Title GV, Government Code

Sec. 532.0451. HOSPITAL EMERGENCY ROOM USE REDUCTION INITIATIVES. (a) The commission shall develop and implement a comprehensive plan to reduce recipients' use of hospital emergency room services. The plan may include: (1) a pilot program that is designed to assist a program part…

Sec. 532.0452. PHYSICIAN INCENTIVE PROGRAM TO REDUCE HOSPITAL EMERGENCY ROOM USE FOR NON-EMERGENT CONDITIONS. (a) If cost-effective, the executive commissioner by rule shall establish a physician incentive program designed to reduce recipients' use of hospital emergency room serv…

Sec. 532.0453. CONTINUED IMPLEMENTATION OF CERTAIN INTERVENTIONS AND BEST PRACTICES BY PROVIDERS; BIENNIAL REPORT. (a) The commission shall encourage Medicaid providers to continue implementing effective interventions and best practices associated with improvements in the health …

Sec. 532.0454. HEALTH SAVINGS ACCOUNT PILOT PROGRAM. (a) If the commission determines that it is cost-effective and feasible, the commission shall develop and implement a Medicaid health savings account pilot program that is consistent with federal law to: (1) encourage adult rec…

Sec. 532.0455. DURABLE MEDICAL EQUIPMENT REUSE PROGRAM. (a) In this section: (1) "Complex rehabilitation technology equipment": (A) means equipment that is: (i) classified as durable medical equipment under the Medicare program on January 1, 2013; (ii) configured specifically for…

Sec. 532.0501. DEFINITIONS. In this subchapter: (1) "Case management for children and pregnant women program" means the "children and pregnant women program," as defined by Section 540.0702. (2) "Nonmedical health-related needs screening" means a screening performed using the sta…

Sec. 532.0502. MEDICAID MANAGED CARE ORGANIZATION SERVICE COORDINATION BENEFITS NOT AFFECTED. The provision of program services to a recipient does not preempt or otherwise affect a Medicaid managed care organization's obligation to provide service coordination benefits to the re…

Sec. 532.0503. CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN PROGRAM: PROVIDER QUALIFICATIONS. Program services may be provided only by a provider who completes the standardized case management training required by the commission under Section 532.0504 and who is: (1) an advanc…

Sec. 532.0504. CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN PROGRAM: PROVIDER TRAINING. The commission shall require that each provider of program services complete training prescribed by the commission. The training must be trauma-informed and include instruction on: (1) soci…

Sec. 532.0505. INITIAL MEDICAL AND NONMEDICAL HEALTH-RELATED SCREENINGS OF CERTAIN RECIPIENTS. (a) A Medicaid managed care organization that provides health care services to a pregnant woman under the STAR Medicaid managed care program shall conduct an initial health needs screen…

Sec. 532.0506. SCREENING AND PROGRAM SERVICES OPTIONAL. A Medicaid managed care organization providing screenings under Section 532.0505 must inform each pregnant woman who is referred for program services or for whom screening is conducted under that section that: (1) the woman …

Sec. 540.0001. DEFINITIONS. In this chapter: (1) Notwithstanding Section 521.0001(2), "commission" means the Health and Human Services Commission or an agency operating part of the Medicaid managed care program, as appropriate. (2) "Health care service region" or "region" means a…

Sec. 540.0051. PURPOSE AND IMPLEMENTATION. The commission shall implement the Medicaid managed care program by contracting with managed care organizations in a manner that, to the extent possible: (1) improves the health of Texans by: (A) emphasizing prevention; (B) promoting con…

Sec. 540.0052. RECIPIENT DIRECTORY. The commission shall, in accordance with a single source of truth design: (1) maintain an accurate electronic directory of contact information for each recipient enrolled in a Medicaid managed care plan offered by a managed care organization, i…

Sec. 540.0053. STATEWIDE EFFORT TO PROMOTE MEDICAID ELIGIBILITY MAINTENANCE. (a) The commission shall develop and implement a statewide effort to assist recipients who satisfy Medicaid eligibility requirements and who receive Medicaid services through a Medicaid managed care orga…

