reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0251. Definition

Text of section effective on April 01, 2025
Sec. 532.0251.  DEFINITION.  In this subchapter, "electronic visit verification system" means the electronic visit verification system implemented under Section 532.0253.
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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0252. Implementation of Certain Provisions

Text of section effective on April 01, 2025
Sec. 532.0252.  IMPLEMENTATION OF CERTAIN PROVISIONS.  Notwithstanding any other provision of this subchapter, the commission is required to implement a change in law made to former Section 531.024172 by Chapter 909 (S.B. 894), Acts of the 85th Legislature, Regular Session, 2017, only if the commission determines the implementation is appropriate based on the findings of the electronic visit verification system review conducted before April 1, 2018, under Section 531.024172(a) as that section existed before 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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0253. Electronic Visit Verification System Implementation

Text of section effective on April 01, 2025
Sec. 532.0253.  ELECTRONIC VISIT VERIFICATION SYSTEM IMPLEMENTATION.  (a)  Subject to Section 532.0258(a), the commission shall, in accordance with federal law, implement an electronic visit verification system to electronically verify that personal care services, attendant care services, or other services the commission identifies that are provided under Medicaid to recipients, including personal care services or attendant care services provided under the Texas Health Care Transformation and Quality Improvement Program waiver issued under Section 1115 of the Social Security Act (42 U.S.C. Section 1315) or any other Medicaid waiver program, are provided to recipients in accordance with a prior authorization or plan of care.
(b)  The verification must be made through a telephone, global positioning, or computer-based system.
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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0254. Information to Be Verified

Text of section effective on April 01, 2025
Sec. 532.0254.  INFORMATION TO BE VERIFIED.  The electronic visit verification system must allow for verification of only the following information relating to the delivery of Medicaid services:
(1)  the type of service provided;
(2)  the name of the recipient to whom the service was provided;
(3)  the date and times the provider began and ended the service delivery visit;
(4)  the location, including the address, at which the service was provided;
(5)  the name of the individual who provided the service; and
(6)  other information the commission determines is necessary to ensure the accurate adjudication of Medicaid claims.
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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0255. Compliance Standards and Standardized Processes

Text of section effective on April 01, 2025
Sec. 532.0255.  COMPLIANCE STANDARDS AND STANDARDIZED PROCESSES.  (a)  In implementing the electronic visit verification system:
(1)  subject to Subsection (b), the executive commissioner shall adopt compliance standards for health care providers; and
(2)  the commission shall ensure that:
(A)  the information required to be reported by health care providers is standardized across Medicaid managed care organizations and commission programs;
(B)  processes Medicaid managed care organizations require to retrospectively correct data are standardized and publicly accessible to health care providers;
(C)  standardized processes are established for addressing the failure of a Medicaid managed care organization to provide a timely authorization for delivering services necessary to ensure continuity of care; and
(D)  a health care provider is allowed to enter a variable schedule into the system.
(b)  In establishing compliance standards for health care providers under Subsection (a), the executive commissioner shall consider:
(1)  the administrative burdens placed on health care providers required to comply with the standards; and
(2)  the benefits of using emerging technologies for ensuring compliance, including Internet-based, mobile telephone-based, and global positioning-based technologies.
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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0256. Recipient Compliance

Text of section effective on April 01, 2025
Sec. 532.0256.  RECIPIENT COMPLIANCE.  The commission shall inform each recipient who receives personal care services, attendant care services, or other services the commission identifies that the health care provider providing the services and the recipient are each required to comply with the electronic visit verification system.  A Medicaid managed care organization shall also inform recipients described by this section who are enrolled in a managed care plan offered by the organization of those requirements.
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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0257. Health Care Provider Compliance

