reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0062. Penalties and Other Remedies for Failure to Comply With Provider Access Standards

Text of section effective until April 01, 2025
Sec. 533.0062.  PENALTIES AND OTHER REMEDIES FOR FAILURE TO COMPLY WITH PROVIDER ACCESS STANDARDS.  If a managed care organization that has contracted with the commission to provide health care services to recipients fails to comply with one or more provider access standards established under Section 533.0061 and the commission determines the organization has not made substantial efforts to mitigate or remedy the noncompliance, the commission:
(1)  may:
(A)  elect to not retain or renew the commission's contract with the organization; or
(B)  require the organization to pay liquidated damages in accordance with Section 533.005(a)(20)(C); and
(2)  shall suspend default enrollment to the organization in a given service delivery area for at least one calendar quarter if the organization's noncompliance occurs in the service delivery area for two consecutive calendar quarters.
Added by Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 5, 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Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff.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 533.0063. Provider Network Directories

Text of section effective until April 01, 2025
Sec. 533.0063.  PROVIDER NETWORK DIRECTORIES.  (a)  The commission shall ensure that a managed care organization that contracts with the commission to provide health care services to recipients:
(1)  posts on the organization's Internet website:
(A)  the organization's provider network directory; and
(B)  a direct telephone number and e-mail address through which a recipient enrolled in the organization's managed care plan or the recipient's provider may contact the organization to receive assistance with:
(i)  identifying in-network providers and services available to the recipient; and
(ii)  scheduling an appointment for the recipient with an available in-network provider or to access available in-network services; and
(2)  updates the online directory required under Subdivision (1)(A) at least monthly.
(b)  A managed care organization is required to send a paper form of the organization's provider network directory for the program only to a recipient who requests to receive the directory in paper form.
(c)  Repealed by Acts 2021, 87th Leg., R.S., Ch. 413 (S.B. 1829), Sec. 3, eff. June 7, 2021.
Added by Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 5, eff. September 1, 2015.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 413 (S.B. 1829), Sec. 2, eff. June 7, 2021.
Acts 2021, 87th Leg., R.S., Ch. 413 (S.B. 1829), Sec. 3, eff. June 7, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0064. Expedited Credentialing Process for Certain Providers

Text of section effective until April 01, 2025
Sec. 533.0064.  EXPEDITED CREDENTIALING PROCESS FOR CERTAIN PROVIDERS.  (a)  In this section, "applicant provider" means a physician or other health care provider applying for expedited credentialing under this section.
(b)  Notwithstanding any other law and subject to Subsection (c), a managed care organization that contracts with the commission to provide health services to recipients shall, in accordance with this section, establish and implement an expedited credentialing process that would allow applicant providers to provide services to recipients on a provisional basis.
(c)  The commission shall identify the types of providers for which an expedited credentialing process must be established and implemented under this section.
(d)  To qualify for expedited credentialing under this section and payment under Subsection (e), an applicant provider must:
(1)  be a member of an established health care provider group that has a current contract in force with a managed care organization described by Subsection (b);
(2)  be a Medicaid-enrolled provider;
(3)  agree to comply with the terms of the contract described by Subdivision (1); and
(4)  submit all documentation and other information required by the managed care organization as necessary to enable the organization to begin the credentialing process required by the organization to include a provider in the organization's provider network.
(e)  On submission by the applicant provider of the information required by the managed care organization under Subsection (d), and for Medicaid reimbursement purposes only, the organization shall treat the provider as if the provider were in the organization's provider network when the provider provides services to recipients, subject to Subsections (f) and (g).
(f)  Except as provided by Subsection (g), if, on completion of the credentialing process, a managed care organization determines that the applicant provider does not meet the organization's credentialing requirements, the organization may recover from the provider the difference between payments for in-network benefits and out-of-network benefits.
(g)  If a managed care organization determines on completion of the credentialing process that the applicant provider does not meet the organization's credentialing requirements and that the provider made fraudulent claims in the provider's application for credentialing, the organization may recover from the provider the entire amount of any payment paid to the provider.
Added by Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 5, 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 533.0065. Frequency of Provider Credentialing

