Tex. Gov't Code Section 533.0131
Use of Encounter Data in Determining Premium Payment Rates

(a)

In determining premium payment rates and other amounts paid to managed care organizations under a managed care plan, the commission may not base or derive the rates or amounts on or from encounter data, or incorporate in the determination an analysis of encounter data, unless a certifier of encounter data certifies that:

(1)

the encounter data for the most recent state fiscal year is complete, accurate, and reliable; and

(2)

there is no statistically significant variability in the encounter data attributable to incompleteness, inaccuracy, or another deficiency as compared to equivalent data for similar populations and when evaluated against professionally accepted standards.

(b)

For purposes of determining whether data is equivalent data for similar populations under Subsection (a)(2), a certifier of encounter data shall, at a minimum, consider:

(1)

the regional variation in utilization patterns of recipients and costs of health care services;

(2)

the range and type of health care services to be covered by premium payment rates;

(3)

the number of managed care plans in the region; and

(4)

the current number of recipients in each region, including the number for each category of recipient.
Added by Acts 2001, 77th Leg., ch. 506, Sec. 1, eff. Sept. 1, 2001.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.

Source: Section 533.0131 — Use of Encounter Data in Determining Premium Payment Rates, https://statutes.­capitol.­texas.­gov/Docs/GV/htm/GV.­533.­htm#533.­0131 (accessed Jun. 5, 2024).

