The commission must establish and run an ombudsman program that helps Medicaid applicants and recipients get support, information, and problem resolution.
Sec. 523.0358. OMBUDSMAN FOR MANAGED CARE ASSISTANCE. (a) The commission shall establish an ombudsman program to provide support and information services to an individual enrolled in or applying for Medicaid coverage who experiences barriers to receiving health care services. (b) An ombudsman appointed under this section shall give emphasis to assisting an individual with an urgent or immediate medical or support need. (c) The commission shall provide support and information services required by this section through a network of entities coordinated by the commission's ombudsman program and composed of: (1) the commission's ombudsman program or other division of the commission designated by the executive commissioner to coordinate the network; (2) the office of the state long-term care ombudsman required under Subchapter F, Chapter 101A, Human Resources Code; (3) the division within the commission responsible for oversight of Medicaid managed care contracts; (4) area agencies on aging; (5) aging and disability resource centers established under the Aging and Disability Resource Center initiative funded in part by the federal Administration on Aging and the Centers for Medicare and Medicaid Services; and (6) any other entity the executive commissioner determines appropriate. (d) As a part of the support and information services required by this section, the ombudsman program 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) 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; (6) meet the needs of all current and future Medicaid managed care recipients, including children receiving dental benefits; (7) incorporate support services for children enrolled in the child health plan program established under Chapter 62, Health and Safety Code; and (8) 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 ombudsman program must be sufficiently independent from other aspects of Medicaid managed care to represent the best interests of recipients in problem resolution. Added by Acts 1997, 75th Leg., ch. 165, Sec. 14.03(a), eff. Sept. 1, 1997. Amended by: Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.025, eff. April 2, 2015. Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 3, eff. September 1, 2015. Transferred, redesignated and amended from Government Code, Section 531.0213 by Acts 2023, 88th Leg., R.S., Ch. 741 (H.B. 3462), Sec. 10, eff. June 12, 2023. Transferred, redesignated and amended from Government Code, Subchapter Y, Chapter 531 by Acts 2025, 89th Leg., R.S., Ch. 204 (H.B. 1620), Sec. 8.019(a), eff. September 1, 2025.