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 and 533.00252:
(1) Repealed by Acts 2015, 84th Leg., R.S., Ch. 837, Sec. 3.40(a)(14), and Ch. 946, 2.37(b)(13) eff. January 1, 2016.
(2) "Clean claim" means a claim that meets the same criteria for a clean claim used by the Department of Aging and Disability Services for the reimbursement of nursing facility claims.
(3) "Nursing facility" means a convalescent or nursing home or related institution licensed under Chapter 242, Health and Safety Code, that provides long-term services and supports to recipients.
(4) "Potentially preventable event" has the meaning assigned by Section 536.001.
(b) Subject to Section 533.0025, the commission shall expand the STAR + PLUS Medicaid managed care program to all areas of this state to serve individuals eligible for acute care services and long-term services and supports under Medicaid.
Text of subsection effective until September 01, 2023
(c) Subject to Section 533.0025 and notwithstanding any other law, the commission shall provide benefits under Medicaid to recipients who reside in nursing facilities through the STAR + PLUS Medicaid managed care program. In implementing this subsection, the commission shall ensure:
(1) that the commission is responsible for setting the minimum reimbursement rate paid to a nursing facility under the managed care program;
(2) that a nursing facility is paid not later than the 10th day after the date the facility submits a clean claim;
(3) the appropriate utilization of services consistent with criteria established by the commission;
(4) a reduction in the incidence of potentially preventable events and unnecessary institutionalizations;
(5) that a managed care organization providing services under the managed care program provides discharge planning, transitional care, and other education programs to physicians and hospitals regarding all available long-term care settings;
(6) that a managed care organization providing services under the managed care program:
(A) assists in collecting applied income from recipients; and
(B) provides payment incentives to nursing facility providers that reward reductions in preventable acute care costs and encourage transformative efforts in the delivery of nursing facility services, including efforts to promote a resident-centered care culture through facility design and services provided;
(7) the establishment of a portal that is in compliance with state and federal regulations, including standard coding requirements, through which nursing facility providers participating in the STAR + PLUS Medicaid managed care program may submit claims to any participating managed care organization;
(8) that rules and procedures relating to the certification and decertification of nursing facility beds under Medicaid are not affected;
(9) that a managed care organization providing services under the managed care program, to the greatest extent possible, offers nursing facility providers access to:
(A) acute care professionals; and
(B) telemedicine, when feasible and in accordance with state law, including rules adopted by the Texas Medical Board; and
(10) that the commission approves the staff rate enhancement methodology for the staff rate enhancement paid to a nursing facility that qualifies for the enhancement under the managed care program.
Text of subsection effective on September 01, 2023
(c) Subject to Section 533.0025 and notwithstanding any other law, the commission shall provide benefits under Medicaid to recipients who reside in nursing facilities through the STAR + PLUS Medicaid managed care program. In implementing this subsection, the commission shall ensure:
(1) that a nursing facility is paid not later than the 10th day after the date the facility submits a clean claim;
(2) the appropriate utilization of services consistent with criteria established by the commission;
(3) a reduction in the incidence of potentially preventable events and unnecessary institutionalizations;
(4) that a managed care organization providing services under the managed care program provides discharge planning, transitional care, and other education programs to physicians and hospitals regarding all available long-term care settings;
(5) that a managed care organization providing services under the managed care program:
(A) assists in collecting applied income from recipients; and
(B) provides payment incentives to nursing facility providers that reward reductions in preventable acute care costs and encourage transformative efforts in the delivery of nursing facility services, including efforts to promote a resident-centered care culture through facility design and services provided;
(6) the establishment of a portal that is in compliance with state and federal regulations, including standard coding requirements, through which nursing facility providers participating in the STAR + PLUS Medicaid managed care program may submit claims to any participating managed care organization;
(7) that rules and procedures relating to the certification and decertification of nursing facility beds under Medicaid are not affected;
(8) that a managed care organization providing services under the managed care program, to the greatest extent possible, offers nursing facility providers access to:
(A) acute care professionals; and
(B) telemedicine, when feasible and in accordance with state law, including rules adopted by the Texas Medical Board; and
(9) that the commission approves the staff rate enhancement methodology for the staff rate enhancement paid to a nursing facility that qualifies for the enhancement under the managed care program.
(e) The commission shall establish credentialing and minimum performance standards for nursing facility providers seeking to participate in the STAR + PLUS Medicaid managed care program that are consistent with adopted federal and state standards. A managed care organization may refuse to contract with a nursing facility provider if the nursing facility does not meet the minimum performance standards established by the commission under this section.
(f) A managed care organization may not require prior authorization for a nursing facility resident in need of emergency hospital services.
(h) In addition to the minimum performance standards the commission establishes for nursing facility providers seeking to participate in the STAR+PLUS Medicaid managed care program, the executive commissioner shall adopt rules establishing minimum performance standards applicable to nursing facility providers that participate in the program. The commission is responsible for monitoring provider performance in accordance with the standards and requiring corrective actions, as the commission determines necessary, from providers that do not meet the standards. The commission shall share data regarding the requirements of this subsection with STAR+PLUS Medicaid managed care organizations as appropriate.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 2.02, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.212, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.213, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.13, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.40(a)(14), eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.13, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.37(b)(13), eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 1117 (H.B. 3523), Sec. 1, eff. June 19, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1117 (H.B. 3523), Sec. 2, eff. September 1, 2021.
