Medicaid providers get a help team and 30 days’ notice

The text as introduced · 1,477 words

89R16086 KKR-F

By: Buckley
H.B. No. 5512

A BILL TO BE ENTITLED

AN ACT

relating to the participation and reimbursement of and requirements

affecting certain providers, including providers of eye health care

and vision care services, under Medicaid.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subchapter D, Chapter 532, Government Code, as

effective April 1, 2025, is amended by adding Sections 532.01511

and 532.01512 to read as follows:

Sec. 532.01511. PROVIDER ENROLLMENT AND CREDENTIALING

PROCESSES: PROVIDER SUPPORT; COMPLAINTS. (a) The commission shall

ensure that providers have access to a dedicated support team for

the Internet portal established under Section 532.0151 that:

(1) assists current and prospective Medicaid

providers in completing the Medicaid provider enrollment and

credentialing processes; and

(2) reduces the administrative burdens associated

with those processes.

(b) The commission shall:

(1) annually evaluate the performance of the support

team described by Subsection (a), including the timeliness of

assistance the support team provides; and

(2) not later than September 1 of each year, post on

the commission's Internet website a report summarizing the results

of the evaluation conducted under Subdivision (1).

(c) For purposes of improving the commission's Medicaid

provider enrollment and credentialing processes, the commission

shall develop a procedure by which a provider may electronically

submit complaints and feedback about those processes and the

support provided by the support team described by Subsection (a).

Information about the procedure must:

(1) be prominently posted on the commission's or the

commission's designee's Internet website in the same location that

instructions and resources for using the Internet portal

established under Section 532.0151 are posted; and

(2) allow a provider to submit a complaint or provide

feedback through an electronic form from that location.

Sec. 532.01512. NOTICE OF PROVIDER DISENROLLMENT. Before

the commission may disenroll a Medicaid provider during the

provider's enrollment revalidation period, the commission must:

(1) not later than the 30th day before the date of

disenrollment provide electronically and by mail to the provider

written notice of the commission's disenrollment determination;

and

(2) allow the provider to address any deficiencies in

the provider's application for revalidation of enrollment before

the date the provider is disenrolled.

SECTION 2. Subchapter F, Chapter 540, Government Code, as

effective April 1, 2025, is amended by adding Sections 540.0281 and

540.0282 to read as follows:

Sec. 540.0281. ADMINISTRATION OF EYE HEALTH CARE AND VISION

CARE SERVICES. (a) A contract to which this subchapter applies

must prohibit the contracting Medicaid managed care organization

from using a different insurer, health maintenance organization,

third-party administrator, managed care plan, vision plan, or other

plan or entity the organization contracts with, offers, owns, or

otherwise engages to provide or arrange for the provision of eye

health care or vision care services under the managed care plan the

Medicaid managed care organization offers to:

(1) establish an eye health care services provider's

inclusion in the organization's provider network;

(2) contract with an eye health care services provider

to provide or arrange for the provision of eye health care or vision

care services under the organization's Medicaid managed care plan;

(3) reduce, restrict, or limit eye health care or

vision care services that are required to be provided to recipients

and are within the eye health care services provider's scope of

practice; or

(4) deny participation of an eye health care services

provider in the organization's Medicaid managed care plan if the

provider:

(A) seeks to participate in that plan; and

(B) meets the organization's requirements for

participation in the plan.

(b) Notwithstanding Section 1451.152, Insurance Code, an

insurer, health maintenance organization, third-party

administrator, managed care plan, vision plan, or other plan or

entity that a Medicaid managed care organization contracts with,

offers, owns, or otherwise engages to provide or arrange for the

provision of eye health care or vision care services under the

organization's Medicaid managed care plan shall comply with the

requirements of Subchapter D, Chapter 1451, Insurance Code.

