In this update TAHC&H is providing you with a short list of Medicaid bills that deal with the operation and administration of the Medicaid program, especially in regards to managed care. The 86th session was very different for bills filed to address concerns and fix issues with Texas Medicaid and there was not a shortage of bills filed this session. However, the legislators who filed the majority of the bills did not receive hearings. Only a handful of bills that impact our members made it across the finish line and were signed by the Governor. Below are the key bills that are important to your business and the patients you serve.
SB 1207, by Senator Perry, is one of the key Medicaid bills that passed. It relates to the operation and administration of Medicaid, including the Medicaid managed care program and the medically dependent children waiver program (MDCP). The bill also made significant operational changes to the Medicaid program and was signed by the Governor.
This bill modernizes the Texas Medicaid program by reducing or eliminating unnecessary administrative burdens and red tape, strengthening patient protections, and improving care coordination. While the bill itself is effective September 1, 2019 there are sections of the bill that have various dates by when they are required to be effective as HHSC will need to adopt rules and amend the Uniform Managed Care Contract to implement.
Some of the big pieces that are important for TAHC&H members to note are as follows:
- Prior Authorization Reforms: HHSC will now have the authority to establish prior authorization (PA) time frames for Medicaid managed care that allow sufficient time to provide necessary documentation and avoid unnecessary denials without delaying access to care. HHSC will also establish a process similar to the process established under the Alberto N. settlement agreement for MCOs to reconsider adverse determinations on a PA that is solely the result of the provider not submitting sufficient or adequate documentation. The bill requires a notification process for providers and clients when insufficient documentation is provided. The notice must include
- a list of documentation necessary to make a decision,
- information about how to contact the MCO to discuss the situation, and
- a time frame by which the MCO must make a determination.
- MCOs must make PA requirements and information about the PA process readily accessible by posting the requirements and information on their website. HHSC will adopt rules requiring the MCOs to maintain on their website, in an easily searchable format that includes the following;
- timelines for PA decisions,
- description of the notice MCOs are required to provide under the PA reconsideration process,
- accurate and up-to-date catalog of coverage criteria and PA requirements, including for a PA requirement first imposed on or after Sept. 1, 2019 (the effective date of this requirement), and
- list or description of any supporting or other documentation necessary to obtain PA for a specific service.
- MCOs will be required to annually review their PAs in consultation with their provider advisory group and ensure each PA is based on “accurate, up-to-date, evidence based, and peer reviewed clinical criteria that distinguish, as appropriate, between categories, including age, of recipients for who PA requests are submitted.” The bill requires HHSC to periodically review MCOs for compliance with this new provision.
- Client Protection Reforms: HHSC and MCOs will be required to send letters to clients and providers for a denial, partial denial, reduction of services, or termination of eligibility. HHSC will be required to contract with an external medical review organization that has experience providing private duty nursing and long-term services and supports. Clients can opt-in to a review if they have been denied a service or Medicaid medical eligibility. The external review will take place after the appeal process and before a Medicaid fair hearing. If a client chooses the external medical review option, the MCO will be responsible for submitting a detailed reason for the service reduction or denial along with supporting documentation. The bill required HHSC to post data and statistics on the rate of reviews. HHSC, in coordination with MCOs and consultation with the STAR Kids Advisory Committee, will develop and adopt clear policies ensuring the coordination and timely delivery of Medicaid wrap-around benefits for recipients with both primary health benefit plan coverage and Medicaid coverage. The bill directs HHSC to develop a clear, simple process that allows recipients with complex medical needs who have established a relationship with a specialty provider to continue receiving care from that provider.
- STAR Kids Assessment Tool: HHSC will be required to post a plan for public comment no later than March 1, 2020 to improve the STAR Kids Assessment tool. The bill specifies that HHSC should consider changes that will reduce the amount of time needed to complete the “care needs assessment” initially and at reassessment, as well as improve MCO training and consistency.
- MDCP Reforms: This bill has several MDCP reforms, but one that impacts a provider's patient receiving MDCP is that the STAR Kids Care Coordinator will be required to provide the MDCP family the results of the annual MDCP assessment and reassessment and allows the family to request a peer-to-peer discussion with their provider of choice and the MCO Medical Director to dispute the findings. The bill requires HHSC (to the extent allowed under federal law) to streamline the annual MDCP reassessment for clients who have not had a significant change in function to ensure clients that need home and community-based services are not being denied eligibility. This provision applies to assessments or reassessments made on or after Dec. 1, 2019.
