Part 15.
TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353.
MEDICAID MANAGED CARE
The Health and Human Services Commission (HHSC) proposes to amend
Medicaid Managed Care rules Subchapter A, §§353.1 - 353.3, Subchapter
B, §§353.102- 353.105, and Subchapter E, §§353.402, 353.403,
353.405, 353.407, 353.409, 353.411, 353.413, 353.415, 353.417 and 353.419.
The proposed rule change would accommodate a new voluntary managed care model
for rural areas, sponsored by the Statewide Rural Health Care System, also
known as the Rural Community Health System (RCHS). In 1997, the Texas Legislature
adopted Senate Bill 1246, allowing the creation of the statewide RCHS to provide
health care services in rural areas. During the 77th Legislative Session,
Senate Bill 1394 was adopted, authorizing HHSC to use the RCHS for a voluntary
pilot or demonstration program for the Medicaid Program. HHSC plans to implement
the pilot in a multi-county area in the Texas Panhandle.
The proposed rule change would allow a default to the RCHS Managed Care
Organization (MCO) without assignment to a primary care physician (PCP). In
the pilot, members who fail to select the RCHS MCO or the fee-for-service
option during the period established by HHSC would be defaulted to the RCHS
MCO. The proposed rule change would also permit HHSC to allow an exemption
from the restriction against direct contact marketing. Since RCHS MCO will
be the only health plan in the pilot area and therefore not competing with
other health plans, this restriction may not be necessary. For the pilot,
RCHS will partner with a health insurance company rather than a Health Maintenance
Organization (HMO). The proposed rule would therefore expand the financial
standards to include a solvency provision applicable for health insurance
companies. It would also require the RCHS MCO to participate in experience
rebates, just as all HMOs participating in the Medicaid Managed Care program
must do. Finally, the proposed rule would revise outdated language, such as
references to "TDH" instead of "HHSC" as the Medicaid operating agency.
Tom Suehs, Deputy Commissioner of Financial Services, has determined that,
during the first five years that the proposed rule is in effect, the fiscal
impact will be as follows: start-up systems costs are estimated to total $234,600
for all funds while systems changes, enrollment broker services, and ongoing
enrollment broker services are estimated to total $293,786 for all funds for
SFY 04. Savings attributed to the pilot are estimated to total $606,620 for
all funds in SFY 03 and $3,639,718 for all funds in SFY 04. The savings achieved
under this program may be overstated because not all HHSC administrative costs
to support the managed care program are included. The contract period for
the pilot is July 1, 2003, through August 31, 2004.There is no anticipated
fiscal impact on local health and human service agencies. Local governments
will not incur additional costs.
Mr. Suehs has also determined that for each year of the first five years
the proposed rule is in effect, the public will benefit from adoption of the
rule. The anticipated public benefit will be increased choice for Medicaid
clients in their health care delivery.
The proposed rule will not result in additional costs to persons required
to comply with the proposed rule, nor does the proposed rule have any anticipated
adverse affect on small or micro-businesses. RCHS plans to reimburse providers
at Medicaid fee-for-service rates. The proposed rule will not negatively affect
local employment.
HHSC has determined that the proposed rule is not a "major environmental
rule" as defined by §2001.0225, Government Code. "Major environmental
rule" is defined to mean a rule the specific intent of which is to protect
the environment or reduce risks to human health from environmental exposure
and that may adversely affect in a material way the economy, a sector of the
economy, productivity, competition, jobs, the environment, or the public health
and safety of the state or a sector of the state. The proposed rule is not
specifically intended to protect the environment or reduce risks to human
health from environmental exposure.
HHSC has evaluated the takings impact of the proposed rule under §2007.043,
Government Code. HHSC has determined that this proposal does not restrict
or limit an owner's right to his or her property that would otherwise exist
in the absence of governmental action and therefore does not constitute a
taking. The proposed rule is reasonably taken to fulfill requirements of state
law.
Comments on the proposal may be submitted in writing to Kay Ghahremani,
Medicaid/CHIP Division, Texas Health and Human Services Commission, 1100 W.
49th Street, MC H-310, Austin, Texas 78756-3199, or by e-mail to kay.ghahremani@hhsc.state.tx.us
within the 30 days following publication of this proposal in the
Texas Register
.
A public hearing is scheduled for April 9, 2003, from 10 a.m. to 11:30
a.m. The hearing will be held in the Big Bend Conference Room, Health and
Human Services Commission, 12555 Riata Vista Circle, Bldg. #3, Austin, Texas
78727.
Subchapter A. GENERAL PROVISIONS
1 TAC §§353.1 - 353.3
The amendments are proposed under the authority granted to
HHSC by Government Code §531.033, which provides the Commissioner of
HHSC with broad rulemaking authority, and under the Human Resources Code §32.021,
and the Government Code §531.021(a), which provide HHSC with the authority
to administer the federal medical assistance (Medicaid) program in Texas.
The proposed amendments affect Chapter 531 of the Government Code and Chapter
32 of the Human Resources Code. No other statutes, articles, or codes are
affected by the proposed rule.
§353.1.Rules of Other Agencies.
These rules shall be read in conjunction with rules adopted by other
state agencies charged with operation of the state's Medicaid managed care
program, including [
§353.2.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the content clearly indicates otherwise.
(1)
Behavioral health services--Allowable services for the
treatment of mental or emotional disorders and treatment of chemical dependency
disorders.
(2)
Client--Any Medicaid eligible recipient and, where the
context indicates, a Medicaid eligible recipient who meets the qualifications
for enrollment in Medicaid managed care. See also "member."
