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Relating to an independent medical review of certain determinations by the Health and Human Services Commission or a Medicaid managed care organization.
According to the Legislative Budget Board, SB 1140 would have a negative impact of ($1,078,090) through the biennium ending August 31, 2021.
SB 1140 would require the Health and Human Services Commission (HHSC), using money appropriated for the purpose, to contract with at least three third party arbiters to resolve appeals of HHSC or managed care organization (MCO) adverse benefit determinations, or reduction in or denial of health care services on the basis of medical necessity. Also, a third party arbiter must maintain a website through which a recipient may track the status and final disposition of an appeal, view information regarding the appeals process, and review denial data to identify trends.
A patient may go to a clinical expert in the relevant field of medicine to determine whether that service is medically necessary following an internal appeal by the MCO. If the patient is unsuccessful, then the patient can proceed to the appeals process through HHSC that is currently in place.
Texas Action remains neutral on SB 1140 because it does not affect our liberty principles. This bill would merely add an independent arbitration process to the current appeals process to determine whether a procedure is medically necessary, similar to the appeals process for commercial insurance.