Texas Government Code Title 4, Chapter 533 - Medicaid Managed Care Program
SUBCHAPTER A GENERAL PROVISIONS
- Texas Section 533.001 - Definitions
In this chapter: (1) "Commission" means the Health and Human Services Commission or an agency operating part of the state Medicaid managed care program, as...
- Texas Section 533.002 - Purpose
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...
- Texas Section 533.0025 - Delivery Of Services
(a) Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, Sec. 2.287(15), eff. April 2, 2015. (b) Except as otherwise provided by this section and...
- Texas Section 533.00251 - Delivery Of Certain Benefits, Including Nursing Facility Benefits, Through Star + Plus Medicaid Managed Care Program
Sec. 533.00251. DELIVERY OF CERTAIN BENEFITS, INCLUDING NURSING FACILITY BENEFITS, THROUGH STAR + PLUS MEDICAID MANAGED CARE PROGRAM. (a) In this section and Sections 533.002515...
- Texas Section 533.00253 - Star Kids Medicaid Managed Care Program
(a) In this section: (1) "Advisory committee" means the STAR Kids Managed Care Advisory Committee established under Section 533.00254. (2) "Health home" means a primary...
- Texas Section 533.00254 - Star Kids Managed Care Advisory Committee
(a) The STAR Kids Managed Care Advisory Committee is established to advise the commission on the establishment and implementation of the STAR Kids managed care...
- Texas Section 533.00255 - Behavioral Health And Physical Health Services Network
(a) In this section, "behavioral health services" means mental health and substance abuse disorder services. (a-1) Notwithstanding Subsection (a), for purposes of this section, the...
- Texas Section 533.002551 - Monitoring Of Compliance With Behavioral Health Integration
(a) In this section, "behavioral health services" has the meaning assigned by Section 533.00255. (b) In monitoring contracts the commission enters into with managed care...
- Texas Section 533.00256 - 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...
- Texas Section 533.00257 - Delivery Of Medical Transportation Program Services
(a) In this section: (1) "Managed transportation organization" means: (A) a rural or urban transit district created under Chapter 458, Transportation Code; (B) a public...
- Texas Section 533.0026 - Direct Access To Eye Health Care Services Under Medicaid Managed Care Model Or Arrangement
(a) Notwithstanding any other law, the commission shall ensure that a managed care plan offered by a managed care organization that contracts with the commission...
- Texas Section 533.0027 - Procedures To Ensure Certain Recipients Are Enrolled In Same Managed Care Plan
The commission shall ensure that all recipients who are children and who reside in the same household may, at the family's election, be enrolled in...
- Texas Section 533.0028 - Evaluation Of Certain Star + Plus Medicaid Managed Care Program Services
Sec. 533.0028. EVALUATION OF CERTAIN STAR + PLUS MEDICAID MANAGED CARE PROGRAM SERVICES. The external quality review organization shall periodically conduct studies and surveys to...
- Texas Section 533.00281 - Utilization Review For Star + Plus Medicaid Managed Care Organizations
Sec. 533.00281. UTILIZATION REVIEW FOR STAR + PLUS MEDICAID MANAGED CARE ORGANIZATIONS. (a) The commission's office of contract management shall establish an annual utilization review...
- Texas Section 533.0029 - Promotion And Principles Of Patient-centered Medical Homes For Recipients
(a) For purposes of this section, a "patient-centered medical home" means a medical relationship: (1) between a primary care physician and a child or adult...
- Texas Section 533.003 - Considerations In Awarding Contracts
(a) In awarding contracts to managed care organizations, the commission shall: (1) give preference to organizations that have significant participation in the organization's provider network...
- Texas Section 533.004 - Mandatory Contracts
(a) In providing health care services through Medicaid managed care to recipients in a health care service region, the commission shall contract with a managed...
- Texas Section 533.005 - Required Contract Provisions
(a) A contract between a managed care organization and the commission for the organization to provide health care services to recipients must contain: (1) procedures...
