Sec. 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 disease management programs to manage a disease or other chronic health conditions, such as heart disease, chronic kidney disease and its medical complications, respiratory illness, including asthma, diabetes, end-stage renal disease, HIV infection, or AIDS, and with respect to which the commission identifies populations for which disease management would be cost-effective.
(b) A managed health care plan provided under this chapter must provide disease management services in the manner required by the commission, including:
(1) patient self-management education;
(2) provider education;
(3) evidence-based models and minimum standards of care;
(4) standardized protocols and participation criteria; and
(5) physician-directed or physician-supervised care.
(c) The executive commissioner, by rule, shall prescribe the minimum requirements that a managed care organization, in providing a disease management program, must meet to be eligible to receive a contract under this section. The managed care organization must, at a minimum, be required to:
(1) provide disease management services that have performance measures for particular diseases that are comparable to the relevant performance measures applicable to a provider of disease management services under Section 32.057, Human Resources Code;
(2) show evidence of ability to manage complex diseases in the Medicaid population; and
(3) if a disease management program provided by the organization has low active participation rates, identify the reason for the low rates and develop an approach to increase active participation in disease management programs for high-risk recipients.
(d) Expired.
(e) Expired.
(f) If a managed care organization implements a special disease management program to manage chronic kidney disease and its medical complications as provided by Subsection (a) and the managed care organization develops a program to provide screening for and diagnosis and treatment of chronic kidney disease and its medical complications to recipients under the organization's managed care plan, the program for screening, diagnosis, and treatment must use generally recognized clinical practice guidelines and laboratory assessments that identify chronic kidney disease on the basis of impaired kidney function or the presence of kidney damage.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997. Amended by Acts 2001, 77th Leg., ch. 698, Sec. 1, eff. Sept. 1, 2001; Acts 2003, 78th Leg., ch. 589, Sec. 7, eff. June 20, 2003.
Amended by:
Acts 2005, 79th Leg., Ch. 349 (S.B. 1188), Sec. 19(a), eff. September 1, 2005.
Acts 2005, 79th Leg., Ch. 1047 (H.B. 1252), Sec. 1, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 921 (H.B. 3167), Sec. 17.001(38), eff. September 1, 2007.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.228, eff. April 2, 2015.
Acts 2021, 87th Leg., R.S., Ch. 820 (H.B. 2658), Sec. 5, eff. September 1, 2021.
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