S.B. No. 760
 
 
 
 
AN ACT
  relating to access and assignment requirements for, support and
  information regarding, and investigations of certain providers of
  health care and long-term services.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  The heading to Section 261.404, Family Code, as
  amended by S.B. No. 219, Acts of the 84th Legislature, Regular
  Session, 2015, is amended to read as follows:
         Sec. 261.404.  INVESTIGATIONS REGARDING CERTAIN CHILDREN
  RECEIVING SERVICES FROM CERTAIN PROVIDERS [WITH MENTAL ILLNESS OR
  AN INTELLECTUAL DISABILITY].
         SECTION 2.  Section 261.404, Family Code, as amended by S.B.
  No. 219, Acts of the 84th Legislature, Regular Session, 2015, is
  amended by amending Subsections (a) and (b) and adding Subsections
  (a-1), (a-2), and (a-3) to read as follows:
         (a)  The department shall investigate a report of abuse,
  neglect, or exploitation of a child receiving services from a
  provider, as those terms are defined by Section 48.251, Human
  Resources Code, or as otherwise defined by rule.  The department
  shall also investigate, under Subchapter F, Chapter 48, Human
  Resources Code, a report of abuse, neglect, or exploitation of a
  child receiving services from an officer, employee, agent,
  contractor, or subcontractor of a home and community support
  services agency licensed under Chapter 142, Health and Safety Code,
  if the officer, employee, agent, contractor, or subcontractor is or
  may be the person alleged to have committed the abuse, neglect, or
  exploitation[:
               [(1)     in a facility operated by the Department of Aging
  and Disability Services or a mental health facility operated by the
  Department of State Health Services;
               [(2)     in or from a community center, a local mental
  health authority, or a local intellectual and developmental
  disability authority;
               [(3)     through a program providing services to that
  child by contract with a facility operated by the Department of
  Aging and Disability Services, a mental health facility operated by
  the Department of State Health Services, a community center, a
  local mental health authority, or a local intellectual and
  developmental disability authority;
               [(4)     from a provider of home and community-based
  services who contracts with the Department of Aging and Disability
  Services; or
               [(5)     in a facility licensed under Chapter 252, Health
  and Safety Code].
         (a-1)  For an investigation of a child living in a residence
  owned, operated, or controlled by a provider of services under the
  home and community-based services waiver program described by
  Section 534.001(11)(B), Government Code, the department, in
  accordance with Subchapter E, Chapter 48, Human Resources Code, may
  provide emergency protective services necessary to immediately
  protect the child from serious physical harm or death and, if
  necessary, obtain an emergency order for protective services under
  Section 48.208, Human Resources Code.
         (a-2)  For an investigation of a child living in a residence
  owned, operated, or controlled by a provider of services under the
  home and community-based services waiver program described by
  Section 534.001(11)(B), Government Code, regardless of whether the
  child is receiving services under that waiver program from the
  provider, the department shall provide protective services to the
  child in accordance with Subchapter E, Chapter 48, Human Resources
  Code.
         (a-3)  For purposes of this section, Subchapters E and F,
  Chapter 48, Human Resources Code, apply to an investigation of a
  child and to the provision of protective services to that child in
  the same manner those subchapters apply to an investigation of an
  elderly person or person with a disability and the provision of
  protective services to that person.
         (b)  The department shall investigate the report under rules
  developed by the executive commissioner [with the advice and
  assistance of the department, the Department of Aging and
  Disability Services, and the Department of State Health Services].
         SECTION 3.  Section 531.0213, Government Code, is amended by
  adding Subsections (b-1) and (e), amending Subsection (c), and
  amending Subsection (d), as amended by S.B. No. 219, Acts of the
  84th Legislature, Regular Session, 2015, to read as follows:
         (b-1)  The commission shall provide support and information
  services required by this section through a network of entities
  coordinated by the commission's office of the ombudsman or other
  division of the commission designated by the executive commissioner
  and composed of:
               (1)  the commission's office of the ombudsman or other
  division of the commission designated by the executive commissioner
  to coordinate the network;
               (2)  the office of the state long-term care ombudsman
  required under Subchapter F, Chapter 101A, Human Resources Code;
               (3)  the division within the commission responsible for
  oversight of Medicaid managed care contracts;
               (4)  area agencies on aging;
               (5)  aging and disability resource centers established
  under the Aging and Disability Resource Center initiative funded in
  part by the federal Administration on Aging and the Centers for
  Medicare and Medicaid Services; and
               (6)  any other entity the executive commissioner
  determines appropriate, including nonprofit organizations with
  which the commission contracts under Subsection (c).
         (c)  The commission may provide support and information
  services by contracting with [a] nonprofit organizations
  [organization] that are [is] not involved in providing health care,
  health insurance, or health benefits.
         (d)  As a part of the support and information services
  required by this section, the commission [or nonprofit
  organization] shall:
               (1)  operate a statewide toll-free assistance
  telephone number that includes relay services for persons with
  speech or hearing disabilities [TDD lines] and assistance for
  persons who speak Spanish;
               (2)  intervene promptly with the state Medicaid office,
  managed care organizations and providers, and any other appropriate
  entity on behalf of a person who has an urgent need for medical
  services;
               (3)  assist a person who is experiencing barriers in
  the Medicaid application and enrollment process and refer the
  person for further assistance if appropriate;
               (4)  educate persons so that they:
                     (A)  understand the concept of managed care;
                     (B)  understand their rights under Medicaid,
  including grievance and appeal procedures; and
                     (C)  are able to advocate for themselves;
               (5)  collect and maintain statistical information on a
  regional basis regarding calls received by the assistance lines and
  publish quarterly reports that:
                     (A)  list the number of calls received by region;
                     (B)  identify trends in delivery and access
  problems;
                     (C)  identify recurring barriers in the Medicaid
  system; and
                     (D)  indicate other problems identified with
  Medicaid managed care; [and]
               (6)  assist the state Medicaid office and managed care
  organizations and providers in identifying and correcting
  problems, including site visits to affected regions if necessary;
               (7)  meet the needs of all current and future Medicaid
  managed care recipients, including children receiving dental
  benefits and other recipients receiving benefits, under the:
                     (A)  STAR Medicaid managed care program;
                     (B)  STAR + PLUS Medicaid managed care program,
  including the Texas Dual Eligibles Integrated Care Demonstration
  Project provided under that program;
                     (C)  STAR Kids managed care program established
  under Section 533.00253; and
                     (D)  STAR Health program;
               (8)  incorporate support services for children
  enrolled in the child health plan established under Chapter 62,
  Health and Safety Code; and
               (9)  ensure that staff providing support and
  information services receives sufficient training, including
  training in the Medicare program for the purpose of assisting
  recipients who are dually eligible for Medicare and Medicaid, and
  has sufficient authority to resolve barriers experienced by
  recipients to health care and long-term services and supports.