- Texas Section 533.0051 - Performance Measures And Incentives For Value-based Contracts
(a) The commission shall establish outcome-based performance measures and incentives to include in each contract between a health maintenance organization and the commission for the...
- Texas Section 533.00511 - Quality-based Enrollment Incentive Program For Managed Care Organizations
(a) In this section, "potentially preventable event" has the meaning assigned by Section 536.001. (b) The commission shall create an incentive program that automatically enrolls...
- Texas Section 533.0052 - Star Health Program: Trauma-informed Care Training
(a) A contract between a managed care organization and the commission for the organization to provide health care services to recipients under the STAR Health...
- Texas Section 533.0053 - Compliance With Texas Health Steps
The commission shall encourage each managed care organization providing health care services to a recipient under the STAR Health program to ensure that the organization's...
- Texas Section 533.0055 - Provider Protection Plan
(a) The commission shall develop and implement a provider protection plan that is designed to reduce administrative burdens placed on providers participating in a Medicaid...
- Texas Section 533.006 - Provider Networks
(a) The commission shall require that each managed care organization that contracts with the commission to provide health care services to recipients in a region:...
- Texas Section 533.0061 - Frequency Of Provider Credentialing
A managed care organization that contracts with the commission to provide health care services to Medicaid recipients under a managed care plan issued by the...
- Texas Section 533.0061 - Provider Access Standards; Report
(a) The commission shall establish minimum provider access standards for the provider network of a managed care organization that contracts with the commission to provide...
- Texas Section 533.0062 - Penalties And Other Remedies For Failure To Comply With Provider Access Standards
If a managed care organization that has contracted with the commission to provide health care services to recipients fails to comply with one or more...
- Texas Section 533.0063 - Provider Network Directories
(a) The commission shall ensure that a managed care organization that contracts with the commission to provide health care services to recipients: (1) posts on...
- Texas Section 533.0064 - Expedited Credentialing Process For Certain Providers
(a) In this section, "applicant provider" means a physician or other health care provider applying for expedited credentialing under this section. (b) Notwithstanding any other...
- Texas Section 533.0066 - Provider Incentives
The commission shall, to the extent possible, work to ensure that managed care organizations provide payment incentives to health care providers in the organizations' networks...
- Texas Section 533.007 - Contract Compliance
(a) The commission shall review each managed care organization that contracts with the commission to provide health care services to recipients through a managed care...
- Texas Section 533.0071 - Administration Of Contracts
The commission shall make every effort to improve the administration of contracts with managed care organizations. To improve the administration of these contracts, the commission...
- Texas Section 533.0072 - Internet Posting Of Sanctions Imposed For Contractual Violations
(a) The commission shall prepare and maintain a record of each enforcement action initiated by the commission that results in a sanction, including a penalty,...
- Texas Section 533.0073 - Medical Director Qualifications
A person who serves as a medical director for a managed care plan must be a physician licensed to practice medicine in this state under...
- Texas Section 533.0075 - Recipient Enrollment
The commission shall: (1) encourage recipients to choose appropriate managed care plans and primary health care providers by: (A) providing initial information to recipients and...
- Texas Section 533.0076 - Limitations On Recipient Disenrollment
(a) Except as provided by Subsections (b) and (c), and to the extent permitted by federal law, a recipient enrolled in a managed care plan...
- Texas Section 533.0077 - Statewide Effort To Promote Maintenance Of Eligibility
(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...
- Texas Section 533.008 - Marketing Guidelines
(a) The commission shall establish marketing guidelines for managed care organizations that contract with the commission to provide health care services to recipients, including guidelines...
- Texas Section 533.009 - Special Disease Management
(a) The commission shall ensure that managed care organizations under contract with the commission to provide health care services to recipients develop and implement special...
- Texas Section 533.010 - Special Protocols
In conjunction with an academic center, the commission may study the treatment of indigent populations to develop special protocols for managed care organizations to use...
