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A BILL TO BE ENTITLED
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AN ACT
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relating to the coordination of Medicaid and private health |
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benefits for Medicaid recipients with complex medical needs. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 533.038, Government Code, is amended by |
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amending Subsections (a) and (g) and adding Subsection (h) to read |
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as follows: |
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(a) In this section:[,] |
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(1) "Durable medical equipment" means equipment, |
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services, and supplies, including repair and replacement parts for |
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the equipment, that: |
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(A) is primarily and customarily used to serve a |
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medical purpose as prescribed for medical necessity; and |
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(B) includes, but is not limited to, ventilators, |
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infusion pumps, medical devices, prostheses, complex |
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rehabilitation technology (CRT), and such other medical equipment, |
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supplies, and services as prescribed by the treating provider. |
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(2) "Medicaid wrap-around benefit" means a |
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Medicaid-covered service, including a pharmacy or medical benefit, |
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that is provided to a recipient with both Medicaid and primary |
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health benefit plan coverage when the recipient has exceeded the |
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primary health benefit plan coverage limit or when the service is |
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not covered by the primary health benefit plan issuer. |
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(3) The guarantee of continuity of care is applicable |
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to all Medicaid recipients regardless of: |
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(A) whether the recipient is a Medicaid |
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wrap-around beneficiary; |
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(B) primary health benefit plan coverage; |
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(C) date of enrollment of the recipient; or |
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(D) network status of the provider. |
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(D-1) In network specialty provider contract |
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cancellation does not void the guarantee of continuity of care. The |
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recipient retains the right to select their preferred specialty |
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provider should contract cancellation occur. |
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(4) "Specialty provider" means a person who provides |
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health-related goods or services to a recipient, including: |
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(A) a physician licensed under Subtitle B, Title |
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3, Occupations Code; |
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(B) an audiologist licensed under Chapter 401, |
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Occupations Code; |
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(C) a chiropractor licensed under Chapter 201, |
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Occupations Code; |
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(D) a dietitian licensed under Chapter 701, |
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Occupations Code; |
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(E) an optometrist licensed under Chapter 351, |
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Occupations Code; |
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(F) a podiatrist licensed under Chapter 202, |
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Occupations Code; |
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(G) a pharmacist licensed under Subtitle J, Title |
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3, Occupations Code; |
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(H) a durable medical equipment provider; and |
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(I) any other provider of health-related goods, |
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including medication, therapy, equipment, and services to a person |
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with complex medical needs. |
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(g) The commission shall develop a clear and easy process, |
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to be implemented through a contract, that allows a recipient with |
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complex medical needs who has established a relationship at any |
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time with a specialty provider to receive care, including |
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equipment, supplies, and services necessary to provide that care, |
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from that provider. A Medicaid managed care organization shall |
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provide a recipient with access to that care from that specialty |
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provider. A Medicaid managed care organization shall provide |
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reimbursement to the specialty provider as described by 1 T.A.C. |
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Section 353.4(e)(2) and (e)(3). |
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SECTION 2. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 3. This Act takes effect September 1, 2021. |