HB159 - Relating to certain payment recovery and recoupment efforts under Medicaid and the child health plan program.

  89R223 KKR-D     By: Raymond H.B. No. 159       A BILL TO BE ENTITLED   AN ACT   relating to certain payment recovery and recoupment efforts under   Medicaid and the child health plan program.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 544.0502, Government Code, as effective   April 1, 2025, is amended by amending Subsection (i) and adding   Subsection (j) to read as follows:          (i)  The executive commissioner shall adopt rules necessary   to implement this section, including rules establishing due process   procedures that a managed care organization must follow when   engaging in payment recovery efforts as provided by this section.   In adopting the rules establishing due process procedures, the   executive commissioner shall require that a managed care   organization or an organization's contracted entity that engages in   payment recovery efforts as provided by this section and Section   544.0503 provide to [ a provider required to use electronic visit   verification ]:                (1)   a provider required to use electronic visit   verification written notice of the organization's intent to recoup   overpayments in accordance with Section 544.0503; and                (2)   a provider, regardless of whether the provider is   required to use electronic visit verification, a minimum of [ at   least ] 60 days after the provider has exhausted all rights to an   appeal to cure any defect in a claim , including by submitting   necessary documentation for the claim or resubmitting the claim,   before the organization may begin efforts to collect overpayments.           (j)     A managed care organization or the organization's   contracted entity that engages in payment recovery efforts under   this section or Section 544.0503, in conducting an audit or other   review of a claim for equipment, supplies, or services for which the   organization granted prior authorization, may not review:                 (1)  the medical necessity determination; or                 (2)     an error in the claim documentation for the   previously approved equipment, supplies, or services, if the error   was not made by the provider.          SECTION 2.  Section 544.0504, Government Code, as effective   April 1, 2025, is amended to read as follows:          Sec. 544.0504.  RECOVERY AUDIT CONTRACTORS.  To the extent   required under Section 1902(a)(42), Social Security Act (42 U.S.C.   Section 1396a(a)(42)), the commission shall establish a program   under which the commission contracts with one or more recovery   audit contractors to identify [ Medicaid ] underpayments and   overpayments under Medicaid, including under the Medicaid managed   care program, and recover the overpayments.          SECTION 3.  If before implementing any provision of this Act   a state agency determines that a waiver or authorization from a   federal agency is necessary for implementation of that provision,   the agency affected by the provision shall request the waiver or   authorization and may delay implementing that provision until the   waiver or authorization is granted.          SECTION 4.  This Act takes effect September 1, 2025.