Text of section effective on April 01, 2025
Sec. 532.0257.  HEALTH CARE PROVIDER COMPLIANCE.  A health care provider that provides to recipients personal care services, attendant care services, or other services the commission identifies shall:
(1)  use the electronic visit verification system or a proprietary system the commission allows as provided by Section 532.0258 to document the provision of those services;
(2)  comply with all documentation requirements the commission establishes;
(3)  comply with federal and state laws regarding confidentiality of recipients' information;
(4)  ensure that the commission or the Medicaid managed care organization with which a claim for reimbursement for a service is filed may review electronic visit verification system documentation related to the claim or obtain a copy of that documentation at no charge to the commission or the organization; and
(5)  at any time, allow the commission or a Medicaid managed care organization with which a health care provider contracts to provide health care services to recipients enrolled in the organization's managed care plan to have direct, on-site access to the electronic visit verification system in use by the health care provider.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0258. Health Care Provider: Use of Proprietary System

Text of section effective on April 01, 2025
Sec. 532.0258.  HEALTH CARE PROVIDER: USE OF PROPRIETARY SYSTEM.  (a)  The commission may recognize a health care provider's proprietary electronic visit verification system, whether purchased or developed by the provider, as complying with this subchapter and allow the health care provider to use that system for a period the commission determines if the commission determines that the system:
(1)  complies with all necessary data submission, exchange, and reporting requirements established under this subchapter; and
(2)  meets all other standards and requirements established under this subchapter.
(b)  If feasible, the executive commissioner shall ensure a health care provider is reimbursed for the use of the provider's proprietary electronic visit verification system the commission recognizes.
(c)  For purposes of facilitating the use of proprietary electronic visit verification systems by health care providers and in consultation with industry stakeholders and the work group established under Section 532.0259, the commission or the executive commissioner, as appropriate, shall:
(1)  develop an open model system that mitigates the administrative burdens providers required to use electronic visit verification identify;
(2)  allow providers to use emerging technologies, including Internet-based, mobile telephone-based, and global positioning-based technologies, in the providers' proprietary electronic visit verification systems; and
(3)  adopt rules governing data submission and provider reimbursement.
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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0259. Stakeholder Input

Text of section effective on April 01, 2025
Sec. 532.0259.  STAKEHOLDER INPUT.  The commission shall create a stakeholder work group composed of representatives of affected health care providers, Medicaid managed care organizations, and recipients.  The commission shall periodically solicit from the work group input regarding the ongoing operation of the electronic visit verification system.
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 532 - Medicaid Administration and Operation in General › Subchapter F. Electronic Visit Verification System › Section 532.0260. Rules

Text of section effective on April 01, 2025
Sec. 532.0260.  RULES.  The executive commissioner may adopt rules necessary to implement this subchapter.
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 532 - Medicaid Administration and Operation in General › Subchapter G. Applicants and Recipients › Section 532.0301. Bill of Rights and Bill of Responsibilities

Text of section effective on April 01, 2025
Sec. 532.0301.  BILL OF RIGHTS AND BILL OF RESPONSIBILITIES.  (a)  The executive commissioner by rule shall adopt a bill of rights and a bill of responsibilities for each recipient.
(b)  The bill of rights must address a recipient's right to:
(1)  respect, dignity, privacy, confidentiality, and nondiscrimination;
(2)  a reasonable opportunity to choose a health benefits plan and primary care provider and to change to another plan or provider in a reasonable manner;
(3)  consent to or refuse treatment and actively participate in treatment decisions;
(4)  ask questions and receive complete information relating to the recipient's medical condition and treatment options, including specialty care;
(5)  access each available complaint process, receive a timely response to a complaint, and receive a fair hearing; and
(6)  timely access to care that does not have any communication or physical access barriers.
(c)  The bill of responsibilities must address a recipient's responsibility to:
(1)  learn and understand each right the recipient has under Medicaid;
(2)  abide by the health plan and Medicaid policies and procedures;
(3)  share information relating to the recipient's health status with the primary care provider and become fully informed about service and treatment options; and
(4)  actively participate in decisions relating to service and treatment options, make personal choices, and take action to maintain the recipient's health.
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 532 - Medicaid Administration and Operation in General › Subchapter G. Applicants and Recipients › Section 532.0302. Uniform Fair Hearing Rules

