procedures engagement.
Added by Acts 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 D. Strategy for Managing Audit Resources › Section 540.0156. Audits of Pharmacy Benefit Managers

Text of section effective on April 01, 2025
Sec. 540.0156.  AUDITS OF PHARMACY BENEFIT MANAGERS.  To obtain greater assurance about the effectiveness of pharmacy benefit managers' internal controls and compliance with state requirements, the commission shall:
(1)  periodically audit each pharmacy benefit manager that contracts with a managed care organization; and
(2)  develop, document, and implement a monitoring process to ensure that managed care organizations correct and resolve negative findings reported in performance audits or agreed-upon procedures engagements of pharmacy benefit managers.
Added by Acts 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 D. Strategy for Managing Audit Resources › Section 540.0157. Collecting Costs for Audit-Related Services

Text of section effective on April 01, 2025
Sec. 540.0157.  COLLECTING COSTS FOR AUDIT-RELATED SERVICES.  The commission shall develop, document, and implement billing processes in the commission's Medicaid and CHIP services department to ensure that managed care organizations reimburse the commission for audit-related services as required by contract.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter D. Strategy for Managing Audit Resources › Section 540.0158. Collection Activities Related to Profit Sharing

Text of section effective on April 01, 2025
Sec. 540.0158.  COLLECTION ACTIVITIES RELATED TO PROFIT SHARING.  To strengthen the commission's process for collecting shared profits from managed care organizations, the commission shall develop, document, and implement monitoring processes in the commission's Medicaid and CHIP services department to ensure that the commission:
(1)  identifies experience rebates deposited in the commission's suspense account and timely transfers those rebates to the appropriate accounts; and
(2)  timely follows up on and resolves disputes over experience rebates managed care organizations claim.
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 D. Strategy for Managing Audit Resources › Section 540.0159. Using Information From External Quality Reviews

Text of section effective on April 01, 2025
Sec. 540.0159.  USING INFORMATION FROM EXTERNAL QUALITY REVIEWS.  (a)  To enhance the commission's monitoring of managed care organizations, the commission shall use the information provided by the external quality review organization, including:
(1)  detailed data from results of surveys of:
(A)  recipients and, if applicable, child health plan program enrollees;
(B)  caregivers of those recipients and enrollees; and
(C)  Medicaid and, as applicable, child health plan program providers; and
(2)  the validation results of matching paid claims data with medical records.
(b)  The commission shall document how the commission uses the information described by Subsection (a) to monitor managed care organizations.
Added by Acts 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 D. Strategy for Managing Audit Resources › Section 540.0160. Security of and Processing Controls Over Information Technology Systems

Text of section effective on April 01, 2025
Sec. 540.0160.  SECURITY OF AND PROCESSING CONTROLS OVER INFORMATION TECHNOLOGY SYSTEMS.  The commission shall:
(1)  strengthen user access controls for the commission's accounts receivable tracking system and network folders that the commission uses to manage the collection of experience rebates;
(2)  document daily reconciliations of deposits recorded in the accounts receivable tracking system to the transactions processed in:
(A)  the commission's cost accounting system for all health and human services agencies; and
(B)  the uniform statewide accounting system; and
(3)  develop, document, and implement a process to ensure that the commission formally documents:
(A)  all programming changes made to the accounts receivable tracking system; and
(B)  the authorization and testing of the changes described by Paragraph (A).
Added by Acts 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 E. Contract Administration › Section 540.0201. Contract Administration Improvement Efforts