(3)
Complaint--Any dissatisfaction, expressed by a complainant
orally or in writing to the managed care organization (MCO), with any aspect
of the MCO's operation, including but not limited to dissatisfaction with
plan administration; the denial, reduction or termination of a service; the
way a service is provided; or disenrollment decisions expressed by a complainant.
A complaint is not a misunderstanding or misinformation that is resolved informally
by supplying the appropriate information for clearing up the misunderstanding
to the satisfaction of the member.
(4)
Health care services--Physical medicine, behavioral health
care and health-related services.
(5)
HHSC--The Texas Health and Human Services Commission.
(6)
MCO--Managed care organization. An entity which has a current
Texas Department of Insurance certificate of authority to operate as a health
maintenance organization under Texas Insurance Code, Article 20A, or as an
approved nonprofit health corporation under Texas Insurance Code, Article
21.52F
, or an organization sponsored by the Statewide Rural Health Care
System, established by the Texas Insurance Code, Chapter 20C
.
(7)
Medical home--A primary care provider who has accepted
the responsibility for providing accessible, continuous, comprehensive and
coordinated care to members participating in the state's Medicaid managed
care program.
(8)
Member--Any eligible Medicaid recipient who is enrolled
in the state's Medicaid managed care program.
(9)
Member education program--A planned program of education:
(A)
regarding access to health care through the managed care
organization and about specific health topics;
(B)
that is approved by the
Health and Human Services
Commission;
[
(C)
is provided to members through a variety of mechanisms
which must include, at a minimum, written materials and face-to-face or audiovisual
communications.
(10)
Primary care provider--An individual who has agreed with
the state or an MCO to provide a medical home for members.
(11)
Provider--An individual or entity and its employees and
contractors that provide health care services to members under the state's
Medicaid managed care program.
(12)
Provider education program--Program of education about
the Medicaid managed care program and about specific health care issues presented
by the managed care organization to its providers through written materials
and training events.
(13)
Statewide Rural Health Care
System- A quasi-governmental nonprofit organization authorized to sponsor,
provide, or arrange for the provision of health care services in rural areas
under the Texas Insurance Code, Chapter 20C.
(14)
[
§353.3.Experience Rebate in the STAR and STAR+Plus Programs.
(a)
Each health maintenance organization (HMO)
and the
Statewide Rural Health Care System
participating in the State of Texas
Access Reform (STAR) and the State of Texas Access Reform Plus (STAR+Plus)
program must pay to the state an experience rebate calculated according to
the graduated rebate method described in subsection (b) of this section. The
experience rebate is based on the excess of allowable HMO
or Statewide
Rural Health Care System
revenues, as defined by the state, over allowable
HMO
or Statewide Rural Health Care System
expenses, as defined
by the state, as reviewed and confirmed by the state.
(b)
The graduated rebate method is as follows:
(1)
The HMO
or Statewide Rural Health Care System
retains
100 percent of that portion of excess allowable revenues that falls between
zero and less than or equal to three percent of total allowable revenues.
(2)
The HMO
or Statewide Rural Health Care System
retains
75 percent of that portion of excess allowable revenues that falls between
three percent and less than or equal to seven percent of total allowable revenues.
The remaining 25 percent is paid to the state.
(3)
The HMO
or Statewide Rural Health Care System
retains
50 percent of that portion of excess allowable revenues that falls between
seven percent but less than or equal to 10 percent of total allowable revenues.
The remaining 50 percent is paid to the state.
(4)
The HMO
or Statewide Rural Health Care System
retains
25 percent of that portion of excess allowable revenues that falls between
10 percent but less than or equal to 15 percent of total allowable revenues.
The remaining 75 percent is paid to the state.
(5)
The HMO
or Statewide Rural Health Care System
pays
to the state 100 percent of that portion of excess allowable revenues that
is greater than 15 percent of total allowable revenues.
(c)
The experience rebate is based on a pre-tax basis.
(d)
Losses incurred for one contract period can only be carried
forward to the next contract period.
(e)
There are two settlements for payment of the experience
rebate and will be paid by the HMO
or Statewide Rural Health Care System
to the state as prescribed by the state. The state reserves the right
to make corrections to the settlements based on an audit/review by the state
or other documentation acceptable to the state. The state may also adjust
the experience rebate if the state determines that the HMO
or Statewide
Rural Health Care System
paid affiliates amounts for goods or services
that are higher than the fair market value of the goods and services in the
service area.
(f)
The state has the final authority in assessing the amount
of the experience rebate.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on March 10, 2003.
TRD-200301651
Steve Aragon
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 20, 2003
For further information, please call: (512) 424-6756
1 TAC §§353.102 - 353.105
The amendments are proposed under the authority granted to
HHSC by Government Code §531.033, which provides the Commissioner of
HHSC with broad rulemaking authority, and under the Human Resources Code §32.021,
and the Government Code §531.021(a), which provide HHSC with the authority
to administer the federal medical assistance (Medicaid) program in Texas.
The proposed amendments affect Chapter 531 of the Government Code and Chapter
32 of the Human Resources Code. No other statutes, articles, or codes are
affected by the proposed rule.
§353.102.Provider and Member Education Programs Generally.
The managed care organizations that contract with the
Health and
Human Services Commission
[
§353.103.Contract Compliance.
Managed care organizations shall comply with all terms of their contract
with the
Health and Human Services Commission
[
§353.104.Member Education Program.
A member education program must present information in a manner that
is easy to understand. In addition to any requirements specified in the contract
between the managed care organization and the
Health and Human Services
Commission,
[
(1)
a member's rights and responsibilities under the bill of
rights and the bill of responsibilities prescribed by this chapter;
(2)
how to access health care services, including how to access
behavioral health services;
(3)
how to access complaint procedures and the member's right
to bypass the managed care organization's internal complaint system and use
the notice and appeal procedures otherwise provided by the Medicaid program;
(4)
Medicaid policies, procedures, eligibility standards, and
benefits;
(5)
the policies and procedures of the managed care organization;
and
(6)
the importance of prevention, early intervention and appropriate
use of services.