Text of section effective until April 01, 2025
Sec. 533.0065.  FREQUENCY OF PROVIDER CREDENTIALING.  A managed care organization that contracts with the commission to provide health care services to Medicaid recipients under a managed care plan issued by the organization shall formally recredential a physician or other provider with the frequency required by the single, consolidated Medicaid provider enrollment and credentialing process, if that process is created under Section 531.02118.  The required frequency of recredentialing may be less frequent than once in any three-year period, notwithstanding any other law.
Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.21, eff. September 1, 2015.
Redesignated from Government Code, Section 533.0061 by Acts 2017, 85th Leg., R.S., Ch. 324 (S.B. 1488), Sec. 24.001(18), eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0066. Provider Incentives

Text of section effective until April 01, 2025
Sec. 533.0066.  PROVIDER INCENTIVES.  The commission shall, to the extent possible, work to ensure that managed care organizations provide payment incentives to health care providers in the organizations' networks whose performance in promoting recipients' use of preventive services exceeds minimum established standards.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(e), eff. September 28, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0067. Eye Health Care Service Providers

Text of section effective until April 01, 2025
Sec. 533.0067.  EYE HEALTH CARE SERVICE PROVIDERS.  Subject to Section 32.047, Human Resources Code, but notwithstanding any other law, the commission shall require that each managed care organization that contracts with the commission under any Medicaid managed care model or arrangement to provide health care services to recipients in a region include in the organization's provider network each optometrist, therapeutic optometrist, and ophthalmologist described by Section 531.021191(b)(1)(A) or (B) and an institution of higher education described by Section 531.021191(a)(4) in the region who:
(1)  agrees to comply with the terms and conditions of the organization;
(2)  agrees to accept the prevailing provider contract rate of the organization;
(3)  agrees to abide by the standards of care required by the organization; and
(4)  is an enrolled provider under Medicaid.
Added by Acts 2017, 85th Leg., R.S., Ch. 901 (H.B. 3675), Sec. 3, eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0072. Internet Posting of Sanctions Imposed for Contractual Violations

Text of section effective until April 01, 2025
Sec. 533.0072.  INTERNET POSTING OF SANCTIONS IMPOSED FOR CONTRACTUAL VIOLATIONS.  (a)  The commission shall prepare and maintain a record of each enforcement action initiated by the commission that results in a sanction, including a penalty, being imposed against a managed care organization for failure to comply with the terms of a contract to provide health care services to recipients through a managed care plan issued by the organization.
(b)  The record must include:
(1)  the name and address of the organization;
(2)  a description of the contractual obligation the organization failed to meet;
(3)  the date of determination of noncompliance;
(4)  the date the sanction was imposed;
(5)  the maximum sanction that may be imposed under the contract for the violation; and
(6)  the actual sanction imposed against the organization.
(c)  The commission shall post and maintain the records required by this section on the commission's Internet website in English and Spanish.  The records must be posted in a format that is readily accessible to and understandable by a member of the public.  The commission shall update the list of records on the website at least quarterly.
(d)  The commission may not post information under this section that relates to a sanction while the sanction is the subject of an administrative appeal or judicial review.
(e)  A record prepared under this section may not include information that is excepted from disclosure under Chapter 552.
(f)  The executive commissioner shall adopt rules as necessary to implement this section.
Added by Acts 2005, 79th Leg., Ch. 349 (S.B. 1188), Sec. 6(b), eff. September 1, 2005.
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 533.0073. Medical Director Qualifications

Text of section effective until April 01, 2025
Sec. 533.0073.  MEDICAL DIRECTOR QUALIFICATIONS.  A person who serves as a medical director for a managed care plan must be a physician licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(g), eff. September 28, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0075. Recipient Enrollment

