Tex.
Gov't Code Section 533.0025
Delivery of Services
(a)
Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, Sec. 2.287(15), eff. April 2, 2015.(b)
Except as otherwise provided by this section and notwithstanding any other law, the commission shall provide Medicaid acute care services through the most cost-effective model of Medicaid capitated managed care as determined by the commission. The commission shall require mandatory participation in a Medicaid capitated managed care program for all persons eligible for Medicaid acute care benefits, but may implement alternative models or arrangements, including a traditional fee-for-service arrangement, if the commission determines the alternative would be more cost-effective or efficient.(c)
In determining whether a model or arrangement described by Subsection (b) is more cost-effective, the executive commissioner must consider:(1)
the scope, duration, and types of health benefits or services to be provided in a certain part of this state or to a certain population of recipients;(2)
administrative costs necessary to meet federal and state statutory and regulatory requirements;(3)
the anticipated effect of market competition associated with the configuration of Medicaid service delivery models determined by the commission; and(4)
the gain or loss to this state of a tax collected under Chapter 222 (Life, Health, and Accident Insurance Premium Tax), Insurance Code.(d)
If the commission determines that it is not more cost-effective to use a Medicaid managed care model to provide certain types of Medicaid acute care in a certain area or to certain recipients as prescribed by this section, the commission shall provide Medicaid acute care through a traditional fee-for-service arrangement.(e)
The commission shall determine the most cost-effective alignment of managed care service delivery areas. The executive commissioner may consider the number of lives impacted, the usual source of health care services for residents in an area, and other factors that impact the delivery of health care services in the area.(f)
Expired.(g)
Expired.(h)
If the commission determines that it is feasible, the commission may, notwithstanding any other law, implement an automatic enrollment process under which applicants determined eligible for Medicaid benefits are automatically enrolled in a Medicaid managed care plan chosen by the applicant. The commission may elect to implement the automatic enrollment process as to certain populations of recipients.(i)
Subject to Section 534.152, the commission shall:(1)
implement the most cost-effective option for the delivery of basic attendant and habilitation services for individuals with disabilities under the STAR + PLUS Medicaid managed care program that maximizes federal funding for the delivery of services for that program and other similar programs; and(2)
provide voluntary training to individuals receiving services under the STAR + PLUS Medicaid managed care program or their legally authorized representatives regarding how to select, manage, and dismiss personal attendants providing basic attendant and habilitation services under the program.(1)
Repealed by Acts 2015, 84th Leg., R.S., Ch. 837, Sec. 3.40(a)(14), and Ch. 946, 2.37(b)(13) eff. January 1, 2016.(2)
“Clean claim” means a claim that meets the same criteria for a clean claim used by the Department of Aging and Disability Services for the reimbursement of nursing facility claims.(3)
“Nursing facility” means a convalescent or nursing home or related institution licensed under Chapter 242 (Convalescent and Nursing Facilities and Related Institutions), Health and Safety Code, that provides long-term services and supports to recipients.(4)
“Potentially preventable event” has the meaning assigned by Section 536.001 (Definitions).(b)
Subject to Section 533.0025 (Delivery of Services), the commission shall expand the STAR + PLUS Medicaid managed care program to all areas of this state to serve individuals eligible for acute care services and long-term services and supports under Medicaid.(c)
Subject to Section 533.0025 (Delivery of Services) and notwithstanding any other law, the commission shall provide benefits under Medicaid to recipients who reside in nursing facilities through the STAR + PLUS Medicaid managed care program. In implementing this subsection, the commission shall ensure:(1)
that a nursing facility is paid not later than the 10th day after the date the facility submits a clean claim;(2)
the appropriate utilization of services consistent with criteria established by the commission;(3)
a reduction in the incidence of potentially preventable events and unnecessary institutionalizations;(4)
that a managed care organization providing services under the managed care program provides discharge planning, transitional care, and other education programs to physicians and hospitals regarding all available long-term care settings;(5)
that a managed care organization providing services under the managed care program:(A)
assists in collecting applied income from recipients; and(B)
provides payment incentives to nursing facility providers that reward reductions in preventable acute care costs and encourage transformative efforts in the delivery of nursing facility services, including efforts to promote a resident-centered care culture through facility design and services provided;(6)
the establishment of a portal that is in compliance with state and federal regulations, including standard coding requirements, through which nursing facility providers participating in the STAR + PLUS Medicaid managed care program may submit claims to any participating managed care organization;(7)
that rules and procedures relating to the certification and decertification of nursing facility beds under Medicaid are not affected;(8)
that a managed care organization providing services under the managed care program, to the greatest extent possible, offers nursing facility providers access to:(A)
acute care professionals; and(B)
telemedicine, when feasible and in accordance with state law, including rules adopted by the Texas Medical Board; and(9)
that the commission approves the staff rate enhancement methodology for the staff rate enhancement paid to a nursing facility that qualifies for the enhancement under the managed care program.(e)
The commission shall establish credentialing and minimum performance standards for nursing facility providers seeking to participate in the STAR + PLUS Medicaid managed care program that are consistent with adopted federal and state standards. A managed care organization may refuse to contract with a nursing facility provider if the nursing facility does not meet the minimum performance standards established by the commission under this section.(f)
A managed care organization may not require prior authorization for a nursing facility resident in need of emergency hospital services.(h)
In addition to the minimum performance standards the commission establishes for nursing facility providers seeking to participate in the STAR+PLUS Medicaid managed care program, the executive commissioner shall adopt rules establishing minimum performance standards applicable to nursing facility providers that participate in the program. The commission is responsible for monitoring provider performance in accordance with the standards and requiring corrective actions, as the commission determines necessary, from providers that do not meet the standards. The commission shall share data regarding the requirements of this subsection with STAR+PLUS Medicaid managed care organizations as appropriate.
Source:
Section 533.0025 — Delivery of Services, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.533.htm#533.0025 (accessed Apr. 29, 2024).
