S.B. No. 1207

	AN ACT
	relating to the operation and administration of Medicaid, including
	the Medicaid managed care program and the medically dependent
	children (MDCP) waiver program.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 531.001, Government Code, is amended by
	adding Subdivision (4-c) to read as follows:
	(4-c)  "Medicaid managed care organization" means a
	managed care organization as defined by Section 533.001 that
	contracts with the commission under Chapter 533 to provide health
	care services to Medicaid recipients.
	SECTION 2.  Section 531.024, Government Code, is amended by
	amending Subsection (b) and adding Subsection (c) to read as
	follows:
	(b)  The rules promulgated under Subsection (a)(7) must
	provide due process to an applicant for Medicaid services and to a
	Medicaid recipient who seeks a Medicaid service, including a
	service that requires prior authorization.  The rules must provide
	the protections for applicants and recipients required by 42 C.F.R.
	Part 431, Subpart E, including requiring that:
	(1)  the written notice to an individual of the
	individual's right to a hearing must:
	(A)  contain an explanation of the circumstances
	under which Medicaid is continued if a hearing is requested; and
	(B)  be delivered by mail, and postmarked [mailed]
	at least 10 business days, before the date the individual's
	Medicaid eligibility or service is scheduled to be terminated,
	suspended, or reduced, except as provided by 42 C.F.R. Section
	431.213 or 431.214; and
	(2)  if a hearing is requested before the date a
	Medicaid recipient's service, including a service that requires
	prior authorization, is scheduled to be terminated, suspended, or
	reduced, the agency may not take that proposed action before a
	decision is rendered after the hearing unless:
	(A)  it is determined at the hearing that the sole
	issue is one of federal or state law or policy; and
	(B)  the agency promptly informs the recipient in
	writing that services are to be terminated, suspended, or reduced
	pending the hearing decision.
	(c)  The commission shall develop a process to address a
	situation in which:
	(1)  an individual does not receive adequate notice as
	required by Subsection (b)(1); or
	(2)  the notice required by Subsection (b)(1) is
	delivered without a postmark.
	SECTION 3.  (a)  To the extent of any conflict, Section
	531.024162, Government Code, as added by this section, prevails
	over any provision of another Act of the 86th Legislature, Regular
	Session, 2019, relating to notice requirements regarding Medicaid
	coverage or prior authorization denials or incomplete requests,
	that becomes law.
	(b)  Subchapter B, Chapter 531, Government Code, is amended
	by adding Sections 531.024162, 531.024163, 531.024164, 531.0601,
	531.0602, 531.06021, 531.0603, and 531.0604 to read as follows:
	Sec. 531.024162.  NOTICE REQUIREMENTS REGARDING MEDICAID
	COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
	(a)  The commission shall ensure that notice sent by the commission
	or a Medicaid managed care organization to a Medicaid recipient or
	provider regarding the denial, partial denial, reduction, or
	termination of coverage or denial of prior authorization for a
	service includes:
	(1)  information required by federal and state law and
	applicable regulations;
	(2)  for the recipient:
	(A)  a clear and easy-to-understand explanation
	of the reason for the decision, including a clear explanation of the
	medical basis, applying the policy or accepted standard of medical
	practice to the recipient's particular medical circumstances;
	(B)  a copy of the information sent to the
	provider; and
	(C)  an educational component that includes a
	description of the recipient's rights, an explanation of the
	process related to appeals and Medicaid fair hearings, and a
	description of the role of an external medical review; and
	(3)  for the provider, a thorough and detailed clinical
	explanation of the reason for the decision, including, as
	applicable, information required under Subsection (b).
	(b)  The commission or a Medicaid managed care organization
	that receives from a provider a coverage or prior authorization
	request that contains insufficient or inadequate documentation to
	approve the request shall issue a notice to the provider and the
	Medicaid recipient on whose behalf the request was submitted.  The
	notice issued under this subsection must:
	(1)  include a section specifically for the provider
	that contains:
	(A)  a clear and specific list and description of
	the documentation necessary for the commission or organization to
	make a final determination on the request;
	(B)  the applicable timeline, based on the
	requested service, for the provider to submit the documentation and
	a description of the reconsideration process described by Section
	533.00284, if applicable; and
	(C)  information on the manner through which a
	provider may contact a Medicaid managed care organization or other
	entity as required by Section 531.024163; and
	(2)  be sent:
	(A)  to the provider:
	(i)  using the provider's preferred method
	of communication, to the extent practicable using existing
	resources; and
	(ii)  as applicable, through an electronic
	notification on an Internet portal; and
	(B)  to the recipient using the recipient's
	preferred method of communication, to the extent practicable using
	existing resources.