Text of section effective until April 01, 2025
Sec. 533.0075.  RECIPIENT ENROLLMENT.  The commission shall:
(1)  encourage recipients to choose appropriate managed care plans and primary health care providers by:
(A)  providing initial information to recipients and providers in a region about the need for recipients to choose plans and providers not later than the 90th day before the date on which a managed care organization plans to begin to provide health care services to recipients in that region through managed care;
(B)  providing follow-up information before assignment of plans and providers and after assignment, if necessary, to recipients who delay in choosing plans and providers; and
(C)  allowing plans and providers to provide information to recipients or engage in marketing activities under marketing guidelines established by the commission under Section 533.008 after the commission approves the information or activities;
(2)  consider the following factors in assigning managed care plans and primary health care providers to recipients who fail to choose plans and providers:
(A)  the importance of maintaining existing provider-patient and physician-patient relationships, including relationships with specialists, public health clinics, and community health centers;
(B)  to the extent possible, the need to assign family members to the same providers and plans; and
(C)  geographic convenience of plans and providers for recipients;
(3)  retain responsibility for enrollment and disenrollment of recipients in managed care plans, except that the commission may delegate the responsibility to an independent contractor who receives no form of payment from, and has no financial ties to, any managed care organization;
(4)  develop and implement an expedited process for determining eligibility for and enrolling pregnant women and newborn infants in managed care plans; and
(5)  ensure immediate access to prenatal services and newborn care for pregnant women and newborn infants enrolled in managed care plans, including ensuring that a pregnant woman may obtain an appointment with an obstetrical care provider for an initial maternity evaluation not later than the 30th day after the date the woman applies for Medicaid.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.  Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 7, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.07, eff. Sept. 1, 1999.
Amended by:
Acts 2009, 81st Leg., R.S., Ch. 945 (H.B. 3231), Sec. 2, eff. June 19, 2009.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.227, 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 533.00751. Recipient Directory

Text of section effective until April 01, 2025
Sec. 533.00751.  RECIPIENT DIRECTORY.  The commission shall in accordance with a single source of truth design:
(1)  maintain an accurate electronic directory of contact information for each recipient enrolled in a managed care plan offered by a Medicaid managed care organization under this chapter, including, to the extent feasible, each recipient's:
(A)  home, work, and mobile telephone numbers;
(B)  e-mail address; and
(C)  home and work addresses; and
(2)  ensure that each Medicaid managed care organization and enrollment broker participating in the Medicaid managed care program update the electronic directory required under Subdivision (1) in real time.
Added by Acts 2021, 87th Leg., R.S., Ch. 413 (S.B. 1829), Sec. 1, eff. June 7, 2021.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0076. Limitations on Recipient Disenrollment

Text of section effective until April 01, 2025
Sec. 533.0076.  LIMITATIONS ON RECIPIENT DISENROLLMENT.  (a)  Except as provided by Subsections (b) and (c), and to the extent permitted by federal law, a recipient enrolled in a managed care plan under this chapter may not disenroll from that plan and enroll in another managed care plan during the 12-month period after the date the recipient initially enrolls in a plan.
(b)  At any time before the 91st day after the date of a recipient's initial enrollment in a managed care plan under this chapter, the recipient may disenroll in that plan for any reason and enroll in another managed care plan under this chapter.
(c)  The commission shall allow a recipient who is enrolled in a managed care plan under this chapter to disenroll from that plan and enroll in another managed care plan:
(1)  at any time for cause in accordance with federal law; and
(2)  once for any reason after the periods described by Subsections (a) and (b).
Added by Acts 2001, 77th Leg., Ch. 584, Sec. 6, eff. January 1, 2002.
Amended by:
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(h), eff. September 28, 2011.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.0077. Statewide Effort to Promote Maintenance of Eligibility