- Texas Section 533.011 - Public Notice
Not later than the 30th day before the commission plans to issue a request for applications to enter into a contract with the commission to...
- Texas Section 533.012 - Information For Fraud Control
(a) Each managed care organization contracting with the commission under this chapter shall submit the following, at no cost, to the commission and, on request,...
- Texas Section 533.013 - Premium Payment Rate Determination; Review And Comment
(a) In determining premium payment rates paid to a managed care organization under a managed care plan, the commission shall consider: (1) the regional variation...
- Texas Section 533.0131 - Use Of Encounter Data In Determining Premium Payment Rates
(a) In determining premium payment rates and other amounts paid to managed care organizations under a managed care plan, the commission may not base or...
- Texas Section 533.01315 - Reimbursement For Services Provided Outside Of Regular Business Hours
(a) This section applies only to a recipient receiving benefits through any Medicaid managed care model or arrangement. (b) The commission shall ensure that a...
- Texas Section 533.0132 - State Taxes
The commission shall ensure that any experience rebate or profit sharing for managed care organizations is calculated by treating premium, maintenance, and other taxes under...
- Texas Section 533.014 - Profit Sharing
(a) The executive commissioner shall adopt rules regarding the sharing of profits earned by a managed care organization through a managed care plan providing health...
- Texas Section 533.015 - Coordination Of External Oversight Activities
(a) To the extent possible, the commission shall coordinate all external oversight activities to minimize duplication of oversight of managed care plans under Medicaid and...
- Texas Section 533.015 - Coordination Of External Oversight Activities
(a) To the extent possible, the commission shall coordinate all external oversight activities to minimize duplication of oversight of managed care plans under Medicaid and...
- Texas Section 533.016 - Provider Reporting Of Encounter Data
The commission shall collaborate with managed care organizations that contract with the commission and health care providers under the organizations' provider networks to develop incentives...
- Texas Section 533.0161 - Monitoring Of Psychotropic Drug Prescriptions For Certain Children
(a) In this section, "psychotropic drug" has the meaning assigned by Section 261.111, Family Code. (b) The commission shall implement a system under which the...
- Texas Section 533.017 - Qualifications Of Certifier Of Encounter Data
(a) The person acting as the state Medicaid director shall appoint a person as the certifier of encounter data. (b) The certifier of encounter data...
- Texas Section 533.018 - Certification Of Encounter Data
(a) The certifier of encounter data shall certify the completeness, accuracy, and reliability of encounter data for each state fiscal year. (b) The commission shall...
- Texas Section 533.019 - Value-added Services
The commission shall actively encourage managed care organizations that contract with the commission to offer benefits, including health care services or benefits or other types...
SUBCHAPTER E PILOT PROGRAM TO INCREASE INCENTIVE-BASED PROVIDER PAYMENTS
- Texas Section 533.020 - Managed Care Organizations: Fiscal Solvency And Complaint System Guidelines
(a) The Texas Department of Insurance, in conjunction with the commission, shall establish fiscal solvency standards and complaint system guidelines for managed care organizations that...
- Texas Section 533.081 - Definition
In this subchapter, "pilot program" means the pilot program to increase incentive-based provider payments established under Section 533.082. Added by Acts 2015, 84th Leg., R.S.,...
- Texas Section 533.082 - Pilot Program To Increase Incentive-based Provider Payments
The commission shall develop a pilot program to increase the use and effectiveness of incentive-based provider payments by managed care organizations providing services under the...
- Texas Section 533.083 - Assessment And Implementation Of Pilot Program Findings
Not later than September 1, 2018, and notwithstanding any other law, the commission shall: (1) based on the results of the pilot program, identify which...
- Texas Section 533.084 - Expiration
Sections 533.081 and 533.082 and this section expire September 1, 2018. Added by Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.25(a), eff....
Last modified: September 28, 2016