BILL ANALYSIS

Senate Research Center	C.S.S.B. 1648
87R22973 BDP-F	By: Perry
	Health & Human Services
	4/28/2021
	Committee Report (Substituted)

AUTHOR'S / SPONSOR'S STATEMENT OF INTENT

The Medically Dependent Children's Program (MDCP) is a program within Star Kids. The program offers enhanced, community-based services for individuals who need the level of care provided in a nursing facility but who would like to remain in the community. The program currently serves more than 5,000.

Last session, S.B. 1207 offered numerous reforms to the MDCP program. One of the sections dealt with how a managed care organization coordinates benefits for an enrollee. There were a few subsections addressing enrollees who are covered under Medicaid as well as primary third party coverage. One section, addressing continuity of care, was drafted to be and intended to be for all enrollees regardless of primary third party coverage. However, because all of the subsections addressing coordination of care appeared in the same section, it was interpreted that the provision, which was intended to apply to all, would only be contingent upon primary third party coverage.

S.B. 1648 clarifies that continuity of care applies whether the enrollee is also covered under third party primary or not. In cases where the enrollee does not have third party primary coverage and would like to have continuity of care with that specialty provider, the managed care organization and provider would have to negotiate a single-case agreement. Until that agreement is reached, reimbursement would be specified by current rule in the Texas Administrative Code.

A single-case agreement entered into under this section is not considered an out-of-network provider for the purposes of Medicaid managed care organization network adequacy requirements.

C.S.S.B. 1648 amends current law relating to the provision of benefits to certain Medicaid recipients with complex medical needs.

RULEMAKING AUTHORITY

This bill does not expressly grant any additional rulemaking authority to a state officer, institution, or agency.

SECTION BY SECTION ANALYSIS

SECTION 1. Amends the heading to Section 533.038, Government Code, to read as follows:

Sec. 533.038. COORDINATION OF BENEFITS; CONTINUITY OF SPECIALTY CARE FOR CERTAIN RECIPIENTS.

SECTION 2. Amends Section 533.038, Government Code, by amending Subsection (g) and adding Subsections (h) and (i), as follows:

(g) Requires the Health and Human Services Commission (HHSC) to develop a clear and easy process, to be implemented through a contract, that allows a recipient with complex medical needs who has established a relationship with a specialty provider to continue receiving care from that provider, regardless of whether the recipient has primary health benefit plan coverage in addition to Medicaid coverage.

(h) Requires the managed care organization, if a recipient who has complex medical needs and who does not have primary health benefit plan coverage wants to continue to receive care from a specialty provider that is not in the provider network of the Medicaid managed care organization offering the managed care plan in which the recipient is enrolled, to negotiate a single‑case agreement with the specialty provider. Requires the specialty provider, until the Medicaid managed care organization and the specialty provider enter into the single‑case agreement, to be reimbursed in accordance with the applicable reimbursement methodology specified in HHSC rule, including 1 T.A.C. Chapter 355.

(i) Provides that a single‑case agreement entered into under Section 533.038 (Coordination of Benefits) is not considered accessing an out‑of‑network provider for the purposes of Medicaid managed care organization network adequacy requirements.

SECTION 3. Repealer: Section 531.0601(f) (relating to providing that Section 531.0601 (Long‑Term Care Services Waiver Program Interest Lists) expires December 1, 2021), Government Code.

SECTION 4. Provides that HHSC is required to implement a provision of this Act only if the legislature appropriates money to HHSC specifically for that purpose. Authorizes, but does not require, HHSC, if the legislature does not appropriate money specifically for that purpose, to implement a provision of this Act using other appropriations that are available for that purpose.

SECTION 5. Requires a state agency, if necessary for implementation of a provision of this Act, to request a waiver or authorization from a federal agency, and authorizes delay of implementation until such a waiver or authorization is granted.

SECTION 6. Effective date: September 1, 2021.