	Sec. 531.024163.  ACCESSIBILITY OF INFORMATION REGARDING
	MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a)  The executive
	commissioner by rule shall require each Medicaid managed care
	organization or other entity responsible for authorizing coverage
	for health care services under Medicaid to ensure that the
	organization or entity maintains on the organization's or entity's
	Internet website in an easily searchable and accessible format:
	(1)  the applicable timelines for prior authorization
	requirements, including:
	(A)  the time within which the organization or
	entity must make a determination on a prior authorization request;
	(B)  a description of the notice the organization
	or entity provides to a provider and Medicaid recipient on whose
	behalf the request was submitted regarding the documentation
	required to complete a determination on a prior authorization
	request; and
	(C)  the deadline by which the organization or
	entity is required to submit the notice described by Paragraph (B);
	and
	(2)  an accurate and up-to-date catalogue of coverage
	criteria and prior authorization requirements, including:
	(A)  for a prior authorization requirement first
	imposed on or after September 1, 2019, the effective date of the
	requirement;
	(B)  a list or description of any supporting or
	other documentation necessary to obtain prior authorization for a
	specified service; and
	(C)  the date and results of each review of the
	prior authorization requirement conducted under Section 533.00283,
	if applicable.
	(b)  The executive commissioner by rule shall require each
	Medicaid managed care organization or other entity responsible for
	authorizing coverage for health care services under Medicaid to:
	(1)  adopt and maintain a process for a provider or
	Medicaid recipient to contact the organization or entity to clarify
	prior authorization requirements or to assist the provider in
	submitting a prior authorization request; and
	(2)  ensure that the process described by Subdivision
	(1) is not arduous or overly burdensome to a provider or recipient.
	Sec. 531.024164.  EXTERNAL MEDICAL REVIEW. (a)  In this
	section, "external medical reviewer" and "reviewer" mean a
	third-party medical review organization that provides objective,
	unbiased medical necessity determinations conducted by clinical
	staff with education and practice in the same or similar practice
	area as the procedure for which an independent determination of
	medical necessity is sought in accordance with applicable state law
	and rules.
	(b)  The commission shall contract with an independent
	external medical reviewer to conduct external medical reviews and
	review:
	(1)  the resolution of a Medicaid recipient appeal
	related to a reduction in or denial of services on the basis of
	medical necessity in the Medicaid managed care program; or
	(2)  a denial by the commission of eligibility for a
	Medicaid program in which eligibility is based on a Medicaid
	recipient's medical and functional needs.
	(c)  A Medicaid managed care organization may not have a
	financial relationship with or ownership interest in the external
	medical reviewer with which the commission contracts.
	(d)  The external medical reviewer with which the commission
	contracts must:
	(1)  be overseen by a medical director who is a
	physician licensed in this state; and
	(2)  employ or be able to consult with staff with
	experience in providing private duty nursing services and long-term
	services and supports.
	(e)  The commission shall establish a common procedure for
	reviews. To the greatest extent possible, the procedure must
	reduce administrative burdens on providers and the submission of
	duplicative information or documents. Medical necessity under the
	procedure must be based on publicly available, up-to-date,
	evidence-based, and peer-reviewed clinical criteria. The reviewer
	shall conduct the review within a period specified by the
	commission. The commission shall also establish a procedure and
	time frame for expedited reviews that allows the reviewer to:
	(1)  identify an appeal that requires an expedited
	resolution; and
	(2)  resolve the review of the appeal within a
	specified period.
	(f)  A Medicaid recipient or applicant, or the recipient's or
	applicant's parent or legally authorized representative, must
	affirmatively request an external medical review. If requested:
	(1)  an external medical review described by Subsection
	(b)(1) occurs after the internal Medicaid managed care organization
	appeal and before the Medicaid fair hearing and is granted when a
	Medicaid recipient contests the internal appeal decision of the
	Medicaid managed care organization; and
	(2)  an external medical review described by Subsection
	(b)(2) occurs after the eligibility denial and before the Medicaid
	fair hearing.
