reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter B. Assessment of Clinical Initiatives › Section 543.0056. Commission Action on Clinical Initiative

Text of section effective on April 01, 2025
Sec. 543.0056.  COMMISSION ACTION ON CLINICAL INITIATIVE.  After the commission analyzes a clinical initiative under Section 543.0054:
(1)  if the commission determined that the initiative is cost-effective and will improve the quality of care under Medicaid, the commission may:
(A)  implement the initiative if implementing the initiative is not otherwise prohibited by law; or
(B)  if implementation requires a change in law, submit a copy of the final report together with recommendations relating to the initiative's implementation to the standing committees of the senate and house of representatives with jurisdiction over Medicaid; and
(2)  if the commission determined that the initiative is not cost-effective or will not improve quality of care under Medicaid, the commission may not implement the initiative.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter A. General Provisions › Section 543A.0003. Use of Quality-Based Outcome Measure for Enrollees or Recipients With HIV Infection

Text of section effective on April 01, 2025
Sec. 543A.0003.  USE OF QUALITY-BASED OUTCOME MEASURE FOR ENROLLEES OR RECIPIENTS WITH HIV INFECTION.  (a)  The commission shall include aggregate, nonidentifying data collected using the quality-based outcome measure described by Section 543A.0002(b) in the annual report required by Section 543A.0008.  The commission may include the data in any other report required by this chapter.
(b)  The commission shall determine the appropriateness of including the quality-based outcome measure described by Section 543A.0002(b) in the quality-based payments and payment systems developed under Sections 543A.0004 and 543A.0051.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter A. General Provisions › Section 543A.0005. Payment Methodology Conversion

Text of section effective on April 01, 2025
Sec. 543A.0005.  PAYMENT METHODOLOGY CONVERSION.  (a) To the extent possible, the commission shall convert hospital reimbursement systems under the child health plan program and Medicaid to a diagnosis-related groups (DRG) methodology that will allow the commission to more accurately classify specific patient populations and account for the severity of patient illness and mortality risk.
(b)  Subsection (a) does not authorize the commission to direct a managed care organization to compensate a physician or other health care provider providing services under the organization's managed care plan based on a diagnosis-related groups (DRG) methodology.
(c)  Notwithstanding Subsection (a) and to the extent possible, the commission shall convert outpatient hospital reimbursement systems under the child health plan program and Medicaid to an appropriate prospective payment system that will allow the commission to:
(1)  more accurately classify the full range of outpatient service episodes;
(2)  more accurately account for the intensity of services provided; and
(3)  motivate outpatient service providers to increase efficiency and effectiveness.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter A. General Provisions › Section 543A.0006. Transparency; Considerations

Text of section effective on April 01, 2025
Sec. 543A.0006.  TRANSPARENCY; CONSIDERATIONS. (a) The commission shall:
(1)  ensure transparency in developing and establishing:
(A)  quality-based payment and reimbursement systems under Section 543A.0004 and Subchapters B, C, and D, including in developing outcome and process measures under Section 543A.0002; and
(B)  quality-based payment initiatives under Subchapter E, including developing quality-of-care and cost-efficiency benchmarks under Section 543A.0203(a) and approving efficiency performance standards under Section 543A.0203(b); and
(2)  for developing and establishing the quality-based payment and reimbursement systems and initiatives described by Subdivision (1), develop guidelines that establish procedures to provide notice and information to and receive input from managed care organizations, health care providers, including physicians and experts in the various medical specialty fields, and other stakeholders, as appropriate.
(b)  In developing and establishing the quality-based payment and reimbursement systems and initiatives described by Subsection (a)(1), the commission shall consider that there will be a diminishing rate of improved performance over time as the performance of a physician, other health care provider, or managed care organization improves with respect to an outcome or process measure, quality-of-care and cost-efficiency benchmark, or efficiency performance standard, as applicable.
(c)  The commission shall develop web-based capability that:
(1)  provides health care providers and managed care organizations with data on their clinical and utilization performance, including comparisons to peer organizations and providers located in this state and in the provider's respective region; and
(2)  supports the requirements of the electronic health information exchange system under Sections 525.0206, 525.0207, and 525.0208.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter A. General Provisions › Section 543A.0007. Periodic Evaluation