Sec. 540.0282. REIMBURSEMENT OF EYE HEALTH CARE SERVICES

PROVIDERS. A contract to which this subchapter applies must

require that the contracting Medicaid managed care organization

require any insurer, health maintenance organization, third-party

administrator, managed care plan, vision plan, or other plan or

entity the organization contracts with, offers, owns, or otherwise

engages to provide or arrange for the provision of eye health care

or vision care services under the managed care plan the Medicaid

managed care organization offers to reimburse an eye health care

services provider who provides services to a recipient under the

organization's managed care plan at a rate that is at least equal to

the Medicaid fee-for-service rate for the provision of the same or

similar services.

SECTION 3. Section 540.0651(a), Government Code, as

effective April 1, 2025, is amended to read as follows:

(a) The commission shall require that each managed care

organization that contracts with the commission under any managed

care model or arrangement to provide health care services to

recipients in a region:

(1) seek participation in the organization's provider

network from:

(A) each health care provider in the region who

has traditionally provided care to recipients;

(B) each hospital in the region that has been

designated as a disproportionate share hospital under Medicaid; and

(C) each specialized pediatric laboratory in the

region, including a laboratory located in a children's hospital;

(2) include in the organization's provider network for

at least three years:

(A) each health care provider in the region who:

(i) previously provided care to Medicaid

and charity care recipients at a significant level as the

commission prescribes;

(ii) agrees to accept the organization's

prevailing provider contract rate; and

(iii) has the credentials the organization

requires, provided that lack of board certification or

accreditation by The Joint Commission may not be the sole ground for

exclusion from the provider network;

(B) each accredited primary care residency

program in the region; and

(C) each disproportionate share hospital the

commission designates as a statewide significant traditional

provider; [ and ]

(3) subject to Section 32.047, Human Resources Code,

and notwithstanding any other law, include in the organization's

provider network each optometrist, therapeutic optometrist, and

ophthalmologist described by Section 532.0153(b)(1)(A) or (B) who,

and an institution of higher education described by Section

532.0153(a)(4) in the region that:

(A) seeks participation in the organization's

provider network;

(B) agrees to comply with the organization's

terms;

(C) [ (B) ] agrees to accept the [ organization's

prevailing provider contract ] rate specified in the contract

between the provider and the organization ;

(D) [ (C) ] agrees to abide by the organization's

required standards of care; and

(E) [ (D) ] is an enrolled Medicaid provider ; and

(4) contract directly with each provider described by

Subdivision (3) to participate in the organization's provider

network .

SECTION 4. Notwithstanding Section 532.01511, Government

Code, as added by this Act, the Health and Human Services Commission

shall conduct the initial evaluation and post the report

summarizing the results of the evaluation as required by that

section not later than September 1, 2026.

SECTION 5. As soon as possible after the effective date of

this Act, the Health and Human Services Commission shall:

(1) ensure the Internet portal support team required

by Section 532.01511(a), Government Code, as added by this Act, is

established; and

(2) adopt rules necessary to implement the changes in

law made by this Act.

SECTION 6. (a) The Health and Human Services Commission

shall, in a contract between the commission and a managed care

organization under Chapter 540, Government Code, as effective April

1, 2025, that is entered into or renewed on or after the effective

date of this Act, require that the managed care organization comply

with Sections 540.0281 and 540.0282, Government Code, as added by

this Act, and Section 540.0651, Government Code, as effective April

1, 2025, and amended by this Act.

(b) The Health and Human Services Commission shall seek to

amend contracts entered into with managed care organizations under

Chapter 533, Government Code, or under Chapter 540, Government

Code, as effective April 1, 2025, before the effective date of this

Act to require those managed care organizations to comply with

Sections 540.0281 and 540.0282, Government Code, as added by this

Act, and Section 540.0651, Government Code, as effective April 1,

2025, and amended by this Act. To the extent of a conflict between

those provisions of law and a provision of a contract with a managed

care organization entered into before the effective date of this

Act, the contract provision prevails.

SECTION 7. 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 8. This Act takes effect September 1, 2025.