         (e)  The commission's office of the ombudsman, or other
  division of the commission designated by the executive commissioner
  to coordinate the network of entities responsible for providing
  support and information services under this section, must be
  sufficiently independent from other aspects of Medicaid managed
  care to represent the best interests of recipients in problem
  resolution.
         SECTION 4.  Section 533.005(a), Government Code, as amended
  by S.B. No. 219, Acts of the 84th Legislature, Regular Session,
  2015, is amended to read as follows:
         (a)  A contract between a managed care organization and the
  commission for the organization to provide health care services to
  recipients must contain:
               (1)  procedures to ensure accountability to the state
  for the provision of health care services, including procedures for
  financial reporting, quality assurance, utilization review, and
  assurance of contract and subcontract compliance;
               (2)  capitation rates that ensure the cost-effective
  provision of quality health care;
               (3)  a requirement that the managed care organization
  provide ready access to a person who assists recipients in
  resolving issues relating to enrollment, plan administration,
  education and training, access to services, and grievance
  procedures;
               (4)  a requirement that the managed care organization
  provide ready access to a person who assists providers in resolving
  issues relating to payment, plan administration, education and
  training, and grievance procedures;
               (5)  a requirement that the managed care organization
  provide information and referral about the availability of
  educational, social, and other community services that could
  benefit a recipient;
               (6)  procedures for recipient outreach and education;
               (7)  a requirement that the managed care organization
  make payment to a physician or provider for health care services
  rendered to a recipient under a managed care plan on any claim for
  payment that is received with documentation reasonably necessary
  for the managed care organization to process the claim:
                     (A)  not later than:
                           (i)  the 10th day after the date the claim is
  received if the claim relates to services provided by a nursing
  facility, intermediate care facility, or group home;
                           (ii)  the 30th day after the date the claim
  is received if the claim relates to the provision of long-term
  services and supports not subject to Subparagraph (i); and
                           (iii)  the 45th day after the date the claim
  is received if the claim is not subject to Subparagraph (i) or (ii);
  or
                     (B)  within a period, not to exceed 60 days,
  specified by a written agreement between the physician or provider
  and the managed care organization;
               (7-a)  a requirement that the managed care organization
  demonstrate to the commission that the organization pays claims
  described by Subdivision (7)(A)(ii) on average not later than the
  21st day after the date the claim is received by the organization;
               (8)  a requirement that the commission, on the date of a
  recipient's enrollment in a managed care plan issued by the managed
  care organization, inform the organization of the recipient's
  Medicaid certification date;
               (9)  a requirement that the managed care organization
  comply with Section 533.006 as a condition of contract retention
  and renewal;
               (10)  a requirement that the managed care organization
  provide the information required by Section 533.012 and otherwise
  comply and cooperate with the commission's office of inspector
  general and the office of the attorney general;
               (11)  a requirement that the managed care
  organization's usages of out-of-network providers or groups of
  out-of-network providers may not exceed limits for those usages
  relating to total inpatient admissions, total outpatient services,
  and emergency room admissions determined by the commission;
               (12)  if the commission finds that a managed care
  organization has violated Subdivision (11), a requirement that the
  managed care organization reimburse an out-of-network provider for
  health care services at a rate that is equal to the allowable rate
  for those services, as determined under Sections 32.028 and
  32.0281, Human Resources Code;
               (13)  a requirement that, notwithstanding any other
  law, including Sections 843.312 and 1301.052, Insurance Code, the
  organization:
                     (A)  use advanced practice registered nurses and
  physician assistants in addition to physicians as primary care
  providers to increase the availability of primary care providers in
  the organization's provider network; and
                     (B)  treat advanced practice registered nurses
  and physician assistants in the same manner as primary care
  physicians with regard to:
                           (i)  selection and assignment as primary
  care providers;
                           (ii)  inclusion as primary care providers in
  the organization's provider network; and
                           (iii)  inclusion as primary care providers
  in any provider network directory maintained by the organization;
               (14)  a requirement that the managed care organization
  reimburse a federally qualified health center or rural health
  clinic for health care services provided to a recipient outside of
  regular business hours, including on a weekend day or holiday, at a
  rate that is equal to the allowable rate for those services as
  determined under Section 32.028, Human Resources Code, if the
  recipient does not have a referral from the recipient's primary
  care physician;
               (15)  a requirement that the managed care organization
  develop, implement, and maintain a system for tracking and
  resolving all provider appeals related to claims payment, including
  a process that will require:
                     (A)  a tracking mechanism to document the status
  and final disposition of each provider's claims payment appeal;
                     (B)  the contracting with physicians who are not
  network providers and who are of the same or related specialty as
  the appealing physician to resolve claims disputes related to
  denial on the basis of medical necessity that remain unresolved
  subsequent to a provider appeal;
                     (C)  the determination of the physician resolving
  the dispute to be binding on the managed care organization and
  provider; and
                     (D)  the managed care organization to allow a
  provider with a claim that has not been paid before the time
  prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
  claim;
               (16)  a requirement that a medical director who is
  authorized to make medical necessity determinations is available to
  the region where the managed care organization provides health care
  services;
               (17)  a requirement that the managed care organization
  ensure that a medical director and patient care coordinators and
  provider and recipient support services personnel are located in
  the South Texas service region, if the managed care organization
  provides a managed care plan in that region;
               (18)  a requirement that the managed care organization
  provide special programs and materials for recipients with limited
  English proficiency or low literacy skills;
               (19)  a requirement that the managed care organization
  develop and establish a process for responding to provider appeals
  in the region where the organization provides health care services;
               (20)  a requirement that the managed care organization:
                     (A)  develop and submit to the commission, before
  the organization begins to provide health care services to
  recipients, a comprehensive plan that describes how the
  organization's provider network complies with the provider access