Text of section effective on April 01, 2025
Sec. 540.0201.  CONTRACT ADMINISTRATION IMPROVEMENT EFFORTS.  The commission shall make every effort to improve the administration of contracts with managed care organizations.  To improve contract administration, the commission shall:
(1)  ensure that the commission has appropriate expertise and qualified staff to effectively manage contracts with managed care organizations under the Medicaid managed care program;
(2)  evaluate options for Medicaid payment recovery from a managed care organization if an enrolled recipient:
(A)  dies;
(B)  is incarcerated;
(C)  is enrolled in more than one state program; or
(D)  is covered by another liable third party insurer;
(3)  maximize Medicaid payment recovery options by contracting with private vendors to assist in recovering capitation payments, payments from other liable third parties, and other payments made to a managed care organization with respect to an enrolled recipient who leaves the managed care program;
(4)  decrease the administrative burdens of managed care for this state, managed care organizations, and providers in managed care networks to the extent that those changes are compatible with state law and existing Medicaid managed care contracts, including by:
(A)  where possible, decreasing duplicate administrative reporting and process requirements for managed care organizations and providers, such as requirements for submitting:
(i)  encounter data;
(ii)  quality reports;
(iii)  historically underutilized business reports; and
(iv)  claims payment summary reports;
(B)  allowing a managed care organization to provide updated address information directly to the commission for correction in the state system;
(C)  promoting consistency and uniformity among managed care organization policies, including policies relating to:
(i)  the preauthorization process;
(ii)  lengths of hospital stays;
(iii)  filing deadlines;
(iv)  levels of care; and
(v)  case management services;
(D)  reviewing the appropriateness of primary care case management requirements in the admission and clinical criteria process, such as requirements relating to:
(i)  including a separate cover sheet for all communications;
(ii)  submitting handwritten communications instead of electronic or typed review processes; and
(iii)  admitting patients listed on separate notices; and
(E)  providing a portal through which a provider in any managed care organization's provider network may submit acute care services and long-term services and supports claims; and
(5)  reserve the right to amend a managed care organization's process for resolving provider appeals of denials based on medical necessity to include an independent review process the commission establishes for final determination of these disputes.
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 E. Contract Administration › Section 540.0202. Public Notice of Request for Contract Applications

Text of section effective on April 01, 2025
Sec. 540.0202.  PUBLIC NOTICE OF REQUEST FOR CONTRACT APPLICATIONS.  Not later than the 30th day before the date the commission plans to issue a request for applications to enter into a contract with the commission to provide health care services to recipients in a region, the commission shall publish notice of and make available for public review the request for applications and all related nonproprietary documents, including the proposed contract.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter E. Contract Administration › Section 540.0203. Certification by Commission

Text of section effective on April 01, 2025
Sec. 540.0203.  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 contract terms, including all federal and state law requirements.  Notwithstanding any other law, the commission may not award a contract under this chapter to an organization that does not receive the required certification.
(b)  A managed care organization may appeal the commission's denial of certification.
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 E. Contract Administration › Section 540.0204. Contract Considerations Relating to Managed Care Organizations

Text of section effective on April 01, 2025
Sec. 540.0204.  CONTRACT CONSIDERATIONS RELATING TO MANAGED CARE ORGANIZATIONS.  In awarding contracts to managed care organizations, the commission shall:
(1)  give preference to an organization that has 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 an organization that agrees to assure continuity of care for at least three months beyond a recipient's Medicaid eligibility period;
(3)  consider the need to use different managed care plans to meet the needs of different populations; and
(4)  consider the ability of an organization to process Medicaid claims electronically.
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 E. Contract Administration › Section 540.0205. Contract Considerations Relating to Pharmacy Benefit Managers

Text of section effective on April 01, 2025
Sec. 540.0205.  CONTRACT CONSIDERATIONS RELATING TO PHARMACY BENEFIT MANAGERS.  In considering approval of a subcontract between a managed care organization and a pharmacy benefit manager to provide Medicaid prescription drug benefits, the commission shall review and consider whether in the preceding three years the pharmacy benefit manager has been:
(1)  convicted of:
(A)  an offense involving a material misrepresentation or an act of fraud; or
(B)  another violation of state or federal criminal law;
(2)  adjudicated to have committed a breach of contract; or
(3)  assessed a penalty or fine of $500,000 or more in a state or federal administrative proceeding.
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 E. Contract Administration › Section 540.0207. Contractual Obligations Review

