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Relating to the Medicaid program, including the administration and operation of the Medicaid managed care model.
This bill would establish new requirements for the verification of electronic visits and reimbursement of claims in relation to those visits. The bill would also establish new financial audit requirements and procedures conducted by the office of contract management.
This bill would prohibit a provider from being held liable for a managed care organization’s debt if the MCO is overpaid or owes the commission money. The bill also would amend the code to reflect that a contract with an MCO would have a requirement that the MCO demonstrate to HHSC that within each provider category, the organization pays at least 98% of the claims within the time prescribed by the code, and a requirement that the MCO put information on their website regarding the number of provider appeals and the disposition of those appeals to be available to the public.
The bill would also require an MCO to approve or pend a request from a provider of acute care inpatient services for prior authorization for certain services or equipment not later than 72 hours after getting the request to allow for timely discharge of the patient from an inpatient facility. HHSC would be required to establish minimum standards for determining medical necessity of a health care service covered by Medicaid and ensure that each recipient has equal access to the same covered services regardless of which plan the recipient is enrolled in. The bill would also introduce restrictions on certain reimbursement rate reductions.
The bill would establish new requirements for utilization review audits conducted by the inspector general, including requiring them to notify providers of the applicable criteria the office will use in the audit.
The commission would also be required to adopt criteria to be used by MCOs to determine reimbursement of services provided for treatment related to an inpatient hospital stay, including for behavioral health, of less than 72 hours. The bill would also add a provision to ensure the provision of medically necessary (acute care or long term) services for an individual with an intellectual or developmental disability receiving services under a Medicaid waiver program.