SB 1207 has an effective date of September 1, 2019, but it does allow HHSC the ability to delay implementation pending federal approval. While there are some various implementation dates throughout the bill, all other new requirements must be added to MCO contracts by HHSC no later than Sept. 1, 2020. Many stakeholders including TMA, THA, DRTX, CTD,TAHP & TAHC&H were involved in the drafting of this bill since much of Chairman Frank's managed care bill (HB 4192) is folded in.
Another very large managed care bill is HB 4533 by Rep. Klick and Sen. Kolkhorst which directs HHSC to establish a pilot program within the STAR+PLUS program to test managed care’s delivery of long-term services and supports (LTSS) for home and community-based services (HCBS) for clients with an intellectual or developmental disability (IDD). The bill also includes parts of another managed care bill (SB 1105 by Kolkhorst) that directs Medicaid reforms. SB 7 from the 83rd Legislative Session directed HHSC to complete a pilot program, which they did not comply. This bill provides HHSC with specific direction to complete the pilot program for certain waiver programs before they can be carved into managed care.
The bill extends the IDD Advisory Committee and establishes a pilot work group. The advisory committee along with the pilot work group will develop recommendations related to a transition plan into managed care for the Texas Home Living (2027), Community Living Assistance and Support Services (2029), HCBS (2031), and Deaf Blind with Multiple Disabilities (2031) waiver program services.
The following are the additional reforms that impact TAHC&H membership:
- Eliminate the Texas Provider Identifier (TPI) number no later than Sept. 1, 2023.
- Implement a new Medicaid provider enrollment system no later than Sept. 1, 2020.
- Improve the HHSC complaint process by adopting a standard definition of grievance.
- Increase transparency and oversight of MCOs by posting quality of care information on the HHSC website.
- Improve information in denial letters for both providers and clients similar to the requirements discussed above in SB 1207.
- Ensure the consumer—directed service option is available for clients in MDCP.
- Improve the STAR Kids Assessment Tool using the same criteria as in SB 1207.
- Determine the feasibility of providing services to clients in the STAR Kids program under an accountable care organization or alternative payment model and provide a report to the legislature by Dec. 1, 2022.
- Issue a request for information on a statewide STAR Kids managed care plan.
- Ensure MCOs are nationally accredited by Sept. 1, 2022.
- The bill gives HHSC authority to determine if MCOs must use one accrediting entity or they can choose from multiple organizations.
- Develop a report on the impacts of the 30-day inpatient spell of illness limitations in STAR+PLUS by Dec. 1, 2020.
One other managed care bill to highlight is SB 2138 (HHSC clean-up bill) by Sen. Chuy Hinojosa. It relates to the administration and operation of Medicaid. The legislation allows HHSC to retain up to $8m each fiscal year of funds received to operate certain health care programs under the Medicaid program. This was a legislative priority for the Commission. In the course of the final days of session, the bill was amended in the House and one of the amendments adopted was language from HB 4601 by Rep. Raymond which was the TAHC&H’s Value Based Purchasing Work group bill. However, the language was removed in conference, but Sen. Hinojosa committed his attention to ensuring that HHSC follows through on their own with looking at a uniform value based purchasing methodology and ensuring the Commission engages stakeholders during the process. The plan is to have this done as a subcommittee of the Value-Based Payment and Quality Improvement Advisory Committee at HHSC. Sen. Hinojosa and Sen. Kolkhorst have agreed to write a joint letter to HHSC requesting they move forward even though the legislation was stripped out of the bill. The following is a breakdown of the parts of SB 2138:
- Commissions Authority to Retain Certain Money to Administer Certain Medicaid Programs; report required.
- Compliance with federal coding guidelines
- Medicaid Managed Care Accreditation (must be compliant 9/1/2022) and is also a provision in HB 4533.
It was a very interesting session in regards to Medicaid oversight and administration bills. Very few received hearings and those that did had to be pushed along by leadership in both chambers. As all the provisions move forward with implementation, TAHC&H will be involved as a stakeholder. TAHC&H has already attended some meetings at HHSC that have started planning and plotting out the path towards implementation. Stay tuned on how you can as a member of TAHC&H get involved. We will push out forthcoming information from the commission as we receive it to TAHC&H membership.
Next update for Your Membership at Work; TAHC&H Successes at the Texas Capitol will include the Hospice and Supportive Palliative Care bills that passed. Stay tuned!