§353.105.Provider Education Program.
In addition to any requirements specified in the contract between the
managed care organization and the
Health and Human Services Commission,
[
(1)
Medicaid policies, procedures, eligibility standards and
benefits;
(2)
the specific problems and needs of Medicaid clients;
(3)
screening, identification and referral processes for coordinating
behavioral health and other health care services; and
(4)
the rights and responsibilities of members under the bill
of rights and the bill of responsibilities prescribed by this section.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed
with the Office of the Secretary of State on March 10, 2003.
TRD-200301652
Steve Aragon
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 20, 2003
For further information, please call: (512) 424-6756
1 TAC §§353.402, 353.403, 353.405, 353.407, 353.409, 353.411, 353.413, 353.415, 353.417, 353.419
The amendments are proposed under the authority granted to
HHSC by Government Code §531.033, which provides the Commissioner of
HHSC with broad rulemaking authority, and under the Human Resources Code §32.021,
and the Government Code §531.021(a), which provide HHSC with the authority
to administer the federal medical assistance (Medicaid) program in Texas.
The proposed amendments affect Chapter 531 of the Government Code and Chapter
32 of the Human Resources Code. No other statutes, articles, or codes are
affected by the proposed rule.
§353.402.Definitions.
The following words and terms, when used in this subchapter, shall
have the following meanings unless the context clearly indicates otherwise.
(1)
Behavioral health services--Allowable services for the
treatment of mental or emotional disorders and treatment of chemical dependency
disorders.
(2)
Chronic or complex condition--A physical or developmental
condition which may have no known cure and/or is progressive and/or can be
debilitating or fatal if left untreated or under-treated.
(3)
Client--Any Medicaid eligible recipient and, where the
context indicates, a Medicaid eligible recipient who meets the qualifications
for enrollment in Medicaid managed care. See also "member."
(4)
Commission--The Texas Health and Human Services Commission.
(5)
CMS-The Centers for Medicare &
Medicaid Services, the federal agency charged with oversight of all states
participating in the Medicaid program.
(6)
[
(7)
[
(8)
[
(9)
[
(10)
[
[
(11)
Disability--A physical or mental impairment that substantially
limits one or more of the major life activities of an individual.
(12)
Elective enrollment--Selection of a PCP and MCO by a client
during the enrollment period established by the
Commission
[
(13)
Emergency behavioral health condition--Any condition,
without regard to the nature or cause of the condition, which requires immediate
intervention and/or medical attention without which members would present
an immediate danger to themselves or others or which renders members incapable
of controlling, knowing or understanding the consequences of their actions.
(14)
Emergency behavioral health services--Inpatient or outpatient
behavioral health services provided in response to an emergency behavioral
health condition.
(15)
Emergency care--Physical medicine, emergency behavioral
health services and health-related services provided in response to any condition
requiring immediate intervention and/or medical treatment, including emergency
labor and delivery and any medical condition manifesting itself by acute symptoms
of sufficient severity, including severe pain, such that the absence of immediate
medical attention could reasonably be expected to result in:
(A)
placing the patient's health in serious jeopardy;
(B)
serious impairment to bodily functions;
(C)
serious dysfunction of any bodily organ or part; or
(D)
an emergency behavioral health condition.
(16)
EPSDT--The federally mandated Early and Periodic Screening,
Diagnosis and Treatment program contained at 42 United States Code 1396d(r).
(See definition for Texas Health Steps.) The name has been changed to Texas
Health Steps in the state of Texas.
(17)
EPSDT-CCP--The Early and Periodic Screening, Diagnosis
and Treatment-Comprehensive Care Program, under which the
Commission
[
(18)
Federal waiver--Any waiver permitted under federal law
which allows states to implement Medicaid managed care, in accordance with
a waiver from compliance with federal law, approved by the federal government.
Federal waivers include a §1915(b) waiver, §1115 waiver, or any
other allowable waiver of federal law which would enable the state to implement
Medicaid managed care.
[
(19)
[
(20)
[
(21)
[
(22)
[
(23)
[
(24)
[
(25)
[
(26)
[
(27)
[
(28)
[
(A)
are reasonably necessary for the diagnosis or treatment
of a mental health or chemical dependency disorder or to improve or to maintain
or to prevent deterioration of functioning resulting from such a disorder;
(B)
are in accordance with professionally accepted clinical
guidelines and standards of practice in behavioral health care;
(C)
are furnished in the most appropriate and least restrictive
setting in which services can be safely provided;
(D)
are the most appropriate level or supply of service which
can safely be provided; and
(E)
could not have been omitted without adversely affecting
the member's mental and/or physical health or the quality of care rendered.
(29)
[
(A)
reasonably necessary to prevent illnesses or medical conditions,
or provide early screening, interventions, and/or treatments for conditions
that cause suffering or pain, cause physical deformity or limitations in function,
threaten to cause or worsen a handicap, cause illness or infirmity of a member,
or endanger life;
(B)
provided at appropriate facilities and at the appropriate
levels of care for the treatment of members' medical conditions;
(C)
consistent with health care practice guidelines and standards
that are issued by professionally recognized health care organizations or
governmental agencies;
(D)
consistent with the diagnoses of the conditions; and
(E)
no more intrusive or restrictive than necessary to provide
a proper balance of safety, effectiveness, and efficiency.