Text of section effective on April 01, 2025
Sec. 540.0207.  CONTRACTUAL OBLIGATIONS REVIEW.  The commission shall review each Medicaid managed care organization to determine whether the organization is prepared to meet the organization's contractual obligations.
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 E. Contract Administration › Section 540.0208. Contract Implementation Plan

Text of section effective on April 01, 2025
Sec. 540.0208.  CONTRACT IMPLEMENTATION PLAN.  (a)  Each Medicaid managed care organization that contracts to provide health care services to recipients in a health care service region shall submit an implementation plan not later than the 90th day before the date the organization plans to begin providing those services in that region through managed care.  The implementation plan must include:
(1)  specific staffing patterns by function for all operations, including enrollment, information systems, member services, quality improvement, claims management, case management, and provider and recipient training; and
(2)  specific time frames for demonstrating preparedness for implementation before the date the organization plans to begin providing those services in that region through managed care.
(b)  The commission shall respond to an implementation plan not later than the 10th day after the date a Medicaid managed care organization submits the plan if the plan does not adequately meet preparedness guidelines.
(c)  Each Medicaid managed care organization that contracts to provide health care services to recipients in a health care service region shall submit status reports on the implementation plan:
(1)  not later than the 60th day and the 30th day before the date the organization plans to begin providing those services in that region through managed care; and
(2)  every 30th day after that date until the 180th day after that date.
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 E. Contract Administration › Section 540.0209. Compliance and Readiness Review

Text of section effective on April 01, 2025
Sec. 540.0209.  COMPLIANCE AND READINESS REVIEW.  (a)  The commission shall conduct a compliance and readiness review of each Medicaid managed care organization:
(1)  not later than the 15th day before the date the process of enrolling recipients in a managed care plan the organization issues is to begin in a region; and
(2)  not later than the 15th day before the date the organization plans to begin providing health care services to recipients in that region through managed care.
(b)  The compliance and readiness review must include an on-site inspection and tests of service authorization and claims payment systems, including:
(1)  the Medicaid managed care organization's ability to process claims electronically;
(2)  the Medicaid managed care organization's complaint processing systems; and
(3)  any other process or system the contract between the Medicaid managed care organization and the commission requires.
(c)  The commission may delay recipient enrollment in a managed care plan a Medicaid managed care organization issues if the compliance and readiness review reveals that the organization is not prepared to meet the organization's contractual obligations.  The commission shall notify the organization of a decision to delay enrollment in a plan the organization issues.
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 E. Contract Administration › Section 540.0210. Internet Posting of Sanctions Imposed for Contractual Violations

Text of section effective on April 01, 2025
Sec. 540.0210.  INTERNET POSTING OF SANCTIONS IMPOSED FOR CONTRACTUAL VIOLATIONS.  (a)  The commission shall prepare and maintain a record of each enforcement action the commission initiates that results in a sanction, including a penalty, being imposed against a managed care organization for failure to comply with the terms of a contract to provide health care services to recipients through a Medicaid managed care plan the organization issues.
(b)  The record must include:
(1)  the managed care organization's name and address;
(2)  a description of the contractual obligation the organization failed to meet;
(3)  the date of determination of noncompliance;
(4)  the date the sanction was imposed;
(5)  the maximum sanction that may be imposed under the contract for the violation; and
(6)  the actual sanction imposed against the organization.
(c)  The commission shall:
(1)  post and maintain on the commission's Internet website the records required by this section:
(A)  in English and Spanish; and
(B)  in a format that is readily accessible to and understandable by the public; and
(2)  update the list of records on the website at least quarterly.
(d)  The commission may not post information under this section that relates to a sanction while the sanction is the subject of an administrative appeal or judicial review.
(e)  A record prepared under this section may not include information that is excepted from disclosure under Chapter 552.
(f)  The executive commissioner shall adopt rules as 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 E. Contract Administration › Section 540.0211. Performance Measures and Incentives for Value-Based Contracts