Sec. 540.0054. PROVIDER AND RECIPIENT EDUCATION PROGRAMS. (a) In adopting rules to implement a Medicaid managed care program, the executive commissioner shall establish guidelines for, and require Medicaid managed care organizations to provide, education programs for providers an…

Sec. 540.0055. MARKETING GUIDELINES. (a) The commission shall establish marketing guidelines for Medicaid managed care organizations, including guidelines that prohibit: (1) door-to-door marketing to a recipient by a Medicaid managed care organization or the organization's agent;…

Sec. 540.0056. GUIDELINES FOR COMMUNICATIONS WITH RECIPIENTS. (a) The executive commissioner shall adopt and publish guidelines for Medicaid managed care organizations regarding how an organization may communicate by telephone, text message, or e-mail with a recipient enrolled in…

Sec. 540.0057. COORDINATION OF EXTERNAL OVERSIGHT ACTIVITIES. (a) To the extent possible, the commission shall coordinate all external oversight activities to minimize duplicating oversight of Medicaid managed care plans and disrupting operations under those plans. (b) The execut…

Sec. 540.0058. INFORMATION FOR FRAUD CONTROL. (a) Each Medicaid managed care organization shall submit at no cost to the commission and, on request, the office of the attorney general: (1) a description of any financial or other business relationship between the organization and …

Sec. 540.0059. MANAGED CARE CLINICAL IMPROVEMENT PROGRAM. (a) In consultation with appropriate stakeholders with an interest in the provision of acute care services and long-term services and supports under the Medicaid managed care program, the commission shall: (1) establish a …

Sec. 540.0060. COMPLAINT SYSTEM GUIDELINES. (a) The Texas Department of Insurance, in conjunction with the commission, shall establish complaint system guidelines for Medicaid managed care organizations. (b) The guidelines must require that information regarding a Medicaid manage…

Sec. 540.0101. FISCAL SOLVENCY STANDARDS. The Texas Department of Insurance, in conjunction with the commission, shall establish fiscal solvency standards for Medicaid managed care organizations. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2…

Sec. 540.0102. PROFIT SHARING. (a) The executive commissioner shall adopt rules regarding the sharing of profits earned by a Medicaid managed care organization through a Medicaid managed care plan. (b) Except as provided by Subsection (c), any amount this state receives under thi…

Sec. 540.0103. TREATMENT OF STATE TAXES IN CALCULATING EXPERIENCE REBATE OR PROFIT SHARING. The commission shall ensure that any experience rebate or profit sharing for Medicaid managed care organizations is calculated by treating premium, maintenance, and other taxes under the I…

Sec. 540.0104. TREATMENT AS QUALITY IMPROVEMENT COST OF CERTAIN SERVICES PROVIDED BY COMMUNITY HEALTH WORKERS. (a) In this section, "community health worker" has the meaning assigned by Section 48.001, Health and Safety Code. (b) The commission shall allow each Medicaid managed c…

Sec. 540.0151. DEFINITIONS. In this subchapter: (1) "Accounts receivable tracking system" means the system the commission uses to track experience rebates and other payments collected from managed care organizations. (2) "Agreed-upon procedures engagement" means an evaluation of …

Sec. 540.0152. APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER. This subchapter does not apply to and may not be construed as affecting the conduct of audits by the commission's office of inspector general under the authority provided by Subchapter C, Chapter 544, including an audit…

Sec. 540.0153. OVERALL STRATEGY FOR MANAGING AUDIT RESOURCES. The commission shall develop and implement an overall strategy for planning, managing, and coordinating audit resources that the commission uses to verify the accuracy and reliability of program and financial informati…

Sec. 540.0154. PERFORMANCE AUDIT SELECTION PROCESS AND FOLLOW-UP. (a) To improve the commission's processes for performance audits of managed care organizations, the commission shall: (1) document the process by which the commission selects organizations to audit; (2) include pre…