	(g)  The external medical reviewer's determination of
	medical necessity establishes the minimum level of services a
	Medicaid recipient must receive, except that the level of services
	may not exceed the level identified as medically necessary by the
	ordering health care provider.
	(h)  The external medical reviewer shall require a Medicaid
	managed care organization, in an external medical review relating
	to a reduction in services, to submit a detailed reason for the
	reduction and supporting documents.
	(i)  To the extent money is appropriated for this purpose,
	the commission shall publish data regarding prior authorizations
	reviewed by the external medical reviewer, including the rate of
	prior authorization denials overturned by the external medical
	reviewer and additional information the commission and the external
	medical reviewer determine appropriate.
	Sec. 531.0601.  LONG-TERM CARE SERVICES WAIVER PROGRAM
	INTEREST LISTS.  (a)  This section applies only to a child who is
	enrolled in the medically dependent children (MDCP) waiver program
	but becomes ineligible for services under the program because the
	child no longer meets:
	(1)  the level of care criteria for medical necessity
	for nursing facility care; or
	(2)  the age requirement for the program.
	(b)  A legally authorized representative of a child who is
	notified by the commission that the child is no longer eligible for
	the medically dependent children (MDCP) waiver program following a
	Medicaid fair hearing, or without a Medicaid fair hearing if the
	representative opted in writing to forego the hearing, may request
	that the commission:
	(1)  return the child to the interest list for the
	program unless the child is ineligible due to the child's age; or
	(2)  place the child on the interest list for another
	Section 1915(c) waiver program.
	(c)  At the time a child's legally authorized representative
	makes a request under Subsection (b), the commission shall:
	(1)  for a child who becomes ineligible for the reason
	described by Subsection (a)(1), place the child:
	(A)  on the interest list for the medically
	dependent children (MDCP) waiver program in the first position on
	the list; or
	(B)  except as provided by Subdivision (3), on the
	interest list for another Section 1915(c) waiver program in a
	position relative to other persons on the list that is based on the
	date the child was initially placed on the interest list for the
	medically dependent children (MDCP) waiver program;
	(2)  except as provided by Subdivision (3), for a child
	who becomes ineligible for the reason described by Subsection
	(a)(2), place the child on the interest list for another Section
	1915(c) waiver program in a position relative to other persons on
	the list that is based on the date the child was initially placed on
	the interest list for the medically dependent children (MDCP)
	waiver program; or
	(3)  for a child who becomes ineligible for a reason
	described by Subsection (a) and who is already on an interest list
	for another Section 1915(c) waiver program, move the child to a
	position on the interest list relative to other persons on the list
	that is based on the date the child was initially placed on the
	interest list for the medically dependent children (MDCP) waiver
	program, if that date is earlier than the date the child was
	initially placed on the interest list for the other waiver program.
	(d)  Notwithstanding Subsection (c)(1)(B) or (c)(2), a child
	may be placed on an interest list for a Section 1915(c) waiver
	program in the position described by those subsections only if the
	child has previously been placed on the interest list for that
	waiver program.
	(e)  At the time the commission provides notice to a legally
	authorized representative that a child is no longer eligible for
	the medically dependent children (MDCP) waiver program following a
	Medicaid fair hearing, or without a Medicaid fair hearing if the
	representative opted in writing to forego the hearing, the
	commission shall inform the representative in writing about:
	(1)  the options under this section for placing the
	child on an interest list; and
	(2)  the process for applying for the Medicaid buy-in
	program for children with disabilities implemented under Section
	531.02444.
	(f)  This section expires December 1, 2021.
	Sec. 531.0602.  MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
	PROGRAM ASSESSMENTS AND REASSESSMENTS.  (a)  The commission shall
	ensure that the care coordinator for a Medicaid managed care
	organization under the STAR Kids managed care program provides the
	results of the initial assessment or annual reassessment of medical
	necessity to the parent or legally authorized representative of a
	recipient receiving benefits under the medically dependent
	children (MDCP) waiver program for review.  The commission shall
	ensure the provision of the results does not delay the
	determination of the services to be provided to the recipient or the
	ability to authorize and initiate services.