Text of section effective on April 01, 2025
Sec. 532.0302.  UNIFORM FAIR HEARING RULES.  (a)  The executive commissioner shall adopt uniform fair hearing rules for Medicaid-funded services.  The rules must provide:
(1)  due process to a Medicaid applicant and to a recipient who seeks a Medicaid service, including a service that requires prior authorization; and
(2)  the protections for applicants and recipients required by 42 C.F.R. Part 431, Subpart E, including requiring that:
(A)  the written notice to an individual of the individual's right to a hearing must:
(i)  contain an explanation of the circumstances under which Medicaid is continued if a hearing is requested; and
(ii)  be delivered by mail, and postmarked at least 10 business days, before the date the individual's Medicaid eligibility or service is scheduled to be terminated, suspended, or reduced, except as provided by 42 C.F.R. Section 431.213 or 431.214; and
(B)  if a hearing is requested before the date a recipient's service, including a service that requires prior authorization, is scheduled to be terminated, suspended, or reduced, the agency may not take that proposed action before a decision is rendered after the hearing unless:
(i)  it is determined at the hearing that the sole issue is one of federal or state law or policy; and
(ii)  the agency promptly informs the recipient in writing that services are to be terminated, suspended, or reduced pending the hearing decision.
(b)  The commission shall develop a process to address a situation in which:
(1)  an individual does not receive adequate notice as required by Subsection (a)(2)(A); or
(2)  the notice required by Subsection (a)(2)(A) is delivered without a postmark.
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 532 - Medicaid Administration and Operation in General › Subchapter G. Applicants and Recipients › Section 532.0305. Therapy Services Assessments

Text of section effective on April 01, 2025
Sec. 532.0305.  THERAPY SERVICES ASSESSMENTS.  (a)  In this section, "therapy services" includes occupational, physical, and speech therapy services.
(b)  After implementing the objective assessment process for acute nursing services in accordance with Section 532.0304, the commission shall consider whether implementing age- and diagnosis-appropriate objective assessment processes for use in assessing a recipient's need for therapy services would be feasible and beneficial.
(c)  If the commission determines that implementing age- and diagnosis-appropriate processes with respect to one or more types of therapy services is feasible and would be beneficial, the commission may implement the processes within:
(1)  the Medicaid fee-for-service model;
(2)  the primary care case management Medicaid managed care model; and
(3)  the STAR and STAR+PLUS Medicaid managed care programs.
(d)  An objective assessment process implemented under this section must include a process that allows a therapy services provider to request and obtain a review of the results of an assessment conducted as provided by this section. The review process must be comparable to the review process implemented under Section 532.0304(e).
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 532 - Medicaid Administration and Operation in General › Subchapter G. Applicants and Recipients › Section 532.0306. Wellness Screening Program

Text of section effective on April 01, 2025
Sec. 532.0306.  WELLNESS SCREENING PROGRAM.  If cost-effective, the commission may implement a wellness screening program for recipients that is designed to evaluate a recipient's risk for having certain diseases and medical conditions to establish:
(1)  a health baseline for each recipient that may be used to tailor the recipient's treatment plan; or
(2)  the recipient's health goals.
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 532 - Medicaid Administration and Operation in General › Subchapter G. Applicants and Recipients › Section 532.0307. Federally Qualified Health Center and Rural Health Clinic Services

Text of section effective on April 01, 2025
Sec. 532.0307.  FEDERALLY QUALIFIED HEALTH CENTER AND RURAL HEALTH CLINIC SERVICES.  (a)  In this section:
(1)  "Federally qualified health center services" has the meaning assigned by 42 U.S.C. Section 1396d(l)(2)(A).
(2)  "Rural health clinic services" has the meaning assigned by 42 U.S.C. Section 1396d(l)(1).
(b)  Notwithstanding any provision of this chapter, Chapter 32, Human Resources Code, or any other law, the commission shall:
(1)  promote recipient access to federally qualified health center services or rural health clinic services; and
(2)  ensure that payment for federally qualified health center services or rural health clinic services is in accordance with 42 U.S.C. Section 1396a(bb).
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 532 - Medicaid Administration and Operation in General › Subchapter H. Programs and Services for Certain Categories of Medicaid Population › Section 532.0352. Waiver Program for Certain Individuals With Chronic Health Conditions