  standards established under Section 533.0061 [will provide
  recipients sufficient access to:
                           [(i)  preventive care;
                           [(ii)  primary care;
                           [(iii)  specialty care;
                           [(iv)  after-hours urgent care;
                           [(v)  chronic care;
                           [(vi)  long-term services and supports;
                           [(vii)  nursing services; and
                           [(viii)     therapy services, including
  services provided in a clinical setting or in a home or
  community-based setting]; [and]
                     (B)  as a condition of contract retention and
  renewal:
                           (i)  continue to comply with the provider
  access standards established under Section 533.0061; and
                           (ii)  make substantial efforts, as
  determined by the commission, to mitigate or remedy any
  noncompliance with the provider access standards established under
  Section 533.0061;
                     (C)  pay liquidated damages for each failure, as
  determined by the commission, to comply with the provider access
  standards established under Section 533.0061 in amounts that are
  reasonably related to the noncompliance; and
                     (D)  regularly, as determined by the commission,
  submit to the commission and make available to the public a report
  containing data on the sufficiency of the organization's provider
  network with regard to providing the care and services described
  under Section 533.0061(a) [Paragraph (A)] and specific data with
  respect to access to primary care, specialty care, long-term
  services and supports, nursing services, and therapy services
  [Paragraphs (A)(iii), (vi), (vii), and (viii)] on the average
  length of time between:
                           (i)  the date a provider requests prior
  authorization [makes a referral] for the care or service and the
  date the organization approves or denies the request [referral];
  and
                           (ii)  the date the organization approves a
  request for prior authorization [referral] for the care or service
  and the date the care or service is initiated;
               (21)  a requirement that the managed care organization
  demonstrate to the commission, before the organization begins to
  provide health care services to recipients, that, subject to the
  provider access standards established under Section 533.0061:
                     (A)  the organization's provider network has the
  capacity to serve the number of recipients expected to enroll in a
  managed care plan offered by the organization;
                     (B)  the organization's provider network
  includes:
                           (i)  a sufficient number of primary care
  providers;
                           (ii)  a sufficient variety of provider
  types;
                           (iii)  a sufficient number of providers of
  long-term services and supports and specialty pediatric care
  providers of home and community-based services; and
                           (iv)  providers located throughout the
  region where the organization will provide health care services;
  and
                     (C)  health care services will be accessible to
  recipients through the organization's provider network to a
  comparable extent that health care services would be available to
  recipients under a fee-for-service or primary care case management
  model of Medicaid managed care;
               (22)  a requirement that the managed care organization
  develop a monitoring program for measuring the quality of the
  health care services provided by the organization's provider
  network that:
                     (A)  incorporates the National Committee for
  Quality Assurance's Healthcare Effectiveness Data and Information
  Set (HEDIS) measures;
                     (B)  focuses on measuring outcomes; and
                     (C)  includes the collection and analysis of
  clinical data relating to prenatal care, preventive care, mental
  health care, and the treatment of acute and chronic health
  conditions and substance abuse;
               (23)  subject to Subsection (a-1), a requirement that
  the managed care organization develop, implement, and maintain an
  outpatient pharmacy benefit plan for its enrolled recipients:
                     (A)  that exclusively employs the vendor drug
  program formulary and preserves the state's ability to reduce
  waste, fraud, and abuse under Medicaid;
                     (B)  that adheres to the applicable preferred drug
  list adopted by the commission under Section 531.072;
                     (C)  that includes the prior authorization
  procedures and requirements prescribed by or implemented under
  Sections 531.073(b), (c), and (g) for the vendor drug program;
                     (D)  for purposes of which the managed care
  organization:
                           (i)  may not negotiate or collect rebates
  associated with pharmacy products on the vendor drug program
  formulary; and
                           (ii)  may not receive drug rebate or pricing
  information that is confidential under Section 531.071;
                     (E)  that complies with the prohibition under
  Section 531.089;
                     (F)  under which the managed care organization may
  not prohibit, limit, or interfere with a recipient's selection of a
  pharmacy or pharmacist of the recipient's choice for the provision
  of pharmaceutical services under the plan through the imposition of
  different copayments;
                     (G)  that allows the managed care organization or
  any subcontracted pharmacy benefit manager to contract with a
  pharmacist or pharmacy providers separately for specialty pharmacy
  services, except that:
                           (i)  the managed care organization and
  pharmacy benefit manager are prohibited from allowing exclusive
  contracts with a specialty pharmacy owned wholly or partly by the
  pharmacy benefit manager responsible for the administration of the
  pharmacy benefit program; and
                           (ii)  the managed care organization and
  pharmacy benefit manager must adopt policies and procedures for
  reclassifying prescription drugs from retail to specialty drugs,
  and those policies and procedures must be consistent with rules
  adopted by the executive commissioner and include notice to network
  pharmacy providers from the managed care organization;
                     (H)  under which the managed care organization may
  not prevent a pharmacy or pharmacist from participating as a
  provider if the pharmacy or pharmacist agrees to comply with the
  financial terms and conditions of the contract as well as other
  reasonable administrative and professional terms and conditions of
  the contract;
                     (I)  under which the managed care organization may
  include mail-order pharmacies in its networks, but may not require
  enrolled recipients to use those pharmacies, and may not charge an
  enrolled recipient who opts to use this service a fee, including
  postage and handling fees;
                     (J)  under which the managed care organization or
  pharmacy benefit manager, as applicable, must pay claims in
  accordance with Section 843.339, Insurance Code; and
                     (K)  under which the managed care organization or
  pharmacy benefit manager, as applicable:
                           (i)  to place a drug on a maximum allowable
  cost list, must ensure that:
                                 (a)  the drug is listed as "A" or "B"
  rated in the most recent version of the United States Food and Drug
  Administration's Approved Drug Products with Therapeutic
  Equivalence Evaluations, also known as the Orange Book, has an "NR"
  or "NA" rating or a similar rating by a nationally recognized
  reference; and
                                 (b)  the drug is generally available
  for purchase by pharmacies in the state from national or regional
  wholesalers and is not obsolete;