Text of section effective on April 01, 2025
Sec. 543A.0007.  PERIODIC EVALUATION.  At least once each two-year period, the commission shall evaluate the outcomes and cost-effectiveness of any quality-based payment system or other payment initiative implemented under this chapter.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter A. General Provisions › Section 543A.0008. Annual Report

Text of section effective on April 01, 2025
Sec. 543A.0008.  ANNUAL REPORT.  (a) The commission shall submit to the legislature and make available to the public an annual report on:
(1)  the quality-based outcome and process measures developed under Section 543A.0002, including measures based on each potentially preventable event; and
(2)  the progress of implementing quality-based payment systems and other payment initiatives under this chapter.
(b)  The commission shall, as appropriate, report outcome and process measures under Subsection (a)(1) by:
(1)  geographic location, which may require reporting by county, health care service region, or another appropriately defined geographic area;
(2)  enrollee or recipient population or eligibility group served;
(3)  type of health care provider, such as acute care or long-term care provider;
(4)  number of enrollees and recipients who relocated to a community-based setting from a less integrated setting;
(5)  quality-based payment system; and
(6)  service delivery model.
(c)  The report may not identify a specific 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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter B. Quality-Based Payments Relating to Managed Care Organizations › Section 543A.0051. Quality-Based Premium Payments; Performance Reporting

Text of section effective on April 01, 2025
Sec. 543A.0051.  QUALITY-BASED PREMIUM PAYMENTS; PERFORMANCE REPORTING. (a) Subject to Section 1903(m)(2)(A), Social Security Act (42 U.S.C. Section 1396b(m)(2)(A)), and other federal law, the commission shall base a percentage of the premiums paid to a managed care organization participating in the child health plan program or Medicaid on the organization's performance with respect to outcome and process measures developed under Section 543A.0002 that address potentially preventable events.  The percentage may increase each year.
(b)  The commission shall make available information relating to a managed care organization's performance with respect to outcome and process measures under this subchapter to an enrollee or recipient before the enrollee or recipient chooses a managed care plan.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter B. Quality-Based Payments Relating to Managed Care Organizations › Section 543A.0052. Financial Incentives and Contract Award Preferences

Text of section effective on April 01, 2025
Sec. 543A.0052.  FINANCIAL INCENTIVES AND CONTRACT AWARD PREFERENCES.  (a)  The commission may allow a managed care organization participating in the child health plan program or Medicaid increased flexibility to implement quality initiatives in a managed care plan offered by the organization, including flexibility with respect to financial arrangements, to:
(1)  achieve high-quality, cost-effective health care;
(2)  increase the use of high-quality, cost-effective delivery models;
(3)  reduce the incidence of unnecessary institutionalization and potentially preventable events; and
(4)  in collaboration with physicians and other health care providers, increase the use of alternative payment systems, including shared savings models.
(b)  The commission shall develop quality-of-care and cost-efficiency benchmarks, including benchmarks based on a managed care organization's performance with respect to:
(1)  reducing potentially preventable events; and
(2)  containing the growth rate of health care costs.
(c)  The commission may include in a contract between a managed care organization and the commission financial incentives that are based on the organization's successful implementation of quality initiatives under Subsection (a) or success in achieving quality-of-care and cost-efficiency benchmarks under Subsection (b).  The commission may implement the financial incentives only if implementing the incentives would be cost-effective.
(d)  In awarding contracts to managed care organizations under the child health plan program and Medicaid, the commission shall, in addition to considerations under Section 540.0204 of this code and Section 62.155, Health and Safety Code, give preference to an organization that offers a managed care plan that:
(1)  successfully implements quality initiatives under Subsection (a) as the commission determines based on data or other evidence the organization provides; or
(2)  meets quality-of-care and cost-efficiency benchmarks under Subsection (b).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter C. Quality-Based Health Home Payment Systems › Section 543A.0101. Definition

