GOVERNMENT CODE

TITLE 4. EXECUTIVE BRANCH

SUBTITLE I. HEALTH AND HUMAN SERVICES

Text of chapter effective until April 1, 2025

CHAPTER 533. MEDICAID MANAGED CARE PROGRAM

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 533.00257.  DELIVERY OF MEDICAL TRANSPORTATION PROGRAM SERVICES THROUGH MANAGED TRANSPORTATION ORGANIZATION.
 
Without reference to the amendment of this subsection, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

 
(j)  The commission may not delay providing medical transportation program services through a managed transportation delivery model in:
(1)  a county with a population of one million or more:
(A)  in which all or part of a municipality with a population of one million or more is located; and
(B)  that is located adjacent to a county with a population of 2.5 million or more; or
(2)  a county with a population of at least 60,000 but not more than 70,000 that is located adjacent to a county with a population of at least 500,000 but not more than 1.5 million.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1311 (S.B. 8), Sec. 7(a), eff. September 1, 2013.
Amended by: 
Acts 2019, 86th Leg., R.S., Ch. 1235 (H.B. 1576), Sec. 5, eff. June 14, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1235 (H.B. 1576), Sec. 6, eff. June 14, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1235 (H.B. 1576), Sec. 7, eff. June 14, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1235 (H.B. 1576), Sec. 9, eff. June 14, 2019.
Acts 2023, 88th Leg., R.S., Ch. 644 (H.B. 4559), Sec. 45, eff. September 1, 2023.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.

Sec. 533.005.  REQUIRED CONTRACT PROVISIONS.
 
Without reference to the amendment of this subsection, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

 
(a-1)  The requirements imposed by Subsections (a)(23)(A), (B), and (C) do not apply, and may not be enforced, on and after August 31, 2033.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.  Amended by Acts 1999, 76th Leg., ch. 493, Sec. 2, eff. Sept. 1, 1999;  Acts 1999, 76th Leg., ch. 1447, Sec. 4, eff. June 19, 1999;  Acts 1999, 76th Leg., ch. 1460, Sec. 9.04, eff. Sept. 1, 1999;  Acts 2003, 78th Leg., ch. 198, Sec. 2.35, eff. Sept. 1, 2003.
Amended by: 
Acts 2005, 79th Leg., Ch. 349 (S.B. 1188), Sec. 6(a), eff. September 1, 2005.
Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.02(d), eff. September 28, 2011.
Acts 2013, 83rd Leg., R.S., Ch. 418 (S.B. 406), Sec. 20, eff. November 1, 2013.
Acts 2013, 83rd Leg., R.S., Ch. 1191 (S.B. 1106), Sec. 1, eff. September 1, 2013.
Acts 2013, 83rd Leg., R.S., Ch. 1261 (H.B. 595), Sec. 1, eff. September 1, 2013.
Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 2.04, eff. September 1, 2013.
Acts 2013, 83rd Leg., R.S., Ch. 1311 (S.B. 8), Sec. 8, eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.222, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 4, eff. September 1, 2015.
Acts 2017, 85th Leg., R.S., Ch. 302 (S.B. 654), Sec. 1, eff. September 1, 2017.
Acts 2017, 85th Leg., R.S., Ch. 832 (H.B. 1917), Sec. 1, eff. June 15, 2017.
Acts 2019, 86th Leg., R.S., Ch. 619 (S.B. 1096), Sec. 3, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 981 (S.B. 1177), Sec. 1, eff. September 1, 2019.
Acts 2019, 86th Leg., R.S., Ch. 1343 (S.B. 1283), Sec. 2, eff. September 1, 2019.
Acts 2021, 87th Leg., R.S., Ch. 348 (H.B. 2822), Sec. 2, eff. September 1, 2021.
Acts 2021, 87th Leg., R.S., Ch. 820 (H.B. 2658), Sec. 3, eff. September 1, 2021.
Acts 2021, 87th Leg., R.S., Ch. 915 (H.B. 3607), Sec. 21.001(34), eff. September 1, 2021.
Acts 2023, 88th Leg., R.S., Ch. 491 (H.B. 1283), Sec. 1, eff. September 1, 2023.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.