                           (ii)  must provide to a network pharmacy
  provider, at the time a contract is entered into or renewed with the
  network pharmacy provider, the sources used to determine the
  maximum allowable cost pricing for the maximum allowable cost list
  specific to that provider;
                           (iii)  must review and update maximum
  allowable cost price information at least once every seven days to
  reflect any modification of maximum allowable cost pricing;
                           (iv)  must, in formulating the maximum
  allowable cost price for a drug, use only the price of the drug and
  drugs listed as therapeutically equivalent in the most recent
  version of the United States Food and Drug Administration's
  Approved Drug Products with Therapeutic Equivalence Evaluations,
  also known as the Orange Book;
                           (v)  must establish a process for
  eliminating products from the maximum allowable cost list or
  modifying maximum allowable cost prices in a timely manner to
  remain consistent with pricing changes and product availability in
  the marketplace;
                           (vi)  must:
                                 (a)  provide a procedure under which a
  network pharmacy provider may challenge a listed maximum allowable
  cost price for a drug;
                                 (b)  respond to a challenge not later
  than the 15th day after the date the challenge is made;
                                 (c)  if the challenge is successful,
  make an adjustment in the drug price effective on the date the
  challenge is resolved, and make the adjustment applicable to all
  similarly situated network pharmacy providers, as determined by the
  managed care organization or pharmacy benefit manager, as
  appropriate;
                                 (d)  if the challenge is denied,
  provide the reason for the denial; and
                                 (e)  report to the commission every 90
  days the total number of challenges that were made and denied in the
  preceding 90-day period for each maximum allowable cost list drug
  for which a challenge was denied during the period;
                           (vii)  must notify the commission not later
  than the 21st day after implementing a practice of using a maximum
  allowable cost list for drugs dispensed at retail but not by mail;
  and
                           (viii)  must provide a process for each of
  its network pharmacy providers to readily access the maximum
  allowable cost list specific to that provider;
               (24)  a requirement that the managed care organization
  and any entity with which the managed care organization contracts
  for the performance of services under a managed care plan disclose,
  at no cost, to the commission and, on request, the office of the
  attorney general all discounts, incentives, rebates, fees, free
  goods, bundling arrangements, and other agreements affecting the
  net cost of goods or services provided under the plan; [and]
               (25)  a requirement that the managed care organization
  not implement significant, nonnegotiated, across-the-board
  provider reimbursement rate reductions unless:
                     (A)  subject to Subsection (a-3), the
  organization has the prior approval of the commission to make the
  reduction; or
                     (B)  the rate reductions are based on changes to
  the Medicaid fee schedule or cost containment initiatives
  implemented by the commission; and
               (26)  a requirement that the managed care organization
  make initial and subsequent primary care provider assignments and
  changes.
         SECTION 5.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Sections 533.0061, 533.0062, 533.0063, and
  533.0064 to read as follows:
         Sec. 533.0061.  PROVIDER ACCESS STANDARDS; REPORT.  (a)  The
  commission shall establish minimum provider access standards for
  the provider network of a managed care organization that contracts
  with the commission to provide health care services to recipients.  
  The access standards must ensure that a managed care organization
  provides recipients sufficient access to:
               (1)  preventive care;
               (2)  primary care;
               (3)  specialty care;
               (4)  after-hours urgent care;
               (5)  chronic care;
               (6)  long-term services and supports;
               (7)  nursing services;
               (8)  therapy services, including services provided in a
  clinical setting or in a home or community-based setting; and
               (9)  any other services identified by the commission.
         (b)  To the extent it is feasible, the provider access
  standards established under this section must:
               (1)  distinguish between access to providers in urban
  and rural settings; and
               (2)  consider the number and geographic distribution of
  Medicaid-enrolled providers in a particular service delivery area.
         (c)  The commission shall biennially submit to the
  legislature and make available to the public a report containing
  information and statistics about recipient access to providers
  through the provider networks of the managed care organizations and
  managed care organization compliance with contractual obligations
  related to provider access standards established under this
  section.  The report must contain:
               (1)  a compilation and analysis of information
  submitted to the commission under Section 533.005(a)(20)(D);
               (2)  for both primary care providers and specialty
  providers, information on provider-to-recipient ratios in an
  organization's provider network, as well as benchmark ratios to
  indicate whether deficiencies exist in a given network; and
               (3)  a description of, and analysis of the results
  from, the commission's monitoring process established under
  Section 533.007(l).
         Sec. 533.0062.  PENALTIES AND OTHER REMEDIES FOR FAILURE TO
  COMPLY WITH PROVIDER ACCESS STANDARDS. If a managed care
  organization that has contracted with the commission to provide
  health care services to recipients fails to comply with one or more
  provider access standards established under Section 533.0061 and
  the commission determines the organization has not made substantial
  efforts to mitigate or remedy the noncompliance, the commission:
               (1)  may:
                     (A)  elect to not retain or renew the commission's
  contract with the organization; or
                     (B)  require the organization to pay liquidated
  damages in accordance with Section 533.005(a)(20)(C); and
               (2)  shall suspend default enrollment to the
  organization in a given service delivery area for at least one
  calendar quarter if the organization's noncompliance occurs in the
  service delivery area for two consecutive calendar quarters.
         Sec. 533.0063.  PROVIDER NETWORK DIRECTORIES. (a)  The
  commission shall ensure that a managed care organization that
  contracts with the commission to provide health care services to
  recipients:
               (1)  posts on the organization's Internet website:
                     (A)  the organization's provider network
  directory; and
                     (B)  a direct telephone number and e-mail address
  through which a recipient enrolled in the organization's managed
  care plan or the recipient's provider may contact the organization
  to receive assistance with:
                           (i)  identifying in-network providers and
  services available to the recipient; and
                           (ii)  scheduling an appointment for the
  recipient with an available in-network provider or to access
  available in-network services; and
               (2)  updates the online directory required under
  Subdivision (1)(A) at least monthly.
         (b)  Except as provided by Subsection (c), a managed care
  organization is required to send a paper form of the organization's
  provider network directory for the program only to a recipient who
  requests to receive the directory in paper form.