Text of section effective on April 01, 2025
Sec. 540.0211.  PERFORMANCE MEASURES AND INCENTIVES FOR VALUE-BASED CONTRACTS.  (a)  The commission shall establish outcome-based performance measures and incentives to include in each contract between the commission and a health maintenance organization to provide health care services to recipients that is procured and managed under a value-based purchasing model.  The performance measures and incentives must:
(1)  be designed to facilitate and increase recipient access to appropriate health care services; and
(2)  to the extent possible, align with other state and regional quality care improvement initiatives.
(b)  Subject to Subsection (c), the commission shall include the performance measures and incentives in each contract described by Subsection (a) in addition to all other contract provisions required by this chapter and Chapter 540A.
(c)  The commission may use a graduated approach to including the performance measures and incentives in contracts described by Subsection (a) to ensure incremental and continued improvements over time.
(d)  Subject to Subsection (e), the commission shall assess the feasibility and cost-effectiveness of including provisions in a contract described by Subsection (a) that require the health maintenance organization to provide to the providers in the organization's provider network pay-for-performance opportunities that support quality improvements in recipient care.  Pay-for-performance opportunities may include incentives for providers to:
(1)  provide care after normal business hours;
(2)  participate in the early and periodic screening, diagnosis, and treatment program; and
(3)  participate in other activities that improve recipient access to care.
(e)  The commission shall, to the extent possible, base an assessment of feasibility and cost-effectiveness under Subsection (d) on publicly available, scientifically valid, evidence-based criteria appropriate for assessing the Medicaid population.
(f)  In assessing feasibility and cost-effectiveness under Subsection (d), the commission may consult with participating Medicaid providers, including providers with expertise in quality improvement and performance measurement.
(g)  If the commission determines that the provisions described by Subsection (d) are feasible and may be cost-effective, the commission shall develop and implement a pilot program in at least one health care service region under which the commission will include the provisions in contracts with health maintenance organizations offering Medicaid managed care plans in the region.
(h)  The commission shall post the financial statistical report on the commission's Internet website in a comprehensive and understandable format.
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 E. Contract Administration › Section 540.0212. Monitoring Compliance With Behavioral Health Integration

Text of section effective on April 01, 2025
Sec. 540.0212.  MONITORING COMPLIANCE WITH BEHAVIORAL HEALTH INTEGRATION.  (a)  In this section, "behavioral health services" has the meaning assigned by Section 540.0703.
(b)  In monitoring contracts the commission enters into with Medicaid managed care organizations under this chapter, the commission shall:
(1)  ensure the organizations fully integrate behavioral health services into a recipient's primary care coordination;
(2)  use performance audits and other oversight tools to improve monitoring of the provision and coordination of behavioral health services; and
(3)  establish performance measures that may be used to determine the effectiveness of the behavioral health services integration.
(c)  In monitoring a Medicaid managed care organization's compliance with behavioral health services integration requirements under this section, the commission shall give particular attention to an organization that provides behavioral health services through a contract with a third party.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0251. Applicability

Text of section effective on April 01, 2025
Sec. 540.0251.  APPLICABILITY.  This subchapter applies to a contract between a Medicaid managed care organization and the commission to provide 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 F. Required Contract Provisions › Section 540.0252. Accountability to State

Text of section effective on April 01, 2025
Sec. 540.0252.  ACCOUNTABILITY TO STATE.  A contract to which this subchapter applies must contain procedures to ensure accountability to this state for providing health care services, including procedures for:
(1)  financial reporting;
(2)  quality assurance;
(3)  utilization review; and
(4)  assurance of contract and subcontract compliance.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0253. Capitation Rates

Text of section effective on April 01, 2025
Sec. 540.0253.  CAPITATION RATES.  A contract to which this subchapter applies must contain capitation rates that:
(1)  include acuity and risk adjustment methodologies that consider the costs of providing acute care services and long-term services and supports, including private duty nursing services, provided under the Medicaid managed care plan; and
(2)  ensure the cost-effective provision of quality health care.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0254. Cost Information

