Texas § HR.32.049 - MANAGED CARE CONTRACT COMPLIANCE

§ HR.32.049. MANAGED CARE CONTRACT COMPLIANCE

MANAGED CARE CONTRACT COMPLIANCE. (a) The commission shall review each managed care organization that has contracted with the commission to provide medical assistance to medical assistance recipients through a managed care plan issued by the organization to determine whether the organization is prepared to meet its contractual obligations. (b)(1) The commission shall require each managed care organization that has contracted with the commission to submit an implementation plan not later than the 90th day before the date on which the managed care organization plans to begin to provide medical assistance through a managed care plan in a service area. The implementation plan must include: (A) specific staffing patterns by function for all operations, including enrollment, information systems, member services, quality improvement, claims management, case management, and provider and enrollee training; and (B) specific time frames for demonstrating preparedness for implementation before the date on which the managed care organization plans to begin to provide medical assistance through a managed care plan in a service area. (2) The commission shall respond within 10 working days if the implementation plan does not adequately meet preparedness guidelines. (3) The commission shall require each managed care organization that has contracted with the commission to submit status reports on the implementation plan not later than the 60th day and the 30th day before the date on which the managed care organization plans to begin to provide medical assistance through a managed care plan in a service area and every 30th day after the managed care organization begins to provide medical assistance through a managed care plan in a service area until the 180th day of operations. (c) The commission shall conduct a compliance and readiness review of each managed care organization that contracts with the state not later than the 15th day before the date on which the process of enrolling recipients in a managed care plan issued by the managed care organization is to begin in a service area and again not later than the 15th day before the date on which the managed care organization plans to begin to provide medical assistance through a managed care plan in that service area. The review shall include an on-site inspection and tests of service authorization and claims payment systems, complaint processing systems, and any other process or system required by the contract. (d) The commission may delay enrollment of medical assistance recipients in a managed care plan if the review reveals that the managed care organization is not prepared to meet its contractual obligations. Added by Acts 1997, 75th Leg., ch. 692, Sec. 1, eff. June 17, 1997. Renumbered from Sec. 32.043 by Acts 1999, 76th Leg., ch. 62, Sec. 19.01(75), eff. Sept. 1, 1999. Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219 ), Sec. 4.124, eff. April 2, 2015.