	(b)  The commission shall require the parent's or
	representative's signature to verify the parent or representative
	received the results of the initial assessment or reassessment from
	the care coordinator under Subsection (a).  A Medicaid managed care
	organization may not delay the delivery of care pending the
	signature.
	(c)  The commission shall provide a parent or representative
	who disagrees with the results of the initial assessment or
	reassessment an opportunity to request to dispute the results with
	the Medicaid managed care organization through a peer-to-peer
	review with the treating physician of choice.
	(d)  This section does not affect any rights of a recipient
	to appeal an initial assessment or reassessment determination
	through the Medicaid managed care organization's internal appeal
	process, the Medicaid fair hearing process, or the external medical
	review process.
	Sec. 531.06021.  MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
	PROGRAM QUALITY MONITORING; REPORT. (a)  The commission, based on
	the state's external quality review organization's initial report
	on the STAR Kids managed care program, shall determine whether the
	findings of the report necessitate additional data and research to
	improve the program.  If the commission determines additional data
	and research are needed, the commission, through the external
	quality review organization, may:
	(1)  conduct annual surveys of Medicaid recipients
	receiving benefits under the medically dependent children (MDCP)
	waiver program, or their representatives, using the Consumer
	Assessment of Healthcare Providers and Systems;
	(2)  conduct annual focus groups with recipients
	described by Subdivision (1) or their representatives on issues
	identified through:
	(A)  the Consumer Assessment of Healthcare
	Providers and Systems;
	(B)  other external quality review organization
	activities; or
	(C)  stakeholders, including the STAR Kids
	Managed Care Advisory Committee described by Section 533.00254; and
	(3)  in consultation with the STAR Kids Managed Care
	Advisory Committee described by Section 533.00254 and as frequently
	as feasible, calculate Medicaid managed care organizations'
	performance on performance measures using available data sources
	such as the collaborative innovation improvement network.
	(b)  Not later than the 30th day after the last day of each
	state fiscal quarter, the commission shall submit to the governor,
	the lieutenant governor, the speaker of the house of
	representatives, the Legislative Budget Board, and each standing
	legislative committee with primary jurisdiction over Medicaid a
	report containing, for the most recent state fiscal quarter, the
	following information and data related to access to care for
	Medicaid recipients receiving benefits under the medically
	dependent children (MDCP) waiver program:
	(1)  enrollment in the Medicaid buy-in for children
	program implemented under Section 531.02444;
	(2)  requests relating to interest list placements
	under Section 531.0601;
	(3)  use of the Medicaid escalation help line
	established under Section 533.00253, if the help line was
	operational during the applicable state fiscal quarter;
	(4)  use of, requests for, and outcomes of the external
	medical review procedure established under Section 531.024164; and
	(5)  complaints relating to the medically dependent
	children (MDCP) waiver program, categorized by disposition.
	Sec. 531.0603.  ELIGIBILITY OF CERTAIN CHILDREN FOR
	MEDICALLY DEPENDENT CHILDREN (MDCP) OR DEAF-BLIND WITH MULTIPLE
	DISABILITIES (DBMD) WAIVER PROGRAM. (a)  Notwithstanding any
	other law and to the extent allowed by federal law, in determining
	eligibility of a child for the medically dependent children (MDCP)
	waiver program, the deaf-blind with multiple disabilities (DBMD)
	waiver program, or a "Money Follows the Person" demonstration
	project, the commission shall consider whether the child:
	(1)  is diagnosed as having a condition included in the
	list of compassionate allowances conditions published by the United
	States Social Security Administration; or
	(2)  receives Medicaid hospice or palliative care
	services.
	(b)  If the commission determines a child is eligible for a
	waiver program under Subsection (a), the child's enrollment in the
	applicable program is contingent on the availability of a slot in
	the program.  If a slot is not immediately available, the commission
	shall place the child in the first position on the interest list for
	the medically dependent children (MDCP) waiver program or
	deaf-blind with multiple disabilities (DBMD) waiver program, as
	applicable.