Text of section effective on April 01, 2025
Sec. 543A.0101.  DEFINITION.  In this subchapter, "health home" means a primary care provider practice or, if appropriate, a specialty care provider practice, incorporating several features, including comprehensive care coordination, family-centered care, and data management, that are focused on improving outcome-based quality of care and increasing patient and provider satisfaction under the child health plan program and Medicaid.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter C. Quality-Based Health Home Payment Systems › Section 543A.0102. Quality-Based Health Home Payments

Text of section effective on April 01, 2025
Sec. 543A.0102.  QUALITY-BASED HEALTH HOME PAYMENTS.  (a)  The commission may develop and implement quality-based payment systems for health homes designed to improve quality of care and reduce the provision of unnecessary medical services. A quality-based payment system must:
(1)  base payments made to an enrollee's or recipient's health home on quality and efficiency measures that may include measurable wellness and prevention criteria and the use of evidence-based best practices, sharing a portion of any realized cost savings the health home achieves, and ensuring quality of care outcomes, including a reduction in potentially preventable events; and
(2)  allow for the examination of measurable wellness and prevention criteria, use of evidence-based best practices, and quality-of-care outcomes based on the type of primary or specialty care provider practice.
(b)  The commission may develop a quality-based payment system for health homes only if implementing the system would be feasible and cost-effective.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter C. Quality-Based Health Home Payment Systems › Section 543A.0103. Health Home Eligibility

Text of section effective on April 01, 2025
Sec. 543A.0103.  HEALTH HOME ELIGIBILITY.  To be eligible to receive reimbursement under a quality-based payment system under this subchapter, a health home must:
(1)  directly or indirectly provide enrollees or recipients who have a health home with access to health care services outside of regular business hours;
(2)  educate those enrollees and recipients about the availability of health care services outside of regular business hours; and
(3)  provide evidence satisfactory to the commission that the health home meets the requirement of Subdivision (1).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter D. Quality-Based Hospital Reimbursement System › Section 543A.0151. Collecting Certain Information; Reports to Certain Hospitals

Text of section effective on April 01, 2025
Sec. 543A.0151.  COLLECTING CERTAIN INFORMATION; REPORTS TO CERTAIN HOSPITALS.  (a)  The executive commissioner shall adopt rules for identifying:
(1)  potentially preventable admissions and readmissions of enrollees and recipients, including preventable admissions to long-term care facilities;
(2)  potentially preventable ancillary services provided to or ordered for enrollees and recipients;
(3)  potentially preventable emergency room visits by enrollees and recipients; and
(4)  potentially preventable complications experienced by enrollees and recipients.
(b)  The commission shall collect data from hospitals on present-on-admission indicators for purposes of this section.
(c)  The commission shall establish a program to provide to each hospital in this state that participates in the child health plan program or Medicaid a report regarding the hospital's performance with respect to each potentially preventable event described by Subsection (a). To the extent possible, the report should include all potentially preventable events across all child health plan program and Medicaid payment systems. A hospital shall distribute the information in the report to physicians and other health care providers providing services at the hospital.
(d)  Except as provided by Subsection (e), a report provided to a hospital under Subsection (c) is confidential and not subject to Chapter 552.
(e)  The commission may release information in a report described by Subsection (c):
(1)  not earlier than one year after the date the report is provided to the hospital; and
(2)  only after deleting any data that relates to a hospital's performance with respect to a particular diagnosis-related group or an individual patient.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter D. Quality-Based Hospital Reimbursement System › Section 543A.0152. Reimbursement Adjustments

