Sec. 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 in costs of health care services;
(2) the range and type of health care services to be covered by premium payment rates;
(3) the number of managed care plans in a region;
(4) the current and projected number of recipients in each region, including the current and projected number for each category of recipient;
(5) the ability of the managed care plan to meet costs of operation under the proposed premium payment rates;
(6) the applicable requirements of the federal Balanced Budget Act of 1997 and implementing regulations that require adequacy of premium payments to managed care organizations participating in Medicaid;
(7) the adequacy of the management fee paid for assisting enrollees of Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.) who are voluntarily enrolled in the managed care plan;
(8) the impact of reducing premium payment rates for the category of recipients who are pregnant; and
(9) the ability of the managed care plan to pay under the proposed premium payment rates inpatient and outpatient hospital provider payment rates that are comparable to the inpatient and outpatient hospital provider payment rates paid by the commission under a primary care case management model or a partially capitated model.
(b) In determining the maximum premium payment rates paid to a managed care organization that is licensed under Chapter 843, Insurance Code, the commission shall consider and adjust for the regional variation in costs of services under the traditional fee-for-service component of Medicaid, utilization patterns, and other factors that influence the potential for cost savings. For a service area with a service area factor of.93 or less, or another appropriate service area factor, as determined by the commission, the commission may not discount premium payment rates in an amount that is more than the amount necessary to meet federal budget neutrality requirements for projected fee-for-service costs unless:
(1) a historical review of managed care financial results among managed care organizations in the service area served by the organization demonstrates that additional savings are warranted;
(2) a review of Medicaid fee-for-service delivery in the service area served by the organization has historically shown a significant overutilization by recipients of certain services covered by the premium payment rates in comparison to utilization patterns throughout the rest of the state; or
(3) a review of Medicaid fee-for-service delivery in the service area served by the organization has historically shown an above-market cost for services for which there is substantial evidence that Medicaid managed care delivery will reduce the cost of those services.
(c) The premium payment rates paid to a managed care organization that is licensed under Chapter 843, Insurance Code, shall be established by a competitive bid process but may not exceed the maximum premium payment rates established by the commission under Subsection (b).
(d) Subsection (b) applies only to a managed care organization with respect to Medicaid managed care pilot programs, Medicaid behavioral health pilot programs, and Medicaid Star + Plus pilot programs implemented in a health care service region after June 1, 1999.
(e) The commission shall pursue and, if appropriate, implement premium rate-setting strategies that encourage provider payment reform and more efficient service delivery and provider practices. In pursuing premium rate-setting strategies under this section, the commission shall review and consider strategies employed or under consideration by other states. If necessary, the commission may request a waiver or other authorization from a federal agency to implement strategies identified under this subsection.
Added by Acts 1999, 76th Leg., ch. 1447, Sec. 8, eff. June 19, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 9.08, eff. Sept. 1, 1999. Amended by Acts 2003, 78th Leg., ch. 1276, Sec. 10A.516, eff. Sept. 1, 2003.
Amended by:
Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 5.01, eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.230, 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