Text of section effective on April 01, 2025
Sec. 532.0352.  WAIVER PROGRAM FOR CERTAIN INDIVIDUALS WITH CHRONIC HEALTH CONDITIONS.  (a)  If feasible and cost-effective, the commission may apply for a waiver from the Centers for Medicare and Medicaid Services or another appropriate federal agency to more efficiently leverage the use of state and local funds to maximize the receipt of federal Medicaid matching funds by providing Medicaid benefits to individuals who:
(1)  meet established income and other eligibility criteria; and
(2)  are eligible to receive services through the county for chronic health conditions.
(b)  In establishing the waiver program, the commission shall:
(1)  ensure that this state is a prudent purchaser of the health care services that are needed for the individuals described by Subsection (a);
(2)  solicit broad-based input from interested persons;
(3)  ensure that the benefits an individual receives through the county are not reduced once the individual is enrolled in the waiver program; and
(4)  employ the use of intergovernmental transfers and other procedures to maximize the receipt of federal Medicaid matching funds.
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 532 - Medicaid Administration and Operation in General › Subchapter H. Programs and Services for Certain Categories of Medicaid Population › Section 532.0353. Buy-in Programs for Certain Individuals With Disabilities

Text of section effective on April 01, 2025
Sec. 532.0353.  BUY-IN PROGRAMS FOR CERTAIN INDIVIDUALS WITH DISABILITIES.  (a)  The executive commissioner shall develop and implement:
(1)  a Medicaid buy-in program for individuals with disabilities as authorized by the Ticket to Work and Work Incentives Improvement Act of 1999 (Pub. L. No. 106-170) or the Balanced Budget Act of 1997 (Pub. L. No. 105-33); and
(2)  a Medicaid buy-in program for children with disabilities described by 42 U.S.C. Section 1396a(cc)(1) whose family incomes do not exceed 300 percent of the applicable federal poverty level, as authorized by the Deficit Reduction Act of 2005 (Pub. L. No. 109-171).
(b)  The executive commissioner shall adopt rules in accordance with federal law that provide for:
(1)  eligibility requirements for each program described by Subsection (a); and
(2)  requirements for program participants to pay premiums or cost-sharing payments, subject to Subsection (c).
(c)  Rules the executive commissioner adopts under Subsection (b) with respect to the program for children with disabilities described by Subsection (a)(2) must require a participant to pay monthly premiums according to a sliding scale that is based on family income, subject to the requirements of 42 U.S.C. Sections 1396o(i)(2) and (3).
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 532 - Medicaid Administration and Operation in General › Subchapter I. Utilization Review, Prior Authorization, and Coverage Processes and Determinations › Section 532.0401. Review of Prior Authorization and Utilization Review Processes

Text of section effective on April 01, 2025
Sec. 532.0401.  REVIEW OF PRIOR AUTHORIZATION AND UTILIZATION REVIEW PROCESSES.  The commission shall:
(1)  in accordance with an established schedule, periodically review the prior authorization and utilization review processes within the Medicaid fee-for-service delivery model to determine whether those processes need modification to reduce authorizations of unnecessary services and inappropriate use of services;
(2)  monitor the prior authorization and utilization review processes within the Medicaid fee-for-service delivery model for anomalies and, on identification of an anomaly in a process, review the process for modification earlier than scheduled; and
(3)  monitor Medicaid managed care organizations to ensure that the organizations are using prior authorization and utilization review processes to reduce authorizations of unnecessary services and inappropriate use of 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 532 - Medicaid Administration and Operation in General › Subchapter I. Utilization Review, Prior Authorization, and Coverage Processes and Determinations › Section 532.0402. Accessibility of Information Regarding Prior Authorization Requirements