(30)
[
(31)
[
(32)
[
(33)
[
(34)
[
(35)
[
(36)
[
(37)
Statewide Rural Health Care
System- A quasi-governmental nonprofit organization authorized to sponsor,
provide, or arrange for the provision of health care services in rural areas
under the Texas Insurance Code, Chapter 20C.
(38)
Significant traditional provider--A provider with whom
Medicaid recipients have well-established or longstanding provider/client
relationships, or to whom the recipients have typically or traditionally gone
for health care, emergency care or family planning advice. A provider falling
within this definition shall be determined by criteria established by the
[
(39)
[
(A)
offers services, facilities, and beds for use for more
than 24 hours for two or more unrelated individuals who are regularly admitted,
treated, and discharged and who require services more intensive than room,
board, personal services, and general nursing care;
(B)
has clinical laboratory facilities, diagnostic X-ray facilities,
treatment facilities, or other definitive medical treatment;
(C)
has a medical staff in regular attendance; and
(D)
maintains records of the clinical work performed for each
patient.
(40)
[
(41)
[
(42)
[
§353.403.Enrollment.
(a)
For the purposes of this section, a managed care organization
(MCO) includes a primary care case management (PCCM) provider network.
(b)
The
Commission
[
(c)
The
Commission
[
(d)
The
Commission
[
(e)
Members who are voluntary members
in a service delivery area in which the Statewide Rural Health Care System
MCO is the only participating MCO must select the Statewide Rural Health Care
System MCO or fee-for-service. Members who fail to select the Statewide Rural
Health Care System MCO or fee-for-service during the enrollment period established
by the Commission will be defaulted to the Statewide Rural Health Care System
MCO.
(f)
[
(1)
A member who does not select a PCP and MCO will be assigned
a PCP and MCO through the default process established by the
Commission
[
(2)
Each member, who has not selected a PCP, will be defaulted
to the PCP with whom there is the most recent Medicaid managed care encounter
history. The number of encounters between the member and the PCP may also
be considered.
(3)
If there is no Medicaid managed care encounter history,
each member will be defaulted to the PCP with whom there is the most recent
traditional Medicaid claims history. The number of prior encounters between
the member and the PCP may also be considered.
(4)
If a member does not have history with a PCP, the member
will be defaulted to a PCP on the basis of geographical proximity to the PCP.
(5)
The
Commission
[
(6)
The
Commission
[
(7)
Members who cannot be assigned to a PCP and MCO on the
basis of an automated default process may be assigned through a manual default
process determined by the
Commission
[
(8)
Members with special medical needs may be defaulted on
the basis of a manual default methodology if such members can be identified
and if the automated default process cannot be administered for such members.
(9)
A member who is defaulted to a PCP who is contracted with
only one MCO shall be assigned to that MCO.
(10)
PCP restrictions on client age, gender, and capacity shall
be considered as limitations to default assignments to PCPs.
(11)
Family members shall be defaulted to the same PCP and
MCO to the maximum extent possible within the limitation of PCP restrictions
on client age, gender, and capacity by MCO as well as geographical proximity
considerations.
(12)
The detailed default methodology developed by the
Commission
[
(A)
If a member is defaulted to a PCP who is contracted only
with PCCM program, the member will be defaulted to the PCCM program;
(B)
If a member is defaulted to a PCP who is contracted with
the PCCM program and an HMO, the member will be defaulted to the HMO;
(C)
If a member is defaulted to a PCP who is contracted with
the PCCM program and two or more HMOs, the member will be defaulted to one
of the HMOs on the basis of paragraph (6) of this subsection;
(D)
A member will be defaulted to the PCCM program if a PCCM
provider is the only PCP within reasonable geographical proximity to the member
as defined by the
Commission
[
(g)
[
(h)
[
(i)
[
(j)
[
[
§353.405.Marketing.
(a)
Managed care organizations (MCO) must submit a marketing
plan and all marketing materials to the
Commission
[
(b)
MCOs may present their marketing materials to eligible
Medicaid clients through any method or media determined to be acceptable by
the
Commission
[
(c)
MCO enrollment or marketing representatives are required
to complete the
Commission's
[
(d)
Prohibited marketing practices.
(1)
MCOs and providers shall not conduct any direct contact
marketing except through
Commission
[
(2)
MCOs and providers shall not make any written or oral statement
containing material misrepresentations of fact or law relating to their plan
or the STAR Program.
(3)
MCOs and providers shall not make false, misleading or
inaccurate statements relating to services or benefits, or providers or potential
providers through their plan.
(4)
MCOs and providers shall not offer Medicaid recipients
material or financial gain as an inducement for enrollment, unless an exception
is made by the
Commission
[
(5)
Marketing or enrollment practices of MCOs and providers
shall not discriminate against a client because of a client's race, creed,
age, color, religion, national origin, ancestry, marital status, sexual orientation,
physical or mental disability, health status, or existing need for medical
care.
§353.407.Selection of Managed Care Organizations (MCO).
(a)
An entity or person that contracts with the
Commission
[
(b)
Entities or individuals who subcontract with an MCO to
provide benefits or perform services, or carry out any essential function
of the MCO contract shall meet the same qualifications and contract requirements
as the MCO for the service, benefit, or function delegated under the subcontract.
(c)
The
Commission
[
§353.409.Scope of Services.
(a)
All Managed Care Organizations (MCO) shall provide services
and benefits available to Medicaid recipients under the purchased or fee for
service Medicaid program, except services which are excluded from the STAR
Program or by contract.