521
General Provisions 522
Provisions Applicable to All Health and Human Services Agencies and Certain Other State Entities 523
Health and Human Services Commission 524
Authority over Health and Human Services System 525
General Powers and Duties of Commission and Executive Commissioner 526
Additional Powers and Duties of Commission and Executive Commissioner 531
Health and Human Services Commission 532
Medicaid Administration and Operation in General 533.001
Definitions 533.002
Purpose 533.003
Considerations in Awarding Contracts 533.004
Mandatory Contracts 533.005
Required Contract Provisions 533.006
Provider Networks 533.007
Contract Compliance 533.008
Marketing Guidelines 533.009
Special Disease Management 533.010
Special Protocols 533.011
Public Notice 533.012
Information for Fraud Control 533.013
Premium Payment Rate Determination 533.014
Profit Sharing 533.015
Coordination of External Oversight Activities 533.016
Provider Reporting of Encounter Data 533.017
Qualifications of Certifier of Encounter Data 533.018
Certification of Encounter Data 533.019
Value-added Services 533.020
Managed Care Organizations: Fiscal Solvency and Complaint System Guidelines 533.021
Community Health Workers 533.0025
Delivery of Services 533.0026
Direct Access to Eye Health Care Services Under Medicaid Managed Care Model or Arrangement 533.0027
Procedures to Ensure Certain Recipients Are Enrolled in Same Managed Care Plan 533.0029
Promotion and Principles of Patient-centered Medical Homes for Recipients 533.0031
Medicaid Managed Care Plan Accreditation 533.0035
Certification by Commission 533.038
Coordination of Benefits 533.039
Delivery of Benefits Using Telecommunications and Information Technology 533.0051
Performance Measures and Incentives for Value-based Contracts 533.051
Definitions 533.0052
Star Health Program: Trauma-informed Care Training 533.052
Applicability and Construction of Subchapter 533.0053
Compliance with Texas Health Steps 533.053
Overall Strategy for Managing Audit Resources 533.0054
Health Screening Requirements for Enrollee Under Star Health Program 533.054
Performance Audit Selection Process and Follow-up 533.0055
Provider Protection Plan 533.055
Agreed-upon Procedures Engagements and Corrective Action Plans 533.0056
Star Health Program: Notification of Placement Change 533.056
Audits of Pharmacy Benefit Managers 533.057
Collection of Costs for Audit-related Services 533.058
Collection Activities Related to Profit Sharing 533.059
Use of Information from External Quality Reviews 533.060
Security and Processing Controls over Information Technology Systems 533.0061
Provider Access Standards 533.0062
Penalties and Other Remedies for Failure to Comply with Provider Access Standards 533.0063
Provider Network Directories 533.0064
Expedited Credentialing Process for Certain Providers 533.0065
Frequency of Provider Credentialing 533.0066
Provider Incentives 533.0067
Eye Health Care Service Providers 533.0071
Administration of Contracts 533.071
Preferred Drug List Exceptions 533.0072
Internet Posting of Sanctions Imposed for Contractual Violations 533.0073
Medical Director Qualifications 533.0075
Recipient Enrollment 533.0076
Limitations on Recipient Disenrollment 533.0077
Statewide Effort to Promote Maintenance of Eligibility 533.083
Assessment and Implementation of Pilot Program Findings 533.0091
Sickle Cell Disease Treatment 533.0131
Use of Encounter Data in Determining Premium Payment Rates 533.0132
State Taxes 533.0161
Monitoring of Psychotropic Drug Prescriptions for Certain Children 533.00253
Star Kids Medicaid Managed Care Program 533.00254
Star Kids Managed Care Advisory Committee 533.00255
Behavioral Health and Physical Health Services Network 533.00256
Managed Care Clinical Improvement Program 533.00257
Delivery of Medical Transportation Program Services Through Managed Transportation Organization 533.00258
Nonmedical Transportation Services Under Medicaid Managed Care Program 533.00282
Utilization Review and Prior Authorization Procedures 533.00283
Annual Review of Prior Authorization Requirements 533.00284
Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests 533.00511
Quality-based Enrollment Incentive Program for Managed Care Organizations 533.00515
Medication Therapy Management 533.00521
Star Health Program: Health Care for Foster Children 533.00522
Star Health Program: Mental Health Providers 533.00531
Medicaid Benefits for Certain Children Formerly in Foster Care 533.00751
Recipient Directory 533.01315
Reimbursement for Services Provided Outside of Regular Business Hours 533.002551
Monitoring of Compliance with Behavioral Health Integration 533.002552
Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families 533.002553
Behavioral Health Services Provided Through Third Party or Subsidiary 533.002555
Transition of Case Management for Children and Pregnant Women Program Recipients to Managed Care Program 533.002571
Delivery of Nonemergency Transportation Services to Certain Medicaid Recipients Through Medicaid Managed Care Organization 533.002581
Delivery of Nonmedical Transportation Services Under Medicaid Managed Care Program 533.002821
Prior Authorization Procedures for Hospitalized Recipient 533.002841
Maximum Period for Prior Authorization Decision 534
System Redesign for Delivery of Medicaid Acute Care Services and Long-term Services and Supports to Persons with an Intellectual or Developmental Disability 535
Provision of Human Services and Other 536
Medicaid and the Child Health Plan Program: Quality-based Outcomes and Payments 537
Medicaid Reform Waiver 538
Medicaid Quality Improvement Process for Clinical Initiatives 539.001
Definition 539.002
Grants for Establishment and Expansion of Community Collaboratives 539.003
Acceptable Uses of Grant Money 539.004
Elements of Community Collaboratives 539.005
Outcome Measures for Community Collaboratives 539.006
Annual Review of Outcome Measures 539.007
Reduction and Cessation of Funding 539.008
Rules 539.009
Administrative Costs 539.010
Biennial Report 539.0051
Plan Required for Certain Community Collaboratives 540
Medicaid Managed Care Program 540A
Medicaid Managed Transportation Services 541
Pediatric Tele-connectivity Resource Program for Rural Texas 542
System Redesign for Delivery of Medicaid Acute Care Services and Long-term Services and Supports to Individuals with an Intellectual or Developmental Disability 543
Clinical Initiatives to Improve Medicaid Quality of Care and Cost-effectiveness 543A
Quality-based Outcomes and Payments Under Medicaid and Child Health Plan Program 544
Fraud, Waste, Abuse, and Overcharges Relating to Health and Human Services 545
Certain Public Assistance Benefits 546
Long-term Care and Support Options for Individuals with Disabilities and Elderly Individuals 547
Mental Health and Substance Use Services 547A
Community Collaboratives 548
Health Care Services Provided Through Tele-connective Means 549
Provision of Drugs and Drug Information 550
Human Services and Other Social Services Provided Through Faith- and Community-based Organizations
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 533.0131’s source at texas​.gov