Chapter
540
Medicaid Managed Care Program
Sections
540.0001
Definitions
540.0051
Purpose and Implementation
540.0052
Recipient Directory
540.0053
Statewide Effort to Promote Medicaid Eligibility Maintenance
540.0054
Provider and Recipient Education Programs
540.0055
Marketing Guidelines
540.0056
Guidelines for Communications with Recipients
540.0057
Coordination of External Oversight Activities
540.0058
Information for Fraud Control
540.0059
Managed Care Clinical Improvement Program
540.0060
Complaint System Guidelines
540.0101
Fiscal Solvency Standards
540.0102
Profit Sharing
540.0103
Treatment of State Taxes in Calculating Experience Rebate or Profit Sharing
540.0151
Definitions
540.0152
Applicability and Construction of Subchapter
540.0153
Overall Strategy for Managing Audit Resources
540.0154
Performance Audit Selection Process and Follow-up
540.0155
Agreed-upon Procedures Engagements and Corrective Action Plans
540.0156
Audits of Pharmacy Benefit Managers
540.0157
Collecting Costs for Audit-related Services
540.0158
Collection Activities Related to Profit Sharing
540.0159
Using Information from External Quality Reviews
540.0160
Security of and Processing Controls over Information Technology Systems
540.0201
Contract Administration Improvement Efforts
540.0202
Public Notice of Request for Contract Applications
540.0203
Certification by Commission
540.0204
Contract Considerations Relating to Managed Care Organizations
540.0205
Contract Considerations Relating to Pharmacy Benefit Managers
540.0206
Mandatory Contracts
540.0207
Contractual Obligations Review
540.0208
Contract Implementation Plan
540.0209
Compliance and Readiness Review
540.0210
Internet Posting of Sanctions Imposed for Contractual Violations
540.0211
Performance Measures and Incentives for Value-based Contracts
540.0212
Monitoring Compliance with Behavioral Health Integration
540.0251
Applicability
540.0252
Accountability to State
540.0253
Capitation Rates
540.0254
Cost Information
540.0255
Fraud Control
540.0256
Recipient Outreach and Education
540.0257
Notice of Medicaid Certification Date
540.0258
Primary Care Provider Assignment
540.0259
Compliance with Provider Network Requirements
540.0260
Compliance with Provider Access Standards; Report
540.0261
Provider Network Sufficiency
540.0262
Quality Monitoring Program for Health Care Services
540.0263
Out-of-network Provider Usage and Reimbursement
540.0264
Provider Reimbursement Rate Reduction
540.0265
Prompt Payment of Claims
540.0266
Reimbursement for Certain Services Provided Outside Regular Business Hours
540.0267
Provider Appeals Process
540.0268
Assistance Resolving Recipient and Provider Issues
540.0269
Use of Advanced Practice Registered Nurses and Physician Assistants
540.0270
Medical Director Availability
540.0271
Personnel Required in Certain Service Regions
540.0272
Certain Services Permitted in Lieu of Other Mental Health or Substance Use Disorder Services; Annual Report
540.0273
Outpatient Pharmacy Benefit Plan
540.0274
Pharmacy Benefit Plan: Rebates and Receipt of Confidential Information Prohibited
540.0275
Pharmacy Benefit Plan: Certain Pharmacy Benefits for Sex Offenders Prohibited
540.0276
Pharmacy Benefit Plan: Recipient Selection of Pharmaceutical Services Provider
540.0277
Pharmacy Benefit Plan: Pharmacy Benefit Providers
540.0278
Pharmacy Benefit Plan: Prompt Payment of Pharmacy Benefit Claims
540.0279
Pharmacy Benefit Plan: Maximum Allowable Cost Price and List for Pharmacy Benefits
540.0280
Pharmacy Benefit Plan: Pharmacy Benefits for Child Enrolled in Star Kids Managed Care Program
540.0301
Inapplicability of Certain Other Law to Medicaid Managed Care Utilization Reviews
540.0302
Prior Authorization Procedures for Hospitalized Recipient
540.0303
Prior Authorization Procedures for Nonhospitalized Recipient
540.0304
Annual Review of Prior Authorization Requirements
540.0305
