Texas § GV.540.0605 - CORRECTIVE ACTION PLAN FOR INADEQUATE NETWORK AND PROVIDER REIMBURSEMENT

§ GV.540.0605. CORRECTIVE ACTION PLAN FOR INADEQUATE NETWORK AND PROVIDER REIMBURSEMENT

CORRECTIVE ACTION PLAN FOR INADEQUATE NETWORK AND PROVIDER REIMBURSEMENT. (a) The commission shall initiate a corrective action plan requiring a Medicaid managed care organization to maintain an adequate provider network, provide reimbursement to support that network, and educate recipients enrolled in Medicaid managed care plans provided by the organization regarding the proper use of the plan's provider network, if: (1) as the commission determines, the organization exceeds maximum limits the commission established for out-of-network access to health care services; or (2) based on the commission's investigation of a provider complaint regarding reimbursement, the commission determines that the organization did not reimburse an out-of-network provider based on a reasonable reimbursement methodology. (b) The corrective action plan required by Subsection (a) must include at least one of the following elements: (1) a requirement that reimbursements the Medicaid managed care organization pays to out-of-network providers for a health care service provided to a recipient enrolled in a Medicaid managed care plan provided by the organization equal the allowable rate for the service, as determined under Sections 32.028 and 32.0281 , Human Resources Code, for all health care services provided during the period the organization: (A) is not in compliance with the utilization benchmarks the commission determines; or (B) is not reimbursing out-of-network providers based on a reasonable methodology, as the commission determines; (2) an immediate freeze on the enrollment of additional recipients in a Medicaid managed care plan the organization provides that continues until the commission determines that the provider network under the plan can adequately meet the needs of additional recipients; and (3) other actions the commission determines are necessary to ensure that recipients enrolled in a Medicaid managed care plan the organization provides have access to appropriate health care services and that providers are properly reimbursed for providing medically necessary health care services to those recipients. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025.