Tex.
Gov't Code Section 540.0752
Delivery of Medicaid Benefits to Nursing Facility Residents
(a)
In this section:(1)
“Clean claim” means a claim that meets the same criteria the commission uses for a clean claim in reimbursing nursing facility claims.(2)
“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.(b)
Subject to Section 540.0701 (Acute Care Service Delivery Through Most Cost-effective Model; Managed Care Service Delivery Areas) and notwithstanding any other law, the commission shall provide Medicaid benefits through the STAR+PLUS Medicaid managed care program to recipients who reside in nursing facilities. In implementing this subsection, the commission shall ensure that:(1)
a nursing facility is paid not later than the 10th day after the date the facility submits a clean claim;(2)
services are used appropriately, consistent with criteria the commission establishes;(3)
the incidence of potentially preventable events and unnecessary institutionalizations is reduced;(4)
a Medicaid managed care organization providing services under the program:(A)
provides discharge planning, transitional care, and other education programs to physicians and hospitals regarding all available long-term care settings;(B)
assists in collecting applied income from recipients; and(C)
provides payment incentives to nursing facility providers that:(i)
reward reductions in preventable acute care costs; and(ii)
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;(5)
a portal is established that complies with state and federal regulations, including standard coding requirements, through which nursing facility providers participating in the program may submit claims to any participating Medicaid managed care organization;(6)
rules and procedures relating to certifying and decertifying nursing facility beds under Medicaid are not affected;(7)
a Medicaid managed care organization providing services under the 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(8)
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 program.(c)
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 Medicaid managed care organization may refuse to contract with a nursing facility provider if the nursing facility does not meet the minimum performance standards the commission establishes under this section.(d)
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.(e)
A managed care organization may not require prior authorization for a nursing facility resident in need of emergency hospital services.
Source:
Section 540.0752 — Delivery of Medicaid Benefits to Nursing Facility Residents, https://statutes.capitol.texas.gov/Docs/GV/htm/GV.540.htm#540.0752 (accessed Jun. 5, 2024).
