Text of section effective on April 01, 2025
Sec. 540.0652.  PROVIDER ACCESS STANDARDS; BIENNIAL REPORT.  (a)  The commission shall establish minimum provider access standards for a Medicaid managed care organization's provider network.  The provider access standards must ensure that a Medicaid managed care organization provides recipients sufficient access to:
(1)  preventive care;
(2)  primary care;
(3)  specialty care;
(4)  after-hours urgent care;
(5)  chronic care;
(6)  long-term services and supports;
(7)  nursing services;
(8)  therapy services, including services provided in a clinical setting or in a home or community-based setting; and
(9)  any other services the commission identifies.
(b)  To the extent feasible, the provider access standards must:
(1)  distinguish between access to providers in urban and rural settings;
(2)  consider the number and geographic distribution of Medicaid-enrolled providers in a particular service delivery area; and
(3)  subject to Section 548.0054(a) and consistent with Section 111.007, Occupations Code, consider and include the availability of telehealth services and telemedicine medical services in a Medicaid managed care organization's provider network.
(c)  The commission shall biennially submit to the legislature and make available to the public a report that contains:
(1)  information and statistics on:
(A)  recipient access to providers through Medicaid managed care organizations' provider networks; and
(B)  Medicaid managed care organization compliance with contractual obligations related to provider access standards;
(2)  a compilation and analysis of information Medicaid managed care organizations submit to the commission under Section 540.0260(4);
(3)  for both primary care providers and specialty providers, information on provider-to-recipient ratios in a Medicaid managed care organization's provider network and benchmark ratios to indicate whether deficiencies exist in a given network; and
(4)  a description of, and analysis of the results from, the commission's monitoring process established under Section 540.0601.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.