Untitled Texas Attorney General Opinion
GA-1089
Tex. Att'y Gen.Jul 2, 2014Background
- HHSC administers Texas's Medicaid program, with fee-for-service and managed care models; rulemaking duty is tied to fee-for-service payments.
- Rule 355.8091 reimburses counseling services at 70% of the fee for psychiatrists/psychologists under TMRM.
- The question focuses on whether this rule conflicts with Insurance Code 1451.104 governing health insurance policies.
- Section 1451.104 prohibits discriminatory payment for insured services; HHSC is not an insurer, and the rule targets Medicaid fee-for-service payments.
- Third Court of Appeals held HHSC's duty covers only fee-for-service, not managed care; MCOs negotiate their own rates.
- HHSC argued the rule does not apply to MCOs and that deference to agency interpretation applies if not plainly erroneous.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Does rule 355.8091 conflict with Insurance Code 1451.104? | Raymond posits a conflict. | HHSC contends no conflict since it is not an insurer. | No conflict; rule not applicable to insurers under 1451.104. |
| Is HHSC an insurer under 1451.102 for purposes of 1451.104? | Raymond alleges insurer-like status. | HHSC is not an insurer. | HHSC is not an insurer; 1451.104 does not govern. |
| Does rule 355.8091 apply to MCOs in Medicaid managed care? | Raymond relies on rule applying broadly. | Rule applies only to fee-for-service; MCOs excluded. | Rule does not govern MCOs. |
| Is HHSC entitled to deference on its interpretation of rule 355.8091? | Raymond questions agency interpretation. | Agency interpretation not plainly erroneous. | HHSC interpretation is not plainly erroneous; deference applies. |
Key Cases Cited
- Southwest Pharmacy Solutions, Inc. v. Tex. Health & Human Servs. Comm'n., 408 S.W.3d 549 (Tex. App.—Austin 2013) (affects whether HHSC must regulate MCO payments in managed care)
- Pub. Utils. Comm'n of Tex. v. Gulf States Utils. Co., 809 S.W.2d 201 (Tex. 1991) (agency interpretations must align with regulation and statute)
- Lee v. Tex. Workers' Comp. Comm'n, 272 S.W.3d 806 (Tex. App.—Austin 2008) (statutory interpretation and agency rule alignment)
- McCarty v. Tex. Parks & Wildlife Dep't, 919 S.W.2d 853 (Tex. App.—Austin 1996) (presumption of validity for agency rules)
- R.R. Comm'n v. Lone Star Gas Co., 844 S.W.2d 679 (Tex. 1992) (statutory/regulatory compliance principles)