Text of section effective until April 01, 2025
Sec. 533.0077.  STATEWIDE EFFORT TO PROMOTE MAINTENANCE OF ELIGIBILITY.  (a)  The commission shall develop and implement a statewide effort to assist recipients who satisfy Medicaid eligibility requirements and who receive Medicaid services through a managed care organization with maintaining eligibility and avoiding lapses in coverage under Medicaid.
(b)  As part of its effort under Subsection (a), the commission shall:
(1)  require each managed care organization providing health care services to recipients to assist those recipients with maintaining eligibility;
(2)  if the commission determines it is cost-effective, develop specific strategies for assisting recipients who receive Supplemental Security Income (SSI) benefits under 42 U.S.C. Section 1381 et seq. with maintaining eligibility; and
(3)  ensure information that is relevant to a recipient's eligibility status is provided to the managed care organization through which the recipient receives Medicaid services.
Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.22, 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.
Without reference to the amendment of this section, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.008. Marketing Guidelines

Sec. 533.008.  MARKETING GUIDELINES.  (a)  The commission shall establish marketing guidelines for managed care organizations that contract with the commission to provide health care services to recipients, including guidelines that prohibit:
(1)  door-to-door marketing to recipients by managed care organizations or agents of those organizations;
(2)  the use of marketing materials with inaccurate or misleading information;
(3)  misrepresentations to recipients or providers;
(4)  offering recipients material or financial incentives to choose a managed care plan other than nominal gifts or free health screenings approved by the commission that the managed care organization offers to all recipients regardless of whether the recipients enroll in the managed care plan;
(5)  the use of marketing agents who are paid solely by commission;  and
(6)  face-to-face marketing at public assistance offices by managed care organizations or agents of those organizations.
(b)  This section does not prohibit:
(1)  the distribution of approved marketing materials at public assistance offices;  or
(2)  the provision of information directly to recipients under marketing guidelines established by the commission.
(c)  The executive commissioner shall adopt and publish guidelines for Medicaid managed care organizations regarding how organizations may communicate by telephone, text message, or e-mail with recipients enrolled in the organization's managed care plan using the contact information provided in a recipient's application for Medicaid benefits under Section 32.025(g)(2), Human Resources Code, including updated information provided to the organization in accordance with Section 32.025(h), Human Resources Code.
(d)  In adopting the guidelines under Subsection (c) for a recipient enrolled in a Medicaid managed care organization's managed care plan who provides to the organization the recipient's contact information through any method other than the recipient's Medicaid application, the commission:
(1)  must allow the organization to communicate with the recipient through any electronic means, including telephone, text message, and e-mail, regarding eligibility, enrollment, and other health care matters; and
(2)  may not require the organization to submit the recipient's contact preference information to the commission.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.
Amended by:
Acts 2021, 87th Leg., R.S., Ch. 624 (H.B. 4), Sec. 5, eff. June 15, 2021.
Acts 2023, 88th Leg., R.S., Ch. 582 (H.B. 2802), Sec. 1, eff. September 1, 2023.
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 533.0091. Sickle Cell Disease Treatment

Sec. 533.0091.  SICKLE CELL DISEASE TREATMENT.  To the extent possible, the commission shall:
(1)  in collaboration with the sickle cell task force established under Chapter 52, Health and Safety Code:
(A)  support initiatives to assist managed care plans in promoting timely, evidence-informed health care services to plan enrollees diagnosed with sickle cell disease to ensure the services reflect national clinical practice guidelines and protocols for sickle cell disease treatment and meet medical necessity criteria; and
(B)  address sickle cell disease education for Medicaid providers, including emergency department providers, by collaborating with medical specialty organizations in this state, state agencies, and health-related institutions to promote existing or new continuing education courses or facilitate development of any necessary new courses to improve the diagnosis, treatment, and management of sickle cell disease and the personal treatment of patients with sickle cell disease; and
(2)  use the commission's existing data to identify opportunities for improving health outcomes of recipients diagnosed with sickle cell disease by:
(A)  reducing hospital admissions and readmissions; and
(B)  connecting those recipients to a sickle cell disease health home or sickle cell disease expert.
Added by Acts 2023, 88th Leg., R.S., Ch. 409 (H.B. 1488), Sec. 1, eff. September 1, 2023.
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 533.010. Special Protocols