(b)
The
Commission
[
(c)
MCOs are encouraged to provide any services or benefits
beyond the level and scope required as a condition for participation in the
competitive procurement process. Any services or benefits offered by an MCO
beyond those required by the state will be considered as a selection factor
during the competitive procurement process. These services or benefits can
be any that may make member access to services easier, increase the quality
or timeliness of services or benefits offered members, or increase the scope
of services offered by the MCO. These services and benefits cannot increase
the cost borne or capitation rates paid by the
Commission
[
§353.411.Accessibility of Services.
(a)
Managed care organizations (MCO) must provide a broad-based
and accessible primary care provider (PCP) network within the service area
to ensure member accessibility to providers in time, distance, cultural competency
and language.
(b)
MCOs shall have pediatric and family practitioner PCPs
in their network of providers in sufficient numbers to provide regular and
preventive pediatric care and THSteps services to all eligible children enrolled
in the service area.
(c)
MCOs shall have PCPs available throughout the service area
to ensure that no member must travel more than 30 miles to access the PCP,
unless an exception has been made by the
Commission
[
(d)
MCOs shall have PCPs in sufficient numbers to ensure that
PCPs do not exceed the maximum allowable enrolled members, that no member
must wait an unreasonable amount of time for an appointment, and that no member
must wait an unreasonable amount of time to be seen at their appointed time.
(e)
MCOs shall ensure the reasonable availability and accessibility
of specialists in all areas of medical and behavioral health practice. Specialists
must also be reasonably accessible to members in time, distance, cultural
competency and language.
(f)
A member shall not be required to travel in excess of 75
miles to secure initial contact with referral specialists; special hospitals;
psychiatric hospitals; diagnostic and therapeutic services; and single service
health care physicians, dentists or providers except as provided in subsections
(g) and (h) of this section.
(g)
If any service or provider is not available to a member
within the mileage radius specified in subsection (f) of this section, the
MCO shall submit to the
Commission
[
(h)
The provisions in subsection (f) of this section do not
preclude an MCO from making arrangements with another source outside the service
area for members to receive a higher level of skill or specialty than the
level which is available within the MCO service area such as, but not limited
to, treatment of cancer, burns, and cardiac diseases.
(i)
MCOs shall provide education and training to providers
on the specific health and behavioral health problems and needs of STAR Program
members, and the contract and rule requirements for accessibility and availability.
MCOs and the
Commission
[
(j)
MCOs shall develop a written cultural competency plan describing
how the MCO will effectively provide health care services to members from
varying cultures, races, ethnic backgrounds and religions to ensure those
characteristics do not pose barriers to gaining access to needed services.
As part of the requirement to develop the cultural competency plan, the MCO
must at a minimum:
(1)
employ multi-cultural and multi-lingual staff;
(2)
make available interpreter services for members as necessary
to ensure availability of effective communication regarding treatment, medical
history or health education;
(3)
display to the
Commission
[
(4)
submit the written plan to the
Commission
[
(k)
MCOs must ensure that communication or physical access
barriers do not deter members' timely access to health care services. The
MCOs shall provide information in appropriate communication formats, including
formats accessible to people with disabilities.
(l)
MCOs are prohibited from excluding significant traditional
Medicaid providers from their network for a period of time and under conditions
determined by the state and specified in the contract.
(m)
MCOs shall develop written provider manuals clearly stating
the policies and procedures adopted by the MCO to meet the provider's duties
and obligations required by these and other agency rules and the contract.
§353.413.Managed Care Benefits and Services for Children Under 21 Years of Age.
(a)
The
Commission
[
(b)
The
Commission
[
(c)
MCOs shall coordinate and cooperate with the
Commission
[
(d)
The managed care programs of participating MCOs are intended
to complement and enhance the effectiveness and availability of THSteps benefits
in the service areas. The
Commission
[
§353.415.Member Complaint Procedures.
(a)
Managed care organizations (MCO) shall develop and maintain
a system and process for taking, tracing, reviewing, and reporting member
complaints.
(b)
MCOs shall establish and maintain internal procedures for
the resolution of member complaints. The procedures must be in writing. The
procedures must be detailed and specific regarding how complaints are to be
taken, to whom complaints are referred, and by when a complaint must be resolved.
(c)
MCOs shall establish a procedure to assist members in understanding
and using the MCO's internal complaint process. The members' complaint procedure
must be in writing and distributed to each member upon enrollment. The member
must also receive written notice of the procedure each time the member's benefits
are being reduced, denied, or terminated for any reason. The procedure must
be easy for members to understand and simple to follow. The procedure must
contain a prominent notice to the member that they retain all of their rights
as Medicaid recipients to a fair hearing through the
Commission
[
(d)
The
Commission
[
(e)
The
Commission
[
§353.417.Quality Improvement.
(a)
Each managed care organization (MCO) shall develop and
follow quality standards based on current Quality Assurance Reform Initiative
(QARI) and Health Plan Employer Data and Information Set (HEDIS) guidelines
as a minimum requirement of its internal quality improvement program (QIP).
MCOs shall establish a QIP system that includes at least the following:
(1)
a system of oversight and supervision for the MCO quality
improvement (QI) processes;
(2)
an independent organizational structure within the MCO
responsible for performing QI functions. This organization must meet operational
and documentation requirements of the
Commission
[
(3)
written contracts for all QI functions subcontracted to
outside contractors;
(4)
written policies and procedures for ensuring providers
in the MCO's network are qualified and properly credentialed, and a system
to periodically update and review qualifications and credentials of all providers;
(5)
policies and procedures for disciplinary actions against
providers and an appeal process for providers who have disciplinary action
taken against them;
(6)
a procedure for informing MCO members of their rights and
responsibilities, benefits and services, MCO policies, and other information
required in the [
(7)
performance standards for the availability of and accessibility
to routine and emergency care, referral to specialists, and telephone services;
(8)
time standards within which providers must respond to the
medically necessary physical and behavioral health needs of the members;
(9)
standards for the confidentiality, accessibility, and availability
of medical records;
(10)
a written utilization review and management program which
gives guidelines and criteria for determining medical necessity, preauthorization,
and utilization of services;
(11)
an effective referral and coordination of care system
to ensure comprehensive and coordinated care for members through the PCPs;
and
(12)
a complaint system for members as described in §30.29
of
Title 25
[
(b)
The QIP functions may be subcontracted but the responsibility
for QIP compliance cannot be delegated by the MCO.