Physician Consultation Before Adverse Prior Authorization Determination
540.0306
Reconsideration Following Adverse Determinations on Certain Prior Authorization Requests
540.0307
Maximum Period for Prior Authorization Decision; Access to Care
540.0351
Premium Payment Rate Determination
540.0352
Maximum Premium Payment Rates for Certain Programs
540.0353
Use of Encounter Data in Determining Premium Payment Rates and Other Payment Amounts
540.0401
Provider Reporting of Encounter Data
540.0402
Certifier of Encounter Data Qualifications
540.0403
Encounter Data Certification
540.0451
Medicaid Managed Care Plan Accreditation
540.0452
Medical Director Qualifications
540.0501
Recipient Enrollment in and Disenrollment from Medicaid Managed Care Plan
540.0502
Automatic Enrollment in Medicaid Managed Care Plan
540.0503
Enrollment of Certain Recipients in Same Medicaid Managed Care Plan
540.0504
Quality-based Enrollment Incentive Program for Medicaid Managed Care Organizations
540.0505
Limitations on Recipient Disenrollment from Medicaid Managed Care Plan
540.0551
Guidance Regarding Continuation of Services Under Certain Circumstances
540.0552
Coordination of Benefits; Continuity of Specialty Care for Certain Recipients
540.0601
Monitoring of Provider Networks
540.0602
Report on Out-of-network Provider Services
540.0603
Report on Commission Investigation of Provider Complaint
540.0604
Additional Reimbursement Following Provider Complaint
540.0605
Corrective Action Plan for Inadequate Network and Provider Reimbursement
540.0606
Remedies for Noncompliance with Corrective Action Plan
540.0651
Inclusion of Certain Providers in Medicaid Managed Care Organization Provider Network
540.0652
Provider Access Standards; Biennial Report
540.0653
Penalties and Other Remedies for Failure to Comply with Provider Access Standards
540.0654
Provider Network Directories
540.0655
Provider Protection Plan
540.0656
Expedited Credentialing Process for Certain Providers
540.0657
Frequency of Provider Recredentialing
540.0658
Provider Incentives for Promoting Preventive Services
540.0659
Reimbursement Rate for Certain Services Provided by Certain Health Centers and Clinics Outside Regular Business Hours
540.0701
Acute Care Service Delivery Through Most Cost-effective Model; Managed Care Service Delivery Areas
540.0702
Transition of Case Management for Children and Pregnant Women Program Recipients to Medicaid Managed Care Program
540.0703
Behavioral Health and Physical Health Services
540.0704
Targeted Case Management and Psychiatric Rehabilitative Services for Children, Adolescents, and Families
540.0705
Behavioral Health Services Provided Through Third Party or Subsidiary
540.0706
Psychotropic Medication Monitoring System for Certain Children
540.0707
Medication Therapy Management
540.0708
Special Disease Management
540.0709
Special Protocols for Indigent Populations
540.0710
Direct Access to Eye Health Care Services
540.0711
Delivery of Benefits Using Telecommunications or Information Technology
540.0712
Promotion and Principles of Patient-centered Medical Home
540.0713
Value-added Services
540.0751
Delivery of Acute Care Services and Long-term Services and Supports
540.0752
Delivery of Medicaid Benefits to Nursing Facility Residents
540.0753
Delivery of Basic Attendant and Habilitation Services
540.0754
Evaluation of Certain Program Services
540.0755
Utilization Review; Annual Report
540.0801
Trauma-informed Care Training
540.0802
Mental Health Providers
540.0803
Health Screening Requirements and Compliance with Texas Health Steps
540.0804
Health Care and Other Services for Children in Substitute Care
540.0805
Placement Change Notice and Care Coordination
540.0806
Medicaid Benefits for Certain Children Formerly in Foster Care
540.0851
Star Kids Managed Care Program
540.0852
Care Management and Care Needs Assessment
540.0855
Utilization Review of Prior Authorizations