Text of section effective until April 01, 2025
Sec. 533.010.  SPECIAL PROTOCOLS.  In conjunction with an academic center, the commission may study the treatment of indigent populations to develop special protocols for managed care organizations to use in providing health care services to recipients.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.
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 533.011. Public Notice

Text of section effective until April 01, 2025
Sec. 533.011.  PUBLIC NOTICE.  Not later than the 30th day before the commission plans to issue a request for applications to enter into a contract with the commission to provide health care services to recipients in a region, the commission shall publish notice of and make available for public review the request for applications and all related nonproprietary documents, including the proposed contract.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.
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 533.012. Information for Fraud Control

Text of section effective until April 01, 2025
Sec. 533.012.  INFORMATION FOR FRAUD CONTROL.  (a)  Each managed care organization contracting with the commission under this chapter shall submit the following, at no cost, to the commission and, on request, the office of the attorney general:
(1)  a description of any financial or other business relationship between the organization and any subcontractor providing health care services under the contract;
(2)  a copy of each type of contract between the organization and a subcontractor relating to the delivery of or payment for health care services;
(3)  a description of the fraud control program used by any subcontractor that delivers health care services; and
(4)  a description and breakdown of all funds paid to or by the managed care organization, including a health maintenance organization, primary care case management provider, pharmacy benefit manager, and exclusive provider organization, necessary for the commission to determine the actual cost of administering the managed care plan.
(b)  The information submitted under this section must be submitted in the form required by the commission or the office of the attorney general, as applicable, and be updated as required by the commission or the office of the attorney general, as applicable.
(c)  The commission's office of inspector general or the office of the attorney general, as applicable, shall review the information submitted under this section as appropriate in the investigation of fraud in the Medicaid managed care program.
(d)  Repealed by Acts 2011, 82nd Leg., 1st C.S., Ch. 7, Sec. 1.02(l), eff. September 28, 2011.
(e)  Information submitted to the commission or the office of the attorney general, as applicable, under Subsection (a)(1) is confidential and not subject to disclosure under Chapter 552, Government Code.
Added by Acts 1999, 76th Leg., ch. 493, Sec. 1, eff. Sept. 1, 1999.  Amended by Acts 2003, 78th Leg., ch. 198, Sec. 2.36, eff. Sept. 1, 2003.
Amended by:
Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 11(a), eff. September 1, 2007.
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(i), eff. September 28, 2011.
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(l), eff. September 28, 2011.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.229, 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 533.0131. Use of Encounter Data in Determining Premium Payment Rates

Text of section effective until April 01, 2025
Sec. 533.0131.  USE OF ENCOUNTER DATA IN DETERMINING PREMIUM PAYMENT RATES.  (a)  In determining premium payment rates and other amounts paid to managed care organizations under a managed care plan, the commission may not base or derive the rates or amounts on or from encounter data, or incorporate in the determination an analysis of encounter data, unless a certifier of encounter data certifies that:
(1)  the encounter data for the most recent state fiscal year is complete, accurate, and reliable;  and
(2)  there is no statistically significant variability in the encounter data attributable to incompleteness, inaccuracy, or another deficiency as compared to equivalent data for similar populations and when evaluated against professionally accepted standards.
(b)  For purposes of determining whether data is equivalent data for similar populations under Subsection (a)(2), a certifier of encounter data shall, at a minimum, consider:
(1)  the regional variation in utilization patterns of recipients and costs of health care services;
(2)  the range and type of health care services to be covered by premium payment rates;
(3)  the number of managed care plans in the region;  and
(4)  the current number of recipients in each region, including the number for each category of recipient.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.
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 533.01315. Reimbursement for Services Provided Outside of Regular Business Hours