Sec. 540.0155. AGREED-UPON PROCEDURES ENGAGEMENTS AND CORRECTIVE ACTION PLANS. To enhance the commission's use of agreed-upon procedures engagements to identify managed care organizations' performance and compliance issues, the commission shall: (1) ensure that financial risks id…

Sec. 540.0156. AUDITS OF PHARMACY BENEFIT MANAGERS. To obtain greater assurance about the effectiveness of pharmacy benefit managers' internal controls and compliance with state requirements, the commission shall: (1) periodically audit each pharmacy benefit manager that contract…

Sec. 540.0157. COLLECTING COSTS FOR AUDIT-RELATED SERVICES. The commission shall develop, document, and implement billing processes in the commission's Medicaid and CHIP services department to ensure that managed care organizations reimburse the commission for audit-related servi…

Sec. 540.0158. COLLECTION ACTIVITIES RELATED TO PROFIT SHARING. To strengthen the commission's process for collecting shared profits from managed care organizations, the commission shall develop, document, and implement monitoring processes in the commission's Medicaid and CHIP s…

Sec. 540.0159. USING INFORMATION FROM EXTERNAL QUALITY REVIEWS. (a) To enhance the commission's monitoring of managed care organizations, the commission shall use the information provided by the external quality review organization, including: (1) detailed data from results of su…

Sec. 540.0160. SECURITY OF AND PROCESSING CONTROLS OVER INFORMATION TECHNOLOGY SYSTEMS. The commission shall: (1) strengthen user access controls for the commission's accounts receivable tracking system and network folders that the commission uses to manage the collection of expe…

Sec. 540.0201. CONTRACT ADMINISTRATION IMPROVEMENT EFFORTS. The commission shall make every effort to improve the administration of contracts with managed care organizations. To improve contract administration, the commission shall: (1) ensure that the commission has appropriate …

Sec. 540.0202. PUBLIC NOTICE OF REQUEST FOR CONTRACT APPLICATIONS. Not later than the 30th day before the date the commission plans to issue a request for applications to enter into a contract with the commission to provide health care services to recipients in a region, the comm…

Sec. 540.0203. CERTIFICATION BY COMMISSION. (a) Before the commission may award a contract under this chapter to a managed care organization, the commission shall evaluate and certify that the organization is reasonably able to fulfill the contract terms, including all federal an…

Sec. 540.0204. CONTRACT CONSIDERATIONS RELATING TO MANAGED CARE ORGANIZATIONS. In awarding contracts to managed care organizations, the commission shall: (1) give preference to an organization that has significant participation in the organization's provider network from each hea…

Sec. 540.0205. CONTRACT CONSIDERATIONS RELATING TO PHARMACY BENEFIT MANAGERS. In considering approval of a subcontract between a managed care organization and a pharmacy benefit manager to provide Medicaid prescription drug benefits, the commission shall review and consider wheth…

Sec. 540.0206. MANDATORY CONTRACTS. (a) Subject to the certification required under Section 540.0203 and the considerations required under Section 540.0204, in providing health care services through Medicaid managed care to recipients in a health care service region, the commissi…

Sec. 540.0207. CONTRACTUAL OBLIGATIONS REVIEW. The commission shall review each Medicaid managed care organization to determine whether the organization is prepared to meet the organization's contractual obligations. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. …

Sec. 540.0208. CONTRACT IMPLEMENTATION PLAN. (a) Each Medicaid managed care organization that contracts to provide health care services to recipients in a health care service region shall submit an implementation plan not later than the 90th day before the date the organization p…

Sec. 540.0209. COMPLIANCE AND READINESS REVIEW. (a) The commission shall conduct a compliance and readiness review of each Medicaid managed care organization: (1) not later than the 15th day before the date the process of enrolling recipients in a managed care plan the organizati…

Sec. 540.0210. INTERNET POSTING OF SANCTIONS IMPOSED FOR CONTRACTUAL VIOLATIONS. (a) The commission shall prepare and maintain a record of each enforcement action the commission initiates that results in a sanction, including a penalty, being imposed against a managed care organi…