         (c)  A managed care organization participating in the STAR +
  PLUS Medicaid managed care program or STAR Kids Medicaid managed
  care program established under Section 533.00253 shall, for a
  recipient in that program, issue a provider network directory for
  the program in paper form unless the recipient opts out of receiving
  the directory in paper form.
         Sec. 533.0064.  EXPEDITED CREDENTIALING PROCESS FOR CERTAIN
  PROVIDERS. (a)  In this section, "applicant provider" means a
  physician or other health care provider applying for expedited
  credentialing under this section.
         (b)  Notwithstanding any other law and subject to Subsection
  (c), a managed care organization that contracts with the commission
  to provide health services to recipients shall, in accordance with
  this section, establish and implement an expedited credentialing
  process that would allow applicant providers to provide services to
  recipients on a provisional basis.
         (c)  The commission shall identify the types of providers for
  which an expedited credentialing process must be established and
  implemented under this section.
         (d)  To qualify for expedited credentialing under this
  section and payment under Subsection (e), an applicant provider
  must:
               (1)  be a member of an established health care provider
  group that has a current contract in force with a managed care
  organization described by Subsection (b);
               (2)  be a Medicaid-enrolled provider;
               (3)  agree to comply with the terms of the contract
  described by Subdivision (1); and
               (4)  submit all documentation and other information
  required by the managed care organization as necessary to enable
  the organization to begin the credentialing process required by the
  organization to include a provider in the organization's provider
  network.
         (e)  On submission by the applicant provider of the
  information required by the managed care organization under
  Subsection (d), and for Medicaid reimbursement purposes only, the
  organization shall treat the provider as if the provider were in the
  organization's provider network when the provider provides
  services to recipients, subject to Subsections (f) and (g).
         (f)  Except as provided by Subsection (g), if, on completion
  of the credentialing process, a managed care organization
  determines that the applicant provider does not meet the
  organization's credentialing requirements, the organization may
  recover from the provider the difference between payments for
  in-network benefits and out-of-network benefits.
         (g)  If a managed care organization determines on completion
  of the credentialing process that the applicant provider does not
  meet the organization's credentialing requirements and that the
  provider made fraudulent claims in the provider's application for
  credentialing, the organization may recover from the provider the
  entire amount of any payment paid to the provider.
         SECTION 6.  Section 533.007, Government Code, is amended by
  adding Subsection (l) to read as follows:
         (l)  The commission shall establish and implement a process
  for the direct monitoring of a managed care organization's provider
  network and providers in the network. The process:
               (1)  must be used to ensure compliance with contractual
  obligations related to:
                     (A)  the number of providers accepting new
  patients under the Medicaid managed care program; and
                     (B)  the length of time a recipient must wait
  between scheduling an appointment with a provider and receiving
  treatment from the provider;
               (2)  may use reasonable methods to ensure compliance
  with contractual obligations, including telephone calls made at
  random times without notice to assess the availability of providers
  and services to new and existing recipients; and
               (3)  may be implemented directly by the commission or
  through a contractor.
         SECTION 7.  Section 142.009(c), Health and Safety Code, is
  amended to read as follows:
         (c)  The department or its authorized representative shall
  investigate each complaint received regarding the provision of home
  health, hospice, or personal assistance services[, including any
  allegation of abuse, neglect, or exploitation of a child under the
  age of 18,] and may, as a part of the investigation:
               (1)  conduct an unannounced survey of a place of
  business, including an inspection of medical and personnel records,
  if the department has reasonable cause to believe that the place of
  business is in violation of this chapter or a rule adopted under
  this chapter;
               (2)  conduct an interview with a recipient of home
  health, hospice, or personal assistance services, which may be
  conducted in the recipient's home if the recipient consents;
               (3)  conduct an interview with a family member of a
  recipient of home health, hospice, or personal assistance services
  who is deceased or other person who may have knowledge of the care
  received by the deceased recipient of the home health, hospice, or
  personal assistance services; or
               (4)  interview a physician or other health care
  practitioner, including a member of the personnel of a home and
  community support services agency, who cares for a recipient of
  home health, hospice, or personal assistance services.
         SECTION 8.  Section 260A.002, Health and Safety Code, is
  amended by adding Subsection (a-1) to read as follows:
         (a-1)  Notwithstanding any other provision of this chapter,
  a report made under this section that a provider is or may be
  alleged to have committed abuse, neglect, or exploitation of a
  resident of a facility other than a prescribed pediatric extended
  care center shall be investigated by the Department of Family and
  Protective Services in accordance with Subchapter F, Chapter 48,
  Human Resources Code, and this chapter does not apply to that
  investigation.  In this subsection, "facility" and "provider" have
  the meanings assigned by Section 48.251, Human Resources Code.
         SECTION 9.  Section 48.002(a), Human Resources Code, is
  amended by adding Subdivision (11) to read as follows:
               (11)  "Home and community-based services" has the
  meaning assigned by Section 48.251.
         SECTION 10.  Section 48.002(b), Human Resources Code, as
  amended by S.B. No. 219, Acts of the 84th Legislature, Regular
  Session, 2015, is amended to read as follows:
         (b)  The definitions of "abuse," "neglect," [and]
  "exploitation," and "an individual receiving services" adopted by
  the executive commissioner as prescribed by Section 48.251(b) 
  [48.251] apply to an investigation of abuse, neglect, or
  exploitation conducted under Subchapter F [or H].
         SECTION 11.  Section 48.003, Human Resources Code, is
  amended to read as follows:
         Sec. 48.003.  INVESTIGATIONS IN NURSING FACILITIES [HOMES],
  ASSISTED LIVING FACILITIES, AND SIMILAR FACILITIES. (a)  Except as
  provided by Subsection (c), this [This] chapter does not apply if
  the alleged or suspected abuse, neglect, or exploitation occurs in
  a facility licensed under Chapter 242 or 247, Health and Safety
  Code.
         (b)  Alleged or suspected abuse, neglect, or exploitation
  that occurs in a facility licensed under Chapter 242 or 247, Health
  and Safety Code, is governed by Chapter 260A, Health and Safety
  Code, except as otherwise provided by Subsection (c).
