S.B. No. 10
1-1 AN ACT
1-2 relating to development of a health care delivery system under the
1-3 state Medicaid program that results in cost savings to the state.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Article 4413(502), Revised Statutes, is amended
1-6 by adding Sections 16A, 16B, 16C, 16D, 16E, 16F, and 16G to read as
1-7 follows:
1-8 Sec. 16A. HEALTH CARE DELIVERY SYSTEM. (a) The commission
1-9 shall develop a health care delivery system that restructures the
1-10 delivery of health care services provided under the state Medicaid
1-11 program. The commission shall develop the health care delivery
1-12 system only if the commission obtains a waiver or other
1-13 authorization from all necessary federal agencies to implement the
1-14 system. In developing the health care delivery system, the
1-15 commission shall:
1-16 (1) to the extent possible, design the system in a
1-17 manner that will:
1-18 (A) improve the health of Texans by:
1-19 (i) emphasizing prevention;
1-20 (ii) promoting continuity of care; and
1-21 (iii) providing a medical home for
1-22 Medicaid recipients; and
1-23 (B) ensure that each recipient can receive high
1-24 quality, comprehensive health care services in the recipient's
2-1 local community;
2-2 (2) design the system in a manner that will enable the
2-3 state and the local governmental entities that make resources and
2-4 other funds available for matching to the commission under this
2-5 section to control the costs associated with the state Medicaid
2-6 program and, to the extent possible, will result in cost savings to
2-7 the state and those local governmental entities through health care
2-8 service delivery based on managed care;
2-9 (3) to the extent it is cost-effective to the state
2-10 and local governments, maximize the financing of the state Medicaid
2-11 program by obtaining federal matching funds for all resources and
2-12 other funds available for matching and expand Medicaid eligibility
2-13 to include persons who were eligible to receive indigent health
2-14 care services through the use of those resources or other funds
2-15 available for matching before expansion of eligibility, provided
2-16 that the commission shall give priority to expanding eligibility to
2-17 children and their families;
2-18 (4) to the extent possible, develop a plan to expand
2-19 Medicaid eligibility to include children and other persons, other
2-20 than those persons described by Subdivision (3) of this subsection,
2-21 that is funded by using:
2-22 (A) appropriations that have previously been
2-23 made to other agencies or other programs to provide related health
2-24 care services to those children and other persons;
2-25 (B) earned federal funds;
2-26 (C) contributions by those children or other
2-27 persons or their families; or
3-1 (D) resources or other funds available for
3-2 matching;
3-3 (5) design the system to ensure that if the system
3-4 includes a method to finance the state Medicaid program by
3-5 obtaining federal matching funds for resources and other funds
3-6 available for matching, each entity listed in Subsection (d)(1),
3-7 (2), (3), (7), (8), or (9) or Subsection (e) of this section that
3-8 makes those resources and other funds available receives funds to
3-9 provide health care services to persons who are eligible for
3-10 Medicaid under the expanded eligibility criteria developed under
3-11 Subdivision (3) or (4) of this subsection in an amount that is at
3-12 least equal to the amount of resources or other funds available for
3-13 matching provided by that entity under this section;
3-14 (6) to the extent possible, provide for the entities
3-15 that make resources and other funds available for matching under
3-16 this section an option to operate the health care delivery system
3-17 within their regions including appropriate portions of the
3-18 eligibility determination process, subject to the standards of and
3-19 oversight by the commission;
3-20 (7) design the system to:
3-21 (A) include methods for ensuring accountability
3-22 to the state for the provision of health care services under the
3-23 state Medicaid program, including methods for financial reporting,
3-24 quality assurance, and utilization review;
3-25 (B) provide a single point of accountability for
3-26 collection of uniform data to assess, compile, and analyze outcome
3-27 quality and cost efficiency;
4-1 (C) conduct comparative analyses of compiled
4-2 data to assess the relative value of alternative health care
4-3 delivery systems and report to the governor, lieutenant governor,
4-4 and speaker of the house of representatives;
4-5 (D) oversee the methodology for setting
4-6 capitation and provider payment rates to ensure the cost-effective
4-7 provision of quality health care;
4-8 (E) ensure that both private and public health
