The commission must require Medicaid managed care organizations to build provider networks that seek and include specified providers and facilities, including certain rural providers, subject to listed conditions.
Sec. 540.0651. INCLUSION OF CERTAIN PROVIDERS IN MEDICAID MANAGED CARE ORGANIZATION PROVIDER NETWORK. (a) The commission shall require that each managed care organization that contracts with the commission under any managed care model or arrangement to provide health care services to recipients in a region: (1) seek participation in the organization's provider network from: (A) each health care provider in the region who has traditionally provided care to recipients; (B) each hospital in the region that has been designated as a disproportionate share hospital under Medicaid; and (C) each specialized pediatric laboratory in the region, including a laboratory located in a children's hospital; (2) include in the organization's provider network for at least three years: (A) each health care provider in the region who: (i) previously provided care to Medicaid and charity care recipients at a significant level as the commission prescribes; (ii) agrees to accept the organization's prevailing provider contract rate; and (iii) has the credentials the organization requires, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network; (B) each accredited primary care residency program in the region; and (C) each disproportionate share hospital the commission designates as a statewide significant traditional provider; and (3) subject to Section 32.047, Human Resources Code, and notwithstanding any other law, include in the organization's provider network each optometrist, therapeutic optometrist, and ophthalmologist described by Section 532.0153(b)(1)(A) or (B) who, and an institution of higher education described by Section 532.0153(a)(4) in the region that: (A) agrees to comply with the organization's terms; (B) agrees to accept the organization's prevailing provider contract rate; (C) agrees to abide by the organization's required standards of care; and (D) is an enrolled Medicaid provider. (b) A contract between a Medicaid managed care organization and the commission for the organization to provide health care services to recipients in a health care service region that includes a rural area must require the organization to include in the organization's provider network rural hospitals, physicians, home and community support services agencies, and other rural health care providers who: (1) are sole community providers; (2) provide care to Medicaid and charity care recipients at a significant level as the commission prescribes; (3) agree to accept the organization's prevailing provider contract rate; and (4) have the credentials the organization requires, provided that lack of board certification or accreditation by The Joint Commission may not be the sole ground for exclusion from the provider network. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.