Text of section effective until April 01, 2025
Sec. 533.01315.  REIMBURSEMENT FOR SERVICES PROVIDED OUTSIDE OF REGULAR BUSINESS HOURS.  (a)  This section applies only to a recipient receiving benefits through any Medicaid managed care model or arrangement.
(b)  The commission shall ensure that a federally qualified health center, rural health clinic, or municipal health department's public clinic is reimbursed for health care services provided to a recipient outside of regular business hours, including on a weekend or holiday, at a rate that is equal to the allowable rate for those services as determined under Section 32.028, Human Resources Code, regardless of whether the recipient has a referral from the recipient's primary care provider.
(c)  The executive commissioner shall adopt rules regarding the days, times of days, and holidays that are considered to be outside of regular business hours for purposes of Subsection (b).
Added by Acts 2007, 80th Leg., R.S., Ch. 298 (H.B. 1579), Sec. 1, eff. September 1, 2007.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.231, 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 533.0132. State Taxes

Text of section effective until April 01, 2025
Sec. 533.0132.  STATE TAXES.  The commission shall ensure that any experience rebate or profit sharing for managed care organizations is calculated by treating premium, maintenance, and other taxes under the Insurance Code and any other taxes payable to this state as allowable expenses for purposes of determining the amount of the experience rebate or profit sharing.
Added by Acts 2003, 78th Leg., ch. 198, Sec. 2.30, eff. Sept. 1, 2003.
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 533.014. Profit Sharing

Text of section effective until April 01, 2025
Sec. 533.014.  PROFIT SHARING.  (a)  The executive commissioner shall adopt rules regarding the sharing of profits earned by a managed care organization through a managed care plan providing health care services under a contract with the commission under this chapter.
(b)  Except as provided by Subsection (c), any amount received by the state under this section shall be deposited in the general revenue fund.
(c)  If cost-effective, the commission may use amounts received by the state under this section to provide incentives to specific managed care organizations to promote quality of care, encourage payment reform, reward local service delivery reform, increase efficiency, and reduce inappropriate or preventable service utilization.
Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1, 1999.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 4.05, eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.232, 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 533.015. Coordination of External Oversight Activities

Text of section effective until April 01, 2025
Sec. 533.015.  COORDINATION OF EXTERNAL OVERSIGHT ACTIVITIES.  (a)  To the extent possible, the commission shall coordinate all external oversight activities to minimize duplication of oversight of managed care plans under Medicaid and disruption of operations under those plans.
(b)  The executive commissioner, after consulting with the commission's office of inspector general, shall by rule define the commission's and office's roles in and jurisdiction over, and frequency of, audits of managed care organizations participating in Medicaid that are conducted by the commission and the commission's office of inspector general.
Text of subsection as amended by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.23(a)
(c)  In accordance with Section 531.102(q), the commission shall share with the commission's office of inspector general, at the request of the office, the results of any informal audit or onsite visit that could inform that office's risk assessment when determining whether to conduct, or the scope of, an audit of a managed care organization participating in Medicaid.
Text of subsection as amended by Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 12
(c)  In accordance with Section 531.102(w), the commission shall share with the commission's office of inspector general, at the request of the office, the results of any informal audit or on-site visit that could inform that office's risk assessment when determining whether to conduct, or the scope of, an audit of a managed care organization participating in Medicaid.
Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.233, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.23(a), eff. September 1, 2015.
Acts 2015, 84th Leg., R.S., Ch. 945 (S.B. 207), Sec. 12, 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 533.016. Provider Reporting of Encounter Data