Text of section effective on April 01, 2025
Sec. 532.0402.  ACCESSIBILITY OF INFORMATION REGARDING PRIOR AUTHORIZATION REQUIREMENTS.  (a)  The executive commissioner by rule shall require each Medicaid managed care organization or other entity responsible for authorizing coverage for health care services under Medicaid to ensure that the organization or entity maintains on the organization's or entity's Internet website in an easily searchable and accessible format:
(1)  the applicable timelines for prior authorization requirements, including:
(A)  the time within which the organization or entity must make a determination on a prior authorization request;
(B)  a description of the notice the organization or entity provides to a provider and recipient on whose behalf the request was submitted regarding the documentation required to complete a determination on a prior authorization request; and
(C)  the deadline by which the organization or entity is required to submit the notice described by Paragraph (B); and
(2)  an accurate and current catalog of coverage criteria and prior authorization requirements, including:
(A)  for a prior authorization requirement first imposed on or after September 1, 2019, the effective date of the requirement;
(B)  a list or description of any supporting or other documentation necessary to obtain prior authorization for a specified service; and
(C)  the date and results of each review of a prior authorization requirement conducted under Section 540.0304, if applicable.
(b)  The executive commissioner by rule shall require each Medicaid managed care organization or other entity responsible for authorizing coverage for health care services under Medicaid to:
(1)  adopt and maintain a process for a provider or recipient to contact the organization or entity to clarify prior authorization requirements or to assist the provider in submitting a prior authorization request; and
(2)  ensure that the process described by Subdivision (1) is not arduous or overly burdensome to a provider or recipient.
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 532 - Medicaid Administration and Operation in General › Subchapter I. Utilization Review, Prior Authorization, and Coverage Processes and Determinations › Section 532.0403. Notice Requirements Regarding Coverage or Prior Authorization Denial and Incomplete Requests

Text of section effective on April 01, 2025
Sec. 532.0403.  NOTICE REQUIREMENTS REGARDING COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.  (a)  The commission shall ensure that a notice the commission or a Medicaid managed care organization sends to a recipient or Medicaid provider regarding the denial, partial denial, reduction, or termination of coverage or denial of prior authorization for a service includes:
(1)  information required by federal and state law and regulations;
(2)  for the recipient:
(A)  a clear and easy-to-understand explanation of the reason for the decision, including a clear explanation of the medical basis, applying the policy or accepted standard of medical practice to the recipient's particular medical circumstances;
(B)  a copy of the information the commission or organization sent to the provider; and
(C)  an educational component that includes:
(i)  a description of the recipient's rights;
(ii)  an explanation of the process related to appeals and Medicaid fair hearings; and
(iii)  a description of the role of an external medical review; and
(3)  for the provider, a thorough and detailed clinical explanation of the reason for the decision, including, as applicable, information required under Subsection (b).
(b)  The commission or a Medicaid managed care organization that receives from a provider a coverage or prior authorization request that contains insufficient or inadequate documentation to approve the request shall issue a notice to the provider and the recipient on whose behalf the request was submitted.  The notice must:
(1)  include a section specifically for the provider that contains:
(A)  a clear and specific list and description of the documentation necessary for the commission or organization to make a final determination on the request;
(B)  the applicable timeline, based on the requested service, for the provider to submit the documentation and a description of the reconsideration process described by Section 540.0306, if applicable; and
(C)  information on the manner through which a provider may contact a Medicaid managed care organization or other entity as required by Section 532.0402; and
(2)  be sent:
(A)  to the provider:
(i)  using the provider's preferred method of communication, to the extent practicable using existing resources; and
(ii)  as applicable, through an electronic notification on an Internet portal; and
(B)  to the recipient using the recipient's preferred method of communication, to the extent practicable using existing resources.
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 532 - Medicaid Administration and Operation in General › Subchapter J. Cost-Saving Initiatives › Section 532.0452. Physician Incentive Program to Reduce Hospital Emergency Room Use for Non-Emergent Conditions