Text of section effective on April 01, 2025
Sec. 543A.0152.  REIMBURSEMENT ADJUSTMENTS.  (a)  The commission shall use the data collected under Section 543A.0151 and the diagnosis-related groups (DRG) methodology implemented under Section 543A.0005, if applicable, to adjust, to the extent feasible, child health plan program and Medicaid reimbursements to hospitals, including payments made under the disproportionate share hospitals and upper payment limit supplemental payment programs.  The commission shall base an adjustment for a hospital on the hospital's performance with respect to exceeding or failing to achieve outcome and process measures developed under Section 543A.0002 that address the rates of potentially preventable readmissions and potentially preventable complications.
(b)  The commission must provide the report required by Section 543A.0151(c) to a hospital at least one year before adjusting child health plan program and Medicaid reimbursements to the hospital under 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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter E. Quality-Based Payment Initiatives › Section 543A.0201. Payment Initiatives; Determination of Benefit to State

Text of section effective on April 01, 2025
Sec. 543A.0201.  PAYMENT INITIATIVES; DETERMINATION OF BENEFIT TO STATE. (a) The commission shall establish payment initiatives to test the effectiveness of quality-based payment systems, alternative payment methodologies, and high-quality, cost-effective health care delivery models that provide incentives to physicians and other health care providers to develop health care interventions for enrollees or recipients that will:
(1)  improve the quality of health care provided to the enrollees or recipients;
(2)  reduce potentially preventable events;
(3)  promote prevention and wellness;
(4)  increase the use of evidence-based best practices;
(5)  increase appropriate physician and other health care provider collaboration;
(6)  contain costs; and
(7)  improve integration of acute care services and long-term services and supports, including discharge planning from acute care services to community-based long-term services and supports.
(b)  The commission shall:
(1)  establish a process through which a physician, other health care provider, or managed care organization may submit a proposal for a payment initiative; and
(2)  determine whether implementing one or more proposed payment initiatives is feasible and cost-effective.
(c)  If the commission determines that implementing one or more payment initiatives is feasible and cost-effective for this state, the commission shall establish one or more payment initiatives as provided by 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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter E. Quality-Based Payment Initiatives › Section 543A.0202. Payment Initiative Administration

Text of section effective on April 01, 2025
Sec. 543A.0202.  PAYMENT INITIATIVE ADMINISTRATION.  (a)  The commission shall administer any payment initiative the commission establishes under this subchapter. The executive commissioner may adopt rules, plans, and procedures and enter into contracts and other agreements as the executive commissioner considers appropriate and necessary to administer this subchapter.
(b)  The commission may limit a payment initiative to:
(1)  one or more regions in this state;
(2)  one or more organized networks of physicians and other health care providers; or
(3)  specified types of services provided under the child health plan program or Medicaid, or specified types of enrollees or recipients.
(c)  An implemented payment initiative must be operated for at least one calendar year.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter E. Quality-Based Payment Initiatives › Section 543A.0203. Quality-of-Care and Cost-Efficiency Benchmarks and Goals; Efficiency Performance Standards

Text of section effective on April 01, 2025
Sec. 543A.0203.  QUALITY-OF-CARE AND COST-EFFICIENCY BENCHMARKS AND GOALS; EFFICIENCY PERFORMANCE STANDARDS.  (a)  The executive commissioner shall develop quality-of-care and cost-efficiency benchmarks and measurable goals that a payment initiative must meet to ensure high-quality and cost-effective health care services and healthy outcomes.
(b)  In addition to the benchmarks and goals described by Subsection (a), the executive commissioner may approve efficiency performance standards that may include the sharing of realized cost savings with physicians and other health care providers who provide health care services that exceed the standards. The standards may not create a financial incentive for or involve making a payment to a physician or other health care provider that directly or indirectly induces limiting medically necessary 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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter E. Quality-Based Payment Initiatives › Section 543A.0204. Payment Rates Under Payment Initiatives

