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Subchapter A. General Provisions
Section 533.001. Definitions - Sec. 533.001. DEFINITIONS. In this chapter: (1) "Commission" means the...
Section 533.002. Purpose - Sec. 533.002. PURPOSE. The commission shall implement the Medicaid managed...
Section 533.0025. Delivery of Services - Sec. 533.0025. DELIVERY OF SERVICES. (a) Repealed by Acts 2015,...
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,...
Section 533.00253. Star Kids Medicaid Managed Care Program - Sec. 533.00253. STAR KIDS MEDICAID MANAGED CARE PROGRAM. (a) In...
Section 533.00254. Star Kids Managed Care Advisory Committee - Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE. (a) The...
Section 533.00255. Behavioral Health and Physical Health Services Network - Sec. 533.00255. BEHAVIORAL HEALTH AND PHYSICAL HEALTH SERVICES NETWORK. (a)...
Section 533.002551. Monitoring of Compliance With Behavioral Health Integration - Sec. 533.002551. MONITORING OF COMPLIANCE WITH BEHAVIORAL HEALTH INTEGRATION. (a)...
Section 533.002552. Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families - Sec. 533.002552. TARGETED CASE MANAGEMENT AND PSYCHIATRIC REHABILITATIVE SERVICES FOR...
Section 533.002553. Behavioral Health Services Provided Through Third Party or Subsidiary - Sec. 533.002553. BEHAVIORAL HEALTH SERVICES PROVIDED THROUGH THIRD PARTY OR...
Section 533.002555. Transition of Case Management for Children and Pregnant Women Program Recipients to Managed Care Program - Sec. 533.002555. TRANSITION OF CASE MANAGEMENT FOR CHILDREN AND PREGNANT...
Section 533.00256. Managed Care Clinical Improvement Program - Sec. 533.00256. MANAGED CARE CLINICAL IMPROVEMENT PROGRAM. (a) In consultation...
Section 533.00257. Delivery of Medical Transportation Program Services Through Managed Transportation Organization - Sec. 533.00257. DELIVERY OF MEDICAL TRANSPORTATION PROGRAM SERVICES THROUGH MANAGED...
Section 533.002571. Delivery of Nonemergency Transportation Services to Certain Medicaid Recipients Through Medicaid Managed Care Organization - Sec. 533.002571. DELIVERY OF NONEMERGENCY TRANSPORTATION SERVICES TO CERTAIN MEDICAID...
Section 533.00258. Nonmedical Transportation Services Under Medicaid Managed Care Program - Sec. 533.00258. NONMEDICAL TRANSPORTATION SERVICES UNDER MEDICAID MANAGED CARE PROGRAM....
Section 533.002581. Delivery of Nonmedical Transportation Services Under Medicaid Managed Care Program - Sec. 533.002581. DELIVERY OF NONMEDICAL TRANSPORTATION SERVICES UNDER MEDICAID MANAGED...
Section 533.0026. Direct Access to Eye Health Care Services Under Medicaid Managed Care Model or Arrangement - Sec. 533.0026. DIRECT ACCESS TO EYE HEALTH CARE SERVICES UNDER...
Section 533.0027. Procedures to Ensure Certain Recipients Are Enrolled in Same Managed Care Plan - Sec. 533.0027. PROCEDURES TO ENSURE CERTAIN RECIPIENTS ARE ENROLLED IN...
Section 533.0028. Evaluation of Certain Star + Plus Medicaid Managed Care Program Services - Sec. 533.0028. EVALUATION OF CERTAIN STAR + PLUS MEDICAID MANAGED...
Section 533.00281. Utilization Review for Star + Plus Medicaid Managed Care Organizations - Sec. 533.00281. UTILIZATION REVIEW FOR STAR + PLUS MEDICAID MANAGED...
Section 533.00282. Utilization Review and Prior Authorization Procedures - Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION PROCEDURES. (a) Section...
Section 533.002821. Prior Authorization Procedures for Hospitalized Recipient - Sec. 533.002821. PRIOR AUTHORIZATION PROCEDURES FOR HOSPITALIZED RECIPIENT. In addition...
Section 533.00283. Annual Review of Prior Authorization Requirements - Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION REQUIREMENTS. (a) Each...
Section 533.00284. Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests - Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION...
Section 533.002841. Maximum Period for Prior Authorization Decision; Access to Care - Sec. 533.002841. MAXIMUM PERIOD FOR PRIOR AUTHORIZATION DECISION; ACCESS TO...
Section 533.0029. Promotion and Principles of Patient-Centered Medical Homes for Recipients - Sec. 533.0029. PROMOTION AND PRINCIPLES OF PATIENT-CENTERED MEDICAL HOMES FOR...
Section 533.003. Considerations in Awarding Contracts - Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. (a) In awarding contracts...
Section 533.0031. Medicaid Managed Care Plan Accreditation - Sec. 533.0031. MEDICAID MANAGED CARE PLAN ACCREDITATION. (a) A managed...
Section 533.0035. Certification by Commission - Sec. 533.0035. CERTIFICATION BY COMMISSION. (a) Before the commission may...