(c)
The
Commission
[
(1)
The
Commission
[
(2)
The
Commission
[
(3)
The
Commission
[
(d)
Evaluations of each MCO's quality of services in each Medicaid
managed care service area and the cost-effectiveness, member access, and quality
of care under each waiver shall be conducted by independent, external entities
after initial implementation of Medicaid managed care in a particular service
delivery area. The quality evaluation shall be conducted at the end of the
first year following initial implementation; and the assessment of cost-effectiveness,
member access, and quality of care under each waiver shall be conducted once
during the first two years of the time period for which a waiver has been
approved. The periodicity of both evaluation types shall be re-evaluated by
the
Commission
[
§353.419.Financial Standards.
(a)
Managed care organizations (MCO) must meet solvency standards
established by the Texas Department of Insurance at 28 TAC Chapter 11, Subchapter
S,
or be covered by the Texas Life, Accident, Health and Hospital Service
Insurance Guaranty Association, and meet solvency standards established
[
(b)
The state may share in profits realized by MCOs providing
services on a risk basis at a rate determined by the
Commission
[
(c)
The
Commission
[
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed
with the Office of the Secretary of State on March 10, 2003.
TRD-200301653
Steve Aragon
General Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: April 20, 2003
For further information, please call: (512) 424-6756
Subchapter J. PURCHASED HEALTH SERVICES
the Texas Department of Health, at 25 TAC §§30.21-30.32
(Standards for the State of Texas Access Reform (STAR)), and
] the Texas
Department of Mental Health and Mental Retardation, at 25 TAC [
§§409.401-409.406
]
§§412.301-305 (Mental Health Community Services Standards)
[
(Standards for Managed Care Organizations Providing Behavioral
Healthcare Services to Medicaid Recipients)
].
Texas Department of Health;
] and
(13)
] STAR Program--The State
of Texas Access Reform, which is the name of the State of Texas managed care
program established in response to legislative mandate and by federal waiver.
Subchapter B. PROVIDER AND MEMBER EDUCATION PROGRAMS
Texas Department of Health
] to
provide health care services through the Medicaid program shall provide education
programs for providers and members using a variety of techniques and media
as described in this chapter and in the contract between the
Health and
Human Services Commission
[
Texas Department of Health
] and
the managed care organization.
Texas Department
of Health
] regarding components of the education programs, means of
providing the required education, reporting to the
Health and Human Services
Commission
[
Texas Department of Health
] and other state agencies
about the education programs and any other terms included in the contract.
Texas Department of Health
] a program must include,
at a minimum, information on:
Texas Department of Health
] a provider education program
must include, at a minimum, information on:
Subchapter E. STANDARDS FOR THE STATE OF TEXAS ACCESS REFORM (STAR)
(5)
] Complainant--A member or a
treating provider or other individual designated to act on behalf of the member,
who files a complaint.
(6)
] Complaint--Any dissatisfaction,
expressed by a complainant orally or in writing to the MCO, with any aspect
of the MCO's operation, including but not limited to dissatisfaction with
plan administration; appeal of an adverse determination; the denial, reduction
or termination of a service; the way a service is provided; or disenrollment
decisions expressed by a complainant. A complaint is not a misunderstanding
or misinformation that is resolved promptly by supplying the appropriate information
or clearing up the misunderstanding to the satisfaction of the member.
(7)
] Contract administrator--An
entity contracting with the
Commission
[
department
]
to carry out specific administrative functions under the state's Medicaid
managed care program.
(8)
] Cultural competency--The ability
of individuals and systems to provide services effectively to people of various
cultures, races, ethnic backgrounds, and religions in a manner that recognizes,
values, affirms, and respects the worth of the individuals and protects and
preserves their dignity.
(9)
] Default--Assignment of a client
to a PCP and MCO by the
Commission
[
department
] if the
client does not select a PCP and MCO during the enrollment period established
by the
Commission
[
department
].
For the Statewide
Rural Health Care System, default means the assignment by the Commission of
a client to the Statewide Rural Health Care System MCO if the client fails
to select either the Statewide Rural Health Care System MCO or the fee-for-service
option.
(10)
Department--The Texas Department
of Health].
department
].
For the Statewide Rural Health Care System, the selection
of the Statewide Rural Health Care System or the fee-for-service option during
the enrollment period established by the Commission.
department
] added comprehensive care benefits to the federal
EPSDT program requirements. The name has been changed to Texas Health Steps
in the state of Texas.
(19)
HCFA--The Health Care Financing
Administration, the federal agency charged with oversight of all states participating
in the Medicaid program.]
(20)
] Health care services--Physical
medicine, behavioral health care and health-related services which an enrolled
population might reasonably require in order to be maintained in good health,
including, as a minimum, emergency care and inpatient and outpatient services.
(21)
] HEDIS--The Health Plan Employer
Data and Information Set. (See definition for Medicaid HEDIS.)
(22)
] HMO (Health maintenance organization)--An
organization which holds a certificate of authority from the Texas Department
of Insurance to operate as an HMO under Chapter 20A of the Texas Insurance
Code.
