Tex. Gov't Code Section 540.0552
Coordination of Benefits; Continuity of Specialty Care for Certain Recipients


(a)

In this section, “Medicaid wrap-around benefit” means a Medicaid-covered service, including a pharmacy or medical benefit, that is provided to a recipient who has primary health benefit plan coverage in addition to Medicaid coverage when:

(1)

the recipient has exceeded the primary health benefit plan coverage limit; or

(2)

the service is not covered by the primary health benefit plan issuer.

(b)

The commission, in coordination with Medicaid managed care organizations and in consultation with the STAR Kids Managed Care Advisory Committee, shall develop and adopt a clear policy for a Medicaid managed care organization to ensure the coordination and timely delivery of Medicaid wrap-around benefits for recipients who have primary health benefit plan coverage in addition to Medicaid coverage. In developing the policy, the commission shall consider requiring a Medicaid managed care organization to allow, notwithstanding Subchapter F, Chapter 549 (Provision of Drugs and Drug Information), Section 540.0273 (Outpatient Pharmacy Benefit Plan), and Section 540.0280 (Pharmacy Benefit Plan: Pharmacy Benefits for Child Enrolled in Star Kids Managed Care Program) or any other law, a recipient using a prescription drug for which the recipient’s primary health benefit plan issuer previously provided coverage to continue receiving the prescription drug without requiring additional prior authorization.

(c)

If the commission determines that a recipient’s primary health benefit plan issuer should have been the primary payor of a claim, the Medicaid managed care organization that paid the claim shall:

(1)

work with the commission on the recovery process; and

(2)

make every attempt to reduce health care provider and recipient abrasion.

(d)

The executive commissioner may seek a waiver from the federal government as needed to:

(1)

address federal policies related to coordination of benefits and third-party liability; and

(2)

maximize federal financial participation for recipients who have primary health benefit plan coverage in addition to Medicaid coverage.

(e)

The commission may include in the Medicaid managed care eligibility files an indication of whether a recipient has primary health benefit plan coverage or is enrolled in a group health benefit plan for which the commission provides premium assistance under the health insurance premium payment program. For a recipient with that coverage or for whom that premium assistance is provided, the files may include the following up-to-date, accurate information related to primary health benefit plan coverage to the extent the information is available to the commission:

(1)

the primary health benefit plan issuer’s name and address;

(2)

the recipient’s policy number;

(3)

the primary health benefit plan coverage start and end dates; and

(4)

the primary health benefit plan coverage benefits, limits, copayment, and coinsurance information.

(f)

To the extent allowed by federal law, the commission shall maintain processes and policies to allow a health care provider who is primarily providing services to a recipient through primary health benefit plan coverage to receive Medicaid reimbursement for services ordered, referred, or prescribed, regardless of whether the provider is enrolled as a Medicaid provider. The commission shall allow a provider who is not enrolled as a Medicaid provider to order, refer, or prescribe services to a recipient based on the provider’s national provider identifier number and may not require an additional state provider identifier number to receive reimbursement for the services. The commission may seek a waiver of Medicaid provider enrollment requirements for providers of recipients with primary health benefit plan coverage to implement this subsection.

(g)

The commission shall develop a clear and easy process, to be implemented through a contract, that allows a recipient with complex medical needs who has established a relationship with a specialty provider to continue receiving care from that provider, regardless of whether the recipient has primary health benefit plan coverage in addition to Medicaid coverage.

(h)

If a recipient who has complex medical needs wants to continue to receive care from a specialty provider that is not in the provider network of the Medicaid managed care organization offering the Medicaid managed care plan in which the recipient is enrolled, the organization shall develop a simple, timely, and efficient process to, and shall make a good-faith effort to, negotiate a single-case agreement with the specialty provider. Until the organization and the specialty provider enter into the single-case agreement, the specialty provider shall be reimbursed in accordance with the applicable reimbursement methodology specified in commission rules, including 1 T.A.C. Section 353.4.

(i)

A single-case agreement entered into under this section is not considered accessing an out-of-network provider for the purposes of Medicaid managed care organization network adequacy requirements.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.

