HB5512 - Relating to the participation and reimbursement of and requirements affecting certain providers, including providers of eye health care and vision care services, under Medicaid.

  89R16086 KKR-F     By: Buckley H.B. No. 5512       A BILL TO BE ENTITLED   AN ACT   relating to the participation and reimbursement of and requirements   affecting certain providers, including providers of eye health care   and vision care services, under Medicaid.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subchapter D, Chapter 532, Government Code, as   effective April 1, 2025, is amended by adding Sections 532.01511   and 532.01512 to read as follows:           Sec.   532.01511.     PROVIDER ENROLLMENT AND CREDENTIALING   PROCESSES: PROVIDER SUPPORT; COMPLAINTS.   (a)   The commission shall   ensure that providers have access to a dedicated support team for   the Internet portal established under Section 532.0151 that:                 (1)     assists current and prospective Medicaid   providers in completing the Medicaid provider enrollment and   credentialing processes; and                 (2)     reduces the administrative burdens associated   with those processes.           (b)  The commission shall:                 (1)     annually evaluate the performance of the support   team described by Subsection (a), including the timeliness of   assistance the support team provides; and                 (2)     not later than September 1 of each year, post on   the commission's Internet website a report summarizing the results   of the evaluation conducted under Subdivision (1).           (c)     For purposes of improving the commission's Medicaid   provider enrollment and credentialing processes, the commission   shall develop a procedure by which a provider may electronically   submit complaints and feedback about those processes and the   support provided by the support team described by Subsection (a).     Information about the procedure must:                 (1)     be prominently posted on the commission's or the   commission's designee's Internet website in the same location that   instructions and resources for using the Internet portal   established under Section 532.0151 are posted; and                 (2)     allow a provider to submit a complaint or provide   feedback through an electronic form from that location.           Sec.   532.01512.     NOTICE OF PROVIDER DISENROLLMENT. Before   the commission may disenroll a Medicaid provider during the   provider's enrollment revalidation period, the commission must:                 (1)     not later than the 30th day before the date of   disenrollment provide electronically and by mail to the provider   written notice of the commission's disenrollment determination;   and                 (2)     allow the provider to address any deficiencies in   the provider's application for revalidation of enrollment before   the date the provider is disenrolled.          SECTION 2.  Subchapter F, Chapter 540, Government Code, as   effective April 1, 2025, is amended by adding Sections 540.0281 and   540.0282 to read as follows:           Sec.   540.0281.     ADMINISTRATION OF EYE HEALTH CARE AND VISION   CARE SERVICES.   (a) A contract to which this subchapter applies   must prohibit the contracting Medicaid managed care organization   from using a different insurer, health maintenance organization,   third-party administrator, managed care plan, vision plan, or other   plan or entity the organization contracts with, offers, owns, or   otherwise engages to provide or arrange for the provision of eye   health care or vision care services under the managed care plan the   Medicaid managed care organization offers to:                 (1)     establish an eye health care services provider's   inclusion in the organization's provider network;                 (2)     contract with an eye health care services provider   to provide or arrange for the provision of eye health care or vision   care services under the organization's Medicaid managed care plan;                 (3)     reduce, restrict, or limit eye health care or   vision care services that are required to be provided to recipients   and are within the eye health care services provider's scope of   practice; or                 (4)     deny participation of an eye health care services   provider in the organization's Medicaid managed care plan if the   provider:                       (A)  seeks to participate in that plan; and                       (B)     meets the organization's requirements for   participation in the plan.           (b)     Notwithstanding Section 1451.152, Insurance Code, an   insurer, health maintenance organization, third-party   administrator, managed care plan, vision plan, or other plan or   entity that a Medicaid managed care organization contracts with,   offers, owns, or otherwise engages to provide or arrange for the   provision of eye health care or vision care services under the   organization's Medicaid managed care plan shall comply with the   requirements of Subchapter D, Chapter 1451, Insurance Code.           Sec.   540.0282.     REIMBURSEMENT OF EYE HEALTH CARE SERVICES   PROVIDERS.   