HB 159

relating to certain payment recovery and recoupment efforts under
Medicaid and the child health plan program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1.  Section 544.0502, Government Code, as effective
April 1, 2025, is amended by amending Subsection (i) and adding
Subsection (j) to read as follows:
(i)  The executive commissioner shall adopt rules necessary
to implement this section, including rules establishing due process
procedures that a managed care organization must follow when
engaging in payment recovery efforts as provided by this section.
In adopting the rules establishing due process procedures, the
executive commissioner shall require that a  managed care
organization or an organization's contracted entity that engages in
payment recovery efforts as provided by this section and Section
544.0503 provide to [a provider required to use electronic visit
(1)  a provider required to use electronic visit
verification written notice of the organization's intent to recoup
overpayments in accordance with Section 544.0503; and
(2)  a provider, regardless of whether the provider is
required to use electronic visit verification, a minimum of [at
least] 60 days after the provider has exhausted all rights to an
appeal to cure any defect in a claim, including by submitting
necessary documentation for the claim or resubmitting the claim,
before the organization may begin efforts to collect overpayments.
(j)  A managed care organization or the organization's
contracted entity that engages in payment recovery efforts under
this section or Section 544.0503, in conducting an audit or other
review of a claim for equipment, supplies, or services for which the
organization granted prior authorization, may not review:
(1)  the medical necessity determination; or
(2)  an error in the claim documentation for the
previously approved equipment, supplies, or services, if the error
SECTION 2.  Section 544.0504, Government Code, as effective
April 1, 2025, is amended to read as follows:
Sec. 544.0504.  RECOVERY AUDIT CONTRACTORS.  To the extent
required under Section 1902(a)(42), Social Security Act (42 U.S.C.
Section 1396a(a)(42)), the commission shall establish a program
under which the commission contracts with one or more recovery
audit contractors to identify [Medicaid] underpayments and
overpayments under Medicaid, including under the Medicaid managed
care program, and recover the overpayments.
SECTION 3.  If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 4.  This Act takes effect September 1, 2025.