| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to a direct primary care model pilot program for Medicaid. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Subchapter B, Chapter 531, Government Code, is |
|
|
amended by adding Section 531.024151 to read as follows: |
|
|
Sec. 531.024151. DIRECT PRIMARY CARE MODEL PILOT PROGRAM |
|
|
FOR MEDICAID. (a) In this section: |
|
|
(1) "Direct fee" means a fee charged by a physician to |
|
|
a patient or a patient's designee for primary medical care services |
|
|
provided by, or to be provided by, the physician to the |
|
|
patient. The term includes a fee in any form, including a: |
|
|
(A) retainer; |
|
|
(B) membership fee; |
|
|
(C) subscription fee; or |
|
|
(D) fee paid under a medical service agreement. |
|
|
(2) "Direct primary care," "medical service |
|
|
agreement," "physician," and "primary medical care service" have |
|
|
the meanings assigned by Section 162.251, Occupations Code. |
|
|
(3) "Participating physician" means a physician |
|
|
participating in the pilot program. |
|
|
(4) "Participating recipient" means a Medicaid |
|
|
recipient participating in the pilot program. |
|
|
(5) "Pilot program" means the direct primary care |
|
|
model pilot program established under this section. |
|
|
(b) The commission shall develop a pilot program to |
|
|
implement a direct primary care model in Medicaid through which a |
|
|
Medicaid recipient enters into a medical service agreement with a |
|
|
physician for the provision of primary medical care services in |
|
|
exchange for a direct fee that is paid on a monthly basis. |
|
|
(c) The commission shall implement the pilot program |
|
|
statewide. |
|
|
(d) Under the pilot program, a participating physician: |
|
|
(1) is not required to enroll as a Medicaid provider; |
|
|
and |
|
|
(2) notwithstanding Subdivision (1), has the |
|
|
authority of ordering, referring, and prescribing Medicaid |
|
|
providers for purposes of the pilot program. |
|
|
(e) To be eligible to participate in the pilot program, a |
|
|
physician must be practicing under a direct primary care model that |
|
|
does not accept payment or otherwise seek reimbursement for primary |
|
|
medical care services from a third-party insurer or managed care |
|
|
organization. |
|
|
(f) A Medicaid recipient must be younger than 65 years of |
|
|
age to be eligible to participate in the pilot program. The |
|
|
recipient or the recipient's parent or legally authorized |
|
|
representative on behalf of the recipient must enter into a medical |
|
|
service agreement with a physician eligible to participate in the |
|
|
pilot program. After the commission verifies that the recipient or |
|
|
the recipient's parent or legally authorized representative has |
|
|
entered into the agreement, the commission shall pay the lesser of: |
|
|
(1) the amount of the direct fee required under the |
|
|
agreement; or |
|
|
(2) $40 per month for a recipient who is 18 years of |
|
|
age or younger, or $70 per month for a recipient who is at least 19 |
|
|
years of age but younger than 65 years of age. |
|
|
(g) A participating recipient shall pay the amount of the |
|
|
direct fee required under the medical service agreement that |
|
|
exceeds the maximum fee amount the commission pays under Subsection |
|
|
(f). |
|
|
(h) The commission may pay the amount of the direct fee |
|
|
under a medical service agreement directly to the participating |
|
|
recipient, who is then responsible for paying the participating |
|
|
physician under the agreement, or may establish a system under |
|
|
which the commission pays the fee directly to the physician, either |
|
|
by depositing the fee into an account established for the physician |
|
|
for that purpose or by another means the commission determines most |
|
|
appropriate. If cost-effective, the commission may issue an |
|
|
electronic benefits transfer card to a participating recipient who |
|
|
shall use the card to pay the amount of the direct fee under an |
|
|
agreement. |
|
|
(i) A participating recipient shall immediately notify the |
|
|
commission when a medical service agreement terminates. |
|
|
(j) Not later than December 31, 2024, the commission shall |
|
|
prepare and submit a report to the legislature that includes: |
|
|
(1) a summary of the commission's evaluation of the |
|
|
effect of the pilot program on the provision of primary medical care |
|
|
services and Medicaid costs; and |
|
|
(2) a recommendation as to whether the pilot program |
|
|
should be continued or terminated. |
|
|
(k) The executive commissioner shall adopt rules as |
|
|
necessary to implement this section. |
|
|
(l) The pilot program terminates and this section expires |
|
|
September 1, 2025. |
|
|
SECTION 2. If before implementing any provision of this Act |
|
|
a state agency determines that a waiver or authorization from a |
|
|
federal agency is necessary for implementation of that provision, |
|
|
the agency affected by the provision shall request the waiver or |
|
|
authorization and may delay implementing that provision until the |
|
|
waiver or authorization is granted. |
|
|
SECTION 3. This Act takes effect September 1, 2021. |