The SMMCAC originally established five subcommittees on August 13, 2019. On November 19, 2020, two of the subcommittees (Clinical Oversight & Benefits, and Administrative Simplification) were combined. The four current SMMCAC subcommittees are:
- Clinical Oversight and Administrative Simplification,
- Complaints, Appeals, and Fair Hearings,
- Network Adequacy and Access to Care, and
- Service and Care Coordination.
Clinical Oversight and Administrative Simplification
Summary/Charge: Seeks to strengthen the oversight of utilization management practices to include prior authorization policies and processes used by manage care organizations (MCOs). Focuses on reducing Medicaid provider burden through administrative improvements in four areas: claims payments, eligibility information, provider enrollment processes and prior authorization submissions.
Prior authorization discussions will focus on provider process issues and Health and Human Services Commission oversight of MCO prior authorization data. Also discusses specific Medicaid medical benefits as needed.
Complaints, Appeals and Fair Hearings
Summary/Charge: Focuses on more effectively leveraging complaints data to identify potential problems in the Medicaid program, opportunities for improved MCO contract oversight and increasing program transparency. Also focuses on appeals and fair hearings processes, including implementation of an independent external medical reviewer.
Network Adequacy and Access to Care
Summary/Charge: Supports a comprehensive monitoring strategy to ensure members have timely access to the services they need. Objectives include accuracy of provider directories, incentivizing use of telehealth, telemedicine and telemonitoring services, reducing administrative burden related to network adequacy reporting and monitoring and integrating network adequacy reporting to include additional measures.
Service and Care Coordination
Summary/Charge: Focuses on improvements related to service and care coordination within managed care. Objectives include assessing best practices for care coordination, addressing state-level barriers hindering MCO deliver of care coordination services, clarifying terminology and definitions of service coordination and service management activities and identifying possible improvements to ensure service coordination and service management is consistent within HHSC contract requirements.