Text of section effective on April 01, 2025
Sec. 543A.0204.  PAYMENT RATES UNDER PAYMENT INITIATIVES.  The executive commissioner may contract with appropriate entities, including qualified actuaries, to assist in determining appropriate payment rates for an implemented payment initiative.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter F. Quality-Based Long-Term Services and Supports Payment Systems › Section 543A.0251. Quality-Based Payment Systems for Long-Term Services and Supports

Text of section effective on April 01, 2025
Sec. 543A.0251.  QUALITY-BASED PAYMENT SYSTEMS FOR LONG-TERM SERVICES AND SUPPORTS.  (a)  The commission, after consulting with appropriate stakeholders representing nursing facility providers with an interest in providing long-term services and supports, may develop and implement quality-based payment systems for Medicaid long-term services and supports providers designed to improve quality of care and reduce the provision of unnecessary services. A quality-based payment system must base payments made to providers on quality and efficiency measures that may include measurable wellness and prevention criteria and the use of evidence-based best practices, sharing a portion of any realized cost savings the provider achieves, and ensuring quality of care outcomes, including a reduction in potentially preventable events.
(b)  The commission may develop a quality-based payment system for Medicaid long-term services and supports providers only if implementing the system would be feasible and cost-effective.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter F. Quality-Based Long-Term Services and Supports Payment Systems › Section 543A.0252. Data Set Evaluation

Text of section effective on April 01, 2025
Sec. 543A.0252.  DATA SET EVALUATION.  To ensure that the commission is using the best data to inform developing and implementing quality-based payment systems under Section 543A.0251, the commission shall evaluate the reliability, validity, and functionality of post-acute and long-term services and supports data sets. The commission's evaluation should assess:
(1)  to what degree data sets on which the commission relies meet a standard:
(A)  for integrating care;
(B)  for developing coordinated care plans; and
(C)  that would allow for the meaningful development of risk adjustment techniques;
(2)  whether the data sets will provide value for outcome or performance measures and cost containment; and
(3)  how classification systems and data sets used for Medicaid long-term services and supports providers can be standardized and, where possible, simplified.
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 543A - Quality-Based Outcomes and Payments Under Medicaid and Child Health Plan Program › Subchapter F. Quality-Based Long-Term Services and Supports Payment Systems › Section 543A.0253. Collecting Certain Information; Reports to Certain Providers

Text of section effective on April 01, 2025
Sec. 543A.0253.  COLLECTING CERTAIN INFORMATION; REPORTS TO CERTAIN PROVIDERS.  (a) The executive commissioner shall adopt rules for identifying the incidence of potentially preventable admissions, potentially preventable readmissions, and potentially preventable emergency room visits by Medicaid long-term services and supports recipients.
(b)  The commission shall establish a program to provide to each Medicaid long-term services and supports provider in this state a report regarding the provider's performance with respect to potentially preventable admissions, potentially preventable readmissions, and potentially preventable emergency room visits. To the extent possible, the report should include applicable potentially preventable events information across all Medicaid payment systems.
(c)  Except as provided by Subsection (d), a report provided to a provider under Subsection (b) is confidential and not subject to Chapter 552.
(d)  The commission may release information in a report described by Subsection (b):
(1)  not earlier than one year after the date the report is provided to the provider; and
(2)  only after deleting any data that relates to a provider's performance with respect to a particular resource utilization group or an individual 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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter A. General Provisions › Section 544.0002. Reference to Office of Investigations and Enforcement

Text of section effective on April 01, 2025
Sec. 544.0002.  REFERENCE TO OFFICE OF INVESTIGATIONS AND ENFORCEMENT.  Notwithstanding any other law, a reference in law or rule to the commission's office of investigations and enforcement means the office of inspector 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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter A. General Provisions › Section 544.0003. Authority of State Agency or Governmental Entity Not Limited