Text of section effective on April 01, 2025
Sec. 540.0254.  COST INFORMATION.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization and any entity with which the organization contracts to perform services under a Medicaid managed care plan to disclose at no cost to the commission and, on request, the office of the attorney general all agreements affecting the net cost of goods or services provided under the plan, including:
(1) discounts;
(2) incentives;
(3) rebates;
(4) fees;
(5) free goods; and
(6) bundling arrangements.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0255. Fraud Control

Text of section effective on April 01, 2025
Sec. 540.0255.  FRAUD CONTROL.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to:
(1)  provide the information required by Section 540.0058; and
(2)  otherwise comply and cooperate with the commission's office of inspector general and the office of the attorney general.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0256. Recipient Outreach and Education

Text of section effective on April 01, 2025
Sec. 540.0256.  RECIPIENT OUTREACH AND EDUCATION.  A contract to which this subchapter applies must:
(1)  require the contracting Medicaid managed care organization to provide:
(A)  information about the availability of and referral to educational, social, and other community services that could benefit a recipient; and
(B)  special programs and materials for recipients with limited English proficiency or low literacy skills; and
(2)  contain procedures for recipient outreach and education.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0257. Notice of Medicaid Certification Date

Text of section effective on April 01, 2025
Sec. 540.0257.  NOTICE OF MEDICAID CERTIFICATION DATE.  A contract to which this subchapter applies must require the commission to inform the contracting Medicaid managed care organization, on the date of a recipient's enrollment in a Medicaid managed care plan the organization issues, of the recipient's Medicaid certification date.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0258. Primary Care Provider Assignment

Text of section effective on April 01, 2025
Sec. 540.0258.  PRIMARY CARE PROVIDER ASSIGNMENT.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to make initial and subsequent primary care provider assignments and changes.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0259. Compliance With Provider Network Requirements

Text of section effective on April 01, 2025
Sec. 540.0259.  COMPLIANCE WITH PROVIDER NETWORK REQUIREMENTS.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to comply with Sections 540.0651(a)(1) and (2) and (b) as a condition of contract retention and renewal.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0260. Compliance With Provider Access Standards; Report

Text of section effective on April 01, 2025
Sec. 540.0260.  COMPLIANCE WITH PROVIDER ACCESS STANDARDS; REPORT.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to:
(1)  develop and submit to the commission, before the organization begins providing health care services to recipients, a comprehensive plan that describes how the organization's provider network complies with the provider access standards the commission establishes under Section 540.0652;
(2)  as a condition of contract retention and renewal:
(A)  continue to comply with the provider access standards; and
(B)  make substantial efforts, as the commission determines, to mitigate or remedy any noncompliance with the provider access standards;
(3)  pay liquidated damages for each failure, as the commission determines, to comply with the provider access standards in amounts that are reasonably related to the noncompliance; and
(4)  regularly, as the commission determines, submit to the commission and make available to the public a report containing:
(A)  data on the organization's provider network sufficiency with regard to providing the care and services described by Section 540.0652(a); and
(B)  specific data with respect to access to primary care, specialty care, long-term services and supports, nursing services, and therapy services on the average length of time between:
(i)  the date a provider requests prior authorization for the care or service and the date the organization approves or denies the request; and
(ii)  the date the organization approves a request for prior authorization for the care or service and the date the care or service is initiated.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0261. Provider Network Sufficiency

Text of section effective on April 01, 2025
Sec. 540.0261.  PROVIDER NETWORK SUFFICIENCY.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to demonstrate to the commission, before the organization begins providing health care services to recipients, that, subject to the provider access standards the commission establishes under Section 540.0652:
(1)  the organization's provider network has the capacity to serve the number of recipients expected to enroll in a Medicaid managed care plan the organization offers;
(2)  the organization's provider network includes:
(A)  a sufficient number of primary care providers;
(B)  a sufficient variety of provider types;
(C)  a sufficient number of long-term services and supports providers and specialty pediatric care providers of home and community-based services; and
(D)  providers located throughout the region in which the organization will provide health care services; and
(3)  health care services will be accessible to recipients through the organization's provider network to a comparable extent that health care services would be available to recipients under a fee-for-service model or primary care case management Medicaid managed care model.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0262. Quality Monitoring Program for Health Care Services