(23)
] Inpatient stay--At least
a 24-hour stay in a facility licensed to provide hospital care.
(24)
] Major life activities--Functions
such as caring for oneself, performing manual tasks, walking, seeing, hearing,
speaking, breathing, learning, and working.
(25)
] Managed care--A health delivery
system in which the overall care of a patient is coordinated by or through
a single provider or organization.
(26)
] MCO--Managed care organization.
An entity which has a current Texas Department of Insurance certificate of
authority to operate as an HMO under Chapter 20A of the Texas Insurance Code
or as an approved nonprofit health corporation under Chapter 21.52F of the
Texas Insurance Code
, or an organization sponsored by the Statewide Rural
Health Care System, established by the Texas Insurance Code, Chapter 20C
.
(27)
] Medicaid HEDIS--A standardized
set of performance measures published by the National Committee for Quality
Assurance, which are designed specifically to assess how well Medicaid clients
are served by managed care organizations in a capitated managed care system.
(28)
] Medical home--A primary care
provider who has accepted the responsibility for providing accessible, continuous,
comprehensive and coordinated care to members participating in the state's
Medicaid managed care program.
(29)
] Medically necessary behavioral
health services--Those behavioral health services which:
(30)
] Medically necessary health
services--Health services other than behavioral health services which are:
(31)
] Member--Any Medicaid eligible
recipient who is enrolled in the state's Medicaid managed care program.
(32)
] Participating MCOs--Those
MCOs which have a contract with the
Commission
[
department
] to provide services to Medicaid managed care members.
(33)
] PCCM (Primary care case management)--PCCM
is a managed care delivery system allowed under federal waiver in which the
Commission
[
department
] contracts with providers to form
a managed care provider network.
(34)
] Primary care physician or
primary care provider--A physician or provider who has agreed with the
Commission
[
department
] or an MCO to provide a medical home
to members and who is responsible for providing initial and primary care to
patients, maintaining the continuity of patient care, and initiating referral
for care.
(35)
] Provider--An individual or
entity and its employees and contractors that provide health care services
to members under the state's Medicaid managed care program.
(36)
] QARI guidelines--The Quality
Assurance Reform Initiative guidelines of
CMS
[
HCFA
].
(37)
] Service area--The counties
included in a site selected for a STAR pilot program, within which a participating
MCO must provide services.
department and the
] Commission.
(40)
] Special hospital--An establishment
that:
(41)
] STAR Program--The State
of Texas Access Reform Program and is the name of the State of Texas Medicaid
managed care program established in response to legislative mandate and by
federal waiver.
(42)
] THSteps--Texas Health Steps.
(43)
] Texas Health Steps--The name
adopted by the State of Texas for the federally mandated Early and Periodic
Screening, Diagnostic and Treatment (EPSDT) program. It includes the state's
Comprehensive Care Program extension to EPSDT, which adds benefits to the
federal EPSDT requirements contained in 42 United States Code §1396d(r),
and defined and codified at 42 Code of Federal Regulations §440.40 and §§441.56-62.
The department's rules are contained in Chapter 33 of the title (relating
to Early and Periodic Screening, and Diagnosis and Treatment).
department
] shall
determine which Medicaid eligible clients residing in a STAR Program service
area will be mandatory or voluntary members and which Medicaid eligible clients
may be excluded from participation in managed care.
department
] shall
conduct enrollment and disenrollment activities or contract with another agency
or contractor to assume administration of these functions. The
Commission
[
department
] may not contract with a participating managed
care organization to serve as the administrator for enrollment or disenrollment
activities in any area of the state.
department
] shall
establish procedures for enrollment into participating MCOs and primary care
providers (PCP), including enrollment periods and time limits within which
enrollment must occur. Members who are mandatory members must select an MCO
or PCP within the time period allowed by the
Commission
[
department
] or be defaulted to an MCO or PCP.
(e)
] Mandatory members who fail
to select an MCO or PCP during the period established by the
Commission
[
department
] will have an MCO or PCP selected for them by
the
Commission
[
department
] or its contractor using
criteria determined by the
Commission
[
department
].
The
Commission
[
department
] shall establish a detailed
default methodology that incorporates the following requirements.
department
]. A member who selects an MCO but not a PCP,
will be assigned to the selected MCO and the member will be assigned to a
PCP through the default process. A member who selects a PCP but not an MCO
will be assigned to the PCP chosen by the member, subject to PCP restrictions
on client age, gender, and capacity, and the member will be assigned to an
MCO through a manual default process that is established by the
Commission
[
department
] based on the provisions of paragraph (6) of
this subsection.
department
] may identify
other criteria to be used along with the criteria based on geographical proximity
such as, but not limited to, capacity of the PCP, PCP performance, and greatest
variance between the percentage of elective and default enrollments (with
the percentage of default enrollments subtracted from the percentage of elective
enrollments).
department
] shall
develop a methodology for assignment of defaults to each MCO in the service
area. Such methodology may be based on MCO performance, the greatest variance
between the percentage of elective and default enrollments (with the percentage
of default enrollments subtracted from the percentage of elective enrollments),
or other factors determined by the
Commission
[
department
].
department
].
department
] shall be fully applicable to each
MCO in the Medicaid managed care program by service area. However, the number
of defaults assigned to the state administered PCCM network shall be restricted
as follows:
department
].
(f)
] A member may request to change
MCOs at any time and for any reason, regardless of whether the MCO was selected
by the member or assigned by the
Commission
[
department
].
Disenrollment will take place no later than the first day of the second month
after the month in which the member has requested termination. MCOs must inform
members of disenrollment procedures at the time of enrollment. MCOs must notify
members in appropriate communication formats.