Source: Section 540.0552 — Coordination of Benefits; Continuity of Specialty Care for Certain Recipients, https://statutes.­capitol.­texas.­gov/Docs/GV/htm/GV.­540.­htm#540.­0552 (accessed Jun. 5, 2024).

540.0001
Definitions
540.0051
Purpose and Implementation
540.0052
Recipient Directory
540.0053
Statewide Effort to Promote Medicaid Eligibility Maintenance
540.0054
Provider and Recipient Education Programs
540.0055
Marketing Guidelines
540.0056
Guidelines for Communications with Recipients
540.0057
Coordination of External Oversight Activities
540.0058
Information for Fraud Control
540.0059
Managed Care Clinical Improvement Program
540.0060
Complaint System Guidelines
540.0101
Fiscal Solvency Standards
540.0102
Profit Sharing
540.0103
Treatment of State Taxes in Calculating Experience Rebate or Profit Sharing
540.0151
Definitions
540.0152
Applicability and Construction of Subchapter
540.0153
Overall Strategy for Managing Audit Resources
540.0154
Performance Audit Selection Process and Follow-up
540.0155
Agreed-upon Procedures Engagements and Corrective Action Plans
540.0156
Audits of Pharmacy Benefit Managers
540.0157
Collecting Costs for Audit-related Services
540.0158
Collection Activities Related to Profit Sharing
540.0159
Using Information from External Quality Reviews
540.0160
Security of and Processing Controls over Information Technology Systems
540.0201
Contract Administration Improvement Efforts
540.0202
Public Notice of Request for Contract Applications
540.0203
Certification by Commission
540.0204
Contract Considerations Relating to Managed Care Organizations
540.0205
Contract Considerations Relating to Pharmacy Benefit Managers
540.0206
Mandatory Contracts
540.0207
Contractual Obligations Review
540.0208
Contract Implementation Plan
540.0209
Compliance and Readiness Review
540.0210
Internet Posting of Sanctions Imposed for Contractual Violations
540.0211
Performance Measures and Incentives for Value-based Contracts
540.0212
Monitoring Compliance with Behavioral Health Integration
540.0251
Applicability
540.0252
Accountability to State
540.0253
Capitation Rates
540.0254
Cost Information
540.0255
Fraud Control
540.0256
Recipient Outreach and Education
540.0257
Notice of Medicaid Certification Date
540.0258
Primary Care Provider Assignment
540.0259
Compliance with Provider Network Requirements
540.0260
Compliance with Provider Access Standards
540.0261
Provider Network Sufficiency
540.0262
Quality Monitoring Program for Health Care Services
540.0263
Out-of-network Provider Usage and Reimbursement
540.0264
Provider Reimbursement Rate Reduction
540.0265
Prompt Payment of Claims
540.0266
Reimbursement for Certain Services Provided Outside Regular Business Hours
540.0267
Provider Appeals Process
540.0268
Assistance Resolving Recipient and Provider Issues
540.0269
Use of Advanced Practice Registered Nurses and Physician Assistants
540.0270
Medical Director Availability
540.0271
Personnel Required in Certain Service Regions
540.0272
Certain Services Permitted in Lieu of Other Mental Health or Substance Use Disorder Services
540.0273
Outpatient Pharmacy Benefit Plan
540.0274
Pharmacy Benefit Plan: Rebates and Receipt of Confidential Information Prohibited
540.0275
Pharmacy Benefit Plan: Certain Pharmacy Benefits for Sex Offenders Prohibited
540.0276
Pharmacy Benefit Plan: Recipient Selection of Pharmaceutical Services Provider
540.0277
Pharmacy Benefit Plan: Pharmacy Benefit Providers
540.0278
Pharmacy Benefit Plan: Prompt Payment of Pharmacy Benefit Claims
540.0279
Pharmacy Benefit Plan: Maximum Allowable Cost Price and List for Pharmacy Benefits
540.0280
Pharmacy Benefit Plan: Pharmacy Benefits for Child Enrolled in Star Kids Managed Care Program
540.0301
Inapplicability of Certain Other Law to Medicaid Managed Care Utilization Reviews
540.0302
Prior Authorization Procedures for Hospitalized Recipient
540.0303
