SECTION 353.407. Requirements of Managed Care Plans

(a) Entities or individuals who subcontract with an MCO to provide benefits, perform services, or carry out any essential function of the MCO contract must meet the same qualifications and contract requirements as the MCO for the service, benefit, or function delegated under the subcontract.

(b) An MCO must reimburse a Federally Qualified Health Center (FQHC), a Rural Health Clinic (RHC), or a municipal health department's public clinic for health care services provided to a member outside of regular business hours, as defined at §353.2 of this title (relating to Definitions), at a rate that is equal to the allowable rate for those services as determined under §32.028(e) and (f), Human Resources Code, if the member does not have a referral from the member's primary care provider.

(c) An MCO must comply with HHSC's policy on contracting and subcontracting with historically underutilized businesses (HUBs). HHSC's policy is to meet the goals and good faith effort requirements as stated in the Comptroller of Public Accounts rules at 34 TAC Chapter 20, Subchapter B (relating to Historically Underutilized Business Program).

(d) An MCO must contract with advance practice registered nurses and physician assistants as primary care providers in compliance with Texas Government Code §533.005(a)(13).

(e) Beginning March 1, 2015, an MCO must provide Medicaid benefits to nursing facility residents and reimburse nursing facility providers in compliance with Texas Government Code §533.00251(c).

Source Note: The provisions of this §353.407 adopted to be effective December 18, 1996, 21 TexReg 11822; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 10, 2005, 30 TexReg 4466; amended to be effective September 1, 2006, 31 TexReg 6629; amended to be effective December 25, 2007, 32 TexReg 9594; amended to be effective March 1, 2012, 37 TexReg 1283; amended to be effective September 1, 2014, 39 TexReg 5873