1 Tex. Admin. Code § 371.1663 - Managed Care
A person is subject to administrative action or sanctions if the person:
(1) is an MCO or an MCO
provider and fails to provide a health care benefit, service, or item that the
MCO or MCO provider is required to provide according to the terms of its
contract with an operating agency, its fiscal agent, or other contractor to
provide health care services to Medicaid or HHS program recipients;
(2) is an MCO or MCO provider and fails to
provide to an individual a health care benefit, service, or item that the MCO
or MCO provider is required to provide by state or federal law, regulation, or
program rule;
(3) is an MCO and
engages in actions that indicate a pattern of wrongful denial, excessive delay,
barriers to treatment, authorization requirements that exceed professionally
recognized standards of health care, or other wrongful avoidance of payment for
a health care benefit, service or item that the organization is required to
provide under its contract with an operating agency;
(4) is an MCO and engages in actions that
cause a delay in making payment for a health care benefit, service or item that
the organization is required to provide under its contract with an operating
agency, and the delay results in processing or paying the claim on a date later
than that allowed by the MCO's contract;
(5) is an MCO or MCO provider and engages in
fraudulent activity or misrepresents or omits material facts in connection with
the enrollment in the MCO's managed care plan of an individual eligible for
medical assistance or in connection with marketing the organization's services
to an individual eligible for medical assistance;
(6) is an MCO or MCO provider and receives a
capitation payment, premium, or other remuneration after enrolling a member in
the MCO's managed care plan whom the MCO knows or should have known is not
eligible for medical assistance;
(7) is an MCO or MCO provider and
discriminates against MCO-enrollees or prospective MCO-enrollees in any manner,
including marketing and disenrollment, and on any basis, including, without
limitation, age, gender, ethnic origin, or health status;
(8) is an MCO or MCO provider and fails to
comply with any term of a contract with a Medicaid or other HHS program or
operating agency or other contract to provide health care services to Medicaid
or HHS program recipients and the failure leads to patient harm, creates a risk
of fiscal harm to the state, or results in fiscal harm to the state;
(9) is an MCO or an MCO provider and fails to
provide, in the form requested, to the relevant operating agency or its
authorized agent upon written request, accurate encounter data, accurate claims
data, or other information contractually or otherwise required to document the
services and items delivered by or through the MCO to recipients;
(10) is an MCO or an MCO provider and files a
cost report or other report with the Medicaid or other HHS program that
violates any of the cost report violations in §371.1665 of this division
(relating to Cost Report Violations);
(11) is an MCO or MCO provider and
misrepresents, falsifies, makes a material omission, or otherwise
mischaracterizes any facts on a request for proposal, contract, report, or
other document with respect to the MCO's ownership, provider network,
credentials of the provider network, affiliated persons, solvency, special
investigative unit, plan for detecting and preventing fraud, waste, or abuse,
or any other material fact;
(12) is
an MCO or MCO provider and fails to maintain the criteria and conditions
supporting an application and grant of a waiver to HHSC, or fails to
demonstrate the results that were contemplated, based upon representations by
the MCO or provider in its proposal submissions or contract negotiations when
the waiver was granted, if the failure is related to representations made by
the MCO in its proposal, readiness review, contract, marketing materials, audit
management responses, or other written representation submitted to the state,
and the failure leads to patient harm, creates a risk of fiscal harm to the
state, or results in fiscal harm to the state;
(13) is an MCO or MCO provider and
misrepresents, falsifies, makes a material omission, or otherwise
mischaracterizes any facts on a patient assessment or any other document that
would have the effect of increasing the MCO's capitation or reimbursement rate,
would increase incentive payments or premiums, would decrease the amount of
capitation at risk, or would decrease the experience rebate owed to the
Medicaid program;
(14) is an MCO or
MCO provider and fails to simultaneously notify the OIG and the OAG in writing
of the discovery of fraud, waste, or abuse in the Medicaid or CHIP
program;
(15) is an MCO and fails
to ensure that any payment recovery efforts in which the MCO engages are in
accordance with applicable law, contract requirements, or other applicable
procedures established by the Executive Commissioner or the OIG;
(16) is an MCO and engages in payment
recovery of an amount sought that exceeds $100,000 and that is related to
fraud, waste, or abuse in the Medicaid or CHIP program:
(A) without first notifying the OIG and the
OAG in writing of the discovery of fraud, waste, or abuse in the Medicaid or
CHIP program;
(B) within ten
business days after notifying the OIG or the OAG of the discovery or fraud,
waste, or abuse in the Medicaid or CHIP program; or
(C) after receipt of a notice from the OIG or
the OAG indicating that the MCO is not authorized to proceed with recovery
efforts;
(17) is an MCO
and fails to timely submit an accurate monthly report to the OIG detailing the
amount of money recovered after any and all payment recovery efforts engaged in
as a result of the discovery of fraud, waste, or abuse in the Medicaid or CHIP
program;
(18) notwithstanding the
terms of any contract, is an MCO or MCO provider and fails to timely comply
with the requirements of the Texas Medicaid Managed Care program or with the
terms of the MCO contract with HHSC or other contract to provide health care
services to Medicaid or HHS program recipients, and the failure leads to
patient harm, creates a risk of fiscal harm to the state, or results in fiscal
harm to the state;
(19) is an MCO
or MCO provider and engages in marketing services in violation of Texas
Government Code §
545.0202, the program
rules or contract and has not received prior authorization from the program for
the marketing campaign;
(20) is an
MCO or an MCO provider and fails to use prior authorization and utilization
review processes to reduce authorizations of unnecessary services and
inappropriate use of services;
(21)
is an MCO or MCO provider and commits or conspires to commit a violation of
§
32.039(b)
of the Texas Human Resources Code;
(22) is an MCO and fails to implement or
release a payment hold as directed by the OIG or to report accurate payment
hold amounts to the OIG;
(23) is an
MCO and fails to comply with any provision in Chapter 353, Subchapter F of this
title (relating to Special Investigative Units) or Chapter 370, Subchapter F of
this title (relating to Special Investigative Units); or
(24) is an MCO and releases information
pertaining to an OIG investigation of a provider.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.