Government Code § 540.0209

Sec. 540.0209. COMPLIANCE AND READINESS REVIEW. (a) The commission shall conduct a compliance and readiness review of each Medicaid managed care organization: (1) not later than the 15th day before the date the process of enrolling recipients in a managed care plan the organization issues is to begin in a region; and (2) not later than the 15th day before the date the organization plans to begin providing health care services to recipients in that region through managed care. (b) The compliance and readiness review must include an on-site inspection and tests of service authorization and claims payment systems, including: (1) the Medicaid managed care organization's ability to process claims electronically; (2) the Medicaid managed care organization's complaint processing systems; and (3) any other process or system the contract between the Medicaid managed care organization and the commission requires. (c) The commission may delay recipient enrollment in a managed care plan a Medicaid managed care organization issues if the compliance and readiness review reveals that the organization is not prepared to meet the organization's contractual obligations. The commission shall notify the organization of a decision to delay enrollment in a plan the organization issues. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.