Prior Authorization Procedures for Nonhospitalized Recipient
540.0304
Annual Review of Prior Authorization Requirements
540.0305
Physician Consultation Before Adverse Prior Authorization Determination
540.0306
Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests
540.0307
Maximum Period for Prior Authorization Decision
540.0351
Premium Payment Rate Determination
540.0352
Maximum Premium Payment Rates for Certain Programs
540.0353
Use of Encounter Data in Determining Premium Payment Rates and Other Payment Amounts
540.0401
Provider Reporting of Encounter Data
540.0402
Certifier of Encounter Data Qualifications
540.0403
Encounter Data Certification
540.0451
Medicaid Managed Care Plan Accreditation
540.0452
Medical Director Qualifications
540.0501
Recipient Enrollment in and Disenrollment from Medicaid Managed Care Plan
540.0502
Automatic Enrollment in Medicaid Managed Care Plan
540.0503
Enrollment of Certain Recipients in Same Medicaid Managed Care Plan
540.0504
Quality-based Enrollment Incentive Program for Medicaid Managed Care Organizations
540.0505
Limitations on Recipient Disenrollment from Medicaid Managed Care Plan
540.0551
Guidance Regarding Continuation of Services Under Certain Circumstances
540.0552
Coordination of Benefits
540.0601
Monitoring of Provider Networks
540.0602
Report on Out-of-network Provider Services
540.0603
Report on Commission Investigation of Provider Complaint
540.0604
Additional Reimbursement Following Provider Complaint
540.0605
Corrective Action Plan for Inadequate Network and Provider Reimbursement
540.0606
Remedies for Noncompliance with Corrective Action Plan
540.0651
Inclusion of Certain Providers in Medicaid Managed Care Organization Provider Network
540.0652
Provider Access Standards
540.0653
Penalties and Other Remedies for Failure to Comply with Provider Access Standards
540.0654
Provider Network Directories
540.0655
Provider Protection Plan
540.0656
Expedited Credentialing Process for Certain Providers
540.0657
Frequency of Provider Recredentialing
540.0658
Provider Incentives for Promoting Preventive Services
540.0659
Reimbursement Rate for Certain Services Provided by Certain Health Centers and Clinics Outside Regular Business Hours
540.0701
Acute Care Service Delivery Through Most Cost-effective Model
540.0702
Transition of Case Management for Children and Pregnant Women Program Recipients to Medicaid Managed Care Program
540.0703
Behavioral Health and Physical Health Services
540.0704
Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families
540.0705
Behavioral Health Services Provided Through Third Party or Subsidiary
540.0706
Psychotropic Medication Monitoring System for Certain Children
540.0707
Medication Therapy Management
540.0708
Special Disease Management
540.0709
Special Protocols for Indigent Populations
540.0710
Direct Access to Eye Health Care Services
540.0711
Delivery of Benefits Using Telecommunications or Information Technology
540.0712
Promotion and Principles of Patient-centered Medical Home
540.0713
Value-added Services
540.0751
Delivery of Acute Care Services and Long-term Services and Supports
540.0752
Delivery of Medicaid Benefits to Nursing Facility Residents
540.0753
Delivery of Basic Attendant and Habilitation Services
540.0754
Evaluation of Certain Program Services
540.0755
Utilization Review
540.0801
Trauma-informed Care Training
540.0802
Mental Health Providers
540.0803
Health Screening Requirements and Compliance with Texas Health Steps
540.0804
Health Care and Other Services for Children in Substitute Care
540.0805
Placement Change Notice and Care Coordination
540.0806
Medicaid Benefits for Certain Children Formerly in Foster Care
540.0851
Star Kids Managed Care Program
540.0852
Care Management and Care Needs Assessment
540.0855
Utilization Review of Prior Authorizations

Accessed:
Jun. 5, 2024

§ 540.0552’s source at texas​.gov