Text of section effective on April 01, 2025
Sec. 544.0003.  AUTHORITY OF STATE AGENCY OR GOVERNMENTAL ENTITY NOT LIMITED.  Nothing in the following provisions limits the authority of any other state agency or governmental entity:
(1)  Section 544.0052;
(2)  Section 544.0101;
(3)  Section 544.0102;
(4)  Section 544.0103;
(5)  Section 544.0104;
(6)  Section 544.0105;
(7)  Section 544.0106;
(8)  Section 544.0108;
(9)  Sections 544.0109(b) and (d);
(10)  Section 544.0110;
(11)  Section 544.0113;
(12)  Section 544.0114;
(13)  Section 544.0251;
(14)  Section 544.0252(b);
(15)  Section 544.0254;
(16)  Section 544.0255;
(17)  Section 544.0257;
(18)  Section 544.0301;
(19)  Section 544.0302;
(20)  Section 544.0303; and
(21)  Section 544.0304.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter B. Health and Human Services Commission: Administrative Provisions › Section 544.0052. Rules Regarding Enforcement and Punitive Actions

Text of section effective on April 01, 2025
Sec. 544.0052.  RULES REGARDING ENFORCEMENT AND PUNITIVE ACTIONS.  (a)  The executive commissioner, in consultation with the office of inspector general, shall adopt rules establishing criteria for determining enforcement and punitive actions regarding a provider who violated state law, program rules, or the provider's Medicaid provider agreement.
(b)  The rules must include:
(1)  direction for categorizing provider violations according to the nature of the violation and for scaling resulting enforcement actions, taking into consideration:
(A)  the seriousness of the violation;
(B)  the prevalence of errors by the provider;
(C)  the financial or other harm to this state or recipients resulting or potentially resulting from those errors; and
(D)  mitigating factors the office of inspector general determines appropriate; and
(2)  a specific list of potential penalties, including the amount of the penalties, for fraud and other Medicaid violations.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter B. Health and Human Services Commission: Administrative Provisions › Section 544.0053. Provision of Information to Pharmacy Subject to Audit; Informal Hearing on Audit Findings

Text of section effective on April 01, 2025
Sec. 544.0053.  PROVISION OF INFORMATION TO PHARMACY SUBJECT TO AUDIT; INFORMAL HEARING ON AUDIT FINDINGS.  (a)  To increase transparency, the office of inspector general shall, if the office has access to the information, provide to pharmacies that are subject to audit by the office or by an entity that contracts with the federal government to audit Medicaid providers information relating to the extrapolation methodology used as part of the audit and the methods used to determine whether the pharmacy has been overpaid under Medicaid in sufficient detail so that the audit results may be demonstrated to be statistically valid and are fully reproducible.
(b)  A pharmacy has a right to request an informal hearing before the commission's appeals division to contest the findings of an audit that the office of inspector general or an entity that contracts with the federal government to audit Medicaid providers conducted if the audit findings do not include findings that the pharmacy engaged in Medicaid fraud.
(c)  In an informal hearing held under this section, the commission's appeals division staff, assisted by staff responsible for the commission's vendor drug program with expertise in the law governing pharmacies' participation in Medicaid, make the final decision on whether the audit findings are accurate.  Office of inspector general staff may not serve on the panel that makes the decision on the accuracy of an audit.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter B. Health and Human Services Commission: Administrative Provisions › Section 544.0054. Records of Allegations of Fraud or Abuse

Text of section effective on April 01, 2025
Sec. 544.0054.  RECORDS OF ALLEGATIONS OF FRAUD OR ABUSE.  The commission shall maintain a record of all allegations of fraud or abuse against a provider containing the date each allegation was received or identified and the source of the allegation, if available.  The record is confidential under Section 544.0259(e) and is subject to Section 544.0259(f).
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter B. Health and Human Services Commission: Administrative Provisions › Section 544.0055. Record and Confidentiality of Informal Resolution Meetings

