All codes › Government Code › Title 4

Chapter 540

Medicaid Managed Care Program

Subchapter A. General Provisions

540.0001 Definitions

Subchapter B. Administration of Medicaid Managed Care Program

540.0051 Purpose and Implementation 540.0052 Recipient Directory 540.0053 Statewide Effort to Promote Medicaid Eligibility Maintenance 540.0054 Provider and Recipient Education Programs 540.0055 Marketing Guidelines 540.0056 Guidelines for Communications with Recipients 540.0057 Coordination of External Oversight Activities 540.0058 Information for Fraud Control 540.0059 Managed Care Clinical Improvement Program 540.0060 Complaint System Guidelines

Subchapter C. Fiscal Provisions

540.0101 Fiscal Solvency Standards 540.0102 Profit Sharing 540.0103 Treatment of State Taxes in Calculating Experience Rebate or Profit Sharing 540.0104 Treatment as Quality Improvement Cost of Certain Services Provided by Community Health Workers

Subchapter D. Strategy for Managing Audit Resources

540.0151 Definitions 540.0152 Applicability and Construction of Subchapter 540.0153 Overall Strategy for Managing Audit Resources 540.0154 Performance Audit Selection Process and Follow-Up 540.0155 Agreed-Upon Procedures Engagements and Corrective Action Plans 540.0156 Audits of Pharmacy Benefit Managers 540.0157 Collecting Costs for Audit-Related Services 540.0158 Collection Activities Related to Profit Sharing 540.0159 Using Information from External Quality Reviews 540.0160 Security of and Processing Controls Over Information Technology Systems

Subchapter E. Contract Administration

540.0201 Contract Administration Improvement Efforts 540.0202 Public Notice of Request for Contract Applications 540.0203 Certification by Commission 540.0204 Contract Considerations Relating to Managed Care Organizations 540.0205 Contract Considerations Relating to Pharmacy Benefit Managers 540.0206 Mandatory Contracts 540.0207 Contractual Obligations Review 540.0208 Contract Implementation Plan 540.0209 Compliance and Readiness Review 540.0210 Internet Posting of Sanctions Imposed for Contractual Violations 540.0211 Performance Measures and Incentives for Value-Based Contracts 540.0212 Monitoring Compliance with Behavioral Health Integration

Subchapter F. Required Contract Provisions

540.0251 Applicability 540.0252 Accountability to State 540.0253 Capitation Rates 540.0254 Cost Information 540.0255 Fraud Control 540.0256 Recipient Outreach and Education 540.0257 Notice of Medicaid Certification Date 540.0258 Primary Care Provider Assignment 540.0259 Compliance with Provider Network Requirements 540.0260 Compliance with Provider Access Standards; Report 540.0261 Provider Network Sufficiency 540.0262 Quality Monitoring Program for Health Care Services 540.0263 Out-of-Network Provider Usage and Reimbursement 540.0264 Provider Reimbursement Rate Reduction 540.0265 Prompt Payment of Claims 540.0266 Reimbursement for Certain Services Provided Outside Regular Business Hours 540.0267 Provider Appeals Process 540.0268 Assistance Resolving Recipient and Provider Issues 540.0269 Use of Advanced Practice Registered Nurses and Physician Assistants 540.0270 Medical Director Availability 540.0271 Personnel Required in Certain Service Regions 540.0272 Certain Services Permitted in Lieu of State Medicaid Plan Services; Annual Report 540.02721 Pilot Program to Provide Additional Nutrition Support Services to Certain Pregnant Recipients in Lieu of State Medicaid Plan Services 540.0273 Outpatient Pharmacy Benefit Plan 540.0274 Pharmacy Benefit Plan: Rebates and Receipt of Confidential Information Prohibited 540.0275 Pharmacy Benefit Plan: Certain Pharmacy Benefits for Sex Offenders Prohibited 540.0276 Pharmacy Benefit Plan: Recipient Selection of Pharmaceutical Services Provider 540.0277 Pharmacy Benefit Plan: Pharmacy Benefit Providers 540.0278 Pharmacy Benefit Plan: Prompt Payment of Pharmacy Benefit Claims 540.0279 Pharmacy Benefit Plan: Maximum Allowable Cost Price and List for Pharmacy Benefits 540.0280 Pharmacy Benefit Plan: Pharmacy Benefits for Child Enrolled in Star Kids Managed Care Program 540.0283 Nursing Facility Provider Agreements: Compliance with Patient Care Expense Ratio

Subchapter G. Prior Authorization and Utilization Review Procedures

540.0301 Inapplicability of Certain Other Law to Medicaid Managed Care Utilization Reviews 540.0302 Prior Authorization Procedures for Hospitalized Recipient 540.0303 Prior Authorization Procedures for Nonhospitalized Recipient 540.0304 Annual Review of Prior Authorization Requirements 540.0305 Physician Consultation Before Adverse Prior Authorization Determination 540.0306 Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests 540.0307 Maximum Period for Prior Authorization Decision; Access to Care