Acts 2021, 87th Leg., R.S., Ch. 820 (H.B. 2658), Sec. 2, eff. September 1, 2021.
Acts 2021, 87th Leg., R.S., Ch. 820 (H.B. 2658), Sec. 14, eff. September 1, 2023.
For expiration of Subsections (f), (g), (h), (i), (j), and (k), see Subsection (k).
For expiration of Subsections (l), (l-1), and (l-2), see Subsection (l-2).
Structure Texas Statutes
Subtitle I - Health and Human Services
Chapter 533 - Medicaid Managed Care Program
Subchapter A. General Provisions
Section 533.0025. Delivery of Services
Section 533.00253. Star Kids Medicaid Managed Care Program
Section 533.00254. Star Kids Managed Care Advisory Committee
Section 533.00255. Behavioral Health and Physical Health Services Network
Section 533.002551. Monitoring of Compliance With Behavioral Health Integration
Section 533.002553. Behavioral Health Services Provided Through Third Party or Subsidiary
Section 533.00256. Managed Care Clinical Improvement Program
Section 533.00258. Nonmedical Transportation Services Under Medicaid Managed Care Program
Section 533.0027. Procedures to Ensure Certain Recipients Are Enrolled in Same Managed Care Plan
Section 533.0028. Evaluation of Certain Star + Plus Medicaid Managed Care Program Services
Section 533.00281. Utilization Review for Star + Plus Medicaid Managed Care Organizations
Section 533.00282. Utilization Review and Prior Authorization Procedures
Section 533.002821. Prior Authorization Procedures for Hospitalized Recipient
Section 533.00283. Annual Review of Prior Authorization Requirements
Section 533.002841. Maximum Period for Prior Authorization Decision; Access to Care
Section 533.0029. Promotion and Principles of Patient-Centered Medical Homes for Recipients
Section 533.003. Considerations in Awarding Contracts
Section 533.0031. Medicaid Managed Care Plan Accreditation
Section 533.0035. Certification by Commission
Section 533.004. Mandatory Contracts
Section 533.005. Required Contract Provisions
Section 533.0051. Performance Measures and Incentives for Value-Based Contracts
Section 533.00511. Quality-Based Enrollment Incentive Program for Managed Care Organizations
Section 533.00515. Medication Therapy Management
Section 533.0052. Star Health Program: Trauma-Informed Care Training
Section 533.00521. Star Health Program: Health Care for Foster Children
Section 533.00522. Star Health Program: Mental Health Providers
Section 533.0053. Compliance With Texas Health Steps
Section 533.00531. Medicaid Benefits for Certain Children Formerly in Foster Care
Section 533.0054. Health Screening Requirements for Enrollee Under Star Health Program
Section 533.0055. Provider Protection Plan
Section 533.0056. Star Health Program: Notification of Placement Change
Section 533.006. Provider Networks
Section 533.0061. Provider Access Standards; Report
Section 533.0062. Penalties and Other Remedies for Failure to Comply With Provider Access Standards
Section 533.0063. Provider Network Directories
Section 533.0064. Expedited Credentialing Process for Certain Providers
Section 533.0065. Frequency of Provider Credentialing
Section 533.0066. Provider Incentives
Section 533.0067. Eye Health Care Service Providers
Section 533.007. Contract Compliance
Section 533.0071. Administration of Contracts
Section 533.0072. Internet Posting of Sanctions Imposed for Contractual Violations
Section 533.0073. Medical Director Qualifications
Section 533.0075. Recipient Enrollment
Section 533.00751. Recipient Directory
Section 533.0076. Limitations on Recipient Disenrollment
Section 533.0077. Statewide Effort to Promote Maintenance of Eligibility
Section 533.008. Marketing Guidelines
Section 533.009. Special Disease Management
Section 533.010. Special Protocols
Section 533.011. Public Notice
Section 533.012. Information for Fraud Control
Section 533.013. Premium Payment Rate Determination; Review and Comment
Section 533.0131. Use of Encounter Data in Determining Premium Payment Rates
Section 533.01315. Reimbursement for Services Provided Outside of Regular Business Hours
Section 533.014. Profit Sharing
Section 533.015. Coordination of External Oversight Activities
Section 533.016. Provider Reporting of Encounter Data
Section 533.0161. Monitoring of Psychotropic Drug Prescriptions for Certain Children
Section 533.017. Qualifications of Certifier of Encounter Data
Section 533.018. Certification of Encounter Data
Section 533.019. Value-Added Services
Section 533.020. Managed Care Organizations: Fiscal Solvency and Complaint System Guidelines
Section 533.038. Coordination of Benefits; Continuity of Specialty Care for Certain Recipients
Section 533.039. Delivery of Benefits Using Telecommunications and Information Technology