Text of section effective on April 01, 2025
Sec. 540.0262.  QUALITY MONITORING PROGRAM FOR HEALTH CARE SERVICES.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop a monitoring program for measuring the quality of the health care services provided by the organization's provider network that:
(1)  incorporates the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) measures or, as applicable, the national core indicators adult consumer survey and the national core indicators child family survey for individuals with an intellectual or developmental disability;
(2)  focuses on measuring outcomes; and
(3)  includes collecting and analyzing clinical data relating to prenatal care, preventive care, mental health care, and the treatment of acute and chronic health conditions and substance use disorder.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0263. Out-of-Network Provider Usage and Reimbursement

Text of section effective on April 01, 2025
Sec. 540.0263.  OUT-OF-NETWORK PROVIDER USAGE AND REIMBURSEMENT.  (a)  A contract to which this subchapter applies must require that:
(1)  the contracting Medicaid managed care organization's usages of out-of-network providers or groups of out-of-network providers may not exceed limits the commission determines for those usages relating to total inpatient admissions, total outpatient services, and emergency room admissions; and
(2)  the organization reimburse an out-of-network provider for health care services at a rate that is equal to the allowable rate for those services as determined under Sections 32.028 and 32.0281, Human Resources Code, if the commission finds that the organization violated Subdivision (1).
(b)  In accordance with Subsection (a)(2), a Medicaid managed care organization must reimburse an out-of-network provider of poststabilization services for providing the services at the allowable rate for those services until the organization arranges for the recipient's timely transfer, as the recipient's attending physician determines, to a provider in the organization's provider network.  The organization may not refuse to reimburse an out-of-network provider for emergency or poststabilization services provided as a result of the organization's failure to arrange for and authorize a recipient's timely transfer.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0264. Provider Reimbursement Rate Reduction

Text of section effective on April 01, 2025
Sec. 540.0264.  PROVIDER REIMBURSEMENT RATE REDUCTION.  (a) A contract to which this subchapter applies must require that the contracting Medicaid managed care organization not implement a significant, nonnegotiated, across-the-board provider reimbursement rate reduction unless:
(1)  subject to Subsection (b), the organization has the commission's prior approval to implement the reduction; or
(2)  the rate reduction is based on changes to the Medicaid fee schedule or cost containment initiatives the commission implements.
(b)  A provider reimbursement rate reduction a Medicaid managed care organization proposes is considered to have received the commission's prior approval unless the commission issues a written statement of disapproval not later than the 45th day after the date the commission receives notice of the proposed rate reduction from the organization.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0265. Prompt Payment of Claims

Text of section effective on April 01, 2025
Sec. 540.0265.  PROMPT PAYMENT OF CLAIMS.  (a) A contract to which this subchapter applies must require the contracting Medicaid managed care organization to pay a physician or provider for health care services provided to a recipient under a Medicaid managed care plan on any claim for payment the organization receives with documentation reasonably necessary for the organization to process the claim:
(1)  not later than:
(A)  the 10th day after the date the organization receives the claim if the claim relates to services a nursing facility, intermediate care facility, or group home provided;
(B)  the 30th day after the date the organization receives the claim if the claim relates to the provision of long-term services and supports not subject to Paragraph (A); and
(C)  the 45th day after the date the organization receives the claim if the claim is not subject to Paragraph (A) or (B); or
(2)  within a period, not to exceed 60 days, specified by a written agreement between the physician or provider and the organization.
(b)  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to demonstrate to the commission that the organization pays claims described by Subsection (a)(1)(B) on average not later than the 21st day after the date the organization receives the claim.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0266. Reimbursement for Certain Services Provided Outside Regular Business Hours