Text of section effective on April 01, 2025
Sec. 532.0452.  PHYSICIAN INCENTIVE PROGRAM TO REDUCE HOSPITAL EMERGENCY ROOM USE FOR NON-EMERGENT CONDITIONS.  (a)  If cost-effective, the executive commissioner by rule shall establish a physician incentive program designed to reduce recipients' use of hospital emergency room services for non-emergent conditions.
(b)  In establishing the physician incentive program, the executive commissioner may include only the program components identified as cost-effective in the study conducted under former Section 531.086 before that section expired September 1, 2014.
(c)  If the physician incentive program includes the payment of an enhanced reimbursement rate for routine after-hours appointments, the executive commissioner shall implement controls to ensure that the after-hours services billed are actually provided outside of normal business hours.
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 532 - Medicaid Administration and Operation in General › Subchapter J. Cost-Saving Initiatives › Section 532.0453. Continued Implementation of Certain Interventions and Best Practices by Providers; Semiannual Report

Text of section effective on April 01, 2025
Sec. 532.0453.  CONTINUED IMPLEMENTATION OF CERTAIN INTERVENTIONS AND BEST PRACTICES BY PROVIDERS; SEMIANNUAL REPORT.  (a)  The commission shall encourage Medicaid providers to continue implementing effective interventions and best practices associated with improvements in the health outcomes of recipients that were developed and achieved under the Delivery System Reform Incentive Payment (DSRIP) program previously operated under the Texas Health Care Transformation and Quality Improvement Program waiver issued under Section 1115 of the Social Security Act (42 U.S.C. Section 1315), through:
(1)  existing provider incentive programs and the creation of new provider incentive programs;
(2)  the terms included in contracts with Medicaid managed care organizations;
(3)  implementation of alternative payment models; or
(4)  adoption of other cost-effective measures.
(b)  The commission shall semiannually prepare and submit to the legislature a report that contains a summary of the commission's efforts under this section and Section 532.0451(b).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 532 - Medicaid Administration and Operation in General › Subchapter J. Cost-Saving Initiatives › Section 532.0454. Health Savings Account Pilot Program

Text of section effective on April 01, 2025
Sec. 532.0454.  HEALTH SAVINGS ACCOUNT PILOT PROGRAM.  (a)  If the commission determines that it is cost-effective and feasible, the commission shall develop and implement a Medicaid health savings account pilot program that is consistent with federal law to:
(1)  encourage adult recipients' health care cost awareness and sensitivity; and
(2)  promote adult recipients' appropriate use of Medicaid services.
(b)  If the commission implements the pilot program, the commission:
(1)  may include only adult recipients as program participants; and
(2)  shall ensure that:
(A)  participation in the pilot program is voluntary; and
(B)  a recipient who participates in the pilot program may, at the recipient's option and subject to Subsection (c), discontinue participating and resume receiving benefits and services under the traditional Medicaid delivery model.
(c)  A recipient who chooses to discontinue participating in the pilot program and resume receiving benefits and services under the traditional Medicaid delivery model before completion of the health savings account enrollment period forfeits any funds remaining in the recipient's health savings account.
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 532 - Medicaid Administration and Operation in General › Subchapter J. Cost-Saving Initiatives › Section 532.0455. Durable Medical Equipment Reuse Program

Text of section effective on April 01, 2025
Sec. 532.0455.  DURABLE MEDICAL EQUIPMENT REUSE PROGRAM.  (a)  In this section:
(1)  "Complex rehabilitation technology equipment":
(A)  means equipment that is:
(i)  classified as durable medical equipment under the Medicare program on January 1, 2013;
(ii)  configured specifically for an individual to meet the individual's unique medical, physical, and functional needs and capabilities for basic and instrumental daily living activities; and
(iii)  medically necessary to prevent the individual's hospitalization or institutionalization; and
(B)  includes a complex rehabilitation power wheelchair, highly configurable manual wheelchair, adaptive seating and positioning system, standing frame, and gait trainer.
(2)  "Durable medical equipment" means equipment, including repair and replacement parts for the equipment, but excluding complex rehabilitation technology equipment, that:
(A)  can withstand repeated use;
(B)  is primarily and customarily used to serve a medical purpose;
(C)  generally is not useful to an individual in the absence of illness or injury; and
(D)  is appropriate and safe for use in the home.
(b)  If the commission determines that it is cost-effective, the executive commissioner by rule shall establish a program to facilitate the reuse of durable medical equipment provided to recipients.
(c)  The program must include provisions for ensuring that:
(1)  reused equipment meets applicable standards of functionality and sanitation; and
(2)  a recipient's participation in the reuse program is voluntary.
(d)  The program does not:
(1)  waive any immunity from liability of the commission or a commission employee; or
(2)  create a cause of action against the commission or a commission employee arising from the provision of reused durable medical equipment under the program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.001. Definitions

