Amend CSSB 10 by adding the following appropriately numbered 
SECTION to the bill and renumbering subsequent SECTIONS 
appropriately:
	SECTION ____.  (a)  Section 533.005(a), Government Code, 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 not later than the 
45th day after the date a claim for payment is received with 
documentation reasonably necessary for the managed care 
organization to process the claim, or within a period, not to exceed 
60 days, specified by a written agreement between the physician or 
provider and the managed care 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;
		(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 the organization use advanced 
practice nurses in addition to physicians as primary care providers 
to increase the availability of primary care providers in the 
organization's provider network;
		(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;  [and]
		(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;  and
			(C)  the determination of the physician resolving 
the dispute to be binding on the managed care organization and 
provider; and
		(16)  a requirement that the managed care organization 
make payment to a federally qualified health center for health care 
services provided to a recipient at a level and in an amount that is 
not less than the level and amount of payment that the managed care 
organization would make for the services if the services were 
provided by a provider that is not a federally qualified health 
center.
	(b)  Section 533.005(a), Government Code, as amended by this 
section, applies only to a contract between the Health and Human 
Services 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.