Text of section effective on April 01, 2025
Sec. 540.0266.  REIMBURSEMENT FOR CERTAIN SERVICES PROVIDED OUTSIDE REGULAR BUSINESS HOURS.  (a)  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to reimburse a federally qualified health center or rural health clinic 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, if the recipient does not have a referral from the recipient's primary care physician.
(b)  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 (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 F. Required Contract Provisions › Section 540.0267. Provider Appeals Process

Text of section effective on April 01, 2025
Sec. 540.0267.  PROVIDER APPEALS PROCESS.  (a)  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop, implement, and maintain a system for tracking and resolving provider appeals related to claims payment.  The system must include a process that requires:
(1)  a tracking mechanism to document the status and final disposition of each provider's claims payment appeal;
(2)  contracting with physicians who are not network providers and who are of the same or related specialty as the appealing physician to resolve claims disputes that:
(A)  relate to denial on the basis of medical necessity; and
(B)  remain unresolved after a provider appeal;
(3)  the determination of the physician resolving the dispute to be binding on the organization and provider; and
(4)  the organization to allow a provider to initiate an appeal of a claim that has not been paid before the time prescribed by Section 540.0265(a)(1)(B).
(b)  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to develop and establish a process for responding to provider appeals in the region in which the organization provides health care 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 F. Required Contract Provisions › Section 540.0268. Assistance Resolving Recipient and Provider Issues

Text of section effective on April 01, 2025
Sec. 540.0268.  ASSISTANCE RESOLVING RECIPIENT AND PROVIDER ISSUES.  A contract to which this subchapter applies must require the contracting Medicaid managed care organization to provide ready access to a person who assists:
(1)  a recipient in resolving issues relating to enrollment, plan administration, education and training, access to services, and grievance procedures; and
(2)  a provider in resolving issues relating to payment, plan administration, education and training, and grievance procedures.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0269. Use of Advanced Practice Registered Nurses and Physician Assistants

Text of section effective on April 01, 2025
Sec. 540.0269.  USE OF ADVANCED PRACTICE REGISTERED NURSES AND PHYSICIAN ASSISTANTS.  (a)  A contract to which this subchapter applies must require the contracting Medicaid managed care organization, notwithstanding any other law, including Sections 843.312 and 1301.052, Insurance Code, to:
(1)  use advanced practice registered nurses and physician assistants as primary care providers in addition to physicians to increase the availability of primary care providers in the organization's provider network; and
(2)  treat advanced practice registered nurses and physician assistants in the same manner as primary care physicians with regard to:
(A)  selection and assignment as primary care providers;
(B)  inclusion as primary care providers in the organization's provider network; and
(C)  inclusion as primary care providers in any provider network directory the organization maintains.
(b)  For purposes of this section, an advanced practice registered nurse may be included as a primary care provider in a Medicaid managed care organization's provider network regardless of whether the physician supervising the advanced practice registered nurse is in the provider network.  This subsection may not be construed as authorizing a Medicaid managed care organization to supervise or control the practice of medicine as prohibited by Subtitle B, Title 3, Occupations Code.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 540 - Medicaid Managed Care Program › Subchapter F. Required Contract Provisions › Section 540.0270. Medical Director Availability

Text of section effective on April 01, 2025
Sec. 540.0270.  MEDICAL DIRECTOR AVAILABILITY.  A contract to which this subchapter applies must require that a medical director who is authorized to make medical necessity determinations be available to the region in which the contracting Medicaid managed care organization provides health care 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 F. Required Contract Provisions › Section 540.0271. Personnel Required in Certain Service Regions

Text of section effective on April 01, 2025
Sec. 540.0271.  PERSONNEL REQUIRED IN CERTAIN SERVICE REGIONS.  A contract to which this subchapter applies must require a contracting Medicaid managed care organization that provides a Medicaid managed care plan in the South Texas service region to ensure the following personnel are located in that region:
(1)  a medical director;
(2)  patient care coordinators; and
(3)  provider and recipient support services personnel.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.