	Sec. 531.0604.  MEDICALLY DEPENDENT CHILDREN PROGRAM
	ELIGIBILITY REQUIREMENTS; NURSING FACILITY LEVEL OF CARE. To the
	extent allowed by federal law, the commission may not require that a
	child reside in a nursing facility for an extended period of time to
	meet the nursing facility level of care required for the child to be
	determined eligible for the medically dependent children (MDCP)
	waiver program.
	SECTION 4.  Section 533.00253(a)(1), Government Code, is
	amended to read as follows:
	(1)  "Advisory committee" means the STAR Kids Managed
	Care Advisory Committee described by [established under] Section
	533.00254.
	SECTION 5.  Section 533.00253, Government Code, is amended
	by amending Subsection (c) and adding Subsections (c-1), (c-2),
	(f), (g), (h), (i), (j), (k), and (l) to read as follows:
	(c)  The commission may require that care management
	services made available as provided by Subsection (b)(7):
	(1)  incorporate best practices, as determined by the
	commission;
	(2)  integrate with a nurse advice line to ensure
	appropriate redirection rates;
	(3)  use an identification and stratification
	methodology that identifies recipients who have the greatest need
	for services;
	(4)  provide a care needs assessment for a recipient
	[that is comprehensive, holistic, consumer-directed,
	evidence-based, and takes into consideration social and medical
	issues, for purposes of prioritizing the recipient's needs that
	threaten independent living];
	(5)  are delivered through multidisciplinary care
	teams located in different geographic areas of this state that use
	in-person contact with recipients and their caregivers;
	(6)  identify immediate interventions for transition
	of care;
	(7)  include monitoring and reporting outcomes that, at
	a minimum, include:
	(A)  recipient quality of life;
	(B)  recipient satisfaction; and
	(C)  other financial and clinical metrics
	determined appropriate by the commission; and
	(8)  use innovations in the provision of services.
	(c-1)  To improve the care needs assessment tool used for
	purposes of a care needs assessment provided as a component of care
	management services and to improve the initial assessment and
	reassessment processes, the commission in consultation and
	collaboration with the advisory committee shall consider changes
	that will:
	(1)  reduce the amount of time needed to complete the
	care needs assessment initially and at reassessment; and
	(2)  improve training and consistency in the completion
	of the care needs assessment using the tool and in the initial
	assessment and reassessment processes across different Medicaid
	managed care organizations and different service coordinators
	within the same Medicaid managed care organization.
	(c-2)  To the extent feasible and allowed by federal law, the
	commission shall streamline the STAR Kids managed care program
	annual care needs reassessment process for a child who has not had a
	significant change in function that may affect medical necessity.
	(f)  The commission shall operate a Medicaid escalation help
	line through which Medicaid recipients receiving benefits under the
	medically dependent children (MDCP) waiver program or the
	deaf-blind with multiple disabilities (DBMD) waiver program and
	their legally authorized representatives, parents, guardians, or
	other representatives have access to assistance.  The escalation
	help line must be:
	(1)  dedicated to assisting families of Medicaid
	recipients receiving benefits under the medically dependent
	children (MDCP) waiver program or the deaf-blind with multiple
	disabilities (DBMD) waiver program in navigating and resolving
	issues related to the STAR Kids managed care program, including
	complying with requirements related to the continuation of benefits
	during an internal appeal, a Medicaid fair hearing, or a review
	conducted by an external medical reviewer; and
	(2)  operational at all times, including evenings,
	weekends, and holidays.
	(g)  The commission shall ensure staff operating the
	Medicaid escalation help line:
	(1)  return a telephone call not later than two hours
	after receiving the call during standard business hours; and
	(2)  return a telephone call not later than four hours
	after receiving the call during evenings, weekends, and holidays.
	(h)  The commission shall require a Medicaid managed care
	organization participating in the STAR Kids managed care program
	to:
	(1)  designate an individual as a single point of
	contact for the Medicaid escalation help line; and
	(2)  authorize that individual to take action to
	resolve escalated issues.
	(i)  To the extent feasible, a Medicaid managed care
	organization shall provide information that will enable staff
	operating the Medicaid escalation help line to assist recipients,
	such as information related to service coordination and prior
	authorization denials.
	(j)  Not later than September 1, 2020, the commission shall
	assess the utilization of the Medicaid escalation help line and
	determine the feasibility of expanding the help line to additional
	Medicaid programs that serve medically fragile children.