         (c)  Subchapter F applies to an investigation of alleged or
  suspected abuse, neglect, or exploitation in which a provider of
  home and community-based services is or may be alleged to have
  committed the abuse, neglect, or exploitation, regardless of
  whether the facility in which those services were provided is
  licensed under Chapter 242 or 247, Health and Safety Code.
         SECTION 12.  Sections 48.051(a) and (b), Human Resources
  Code, as amended by S.B. No. 219, Acts of the 84th Legislature,
  Regular Session, 2015, are amended to read as follows:
         (a)  Except as prescribed by Subsection (b), a person having
  cause to believe that an elderly person, a [or] person with a
  disability, or an individual receiving services from a provider as
  described by Subchapter F is in the state of abuse, neglect, or
  exploitation[, including a person with a disability who is
  receiving services as described by Section 48.252,] shall report
  the information required by Subsection (d) immediately to the
  department.
         (b)  If a person has cause to believe that an elderly person
  or a person with a disability, other than an individual [a person
  with a disability] receiving services from a provider as described
  by Subchapter F [Section 48.252], has been abused, neglected, or
  exploited in a facility operated, licensed, certified, or
  registered by a state agency, the person shall report the
  information to the state agency that operates, licenses, certifies,
  or registers the facility for investigation by that agency.
         SECTION 13.  Section 48.103, Human Resources Code, is
  amended by amending Subsection (a), as amended by S.B. No. 219, Acts
  of the 84th Legislature, Regular Session, 2015, and adding
  Subsection (c) to read as follows:
         (a)  Except as otherwise provided by Subsection (c), on [On]
  determining after an investigation that an elderly person or a 
  person with a disability has been abused, exploited, or neglected
  by an employee of a home and community support services agency
  licensed under Chapter 142, Health and Safety Code, the department
  shall:
               (1)  notify the state agency responsible for licensing
  the home and community support services agency of the department's
  determination;
               (2)  notify any health and human services agency, as
  defined by Section 531.001, Government Code, that contracts with
  the home and community support services agency for the delivery of
  health care services of the department's determination; and
               (3)  provide to the licensing state agency and any
  contracting health and human services agency access to the
  department's records or documents relating to the department's
  investigation.
         (c)  This section does not apply to an investigation of
  alleged or suspected abuse, neglect, or exploitation in which a
  provider, as defined by Section 48.251, is or may be alleged to have
  committed the abuse, neglect, or exploitation. An investigation
  described by this subsection is governed by Subchapter F.
         SECTION 14.  Section 48.151(e), Human Resources Code, is
  amended to read as follows:
         (e)  This section does not apply to investigations conducted
  under Subchapter F [or H].
         SECTION 15.  Section 48.201, Human Resources Code, as
  amended by S.B. No. 219, Acts of the 84th Legislature, Regular
  Session, 2015, is amended to read as follows:
         Sec. 48.201.  APPLICATION OF SUBCHAPTER.  Except as
  otherwise provided, this subchapter does not apply to an
  investigation conducted under Subchapter F [or H].
         SECTION 16.  Subchapter F, Chapter 48, Human Resources Code,
  as amended by S.B. No. 219, Acts of the 84th Legislature, Regular
  Session, 2015, is amended to read as follows:
  SUBCHAPTER F.  INVESTIGATIONS OF ABUSE, NEGLECT, OR EXPLOITATION OF
  INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS [IN CERTAIN
  FACILITIES, COMMUNITY CENTERS, AND LOCAL MENTAL HEALTH AND
  INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES]
         Sec. 48.251.  DEFINITIONS. (a)  In this subchapter:
               (1)  "Behavioral health services" means:
                     (A)  mental health services, as defined by Section
  531.002, Health and Safety Code; and
                     (B)  interventions provided to treat chemical
  dependency, as defined by Section 461A.002, Health and Safety Code.
               (2)  "Community center" has the meaning assigned by
  Section 531.002, Health and Safety Code.
               (3)  "Facility" means:
                     (A)  a facility listed in Section 532.001(b) or
  532A.001(b), Health and Safety Code, including community services
  operated by the Department of State Health Services or Department
  of Aging and Disability Services, as described by those sections,
  or a person contracting with a health and human services agency to
  provide inpatient mental health services; and
                     (B)  a facility licensed under Chapter 252, Health
  and Safety Code.
               (4)  "Health and human services agency" has the meaning
  assigned by Section 531.001, Government Code.
               (5)  "Home and community-based services" means
  services provided in the home or community in accordance with 42
  U.S.C. Section 1315, 42 U.S.C. Section 1315a, 42 U.S.C. Section
  1396a, or 42 U.S.C. Section 1396n, and as otherwise provided by
  department rule.
               (6)  "Local intellectual and developmental disability
  authority" has the meaning assigned by Section 531.002, Health and
  Safety Code.
               (7)  "Local mental health authority" has the meaning
  assigned by Section 531.002, Health and Safety Code.
               (8)  "Managed care organization" has the meaning
  assigned by Section 533.001, Government Code.
               (9)  "Provider" means:
                     (A)  a facility;
                     (B)  a community center, local mental health
  authority, and local intellectual and developmental disability
  authority;
                     (C)  a person who contracts with a health and
  human services agency or managed care organization to provide home
  and community-based services;
                     (D)  a person who contracts with a Medicaid
  managed care organization to provide behavioral health services;
                     (E)  a managed care organization;
                     (F)  an officer, employee, agent, contractor, or
  subcontractor of a person or entity listed in Paragraphs (A)-(E);
  and
                     (G)  an employee, fiscal agent, case manager, or
  service coordinator of an individual employer participating in the
  consumer-directed service option, as defined by Section 531.051,
  Government Code.
         (b)  The executive commissioner by rule shall adopt
  definitions of "abuse," "neglect," "exploitation," and "an
  individual receiving services" for purposes of this subchapter and
  ["exploitation" to govern] investigations conducted under this
  subchapter [and Subchapter H].