Text of section effective on April 01, 2025
Sec. 544.0055.  RECORD AND CONFIDENTIALITY OF INFORMAL RESOLUTION MEETINGS.  (a)  On the written request of a provider who requests an informal resolution meeting held under Section 544.0304 or 544.0506(b), the commission shall, at no expense to the provider, provide for the meeting to be recorded and for the recording to be made available to the provider.  The commission may not record an informal resolution meeting unless the commission receives a written request from a provider.
(b)  Notwithstanding Section 544.0259(e) and except as provided by this section:
(1)  an informal resolution meeting held under Section 544.0304 or 544.0506(b) is confidential; and
(2)  any information or materials the office of inspector general, including the office's employees or agents, obtains during or in connection with an informal resolution meeting, including a recording made under Subsection (a), are privileged, confidential, and not subject to disclosure under Chapter 552 or any other means of legal compulsion for release, including disclosure, discovery, or subpoena.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter B. Health and Human Services Commission: Administrative Provisions › Section 544.0056. Expunction of Child's Chemical Dependency Diagnosis in Certain Records

Text of section effective on April 01, 2025
Sec. 544.0056.  EXPUNCTION OF CHILD'S CHEMICAL DEPENDENCY DIAGNOSIS IN CERTAIN RECORDS.  (a)  In this section:
(1)  "Chemical dependency" has the meaning assigned by Section 461A.002, Health and Safety Code.
(2)  "Child" means an individual who is 13 years of age or younger.
(b)  After a chemical dependency treatment provider is finally convicted of an offense in which an element of the offense involves submitting a fraudulent claim for reimbursement for services under Medicaid, the commission or other health and human services agency that operates a portion of Medicaid shall expunge or provide for the expunction of a child's diagnosis of chemical dependency that the provider made and that has been entered in any:
(1)  appropriate official record of the commission or agency;
(2)  applicable medical record that is in the commission's or agency's custody; and
(3)  applicable record of a company with which the commission contracts for processing and paying 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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0101. Appointment of Inspector General; Term

Text of section effective on April 01, 2025
Sec. 544.0101.  APPOINTMENT OF INSPECTOR GENERAL; TERM.  (a)  The governor shall appoint an inspector general to serve as director of the office of inspector general.
(b)  The inspector general serves a one-year term that expires February 1.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0104. Employment of Medical Director

Text of section effective on April 01, 2025
Sec. 544.0104.  EMPLOYMENT OF MEDICAL DIRECTOR.  (a)  The office of inspector general shall employ a medical director who:
(1)  is a licensed physician under Subtitle B, Title 3, Occupations Code, and the rules the Texas Medical Board adopts under that subtitle; and
(2)  preferably has significant knowledge of Medicaid.
(b)  The medical director shall ensure that any investigative findings based on medical necessity or the quality of medical care have been reviewed by a qualified expert as described by the Texas Rules of Evidence before the office of inspector general imposes a payment hold or seeks recoupment of an overpayment, damages, or penalties.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0105. Employment of Dental Director

Text of section effective on April 01, 2025
Sec. 544.0105.  EMPLOYMENT OF DENTAL DIRECTOR.  (a)  The office of inspector general shall employ a dental director who:
(1)  is a licensed dentist under Subtitle D, Title 3, Occupations Code, and the rules the State Board of Dental Examiners adopts under that subtitle; and
(2)  preferably has significant knowledge of Medicaid.
(b)  The dental director shall ensure that any investigative findings based on the necessity of dental services or the quality of dental care have been reviewed by a qualified expert as described by the Texas Rules of Evidence before the office of inspector general imposes a payment hold or seeks recoupment of an overpayment, damages, or penalties.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0106. Contract for Review of Investigative Findings by Qualified Expert