4-9 care providers and managed care organizations, including a hospital
4-10 that has been designated as a disproportionate share hospital under
4-11 the state Medicaid program, will have an opportunity to participate
4-12 in the system;
4-13 (F) ensure, in adopting rules implementing the
4-14 system, that in developing the provider network for the system, the
4-15 commission, each intergovernmental initiative, and each managed
4-16 care organization, as applicable, give extra consideration to a
4-17 health care provider who has traditionally provided care to
4-18 Medicaid and charity care patients;
4-19 (G) give extra consideration to providers who
4-20 agree to assure continuity of care for Medicaid clients for 12
4-21 months beyond the period of eligibility; and
4-22 (H) require that the commission, each
4-23 intergovernmental initiative, and each managed care organization,
4-24 as applicable, include in its provider network, for not less than
4-25 three years, each health care provider who:
4-26 (i) previously provided care to Medicaid
4-27 and charity care patients at a significant level as prescribed by
5-1 the commission;
5-2 (ii) agrees to accept the standard
5-3 provider reimbursement rate of the commission, the
5-4 intergovernmental initiative, or the managed care organization, as
5-5 applicable;
5-6 (iii) meets the credentialing requirements
5-7 under the system of the commission, the intergovernmental
5-8 initiative, or the managed care organization, as applicable,
5-9 provided that lack of board certification or accreditation by the
5-10 Joint Commission on Accreditation of Healthcare Organizations may
5-11 not be the sole grounds for exclusion from the provider network;
5-12 and
5-13 (iv) agrees to comply and does comply with
5-14 all of the terms and conditions of the standard provider agreement
5-15 of the commission, intergovernmental initiative, or managed care
5-16 organization, as applicable;
5-17 (8) design the system in a manner that, to the extent
5-18 possible, enables the state to manage care to lower the cost of
5-19 providing Medicaid services through the use of health care delivery
5-20 systems such as a primary care case management system, partially
5-21 capitated system, or fully capitated system or a combination of one
5-22 or more of those systems and use, where possible, multiple,
5-23 competing managed care organizations within those systems;
5-24 (9) design the system in a manner that enables the
5-25 state to:
5-26 (A) use different types of health care delivery
5-27 systems to meet the needs of different populations, including the
6-1 establishment of pilot programs to deliver health care services to
6-2 children with special health care needs;
6-3 (B) recognize the unique role of rural
6-4 hospitals, physicians, home and community support services
6-5 agencies, and other rural health care providers in providing access
6-6 to health care services for rural Texans; and
6-7 (C) review data from existing or new pilot
6-8 programs that cover all prescription drugs that are medically
6-9 indicated for a person by a licensed health care provider in
6-10 primary and preventive care and implement any changes in the state
6-11 Medicaid program that as a result of the review are determined to
6-12 be cost-effective and cost-neutral;
6-13 (10) establish geographic health care service regions
6-14 after consulting with local governmental entities that provide
6-15 resources or other funds available for matching under this section
6-16 and emphasize regional coordination in the provision of indigent
6-17 health care;
6-18 (11) simplify eligibility criteria and streamline
6-19 eligibility determination processes;
6-20 (12) to the extent possible, provide a one-stop
6-21 approach for client information and referral for managed care
6-22 services;
6-23 (13) to the extent possible, design the system in a
6-24 manner that encourages the training of and access to primary care
6-25 physicians;
6-26 (14) develop and prepare, after consulting with the
6-27 following entities, the waiver or other documents necessary to
7-1 obtain federal authorization for the system:
7-2 (A) governmental entities that provide health
7-3 care services and assistance to indigent persons in this state;
7-4 (B) consumer representatives;
7-5 (C) managed care organizations; and
7-6 (D) health care providers;
7-7 (15) design the system to ensure that if the system
7-8 includes a method to finance the state Medicaid program by
7-9 obtaining federal matching funds for resources and other funds
7-10 available for matching, an amount not to exceed $20 million a year
7-11 must be dedicated under the system as prescribed in the waiver for
7-12 special payments to rural hospitals that:
7-13 (A) are sole community providers and provide a
