Texas Register, Volume 49, Number 7, Pages 805-932, February 16, 2024 Page: 855
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CQIDOPTED
S Adopted rules include new rules, amendments to existing rules, and repeals of exist
L S rules. A rule adopted by a state agency takes effect 20 days after the date on which
filed with the Secretary of State unless a later date is required by statute or specified
the rule (Government Code, 2001.036). If a rule is adopted without change to the text of the proposed rule, then t
Texas Register does not republish the rule text here. If a rule is adopted with change to the text of the proposed rule, th
the final rule text is included here. The final rule text will appear in the Texas Administrative Code on the effective daling
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e.TITLE 1. ADMINISTRATION
PART 15. TEXAS HEALTH AND
HUMAN SERVICES COMMISSION
CHAPTER 354. MEDICAID HEALTH
SERVICES
SUBCHAPTER J. MEDICAID THIRD PARTY
RECOVERY
The Executive Commissioner of the Texas Health and Human
Services Commission (HHSC) adopts amendments in Texas
Administrative Code (TAC), Title 1, Part 15, Chapter 354,
Subchapter J, to 354.2301, concerning Basis and Purpose;
354.2302, concerning Definitions; 354.2311, concerning
Applicant and Recipient Assignment of Rights; 354.2313, con-
cerning Duty of Applicant or Recipient to Inform and Cooperate;
354.2315, concerning Duty of Attorney or Representative
of a Recipient; 354.2321, concerning Provider Billing and
Recovery from Third Party Resources; 354.2322, concerning
Provider Billing and Recovery from Other Liable Third Parties;
354.2331, concerning Requests for Information; 354.2332,
concerning Distribution of Recoveries; 354.2333, concerning
Waiver Authority of the Executive Commissioner; 354.2334,
concerning Notices and Payments; 354.2341, concerning
Third Party Health Insurer Payment and Information Require-
ments; 354.2343, concerning Administrative Penalties for
Failure to Provide Information; 354.2344, concerning Notice
and Appeal of Administrative Penalty; 354.2354, concerning
Billing Medicare Intermediaries; 354.2355, concerning Long
Term Care Providers; and 354.2356, concerning Provider
Requirements to Bill Third Party Health Coverage.
The amendments to 354.2301, 354.2302, 354.2311,
354.2313, 354.2315, 354.2321, 354.2322, 354.2331 - 354.2334,
354.2341, 354.2343, 354.2344 and 354.2354 - 354.2356 are
adopted without changes to the proposed text as published in
the November 17, 2023, issue of the Texas Register (48 TexReg
6696). These rules will not be republished.
BACKGROUND AND JUSTIFICATION
The federal Consolidated Appropriations Act of 2022 (H.R. 2471)
amended 1902(a)(25)(1) of the Social Security Act to require a
state plan for medical assistance to make certain assurances
to the Secretary of Health and Human Services that state law
imposes certain requirements on responsible third party health
insurers.
Senate Bill (SB) 1342, 88th Legislature, Regular Session,2023, implemented H.R. 2471 by amending Texas Human
Resources Code 32.0424. SB 1342 also repealed Texas
Human Resources Code 32.042. Section 32.0424 requiresa third party health insurer to: (i) provide certain insurance
coverage information, upon timely request, to HHSC or HHSC's
designee; (ii) with some exceptions, accept authorization from
HHSC or HHSC's designee that an item or service is covered
by Medicaid as if that authorization is a prior authorization made
by the third party health insurer; and (iii) respond within 60 days
to an inquiry from HHSC or HHSC's designee regarding a claim
for payment for health care submitted to the third party health
insurer. Further, Texas Human Resources Code 32.0424
defines "third party health insurer" to mean a health insurer or
other person or arrangement that is legally responsible by state
or federal law or private agreement to pay some or all claims for
health care items or services provided to an individual.
One purpose of the amendments is to implement the recent
changes to the Texas Human Resources Code as it applies to
Medicaid Third Party Recovery. Additionally, the amendments
implement other changes made to 1902(a)(25)(1) of the Social
Security Act prior to H.R. 2471, such as obligating the state to
require health insurers to accept the State's right of recovery
and assignment to the State of any right to payment for an item
or service for which payment has been made under Medicaid
and to agree not to deny a claim submitted by the State solely
on the basis of the date of submission of the claim or the type or
format of the claim form. The amendments also add and update
definitions; clarify the sections of the amendments that would
apply to managed care organizations; add HHSC's right, based
on the United States Supreme Court decision in Gallardo v.
Marstiller; 142 S. Ct. 1751 (2022), to seek reimbursement from
settlement amounts representing past or future payments for
medical care; and update certain outdated terms and phrases
throughout TAC Chapter 354, Subchapter J.
COMMENTS
The 31-day comment period ended December 18, 2023.
During this period, the Health and Human Services Office of In-
spector General (OIG) received one comment regarding the pro-
posed rules from Kyle Mauro, HillCo Partners. A summary of the
comment relating to the amended rules and OIG's response fol-
lows.
Comment: One general question was received inquiring if the
rule amendments will require a State Plan Amendment (SPA).
Response: No changes are made to the rules in response to
this comment OIG believes a SPA is not required for the rule
amendments because the current Texas Medicaid State Plan,
Third Party Liability section, provides that the State has laws in
effect that require third parties to comply with the provisions of
section 1902(a)(25)(1) of the Social Security Act.
DIVISION 1. GENERAL PROVISIONS1 TAC 354.2301, 354.2302
ADOPTED RULES February 16, 2024 49 TexReg 855
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Texas. Secretary of State. Texas Register, Volume 49, Number 7, Pages 805-932, February 16, 2024, periodical, February 16, 2024; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth1657764/m1/51/: accessed July 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.