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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.
Estimated Two-year Net Impact to General Revenue Related Funds for SB 1140, As Engrossed: a negative impact of ($1,384,518) through the biennium ending August 31, 2021.
The bill would make no appropriation but could provide the legal basis for an appropriation of
funds to implement the provisions of the bill.
SB 1140 would require the Health and Human Services Commission (HHSC), using money appropriated for the purpose, to contract with at least three independent, 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.
This appeal of a Medicaid MCO adverse benefit determination would occur after the Medicaid MCO internal appeal decision and before the Medicaid fair hearing, and the appeal would be granted when a recipient contests the internal appeal decision. Any other appeal would occur after HHSC's denial is issued or action is taken, and before the Medicaid fair hearing.
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.