7-14 significant amount of care to Medicaid and charity care patients as
7-15 prescribed by the commission; and
7-16 (B) are located in a county in which the county
7-17 or another entity located in the county and described by Subsection
7-18 (d) or (e) of this section:
7-19 (i) has executed a matching funds
7-20 agreement with the commission under this section; and
7-21 (ii) participates in an intergovernmental
7-22 initiative under Section 16B of this article with a county that is
7-23 contiguous to the county in which the rural hospital is located or
7-24 with another entity described by Subsection (d) or (e) of this
7-25 section that is located in the contiguous county if the contiguous
7-26 county or the entity located in the contiguous county is one of the
7-27 entities that forms an intergovernmental initiative under Section
8-1 16B of this article;
8-2 (16) if necessary to ensure that all resources or
8-3 other funds available for matching are maximized in accordance with
8-4 Subdivision (3) of this subsection, design the system to ensure
8-5 that an amount determined by the commission is dedicated under the
8-6 system as prescribed in the waiver for special payments to
8-7 hospitals that provide at least 14,000 low-income patient days as
8-8 determined by the commission under the methodology used for
8-9 calculating eligibility for the Medicaid disproportionate share
8-10 program;
8-11 (17) design a cost-neutral system to provide for a
8-12 sliding scale copayment system for individuals who are above 100
8-13 percent of the federal poverty level;
8-14 (18) to the extent possible and subject to the
8-15 availability of funds, design a cost-neutral system to allow the
8-16 development of a buy-in program with sliding scale premiums for
8-17 Medicaid recipients who are leaving the program and have incomes
8-18 between 150 percent and 250 percent of the federal poverty level;
8-19 (19) design the system in a manner that, to the extent
8-20 possible, will maintain administrative costs at a level not to
8-21 exceed five percent of the cost of the state Medicaid program; and
8-22 (20) develop and implement, in consultation with any
8-23 professional association representing 51 percent or more of the
8-24 licensed dentists in the state, a pilot program for child and adult
8-25 dental care and design the pilot program in a manner that enables:
8-26 (A) the program to be prevention-based;
8-27 (B) the choice of dentists to be at the
9-1 discretion of the eligible recipient, who will choose from a list
9-2 of qualified and participating providers or dental managed care
9-3 organizations; and
9-4 (C) the exploration of the use of local funds
9-5 currently spent on dental health care as a method for financing the
9-6 state share of the pilot program.
9-7 (b) In determining what constitutes a significant level of
9-8 care provided to Medicaid and charity care patients for purposes of
9-9 Subsection (a)(7)(H)(i) of this section, some of the factors the
9-10 commission must consider are:
9-11 (1) minimized disruption to existing physician-patient
9-12 relationships;
9-13 (2) access by a patient to quality health care
9-14 services in the patient's local community;
9-15 (3) the dollar amount of Medicaid care delivered by a
9-16 particular non-hospital provider in proportion to the dollar amount
9-17 of Medicaid care delivered by other similar non-hospital providers
9-18 in the same field of practice; and
9-19 (4) the level of Medicaid and charity care delivered
9-20 by a particular hospital, as measured under the Medicaid
9-21 disproportionate share program, in proportion to that delivered by
9-22 other hospitals.
9-23 (c) If the state is authorized by the federal government to
9-24 expand the eligibility requirements for participation in the state
9-25 Medicaid program under the health care delivery system developed
9-26 under this section and Sections 16B-16E of this article, the
9-27 commission shall adopt procedures to ensure that appropriations
10-1 from the general revenue fund, including accounts consolidated in
10-2 the general revenue fund, may not be used to provide health care
10-3 services under the system to persons described by Subsection (a)(3)
10-4 or (4) of this section. These procedures do not apply to:
10-5 (1) federal funds appropriated from the general
10-6 revenue fund;
10-7 (2) amounts local governmental entities make available
10-8 for matching under this section;
10-9 (3) appropriations from the general revenue fund to an
10-10 entity described by Subsection (d)(4), (5), or (6) of this section
10-11 to provide indigent health care services;
10-12 (4) appropriations from the general revenue fund used
10-13 for matching under the Medicaid disproportionate share program; or
10-14 (5) appropriations from the general revenue fund to
10-15 provide health care services to children.