	(k)  Subsections (f), (g), (h), (i), and (j) and this
	subsection expire September 1, 2024.
	(l)  Not later than September 1, 2020, the commission shall
	evaluate risk-adjustment methods used for recipients under the STAR
	Kids managed care program, including recipients with private health
	benefit plan coverage, in the quality-based payment program under
	Chapter 536 to ensure that higher-volume providers are not unfairly
	penalized.  This subsection expires January 1, 2021.
	SECTION 6.  Subchapter A, Chapter 533, Government Code, is
	amended by adding Sections 533.00254, 533.00282, 533.00283,
	533.00284, 533.002841, and 533.038 to read as follows:
	Sec. 533.00254.  STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
	(a)  The STAR Kids Managed Care Advisory Committee established by
	the executive commissioner under Section 531.012 shall:
	(1)  advise the commission on the operation of the STAR
	Kids managed care program under Section 533.00253; and
	(2)  make recommendations for improvements to that
	program.
	(b)  On December 31, 2023:
	(1)  the advisory committee is abolished; and
	(2)  this section expires.
	Sec. 533.00282.  UTILIZATION REVIEW AND PRIOR AUTHORIZATION
	PROCEDURES.  (a)  Section 4201.304(a)(2), Insurance Code, does not
	apply to a Medicaid managed care organization or a utilization
	review agent who conducts utilization reviews for a Medicaid
	managed care organization.
	(b)  In addition to the requirements of Section 533.005, a
	contract between a Medicaid managed care organization and the
	commission must require that:
	(1)  before issuing an adverse determination on a prior
	authorization request, the organization provide the physician
	requesting the prior authorization with a reasonable opportunity to
	discuss the request with another physician who practices in the
	same or a similar specialty, but not necessarily the same
	subspecialty, and has experience in treating the same category of
	population as the recipient on whose behalf the request is
	submitted; and
	(2)  the organization review and issue determinations
	on prior authorization requests with respect to a recipient who is
	not hospitalized at the time of the request according to the
	following time frames:
	(A)  within three business days after receiving
	the request; or
	(B)  within the time frame and following the
	process established by the commission if the organization receives
	a request for prior authorization that does not include sufficient
	or adequate documentation.
	(c)  In consultation with the state Medicaid managed care
	advisory committee, the commission shall establish a process for
	use by a Medicaid managed care organization that receives a prior
	authorization request, with respect to a recipient who is not
	hospitalized at the time of the request, that does not include
	sufficient or adequate documentation.  The process must provide a
	time frame within which a provider may submit the necessary
	documentation. The time frame must be longer than the time frame
	specified by Subsection (b)(2)(A) within which a Medicaid managed
	care organization must issue a determination on a prior
	authorization request.
	Sec. 533.00283.  ANNUAL REVIEW OF PRIOR AUTHORIZATION
	REQUIREMENTS. (a)  Each Medicaid managed care organization, in
	consultation with the organization's provider advisory group
	required by contract, shall develop and implement a process to
	conduct an annual review of the organization's prior authorization
	requirements, other than a prior authorization requirement
	prescribed by or implemented under Section 531.073 for the vendor
	drug program. In conducting a review, the organization must:
	(1)  solicit, receive, and consider input from
	providers in the organization's provider network; and
	(2)  ensure that each prior authorization requirement
	is based on accurate, up-to-date, evidence-based, and
	peer-reviewed clinical criteria that distinguish, as appropriate,
	between categories, including age, of recipients for whom prior
	authorization requests are submitted.
	(b)  A Medicaid managed care organization may not impose a
	prior authorization requirement, other than a prior authorization
	requirement prescribed by or implemented under Section 531.073 for
	the vendor drug program, unless the organization has reviewed the
	requirement during the most recent annual review required under
	this section.
	(c)  The commission shall periodically review each Medicaid
	managed care organization to ensure the organization's compliance
	with this section.
	Sec. 533.00284.  RECONSIDERATION FOLLOWING ADVERSE
	DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a)  In
	consultation with the state Medicaid managed care advisory
	committee, the commission shall establish a uniform process and
	timeline for Medicaid managed care organizations to reconsider an
	adverse determination on a prior authorization request that
	resulted solely from the submission of insufficient or inadequate
	documentation. In addition to the requirements of Section 533.005,
	a contract between a Medicaid managed care organization and the
	commission must include a requirement that the organization
	implement the process and timeline.