(g)
] The
Commission
[
department
] shall establish limits for the number of members each PCP
may accept to ensure members have reasonable access to the provider. The
Commission
[
department
] shall develop criteria to allow exceptions
to this limit on a case-by-case basis, provided the exceptions do not adversely
affect member access.
(h)
] The
Commission
[
department
] may not enroll any Medicaid eligible recipient who is excluded
from participation by federal rule or regulation.
(i)
] Recipients who are located
more than 30 miles from the nearest PCP in an MCO cannot be enrolled in the
MCO unless an exception is made by the
Commission
[
department
].
(j)
Medicaid recipients and Medicare
beneficiaries must constitute less than 75% of the total enrollment of an
MCO, unless the MCO has received a waiver for this requirement under 42 Code
of Federal Regulations §434.26.]
department
] for prior written approval.
department
]. The media may include but
are not limited to: written materials, such as brochures, posters, or fliers
which can be mailed directly to the client or left at Texas Department of
Human Services eligibility offices;
Commission
[
department
] -sponsored community enrollment events; and public service announcements
on radio.
department
] marketing
orientation and training program prior to engaging in marketing activities
on behalf of the MCO.
department
] -sponsored
enrollment events,
unless an exception is allowed by the Commission.
department
].
department
] under a federal waiver to provide or arrange
for services under this subchapter on a risk comprehensive basis, as defined
at 42 CFR 434.21(b), must be an MCO as defined in this subchapter.
department
] shall
require all MCOs to comply with the
Commission's
[
department's
] policy on contracting and subcontracting with historically underutilized
businesses (HUBs). The
Commission's
[
department's
] policy
is to meet the goals and good faith effort requirements as stated in the
Texas Building and Procurement Commission
[
MF3
] [
General
Services Commission
] rules, at 1 Texas Administrative Code (TAC) §§111.11-111.24.
department
] shall
establish the scope and level of benefits which all MCOs must agree to provide
as a condition for participation. These requirements may exceed the scope
and level of covered benefits and services available to purchased or fee-for-service
Medicaid recipients. These requirements shall be contained in all contracts
entered into by MCOs and the
Commission
[
department
].
department
] during any current contract term or in any subsequent contract
term. These services or benefits cannot violate any other state or federal
rule or regulation.
department
].
department
] for
approval health care utilization data which indicates a normal pattern for
securing health care services within the service area.
department
] shall cooperate
and coordinate education and training activities for providers.
department
]
through the written plan a method for incorporating the plan into the MCO's
policy-making process, administration, and daily practices; and
department
] for review and approval at intervals specified by the
Commission
[
department
].
department
] shall
require all participating managed care organizations (MCO) to provide comprehensive,
timely and cost-effective diagnostic, screening and treatment services of
the medical, vision, hearing, and dental needs of eligible STAR Program members
under the age of 21, at a level and frequency that meet the requirements of
the federal EPSDT Program found at 42 United States Code §1396d(r) and
the Texas Health Steps Program (THSteps) found at Chapter 33 of
Title
25
[
this title
] (relating to Early and Periodic Screening,
Diagnosis and Treatment). These requirements shall be contained in all contracts.
department
] shall
require the MCOs to make available special training about THSteps benefits
and goals to all providers of health and dental services contracting with
the MCO, to providers' staffs, and to all employees and contractors of the
MCO who will provide oral presentations or marketing to members or prospective
members. To fulfill this requirement, the MCOs may use the training programs
created by the
Commission
[
department
] or its contractors,
or they may create their own training programs. Any training program created
by the MCO under this subsection must meet the requirements of the
Commission
[
department
] and be approved by the
Commission
[
department
].
department
] in developing effective outreach, access, and
monitoring systems to ensure that all qualified members receive THSteps benefits.
department
] shall
not delegate the responsibility and accountability of monitoring and for ensuring
that THSteps benefits are available and accessible to all eligible children.
department
], in addition to the MCO's complaint process.
department
] shall
review the MCO's complaint procedures to determine they comply with the
Commission's
[
department's
] standards before approval for
MCO use of the complaint procedure is given by the
Commission
[
department
]. Reports containing complaint summaries shall be submitted
to the
Commission
[
department
] in compliance with
Commission
[
department
] policy.
department
] shall
retain the authority to make the final decision following the
Commission
's
[
department's
] fair hearing process.
department
], including the requirement that membership includes Medicaid managed
care members and members with disabilities or a chronic or complex condition;
Texas Health and Human Services
] Commission's
rules on client education and member bill of rights and responsibilities,
and the MCO contract with the
Commission
[
department
];
this title
] (relating to Member Complaint
Procedures).
department
] shall
develop monitoring and review systems and procedures to ensure MCO compliance
with MCO contracts, this subchapter, and all related state and federal rules,
regulations, and guidelines.
Commission
[
Department
]
monitoring and review shall include but not be limited to the following.
department
] shall
monitor each MCO to ensure it is following its QIP standards.
department
] shall
require MCOs to submit QIP information at regular and periodic intervals.
department
] shall
require all MCOs to submit to periodic inspection and review to determine
compliance with all contract terms, and state and federal rules, regulations,
and policies.
department
] after each evaluation is
initially completed in a managed care service delivery area.
and
] by the
Commission
[
department
] in its competitive
procurement proposals.
department
], as long as the profit-sharing arrangement complies with
federal law and is contained in the contract between the MCO and the
Commission
[
department
].
department
] may establish
incentive payment programs to encourage MCOs to meet or exceed the goals and
objectives of the STAR Program established by the
Commission
[
department
] through its contract.
Chapter 355.
MEDICAID REIMBURSEMENT RATES