Subchapter H. Premium Payment Rates

540.0351 Premium Payment Rate Determination 540.0352 Maximum Premium Payment Rates for Certain Programs 540.0353 Use of Encounter Data in Determining Premium Payment Rates and Other Payment Amounts

Subchapter I. Encounter Data

540.0401 Provider Reporting of Encounter Data 540.0402 Certifier of Encounter Data Qualifications 540.0403 Encounter Data Certification

Subchapter J. Managed Care Plan Requirements

540.0451 Medicaid Managed Care Plan Accreditation 540.0452 Medical Director Qualifications

Subchapter K. Medicaid Managed Care Plan Enrollment and Disenrollment

540.0501 Recipient Enrollment in and Disenrollment from Medicaid Managed Care Plan 540.0502 Automatic Enrollment in Medicaid Managed Care Plan 540.0503 Enrollment of Certain Recipients in Same Medicaid Managed Care Plan 540.0504 Quality-Based Enrollment Incentive Program for Medicaid Managed Care Organizations 540.0505 Limitations on Recipient Disenrollment from Medicaid Managed Care Plan

Subchapter L. Continuity of Care and Coordination of Benefits

540.0551 Guidance Regarding Continuation of Services under Certain Circumstances 540.0552 Coordination of Benefits; Continuity of Specialty Care for Certain Recipients

Subchapter M. Provider Network Adequacy

540.0601 Monitoring of Provider Networks 540.0602 Report on Out-of-Network Provider Services 540.0603 Report on Commission Investigation of Provider Complaint 540.0604 Additional Reimbursement Following Provider Complaint 540.0605 Corrective Action Plan for Inadequate Network and Provider Reimbursement 540.0606 Remedies for Noncompliance with Corrective Action Plan

Subchapter N. Providers

540.0651 Inclusion of Certain Providers in Medicaid Managed Care Organization Provider Network 540.0652 Provider Access Standards; Biennial Report 540.0653 Penalties and Other Remedies for Failure to Comply with Provider Access Standards 540.0654 Provider Network Directories 540.0655 Provider Protection Plan 540.0656 Expedited Credentialing Process for Certain Providers 540.0657 Frequency of Provider Recredentialing 540.0658 Provider Incentives for Promoting Preventive Services 540.0659 Reimbursement Rate for Certain Services Provided by Certain Health Centers and Clinics Outside Regular Business Hours

Subchapter O. Delivery of Services: General Provisions

540.0701 Acute Care Service Delivery Through Most Cost-Effective Model; Managed Care Service Delivery Areas 540.0702 Transition of Case Management for Children and Pregnant Women Program Recipients to Medicaid Managed Care Program 540.0703 Behavioral Health and Physical Health Services 540.0704 Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families 540.0705 Behavioral Health Services Provided Through Third Party or Subsidiary 540.0706 Psychotropic Medication Monitoring System for Certain Children 540.0707 Medication Therapy Management 540.0708 Special Disease Management 540.0709 Special Protocols for Indigent Populations 540.0710 Direct Access to Eye Health Care Services 540.0711 Delivery of Benefits Using Telecommunications or Information Technology 540.0712 Promotion and Principles of Patient-Centered Medical Home 540.0713 Value-Added Services 540.0714 Sickle Cell Disease Treatment

Subchapter P. Delivery of Services: Star+plus Medicaid Managed Care Program

540.0751 Delivery of Acute Care Services and Long-Term Services and Supports 540.0752 Delivery of Medicaid Benefits to Nursing Facility Residents 540.0753 Delivery of Basic Attendant and Habilitation Services 540.0754 Evaluation of Certain Program Services 540.0755 Utilization Review; Annual Report

Subchapter Q. Delivery of Services: Star Health Program

540.0801 Trauma-Informed Care Training 540.0802 Mental Health Providers 540.0803 Health Screening Requirements and Compliance with Texas Health Steps 540.0804 Health Care and Other Services for Children in Substitute Care 540.0805 Placement Change Notice and Care Coordination 540.0806 Medicaid Benefits for Certain Children Formerly in Foster Care 540.0807 Access to Care Paid for by Certain Medical Consenters

Subchapter R. Delivery of Services: Star Kids Managed Care Program

540.0851 Star Kids Managed Care Program 540.0852 Care Management and Care Needs Assessment 540.0853 Benefits for Children in Medically Dependent Children (mdcp) Waiver Program 540.0854 Benefits Transition from Star Kids to Star+plus Medicaid Managed Care Program 540.0855 Utilization Review of Prior Authorizations

Subchapter S. Prescription Drug Benefits under Certain Outpatient Pharmacy Benefit Plans

540.0901 Preferred Drug List Exceptions