Text of section effective until April 01, 2025
Sec. 533.016.  PROVIDER REPORTING OF ENCOUNTER DATA.  The commission shall collaborate with managed care organizations that contract with the commission and health care providers under the organizations' provider networks to develop incentives and mechanisms to encourage providers to report complete and accurate encounter data to managed care organizations in a timely manner.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.
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 533.0161. Monitoring of Psychotropic Drug Prescriptions for Certain Children

Text of section effective until April 01, 2025
Sec. 533.0161.  MONITORING OF PSYCHOTROPIC DRUG PRESCRIPTIONS FOR CERTAIN CHILDREN.  (a)  In this section, "psychotropic drug" has the meaning assigned by Section 261.111, Family Code.
(b)  The commission shall implement a system under which the commission will use Medicaid prescription drug data to monitor the prescribing of psychotropic drugs for:
(1)  children who are in the conservatorship of the Department of Family and Protective Services and enrolled in the STAR Health Medicaid managed care program or eligible for both Medicaid and Medicare; and
(2)  children who are under the supervision of the Department of Family and Protective Services through an agreement under the Interstate Compact on the Placement of Children under Subchapter B, Chapter 162, Family Code.
(c)  The commission shall include as a component of the monitoring system required by this section a medical review of a prescription to which Subsection (b) applies when that review is appropriate.
Added by Acts 2011, 82nd Leg., R.S., Ch. 843 (H.B. 3531), Sec. 1, eff. September 1, 2011.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 204 (H.B. 915), Sec. 14, eff. September 1, 2013.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.017. Qualifications of Certifier of Encounter Data

Text of section effective until April 01, 2025
Sec. 533.017.  QUALIFICATIONS OF CERTIFIER OF ENCOUNTER DATA.  (a)  The person acting as the state Medicaid director shall appoint a person as the certifier of encounter data.
(b)  The certifier of encounter data must have:
(1)  demonstrated expertise in estimating premium payment rates paid to a managed care organization under a managed care plan;  and
(2)  access to actuarial expertise, including expertise in estimating premium payment rates paid to a managed care organization under a managed care plan.
(c)  A person may not be appointed under this section as the certifier of encounter data if the person participated with the commission in developing premium payment rates for managed care organizations under managed care plans in this state during the three-year period before the date the certifier is appointed.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.
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 533.018. Certification of Encounter Data

Text of section effective until April 01, 2025
Sec. 533.018.  CERTIFICATION OF ENCOUNTER DATA.  (a)  The certifier of encounter data shall certify the completeness, accuracy, and reliability of encounter data for each state fiscal year.
(b)  The commission shall make available to the certifier all records and data the certifier considers appropriate for evaluating whether to certify the encounter data.  The commission shall provide to the certifier selected resources and assistance in obtaining, compiling, and interpreting the records and data.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.
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 533.019. Value-Added Services

Text of section effective until April 01, 2025
Sec. 533.019.  VALUE-ADDED SERVICES.  The commission shall actively encourage managed care organizations that contract with the commission to offer benefits, including health care services or benefits or other types of services, that:
(1)  are in addition to the services ordinarily covered by the managed care plan offered by the managed care organization; and
(2)  have the potential to improve the health status of enrollees in the plan.
Added by Acts 2007, 80th Leg., R.S., Ch. 268 (S.B. 10), Sec. 12(a), eff. September 1, 2007.
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 533.020. Managed Care Organizations: Fiscal Solvency and Complaint System Guidelines

Text of section effective until April 01, 2025
Sec. 533.020.  MANAGED CARE ORGANIZATIONS:  FISCAL SOLVENCY AND COMPLAINT SYSTEM GUIDELINES.  (a)  The Texas Department of Insurance, in conjunction with the commission, shall establish fiscal solvency standards and complaint system guidelines for managed care organizations that serve recipients.
(b)  The guidelines must require that information regarding a managed care organization's complaint process be made available to a recipient in an appropriate communication format when the recipient enrolls in the Medicaid managed care program.
Added by Acts 2007, 80th Leg., R.S., Ch. 730 (H.B. 2636), Sec. 1K.001, eff. April 1, 2009.
Renumbered from Government Code, Section 533.019 by Acts 2009, 81st Leg., R.S., Ch. 87 (S.B. 1969), Sec. 27.001(38), eff. September 1, 2009.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.234, 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.
Without reference to the addition of this section, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter A. General Provisions › Section 533.021. Community Health Workers