Without reference to the amendment of this section, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

Sec. 533.008.  MARKETING GUIDELINES.
(c)  The executive commissioner shall adopt and publish guidelines for Medicaid managed care organizations regarding how organizations may communicate by telephone, text message, or e-mail with recipients enrolled in the organization's managed care plan using the contact information provided in a recipient's application for Medicaid benefits under Section 32.025(g)(2), Human Resources Code, including updated information provided to the organization in accordance with Section 32.025(h), Human Resources Code.
(d)  In adopting the guidelines under Subsection (c) for a recipient enrolled in a Medicaid managed care organization's managed care plan who provides to the organization the recipient's contact information through any method other than the recipient's Medicaid application, the commission:
(1)  must allow the organization to communicate with the recipient through any electronic means, including telephone, text message, and e-mail, regarding eligibility, enrollment, and other health care matters; and
(2)  may not require the organization to submit the recipient's contact preference information to the commission.
Added by Acts 1997, 75th Leg., ch. 1262, Sec. 2, eff. June 20, 1997.
Amended by: 
Acts 2021, 87th Leg., R.S., Ch. 624 (H.B. 4), Sec. 5, eff. June 15, 2021.
Acts 2023, 88th Leg., R.S., Ch. 582 (H.B. 2802), Sec. 1, eff. September 1, 2023.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.

Without reference to the addition of this section, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

Sec. 533.0091.  SICKLE CELL DISEASE TREATMENT.  To the extent possible, the commission shall:
(1)  in collaboration with the sickle cell task force established under Chapter 52, Health and Safety Code:
(A)  support initiatives to assist managed care plans in promoting timely, evidence-informed health care services to plan enrollees diagnosed with sickle cell disease to ensure the services reflect national clinical practice guidelines and protocols for sickle cell disease treatment and meet medical necessity criteria; and
(B)  address sickle cell disease education for Medicaid providers, including emergency department providers, by collaborating with medical specialty organizations in this state, state agencies, and health-related institutions to promote existing or new continuing education courses or facilitate development of any necessary new courses to improve the diagnosis, treatment, and management of sickle cell disease and the personal treatment of patients with sickle cell disease; and
(2)  use the commission's existing data to identify opportunities for improving health outcomes of recipients diagnosed with sickle cell disease by:
(A)  reducing hospital admissions and readmissions; and
(B)  connecting those recipients to a sickle cell disease health home or sickle cell disease expert.
Added by Acts 2023, 88th Leg., R.S., Ch. 409 (H.B. 1488), Sec. 1, eff. September 1, 2023.

Without reference to the addition of this section, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

Sec. 533.021.  COMMUNITY HEALTH WORKERS.  (a)  In this section, "community health worker" has the meaning assigned by Section 48.001, Health and Safety Code.
(b)  The commission shall allow each Medicaid managed care organization providing health care services under the STAR Medicaid managed care program to categorize services provided by a community health worker as a quality improvement cost, as authorized by federal law, instead of as an administrative expense.
Added by Acts 2023, 88th Leg., R.S., Ch. 796 (H.B. 113), Sec. 1, eff. June 13, 2023.

Without reference to the addition of this subchapter, this chapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

SUBCHAPTER C. PRESCRIPTION DRUG BENEFITS UNDER CERTAIN OUTPATIENT PHARMACY BENEFIT PLANS

Sec. 533.071.  PREFERRED DRUG LIST EXCEPTIONS.  (a)  The commission shall adopt rules allowing exceptions to the preferred drug list if:
(1)  the drug required under the preferred drug list:
(A)  is contraindicated;
(B)  will likely cause an adverse reaction in or physical or mental harm to the recipient; or
(C)  is expected to be ineffective based on the known clinical characteristics of the recipient and the known characteristics of the prescription drug regimen;
(2)  the recipient previously discontinued taking the preferred drug at any point in the recipient's clinical history and for any length of time because the drug:
(A)  was not effective;
(B)  had a diminished effect; or
(C)  resulted in an adverse event;
(3)  the recipient was prescribed and is taking a nonpreferred drug in the antidepressant or antipsychotic drug class and the recipient:
(A)  was prescribed the nonpreferred drug before being discharged from an inpatient facility;
(B)  is stable on the nonpreferred drug; and
(C)  is at risk of experiencing complications from switching from the nonpreferred drug to another drug; or
(4)  the preferred drug is not available for reasons outside of the Medicaid managed care organization's control, including because:
(A)  the drug is in short supply according to the Food and Drug Administration Drug Shortages Database; or
(B)  the drug's manufacturer has placed the drug on backorder or allocation.
(b)  An exception provided under this section does not subject the Medicaid managed care plan to liquidated damages for failing to comply with the preferred drug list.
Added by Acts 2023, 88th Leg., R.S., Ch. 739 (H.B. 3286), Sec. 2, eff. September 1, 2023.