         Sec. 48.252.  INVESTIGATION OF REPORTS OF ABUSE, NEGLECT, OR
  EXPLOITATION BY PROVIDER [IN CERTAIN FACILITIES AND IN COMMUNITY
  CENTERS].  (a)  The department shall receive and, except as
  provided by Subsection (b), shall investigate under this subchapter 
  reports of the abuse, neglect, or exploitation of an individual
  [with a disability] receiving services if the person alleged or
  suspected to have committed the abuse, neglect, or exploitation is
  a provider[:
               [(1)  in:
                     [(A)     a mental health facility operated by the
  Department of State Health Services; or
                     [(B)     a facility licensed under Chapter 252,
  Health and Safety Code;
               [(2)     in or from a community center, a local mental
  health authority, or a local intellectual and developmental
  disability authority; or
               [(3)     through a program providing services to that
  person by contract with a mental health facility operated by the
  Department of State Health Services, a community center, a local
  mental health authority, or a local intellectual and developmental
  disability authority].
         (b)  The department may not [shall receive and shall]
  investigate under this subchapter reports of [the] abuse, neglect,
  or exploitation alleged or suspected to have been committed by a
  provider that is operated, licensed, certified, or registered by a
  state agency that has authority under this chapter or other law to
  investigate reports of abuse, neglect, or exploitation of an
  individual by the provider. The department shall forward any
  report of abuse, neglect, or exploitation alleged or suspected to
  have been committed by a provider described by this subsection to
  the appropriate state agency for investigation [of an individual
  with a disability receiving services:
               [(1)     in a state supported living center or the ICF-IID
  component of the Rio Grande State Center; or
               [(2)     through a program providing services to that
  person by contract with a state supported living center or the
  ICF-IID component of the Rio Grande State Center].
         (c)  The department shall receive and investigate under this
  subchapter reports of abuse, neglect, or exploitation of an
  individual who lives in a residence that is owned, operated, or
  controlled by a provider who provides home and community-based
  services under the home and community-based services waiver program
  described by Section 534.001(11)(B), Government Code, regardless
  of whether the individual is receiving services under that waiver
  program from the provider. [The executive commissioner by rule
  shall define who is "an individual with a disability receiving
  services."
         [(d)     In this section, "community center," "local mental
  health authority," and "local intellectual and developmental
  disability authority" have the meanings assigned by Section
  531.002, Health and Safety Code.]
         Sec. 48.253.  ACTION ON REPORT. (a)  On receipt by the
  department of a report of alleged abuse, neglect, or exploitation
  under this subchapter, the department shall initiate a prompt and
  thorough investigation as needed to evaluate the accuracy of the
  report and to assess the need for emergency protective services,
  unless the department, in accordance with rules adopted under this
  subchapter, determines that the report:
               (1)  is frivolous or patently without a factual basis;
  or
               (2)  does not concern abuse, neglect, or exploitation.
         (b)  After receiving a report that alleges that a provider is
  or may be the person who committed the alleged abuse, neglect, or
  exploitation, the department shall notify the provider and the
  appropriate health and human services agency in accordance with
  rules adopted by the executive commissioner.
         (c)  The provider identified under Subsection (b) shall:
               (1)  cooperate completely with an investigation
  conducted under this subchapter; and
               (2)  provide the department complete access during an
  investigation to:
                     (A)  all sites owned, operated, or controlled by
  the provider; and
                     (B)  clients and client records.
         (d)  The executive commissioner shall adopt rules governing
  investigations conducted under this subchapter.
         Sec. 48.254.  FORWARDING OF CERTAIN REPORTS.  (a)  The
  executive commissioner by rule shall establish procedures for the
  department to use to [In accordance with department rules, the
  department shall] forward a copy of the initial intake report and a
  copy of the completed provider investigation report relating to
  alleged or suspected abuse, neglect, or exploitation to the
  appropriate provider and health and human services agency
  [facility, community center, local mental health authority, local
  intellectual and developmental disability authority, or program
  providing mental health or intellectual disability services under
  contract with the facility, community center, or authority].
         (b)  The department shall redact from an initial intake
  report and from the copy of the completed provider investigation
  report any identifying information contained in the report relating
  to the person who reported the alleged or suspected abuse, neglect,
  or exploitation under Section 48.051.
         (c)  A provider that receives a completed investigation
  report under Subsection (a) shall forward the report to the managed
  care organization with which the provider contracts for services
  for the alleged victim.
         Sec. 48.255.  RULES FOR INVESTIGATIONS UNDER THIS
  SUBCHAPTER. (a)  The executive commissioner [department, the
  Department of Aging and Disability Services, and the Department of
  State Health Services] shall adopt [develop] rules to:
               (1)  prioritize investigations conducted under this
  subchapter with the primary criterion being whether there is a risk
  that a delay in the investigation will impede the collection of
  evidence in that investigation;
               (2)  [facilitate investigations in state mental health
  facilities and state supported living centers.
         [(b)  The executive commissioner by rule shall] establish
  procedures for resolving disagreements between the department and
  health and human services agencies [the Department of Aging and
  Disability Services or the Department of State Health Services]
  concerning the department's investigation findings; and
               (3)  provide for an appeals process by the department
  for the alleged victim of abuse, neglect, or exploitation.
         (b) [(c)     The department, the Department of Aging and
  Disability Services, and the Department of State Health Services
  shall develop and propose to the executive commissioner rules to
  facilitate investigations in community centers, local mental
  health authorities, and local intellectual and developmental
  disability authorities.
         [(c-1)     The executive commissioner shall adopt rules
  regarding investigations in a facility licensed under Chapter 252,
  Health and Safety Code, to ensure that those investigations are as
  consistent as practicable with other investigations conducted
  under this subchapter.
         [(d)]  A confirmed investigation finding by the department
  may not be changed by the administrator [a superintendent] of a
  [state mental health] facility, [by a director of a state supported
  living center, by a director of] a community center, [or by] a local 
  mental health authority, or a local intellectual and developmental
  disability authority.
         [(e)     The executive commissioner shall provide by rule for an
  appeals process by the alleged victim of abuse, neglect, or
  exploitation under this section.
         [(f)     The executive commissioner by rule may assign
  priorities to an investigation conducted by the department under
  this section.   The primary criterion used by the executive
  commissioner in assigning a priority must be the risk that a delay
  in the investigation will impede the collection of evidence.]