Section 533.004. Mandatory Contracts - Sec. 533.004. MANDATORY CONTRACTS. (a) Subject to the considerations required...
Section 533.005. Required Contract Provisions - Sec. 533.005. REQUIRED CONTRACT PROVISIONS. (a) A contract between a...
Section 533.0051. Performance Measures and Incentives for Value-Based Contracts - Sec. 533.0051. PERFORMANCE MEASURES AND INCENTIVES FOR VALUE-BASED CONTRACTS. (a)...
Section 533.00511. Quality-Based Enrollment Incentive Program for Managed Care Organizations - Sec. 533.00511. QUALITY-BASED ENROLLMENT INCENTIVE PROGRAM FOR MANAGED CARE ORGANIZATIONS....
Section 533.00515. Medication Therapy Management - Sec. 533.00515. MEDICATION THERAPY MANAGEMENT. The executive commissioner shall collaborate...
Section 533.0052. Star Health Program: Trauma-Informed Care Training - Sec. 533.0052. STAR HEALTH PROGRAM: TRAUMA-INFORMED CARE TRAINING. (a) A...
Section 533.00521. Star Health Program: Health Care for Foster Children - Sec. 533.00521. STAR HEALTH PROGRAM: HEALTH CARE FOR FOSTER CHILDREN....
Section 533.00522. Star Health Program: Mental Health Providers - Sec. 533.00522. STAR HEALTH PROGRAM: MENTAL HEALTH PROVIDERS. A contract...
Section 533.0053. Compliance With Texas Health Steps - Sec. 533.0053. COMPLIANCE WITH TEXAS HEALTH STEPS. The commission shall...
Section 533.00531. Medicaid Benefits for Certain Children Formerly in Foster Care - Sec. 533.00531. MEDICAID BENEFITS FOR CERTAIN CHILDREN FORMERLY IN FOSTER...
Section 533.0054. Health Screening Requirements for Enrollee Under Star Health Program - Sec. 533.0054. HEALTH SCREENING REQUIREMENTS FOR ENROLLEE UNDER STAR HEALTH...
Section 533.0055. Provider Protection Plan - Sec. 533.0055. PROVIDER PROTECTION PLAN. (a) The commission shall develop...
Section 533.0056. Star Health Program: Notification of Placement Change - Sec. 533.0056. STAR HEALTH PROGRAM: NOTIFICATION OF PLACEMENT CHANGE. A...
Section 533.006. Provider Networks - Sec. 533.006. PROVIDER NETWORKS. (a) The commission shall require that...
Section 533.0061. Provider Access Standards; Report - Sec. 533.0061. PROVIDER ACCESS STANDARDS; REPORT. (a) The commission shall...
Section 533.0062. Penalties and Other Remedies for Failure to Comply With Provider Access Standards - Sec. 533.0062. PENALTIES AND OTHER REMEDIES FOR FAILURE TO COMPLY...
Section 533.0063. Provider Network Directories - Sec. 533.0063. PROVIDER NETWORK DIRECTORIES. (a) The commission shall ensure...
Section 533.0064. Expedited Credentialing Process for Certain Providers - Sec. 533.0064. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN PROVIDERS. (a) In...
Section 533.0065. Frequency of Provider Credentialing - Sec. 533.0065. FREQUENCY OF PROVIDER CREDENTIALING. A managed care organization...
Section 533.0066. Provider Incentives - Sec. 533.0066. PROVIDER INCENTIVES. The commission shall, to the extent...
Section 533.0067. Eye Health Care Service Providers - Sec. 533.0067. EYE HEALTH CARE SERVICE PROVIDERS. Subject to Section...
Section 533.007. Contract Compliance - Sec. 533.007. CONTRACT COMPLIANCE. (a) The commission shall review each...
Section 533.0071. Administration of Contracts - Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission shall make every...
Section 533.0072. Internet Posting of Sanctions Imposed for Contractual Violations - Sec. 533.0072. INTERNET POSTING OF SANCTIONS IMPOSED FOR CONTRACTUAL VIOLATIONS....
Section 533.0073. Medical Director Qualifications - Sec. 533.0073. MEDICAL DIRECTOR QUALIFICATIONS. A person who serves as...
Section 533.0075. Recipient Enrollment - Sec. 533.0075. RECIPIENT ENROLLMENT. The commission shall: (1) encourage recipients...
Section 533.00751. Recipient Directory - Sec. 533.00751. RECIPIENT DIRECTORY. The commission shall in accordance with...
Section 533.0076. Limitations on Recipient Disenrollment - Sec. 533.0076. LIMITATIONS ON RECIPIENT DISENROLLMENT. (a) Except as provided...
Section 533.0077. Statewide Effort to Promote Maintenance of Eligibility - Sec. 533.0077. STATEWIDE EFFORT TO PROMOTE MAINTENANCE OF ELIGIBILITY. (a)...
Section 533.008. Marketing Guidelines - Sec. 533.008. MARKETING GUIDELINES. (a) The commission shall establish marketing...