	(b)  The process and timeline must:
	(1)  allow a provider to submit any documentation that
	was identified as insufficient or inadequate in the notice provided
	under Section 531.024162;
	(2)  allow the provider requesting the prior
	authorization to discuss the request with another provider who
	practices in the same or a similar specialty, but not necessarily
	the same subspecialty, and has experience in treating the same
	category of population as the recipient on whose behalf the request
	is submitted; and
	(3)  require the Medicaid managed care organization to
	amend the determination on the prior authorization request as
	necessary, considering the additional documentation.
	(c)  An adverse determination on a prior authorization
	request is considered a denial of services in an evaluation of the
	Medicaid managed care organization only if the determination is not
	amended under Subsection (b)(3) to approve the request.
	(d)  The process and timeline for reconsidering an adverse
	determination on a prior authorization request under this section
	do not affect:
	(1)  any related timelines, including the timeline for
	an internal appeal, a Medicaid fair hearing, or a review conducted
	by an external medical reviewer; or
	(2)  any rights of a recipient to appeal a
	determination on a prior authorization request.
	Sec. 533.002841.  MAXIMUM PERIOD FOR PRIOR AUTHORIZATION
	DECISION; ACCESS TO CARE.  The time frames prescribed by the
	utilization review and prior authorization procedures described by
	Section 533.00282 and the timeline for reconsidering an adverse
	determination on a prior authorization described by Section
	533.00284 together may not exceed the time frame for a decision
	under federally prescribed time frames.  It is the intent of the
	legislature that these provisions allow sufficient time to provide
	necessary documentation and avoid unnecessary denials without
	delaying access to care.
	Sec. 533.038.  COORDINATION OF BENEFITS. (a)  In this
	section, "Medicaid wrap-around benefit" means a Medicaid-covered
	service, including a pharmacy or medical benefit, that is provided
	to a recipient with both Medicaid and primary health benefit plan
	coverage when the recipient has exceeded the primary health benefit
	plan coverage limit or when the service is not covered by the
	primary health benefit plan issuer.
	(b)  The commission, in coordination with Medicaid managed
	care organizations and in consultation with the STAR Kids Managed
	Care Advisory Committee described by Section 533.00254, shall
	develop and adopt a clear policy for a Medicaid managed care
	organization to ensure the coordination and timely delivery of
	Medicaid wrap-around benefits for recipients with both primary
	health benefit plan coverage and Medicaid coverage.  In developing
	the policy, the commission shall consider requiring a Medicaid
	managed care organization to allow, notwithstanding Sections
	531.073 and 533.005(a)(23) or any other law, a recipient using a
	prescription drug for which the recipient's primary health benefit
	plan issuer previously provided coverage to continue receiving the
	prescription drug without requiring additional prior
	authorization.
	(c)  If the commission determines that a recipient's primary
	health benefit plan issuer should have been the primary payor of a
	claim, the Medicaid managed care organization that paid the claim
	shall work with the commission on the recovery process and make
	every attempt to reduce health care provider and recipient
	abrasion.
	(d)  The executive commissioner may seek a waiver from the
	federal government as needed to:
	(1)  address federal policies related to coordination
	of benefits and third-party liability; and
	(2)  maximize federal financial participation for
	recipients with both primary health benefit plan coverage and
	Medicaid coverage.
	(e)  The commission may include in the Medicaid managed care
	eligibility files an indication of whether a recipient has primary
	health benefit plan coverage or is enrolled in a group health
	benefit plan for which the commission provides premium assistance
	under the health insurance premium payment program. For recipients
	with that coverage or for whom that premium assistance is provided,
	the files may include the following up-to-date, accurate
	information related to primary health benefit plan coverage to the
	extent the information is available to the commission:
	(1)  the health benefit plan issuer's name and address
	and the recipient's policy number;
	(2)  the primary health benefit plan coverage start and
	end dates; and
	(3)  the primary health benefit plan coverage benefits,
	limits, copayment, and coinsurance information.
