Text of section effective on April 01, 2025

Sec. 532.0303.  SUPPORT AND INFORMATION SERVICES FOR RECIPIENTS.  (a)  The commission shall provide support and information services to a recipient or applicant for Medicaid who experiences barriers to receiving health care services.  The commission shall give emphasis to assisting an individual with an urgent or immediate medical or support need.
(b)  The commission shall provide the support and information services through a network of entities that are:
(1)  coordinated by the commission's office of the ombudsman or other commission division the executive commissioner designates; and
(2)  composed of:
(A)  the commission's office of the ombudsman or other commission division the executive commissioner designates to coordinate the network;
(B)  the office of the state long-term care ombudsman required under Subchapter F, Chapter 101A, Human Resources Code;
(C)  the commission division responsible for oversight of Medicaid managed care contracts;
(D)  area agencies on aging;
(E)  aging and disability resource centers established under the aging and disability resource center initiative funded in part by the Administration on Aging and the Centers for Medicare and Medicaid Services; and
(F)  any other entity the executive commissioner determines appropriate, including nonprofit organizations with which the commission contracts under Subsection (c).
(c)  The commission may provide the support and information services by contracting with nonprofit organizations that are not involved in providing health care, health insurance, or health benefits.
(d)  As a part of the support and information services, the commission shall:
(1)  operate a statewide toll-free assistance telephone number that includes relay services for individuals with speech or hearing disabilities and assistance for individuals who speak Spanish;
(2)  intervene promptly with the state Medicaid office, Medicaid managed care organizations and providers, and any other appropriate entity on behalf of an individual who has an urgent need for medical services;
(3)  assist an individual who is experiencing barriers in the Medicaid application and enrollment process and refer the individual for further assistance if appropriate;
(4)  educate individuals so that they:
(A)  understand the concept of managed care;
(B)  understand their rights under Medicaid, including grievance and appeal procedures; and
(C)  are able to advocate for themselves;
(5)  collect and maintain statistical information on a regional basis regarding calls the assistance lines receive and publish quarterly reports that:
(A)  list the number of calls received by region;
(B)  identify trends in delivery and access problems;
(C)  identify recurring barriers in the Medicaid system; and
(D)  indicate other identified problems with Medicaid managed care;
(6)  assist the state Medicaid office and Medicaid managed care organizations and providers in identifying and correcting problems, including site visits to affected regions if necessary;
(7)  meet the needs of all current and future managed care recipients, including children receiving dental benefits and other recipients receiving benefits, under:
(A)  the STAR Medicaid managed care program;
(B)  the STAR+PLUS Medicaid managed care program, including the Texas Dual Eligible Integrated Care Demonstration Project provided under that program;
(C)  the STAR Kids managed care program established under Subchapter R, Chapter 540; and
(D)  the STAR Health program;
(8)  incorporate support services for children enrolled in the child health plan program established under Chapter 62, Health and Safety Code; and
(9)  ensure that staff providing support and information services receive sufficient training, including training in the Medicare program for the purpose of assisting recipients who are dually eligible for Medicare and Medicaid, and have sufficient authority to resolve barriers experienced by recipients to health care and long-term services and supports.
(e)  The commission's office of the ombudsman or other commission division the executive commissioner designates to coordinate the network of entities responsible for providing the support and information services must be sufficiently independent from other aspects of Medicaid managed care to represent the best interests of recipients in problem resolution.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.