Text of section effective until April 01, 2025
Sec. 533.001.  DEFINITIONS.  In this chapter:
(1)  "Commission" means the Health and Human Services Commission or an agency operating part of the state Medicaid managed care program, as appropriate.
(2)  "Executive commissioner" means the executive commissioner of the Health and Human Services Commission.
(3)  "Health and human services agencies" has the meaning assigned by Section 531.001.
(4)  "Managed care organization" means a person who is authorized or otherwise permitted by law to arrange for or provide a managed care plan.
(5)  "Managed care plan" means a plan under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services.  A part of the plan must consist of arranging for or providing health care services as distinguished from indemnification against the cost of those services on a prepaid basis through insurance or otherwise.  The term includes a primary care case management provider network.  The term does not include a plan that indemnifies a person for the cost of health care services through insurance.
(6)  "Recipient" means a recipient of Medicaid.
(7)  "Health care service region" or "region" means a Medicaid managed care service area as delineated by the commission.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.209, 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 533.002. Purpose

Text of section effective until April 01, 2025
Sec. 533.002.  PURPOSE.  The commission shall implement the Medicaid managed care program by contracting with managed care organizations in a manner that, to the extent possible:
(1)  improves the health of Texans by:
(A)  emphasizing prevention;
(B)  promoting continuity of care; and
(C)  providing a medical home for recipients;
(2)  ensures that each recipient receives high quality, comprehensive health care services in the recipient's local community;
(3)  encourages the training of and access to primary care physicians and providers;
(4)  maximizes cooperation with existing public health entities, including local departments of health;
(5)  provides incentives to managed care organizations to improve the quality of health care services for recipients by providing value-added services; and
(6)  reduces administrative and other nonfinancial barriers for recipients in obtaining health care services.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.210, 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 533.00254. Star Kids Managed Care Advisory Committee

Text of section effective until April 01, 2025
Sec. 533.00254.  STAR KIDS MANAGED CARE ADVISORY COMMITTEE.  (a)  The STAR Kids Managed Care Advisory Committee established by the executive commissioner under Section 531.012 shall:
(1)  advise the commission on the operation of the STAR Kids managed care program under Section 533.00253; and
(2)  make recommendations for improvements to that program.
(b)  On December 31, 2023:
(1)  the advisory committee is abolished; and
(2)  this section expires.
Added by Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 6, eff. September 1, 2019.
Added by Acts 2019, 86th Leg., R.S., Ch. 1330 (H.B. 4533), Sec. 5, eff. September 1, 2019.
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 533.00255. Behavioral Health and Physical Health Services Network