A contract to which this subchapter applies must   require that the contracting Medicaid managed care organization   require any insurer, health maintenance organization, third-party   administrator, managed care plan, vision plan, or other plan or   entity the organization contracts with, offers, owns, or otherwise   engages to provide or arrange for the provision of eye health care   or vision care services under the managed care plan the Medicaid   managed care organization offers to reimburse an eye health care   services provider who provides services to a recipient under the   organization's managed care plan at a rate that is at least equal to   the Medicaid fee-for-service rate for the provision of the same or   similar services.          SECTION 3.  Section 540.0651(a), Government Code, as   effective April 1, 2025, is amended to read as follows:          (a)  The commission shall require that each managed care   organization that contracts with the commission under any managed   care model or arrangement to provide health care services to   recipients in a region:                (1)  seek participation in the organization's provider   network from:                      (A)  each health care provider in the region who   has traditionally provided care to recipients;                      (B)  each hospital in the region that has been   designated as a disproportionate share hospital under Medicaid; and                      (C)  each specialized pediatric laboratory in the   region, including a laboratory located in a children's hospital;                (2)  include in the organization's provider network for   at least three years:                      (A)  each health care provider in the region who:                            (i)  previously provided care to Medicaid   and charity care recipients at a significant level as the   commission prescribes;                            (ii)  agrees to accept the organization's   prevailing provider contract rate; and                            (iii)  has the credentials the organization   requires, provided that lack of board certification or   accreditation by The Joint Commission may not be the sole ground for   exclusion from the provider network;                      (B)  each accredited primary care residency   program in the region; and                      (C)  each disproportionate share hospital the   commission designates as a statewide significant traditional   provider; [ and ]                (3)  subject to Section 32.047, Human Resources Code,   and notwithstanding any other law, include in the organization's   provider network each optometrist, therapeutic optometrist, and   ophthalmologist described by Section 532.0153(b)(1)(A) or (B) who,   and an institution of higher education described by Section   532.0153(a)(4) in the region that:                      (A)   seeks participation in the organization's   provider network;                       (B)   agrees to comply with the organization's   terms;                       (C)  [ (B) ]  agrees to accept the [ organization's   prevailing provider contract ] rate specified in the contract   between the provider and the organization ;                       (D)  [ (C) ]  agrees to abide by the organization's   required standards of care; and                       (E)  [ (D) ]  is an enrolled Medicaid provider ; and                 (4)     contract directly with each provider described by   Subdivision (3) to participate in the organization's provider   network .          SECTION 4.  Notwithstanding Section 532.01511, Government   Code, as added by this Act, the Health and Human Services Commission   shall conduct the initial evaluation and post the report   summarizing the results of the evaluation as required by that   section not later than September 1, 2026.          SECTION 5.  As soon as possible after the effective date of   this Act, the Health and Human Services Commission shall:                (1)  ensure the Internet portal support team required   by Section 532.01511(a), Government Code, as added by this Act, is   established; and                (2)  adopt rules necessary to implement the changes in   law made by this Act.          SECTION 6.  (a) The Health and Human Services Commission   shall, in a contract between the commission and a managed care   organization under Chapter 540, Government Code, as effective April   1, 2025, that is entered into or renewed on or after the effective   date of this Act, require that the managed care organization comply   with Sections 540.0281 and 540.0282, Government Code, as added by   this Act, and Section 540.0651, Government Code, as effective April   1, 2025, and amended by this Act.          (b)  The Health and Human Services Commission shall seek to   amend contracts entered into with managed care organizations under   Chapter 533, Government Code, or under Chapter 540, Government   Code, as effective April 1, 2025, before the effective date of this   Act to require those managed care organizations to comply with   Sections 540.0281 and 540.0282, Government Code, as ad [Text truncated for display. 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