Text of section effective on April 01, 2025
Sec. 544.0106.  CONTRACT FOR REVIEW OF INVESTIGATIVE FINDINGS BY QUALIFIED EXPERT.  (a)  If the commission does not receive any responsive bids under Chapter 2155 on a competitive solicitation for the services of a qualified expert to review investigative findings under Section 544.0104 or 544.0105 and the number of contracts to be awarded under this subsection is not otherwise limited, the commission may negotiate with and award a contract for the services to a qualified expert on the basis of:
(1)  the contractor's agreement to a set fee, either as a range or lump-sum amount; and
(2)  the contractor's affirmation and the office of inspector general's verification that the contractor possesses the necessary occupational licenses and experience.
(b)  Notwithstanding Sections 2155.083 and 2261.051, a contract awarded under Subsection (a) is not subject to competitive advertising and proposal evaluation 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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0107. Employment of Peace Officers

Text of section effective on April 01, 2025
Sec. 544.0107.  EMPLOYMENT OF PEACE OFFICERS.  (a)  The office of inspector general shall employ and commission not more than five peace officers at any given time to assist the office in carrying out the office's duties relating to the investigation of Medicaid fraud, waste, and abuse.
(b)  A peace officer the office of inspector general employs and commissions is administratively attached to the Department of Public Safety.  The commission shall provide administrative support to the department as necessary to support the assignment of the peace officers.
(c)  A peace officer the office of inspector general employs and commissions:
(1)  is a peace officer for purposes of Article 2.12, Code of Criminal Procedure; and
(2)  shall obtain the office of the attorney general's prior approval before carrying out any duties requiring peace officer status.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0108. Investigative Process Review

Text of section effective on April 01, 2025
Sec. 544.0108.  INVESTIGATIVE PROCESS REVIEW.  (a)  Office of inspector general staff who are not directly involved in investigations the office conducts shall review the office's investigative process, including the office's use of sampling and extrapolation to audit provider records.
(b)  The office of inspector general shall arrange for the Association of Inspectors General or a similar third party to conduct a peer review of the office's sampling and extrapolation techniques.  Based on the review and generally accepted practices among other offices of inspectors general, the executive commissioner, in consultation with the office, shall by rule adopt sampling and extrapolation standards for the office's use in conducting audits.
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 544 - Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services › Subchapter C. Office of Inspector General: General Provisions › Section 544.0109. Performance Audits and Coordination of Audit Activities

Text of section effective on April 01, 2025
Sec. 544.0109.  PERFORMANCE AUDITS AND COORDINATION OF AUDIT ACTIVITIES.  (a)  Notwithstanding any other law, the office of inspector general may conduct a performance audit of any program or project administered or agreement entered into by the commission or a health and human services agency, including an audit related to:
(1)  the commission's or a health and human services agency's contracting procedures; or
(2)  the commission's or a health and human services agency's performance.
(b)  The office of inspector general shall coordinate all audit and oversight activities, including those relating to providers and including developing audit plans, risk assessments, and findings, with the commission to minimize duplicative activities.  In coordinating the activities, the office shall:
(1)  to determine whether to audit a Medicaid managed care organization, annually seek the commission's input and consider previous audits and on-site visits the commission made to determine whether to audit a Medicaid managed care organization; and
(2)  request the results of an informal audit or on-site visit the commission performed that could inform the office's risk assessment when determining whether to conduct or the scope of an audit of a Medicaid managed care organization.
(c)  In addition to the coordination required by Subsection (b), the office of inspector general shall coordinate the office's other audit activities with those of the commission, including developing audit plans, performing risk assessments, and reporting findings, to minimize duplicative audit activities.  In coordinating audit activities with the commission under this subsection, the office shall:
(1)  to determine whether to conduct a performance audit, seek the commission's input and consider previous audits the commission conducted; and
(2)  request the results of an audit the commission conducted if those results could inform the office's risk assessment when determining whether to conduct or the scope of a performance audit.
(d)  In accordance with Section 540.0057(b), the office of inspector general shall consult with the executive commissioner regarding the adoption of rules defining the office's role in and jurisdiction over, and the frequency of, audits of Medicaid managed care organizations that the office and commission conduct.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.