	(f)  To the extent allowed by federal law, the commission
	shall maintain processes and policies to allow a health care
	provider who is primarily providing services to a recipient through
	primary health benefit plan coverage to receive Medicaid
	reimbursement for services ordered, referred, or prescribed,
	regardless of whether the provider is enrolled as a Medicaid
	provider. The commission shall allow a provider who is not enrolled
	as a Medicaid provider to order, refer, or prescribe services to a
	recipient based on the provider's national provider identifier
	number and may not require an additional state provider identifier
	number to receive reimbursement for the services. The commission
	may seek a waiver of Medicaid provider enrollment requirements for
	providers of recipients with primary health benefit plan coverage
	to implement this subsection.
	(g)  The commission shall develop a clear and easy process,
	to be implemented through a contract, that allows a recipient with
	complex medical needs who has established a relationship with a
	specialty provider to continue receiving care from that provider.
	SECTION 7.  (a)  Section 531.0601, Government Code, as added
	by this Act, applies only to a child who becomes ineligible for the
	medically dependent children (MDCP) waiver program on or after
	December 1, 2019.
	(b)  Section 531.0602, Government Code, as added by this Act,
	applies only to an assessment or reassessment of a child's
	eligibility for the medically dependent children (MDCP) waiver
	program made on or after December 1, 2019.
	(c)  Notwithstanding Section 531.06021, Government Code, as
	added by this Act, the Health and Human Services Commission shall
	submit the first report required by that section not later than
	September 30, 2020, for the state fiscal quarter ending August 31,
	2020.
	(d)  Not later than March 1, 2020, the Health and Human
	Services Commission shall:
	(1)  develop a plan to improve the care needs
	assessment tool and the initial assessment and reassessment
	processes as required by Sections 533.00253(c-1) and (c-2),
	Government Code, as added by this Act; and
	(2)  post the plan on the commission's Internet
	website.
	(e)  Sections 533.00282 and 533.00284, Government Code, as
	added by this Act, apply only to a contract between the Health and
	Human Services Commission and a Medicaid managed care organization
	under Chapter 533, Government Code, that is entered into or renewed
	on or after the effective date of this Act.
	(f)  As soon as practicable after the effective date of this
	Act but not later than September 1, 2020, the Health and Human
	Services Commission shall seek to amend contracts entered into with
	Medicaid managed care organizations under Chapter 533, Government
	Code, before the effective date of this Act to include the
	provisions required by Sections 533.00282 and 533.00284,
	Government Code, as added by this Act.
	SECTION 8.  As soon as practicable after the effective date
	of this Act, the executive commissioner of the Health and Human
	Services Commission shall adopt rules necessary to implement the
	changes in law made by this Act.
	SECTION 9.  If before implementing any provision of this Act
	a state agency determines that a waiver or authorization from a
	federal agency is necessary for implementation of that provision,
	the agency affected by the provision shall request the waiver or
	authorization and may delay implementing that provision until the
	waiver or authorization is granted.
	SECTION 10.  The Health and Human Services Commission is
	required to implement a provision of this Act only if the
	legislature appropriates money specifically for that purpose. If
	the legislature does not appropriate money specifically for that
	purpose, the commission may, but is not required to, implement a
	provision of this Act using other appropriations available for that
	purpose.
	SECTION 11.  This Act takes effect September 1, 2019.
	______________________________	______________________________
	President of the Senate	Speaker of the House
	I hereby certify that S.B. No. 1207 passed the Senate on
	April 17, 2019, by the following vote:  Yeas 30, Nays 1;
	May 23, 2019, Senate refused to concur in House amendments and
	requested appointment of Conference Committee; May 23, 2019, House
	granted request of the Senate; May 26, 2019, Senate adopted
	Conference Committee Report by the following vote:  Yeas 30,
	Nays 1.
	______________________________
	Secretary of the Senate
	I hereby certify that S.B. No. 1207 passed the House, with
	amendments, on May 20, 2019, by the following vote:  Yeas 139,
	Nays 0, two present not voting; May 23, 2019, House granted request
	of the Senate for appointment of Conference Committee;
	May 26, 2019, House adopted Conference Committee Report by the
	following vote:  Yeas 145, Nays 0, one present not voting.
	______________________________
	Chief Clerk of the House
	Approved:
	______________________________
	Date
	______________________________
	Governor