Text of section effective until April 01, 2025
Sec. 533.00255.  BEHAVIORAL HEALTH AND PHYSICAL HEALTH SERVICES NETWORK.  (a)  In this section, "behavioral health services" means mental health and substance abuse disorder services.
(b)  The commission shall, to the greatest extent possible, integrate into the Medicaid managed care program implemented under this chapter the following services for Medicaid-eligible persons:
(1)  behavioral health services, including targeted case management and psychiatric rehabilitation services; and
(2)  physical health services.
(c)  A managed care organization that contracts with the commission under this chapter shall develop a network of public and private providers of behavioral health services and ensure adults with serious mental illness and children with serious emotional disturbance have access to a comprehensive array of services.
(d)  In implementing this section, the commission shall ensure that:
(1)  an appropriate assessment tool is used to authorize services;
(2)  providers are well-qualified and able to provide an appropriate array of services;
(3)  appropriate performance and quality outcomes are measured;
(4)  two health home pilot programs are established in two health service areas, representing two distinct regions of the state, for persons who are diagnosed with:
(A)  a serious mental illness; and
(B)  at least one other chronic health condition;
(5)  a health home established under a pilot program under Subdivision (4) complies with the principles for patient-centered medical homes described in Section 533.0029; and
(6)  all behavioral health services provided under this section are based on an approach to treatment where the expected outcome of treatment is recovery.
(e)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 837 , Sec. 3.40(a)(16), eff. January 1, 2016.
(f)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 837 , Sec. 3.40(a)(16), eff. January 1, 2016.
(g)  The commission shall, if the commission determines that it is cost-effective and beneficial to recipients, include a peer specialist as a benefit to recipients or as a provider type.
(h)  To the extent of any conflict between this section and any other law relating to behavioral health services, this section prevails.
(i)  The executive commissioner shall adopt rules necessary to implement this section.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1143 (S.B. 58), Sec. 1, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.18, eff. September 1, 2015.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.19, eff. September 1, 2015.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.40(a)(16), eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.37(b)(15), 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.
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 533.002551. Monitoring of Compliance With Behavioral Health Integration

Text of section effective until April 01, 2025
Sec. 533.002551.  MONITORING OF COMPLIANCE WITH BEHAVIORAL HEALTH INTEGRATION.  (a)  In this section, "behavioral health services" has the meaning assigned by Section 533.00255.
(b)  In monitoring contracts the commission enters into with managed care organizations under this chapter, the commission shall:
(1)  ensure managed care organizations fully integrate behavioral health services into a recipient's primary care coordination;
(2)  use performance audits and other oversight tools to improve monitoring of the provision and coordination of behavioral health services; and
(3)  establish performance measures that may be used to determine the effectiveness of the integration of behavioral health services.
(c)  In monitoring a managed care organization's compliance with behavioral health services integration requirements under this section, the commission shall give particular attention to a managed care organization that provides behavioral health services through a contract with a third party.
Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.20, eff. September 1, 2015.
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 533.002552. Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families

Text of section effective until April 01, 2025
Sec. 533.002552.  TARGETED CASE MANAGEMENT AND PSYCHIATRIC REHABILITATIVE SERVICES FOR CHILDREN, ADOLESCENTS, AND FAMILIES.  (a)  A provider in the provider network of a managed care organization that contracts with the commission to provide behavioral health services under Section 533.00255 may contract with the managed care organization to provide targeted case management and psychiatric rehabilitative services to children, adolescents, and their families.
(b)  Commission rules and guidelines concerning contract and training requirements applicable to the provision of behavioral health services may apply to a provider that contracts with a managed care organization under Subsection (a) only to the extent those contract and training requirements are specific to the provision of targeted case management and psychiatric rehabilitative services to children, adolescents, and their families.
(c)  Commission rules and guidelines applicable to a provider that contracts with a managed care organization under Subsection (a) may not require the provider to provide a behavioral health crisis hotline or a mobile crisis team that operates 24 hours per day and seven days per week.  This subsection does not prohibit a managed care organization that contracts with the commission to provide behavioral health services under Section 533.00255 from specifically contracting with a provider for the provision of a behavioral health crisis hotline or a mobile crisis team that operates 24 hours per day and seven days per week.
(d)  Commission rules and guidelines applicable to a provider that contracts with a managed care organization to provide targeted case management and psychiatric rehabilitative services specific to children and adolescents who are at risk of juvenile justice involvement, expulsion from school, displacement from the home, hospitalization, residential treatment, or serious injury to self, others, or animals may not require the provider to also provide less intensive psychiatric rehabilitative services specified by commission rules and guidelines as applicable to the provision of targeted case management and psychiatric rehabilitative services to children, adolescents, and their families, if that provider has a referral arrangement to provide access to those less intensive psychiatric rehabilitative services.
(e)  Commission rules and guidelines applicable to a provider that contracts with a managed care organization under Subsection (a) may not require the provider to provide services not covered under Medicaid.
Added by Acts 2017, 85th Leg., R.S., Ch. 519 (S.B. 74), Sec. 1, eff. June 9, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.