Section 533.009. Special Disease Management - Sec. 533.009. SPECIAL DISEASE MANAGEMENT. (a) The commission shall ensure...
Section 533.010. Special Protocols - Sec. 533.010. SPECIAL PROTOCOLS. In conjunction with an academic center,...
Section 533.011. Public Notice - Sec. 533.011. PUBLIC NOTICE. Not later than the 30th day...
Section 533.012. Information for Fraud Control - Sec. 533.012. INFORMATION FOR FRAUD CONTROL. (a) Each managed care...
Section 533.013. Premium Payment Rate Determination; Review and Comment - Sec. 533.013. PREMIUM PAYMENT RATE DETERMINATION; REVIEW AND COMMENT. (a)...
Section 533.0131. Use of Encounter Data in Determining Premium Payment Rates - Sec. 533.0131. USE OF ENCOUNTER DATA IN DETERMINING PREMIUM PAYMENT...
Section 533.01315. Reimbursement for Services Provided Outside of Regular Business Hours - Sec. 533.01315. REIMBURSEMENT FOR SERVICES PROVIDED OUTSIDE OF REGULAR BUSINESS...
Section 533.0132. State Taxes - Sec. 533.0132. STATE TAXES. The commission shall ensure that any...
Section 533.014. Profit Sharing - Sec. 533.014. PROFIT SHARING. (a) The executive commissioner shall adopt...
Section 533.015. Coordination of External Oversight Activities - Sec. 533.015. COORDINATION OF EXTERNAL OVERSIGHT ACTIVITIES. (a) To the...
Section 533.016. Provider Reporting of Encounter Data - Sec. 533.016. PROVIDER REPORTING OF ENCOUNTER DATA. The commission shall...
Section 533.0161. Monitoring of Psychotropic Drug Prescriptions for Certain Children - Sec. 533.0161. MONITORING OF PSYCHOTROPIC DRUG PRESCRIPTIONS FOR CERTAIN CHILDREN....
Section 533.017. Qualifications of Certifier of Encounter Data - Sec. 533.017. QUALIFICATIONS OF CERTIFIER OF ENCOUNTER DATA. (a) The...
Section 533.018. Certification of Encounter Data - Sec. 533.018. CERTIFICATION OF ENCOUNTER DATA. (a) The certifier of...
Section 533.019. Value-Added Services - Sec. 533.019. VALUE-ADDED SERVICES. The commission shall actively encourage managed...
Section 533.020. Managed Care Organizations: Fiscal Solvency and Complaint System Guidelines - Sec. 533.020. MANAGED CARE ORGANIZATIONS: FISCAL SOLVENCY AND COMPLAINT SYSTEM...
Section 533.038. Coordination of Benefits; Continuity of Specialty Care for Certain Recipients - Sec. 533.038. COORDINATION OF BENEFITS; CONTINUITY OF SPECIALTY CARE FOR...
Section 533.039. Delivery of Benefits Using Telecommunications and Information Technology - Sec. 533.039. DELIVERY OF BENEFITS USING TELECOMMUNICATIONS AND INFORMATION TECHNOLOGY....
Subchapter B. Strategy for Managing Audit Resources
Section 533.051. Definitions - Sec. 533.051. DEFINITIONS. In this subchapter: (1) "Accounts receivable tracking...
Section 533.052. Applicability and Construction of Subchapter - Sec. 533.052. APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER. This subchapter does...
Section 533.053. Overall Strategy for Managing Audit Resources - Sec. 533.053. OVERALL STRATEGY FOR MANAGING AUDIT RESOURCES. The commission...
Section 533.054. Performance Audit Selection Process and Follow-Up - Sec. 533.054. PERFORMANCE AUDIT SELECTION PROCESS AND FOLLOW-UP. (a) To...
Section 533.055. Agreed-Upon Procedures Engagements and Corrective Action Plans - Sec. 533.055. AGREED-UPON PROCEDURES ENGAGEMENTS AND CORRECTIVE ACTION PLANS. To...
Section 533.056. Audits of Pharmacy Benefit Managers - Sec. 533.056. AUDITS OF PHARMACY BENEFIT MANAGERS. To obtain greater...
Section 533.057. Collection of Costs for Audit-Related Services - Sec. 533.057. COLLECTION OF COSTS FOR AUDIT-RELATED SERVICES. The commission...
Section 533.058. Collection Activities Related to Profit Sharing - Sec. 533.058. COLLECTION ACTIVITIES RELATED TO PROFIT SHARING. To strengthen...
Section 533.059. Use of Information From External Quality Reviews - Sec. 533.059. USE OF INFORMATION FROM EXTERNAL QUALITY REVIEWS. (a)...
Section 533.060. Security and Processing Controls Over Information Technology Systems - Sec. 533.060. SECURITY AND PROCESSING CONTROLS OVER INFORMATION TECHNOLOGY SYSTEMS....
Subchapter E. Pilot Program to Increase Incentive-Based Provider Payments
Section 533.083. Assessment and Implementation of Pilot Program Findings - Sec. 533.083. ASSESSMENT AND IMPLEMENTATION OF PILOT PROGRAM FINDINGS. Not...