         Sec. 48.256.  SHARING PROVIDER INFORMATION. (a)  The
  executive commissioner shall adopt rules that prescribe the
  appropriate manner in which health and human services agencies and
  managed care organizations provide the department with information
  necessary to facilitate identification of individuals receiving
  services from providers and to facilitate notification of providers
  by the department.
         (b)  The executive commissioner shall adopt rules requiring
  a provider to provide information to the administering health and
  human services agency necessary to facilitate identification by the
  department of individuals receiving services from providers and to
  facilitate notification of providers by the department.
         (c)  A provider of home and community-based services under
  the home and community-based services waiver program described by
  Section 534.001(11)(B), Government Code, shall post in a
  conspicuous location inside any residence owned, operated, or
  controlled by the provider in which home and community-based waiver
  services are provided, a sign that states:
               (1)  the name, address, and telephone number of the
  provider;
               (2)  the effective date of the provider's contract with
  the applicable health and human services agency to provide home and
  community-based services; and
               (3)  the name of the legal entity that contracted with
  the applicable health and human services agency to provide those
  services.
         Sec. 48.257.  RETALIATION PROHIBITED. (a)  A provider of
  home and community-based services may not retaliate against a
  person for filing a report or providing information in good faith
  relating to the possible abuse, neglect, or exploitation of an
  individual receiving services.
         (b)  This section does not prohibit a provider of home and
  community-based services from terminating an employee for a reason
  other than retaliation.
         Sec. 48.258.  [SINGLE] TRACKING SYSTEM FOR REPORTS AND
  INVESTIGATIONS. (a)  The health and human services agencies
  [department, the Department of Aging and Disability Services, and
  the Department of State Health Services] shall, at the direction of
  the executive commissioner, jointly develop and implement a
  [single] system to track reports and investigations under this
  subchapter.
         (b)  To facilitate implementation of the system, the health
  and human services agencies [department, the Department of Aging
  and Disability Services, and the Department of State Health
  Services] shall use appropriate methods of measuring the number and
  outcome of reports and investigations under this subchapter.
         SECTION 17.  Section 48.301, Human Resources Code, is
  amended by amending Subsection (a), as amended by S.B. No. 219, Acts
  of the 84th Legislature, Regular Session, 2015, and adding
  Subsection (a-1) to read as follows:
         (a)  If the department receives a report of suspected abuse,
  neglect, or exploitation of an elderly person or a person with a
  disability[, other than a person with a disability who is]
  receiving services [as described by Section 48.252,] in a facility
  operated, licensed, certified, or registered by a state agency, the
  department shall refer the report to that agency.
         (a-1)  This subchapter does not apply to a report of
  suspected abuse, neglect, or exploitation of an individual
  receiving services from a provider as described by Subchapter F.
         SECTION 18.  Sections 48.401(1) and (3), Human Resources
  Code, are amended to read as follows:
               (1)  "Agency" means:
                     (A)  an entity licensed under Chapter 142, Health
  and Safety Code;
                     (B)  a person exempt from licensing under Section
  142.003(a)(19), Health and Safety Code;
                     (C)  a facility licensed under Chapter 252, Health
  and Safety Code; or
                     (D)  a provider [an entity] investigated by the
  department under Subchapter F or under Section 261.404, Family
  Code.
               (3)  "Employee" means a person who:
                     (A)  works for:
                           (i)  an agency; or
                           (ii)  an individual employer participating
  in the consumer-directed service option, as defined by Section
  531.051, Government Code;
                     (B)  provides personal care services, active
  treatment, or any other [personal] services to an individual
  receiving agency services, an individual who is a child for whom an
  investigation is authorized under Section 261.404, Family Code, or
  an individual receiving services through the consumer-directed
  service option, as defined by Section 531.051, Government Code; and
                     (C)  is not licensed by the state to perform the
  services the person performs for the agency or the individual
  employer participating in the consumer-directed service option, as
  defined by Section 531.051, Government Code.
         SECTION 19.  The following are repealed:
               (1)  Section 261.404(f), Family Code, as amended by
  S.B. No. 219, Acts of the 84th Legislature, Regular Session, 2015;
  and
               (2)  Subchapter H, Chapter 48, Human Resources Code.
         SECTION 20.  (a)  The Health and Human Services Commission,
  in a contract between the commission and a managed care
  organization under Chapter 533, Government Code, that is entered
  into or renewed on or after the effective date of this Act, shall
  require that the managed care organization comply with:
               (1)  Section 533.005(a), Government Code, as amended by
  this Act;
               (2)  the standards established under Section
  533.0061(a), Government Code, as added by this Act; and
               (3)  Section 533.0063, Government Code, as added by
  this Act.
         (b)  The Health and Human Services Commission shall seek to
  amend contracts entered into with managed care organizations under
  Chapter 533, Government Code, before the effective date of this Act
  to require that those managed care organizations comply with the
  provisions specified in Subsection (a) of this section.  To the
  extent of a conflict between those provisions and a provision of a
  contract with a managed care organization entered into before the
  effective date of this Act, the contract provision prevails.
         SECTION 21.  The Health and Human Services Commission shall
  submit to the legislature the initial report required under Section
  533.0061(c), Government Code, as added by this Act, not later than
  December 1, 2016.
         SECTION 22.  If before implementing any provision of this
  Act a state agency determines that a waiver or authorization from a
  federal agency is necessary for implementation of that provision,
  the agency affected by the provision shall request the waiver or
  authorization and may delay implementing that provision until the
  waiver or authorization is granted.
         SECTION 23.  This Act takes effect September 1, 2015.
 
 
 
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
         I hereby certify that S.B. No. 760 passed the Senate on
  April 7, 2015, by the following vote: Yeas 31, Nays 0; and that
  the Senate concurred in House amendments on May 28, 2015, by the
  following vote: Yeas 31, Nays 0.
 
 
  ______________________________
  Secretary of the Senate    
 
         I hereby certify that S.B. No. 760 passed the House, with
  amendments, on May 22, 2015, by the following vote: Yeas 140,
  Nays 0, two present not voting.
 
 
  ______________________________
  Chief Clerk of the House   
 
 
 
  Approved:
 
  ______________________________ 
              Date
 
 
  ______________________________ 
            Governor