Sec. 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:
(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 those laboratories located in children's hospitals; and
(2) include in its provider network for not less than 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 prescribed by the commission;
(ii) agrees to accept the prevailing provider contract rate of the managed care organization; and
(iii) has the credentials required by the managed care organization, 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 designated by the commission as a statewide significant traditional provider.
(b) A contract between a managed care organization and the commission for the organization to provide health care services to recipients in a health care service region that includes a rural area must require that the organization include in its provider network rural hospitals, physicians, home and community support services agencies, and other rural health care providers who:
(1) are sole community providers;
(2) provide care to Medicaid and charity care recipients at a significant level as prescribed by the commission;
(3) agree to accept the prevailing provider contract rate of the managed care organization; and
(4) have the credentials required by the managed care organization, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997. Amended by Acts 1999, 76th Leg., ch. 1447, Sec. 5, eff. June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.05, eff. Sept. 1, 1999.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.225, eff. April 2, 2015.
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