Sec. 533.021.  COMMUNITY HEALTH WORKERS.  (a)  In this section, "community health worker" has the meaning assigned by Section 48.001, Health and Safety Code.
(b)  The commission shall allow each Medicaid managed care organization providing health care services under the STAR Medicaid managed care program to categorize services provided by a community health worker as a quality improvement cost, as authorized by federal law, instead of as an administrative expense.
Added by Acts 2023, 88th Leg., R.S., Ch. 796 (H.B. 113), Sec. 1, eff. June 13, 2023.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter B. Strategy for Managing Audit Resources › Section 533.051. Definitions

Text of section effective until April 01, 2025
Sec. 533.051.  DEFINITIONS.  In this subchapter:
(1)  "Accounts receivable tracking system" means the system the commission uses to track experience rebates and other payments collected from managed care organizations.
(2)  "Agreed-upon procedures engagement" means an evaluation of a managed care organization's financial statistical reports or other data conducted by an independent auditing firm engaged by the commission as agreed in the managed care organization's contract with the commission.
(3)  "Experience rebate" means the amount a managed care organization is required to pay the state according to the graduated rebate method described in the managed care organization's contract with the commission.
(4)  "External quality review organization" means an organization that performs an external quality review of a managed care organization in accordance with 42 C.F.R. Section 438.350.
Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter B. Strategy for Managing Audit Resources › Section 533.052. Applicability and Construction of Subchapter

Text of section effective until April 01, 2025
Sec. 533.052.  APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER.  This subchapter does not apply to and may not be construed as affecting the conduct of audits by the commission's office of inspector general under the authority provided by Subchapter C, Chapter 531, including an audit of a managed care organization conducted by the office after coordinating the office's audit and oversight activities with the commission as required by Section 531.102(q), as added by Chapter 837 (S.B. 200), Acts of the 84th Legislature, Regular Session, 2015.
Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter B. Strategy for Managing Audit Resources › Section 533.053. Overall Strategy for Managing Audit Resources

Text of section effective until April 01, 2025
Sec. 533.053.  OVERALL STRATEGY FOR MANAGING AUDIT RESOURCES.  The commission shall develop and implement an overall strategy for planning, managing, and coordinating audit resources that the commission uses to verify the accuracy and reliability of program and financial information reported by managed care organizations.
Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 533 - Medicaid Managed Care Program › Subchapter B. Strategy for Managing Audit Resources › Section 533.054. Performance Audit Selection Process and Follow-Up

Text of section effective until April 01, 2025
Sec. 533.054.  PERFORMANCE AUDIT SELECTION PROCESS AND FOLLOW-UP.  (a)  To improve the commission's processes for performance audits of managed care organizations, the commission shall:
(1)  document the process by which the commission selects managed care organizations to audit;
(2)  include previous audit coverage as a risk factor in selecting managed care organizations to audit; and
(3)  prioritize the highest risk managed care organizations to audit.
(b)  To verify that managed care organizations correct negative performance audit findings, the commission shall:
(1)  establish a process to:
(A)  document how the commission follows up on negative performance audit findings; and
(B)  verify that managed care organizations implement performance audit recommendations; and
(2)  establish and implement policies and procedures to:
(A)  determine under what circumstances the commission must issue a corrective action plan to a managed care organization based on a performance audit; and
(B)  follow up on the managed care organization's implementation of the corrective action plan.
Added by Acts 2017, 85th Leg., R.S., Ch. 909 (S.B. 894), Sec. 4, eff. September 1, 2017.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.