10-16 (d) If the health care delivery system developed under this
10-17 section includes a method to finance the state Medicaid program by
10-18 obtaining federal matching funds for resources and other funds
10-19 available for matching and if the commission has obtained federal
10-20 authorization to implement the system, the following entities, in
10-21 accordance with final, binding matching funds agreements executed
10-22 by those entities under Subsections (i) and (j) of this section,
10-23 shall make resources available for matching to the commission for
10-24 use in implementing the system:
10-25 (1) a hospital district created and established under
10-26 the authority of Sections 4 through 11, Article IX, Texas
10-27 Constitution;
11-1 (2) a hospital authority created and established under
11-2 Chapter 262 or 264, Health and Safety Code, that to some extent
11-3 uses resources for the provision of health care services to
11-4 indigent persons;
11-5 (3) a hospital owned and operated by a municipality,
11-6 county, or hospital authority created under Chapter 262 or 264,
11-7 Health and Safety Code;
11-8 (4) a medical school operated by the state;
11-9 (5) a medical school that receives state funds under
11-10 Section 61.093, Education Code, or a chiropractic school that
11-11 receives state funds under the General Appropriations Act;
11-12 (6) a teaching hospital operated by The University of
11-13 Texas System;
11-14 (7) a county that provides health care services and
11-15 assistance to indigent residents of the county under Subchapter B,
11-16 Chapter 61, Health and Safety Code, if the commissioners court of
11-17 the county adopts a resolution requesting that the county
11-18 participate in the health care delivery system by executing a
11-19 matching funds agreement under Subsections (i) and (j) of this
11-20 section;
11-21 (8) a governmental entity that provides funds to a
11-22 public hospital for the provision of health care services to
11-23 indigent persons under Section 61.062, Health and Safety Code;
11-24 (9) a county with a population of more than 400,000
11-25 that provides funds to a public hospital and that is not included
11-26 in the boundaries of a hospital district; and
11-27 (10) a hospital owned by a municipality and leased to
12-1 and operated by a nonprofit hospital for a public purpose, subject
12-2 to federal approval of matching funds from such an entity.
12-3 (e) In addition to the entities listed in Subsection (d) of
12-4 this section, the following entities may make resources available
12-5 for matching to the commission for use in implementing the health
12-6 care delivery system if the commission designs the system in a
12-7 manner that expands Medicaid eligibility to include some or all of
12-8 the clients of the entity who did not meet the eligibility
12-9 requirements in effect immediately before the Medicaid eligibility
12-10 requirements were expanded and to cover some or all of the health
12-11 care services provided by the entity to those clients:
12-12 (1) a local mental health authority or a local mental
12-13 retardation authority as defined by Section 531.002, Health and
12-14 Safety Code;
12-15 (2) a municipal or county health department; or
12-16 (3) any other governmental entity that provides health
12-17 care services to indigent persons.
12-18 (f) The amount of resources an entity makes available to the
12-19 commission in a fiscal year under Subsection (d) or (e) of this
12-20 section is computed by:
12-21 (1) adding the total amount of resources the entity
12-22 spent on or provided for indigent health care during the entity's
12-23 fiscal year ending in 1994; and
12-24 (2) subtracting from the amount computed under
12-25 Subdivision (1) of this subsection the following adjustments:
12-26 (A) the amount of resources the entity spent on
12-27 or provided for health care services during the entity's fiscal
13-1 year ending in 1994 that were provided by the entity or on the
13-2 entity's behalf to indigent persons who would not have been
13-3 eligible to receive services under the eligibility criteria
13-4 developed under Subsection (a)(3) of this section;
13-5 (B) to the extent and while the commission
13-6 determines whether to continue the current Medicaid
13-7 disproportionate share program and before all the disproportionate
13-8 share funds become part of the health care delivery system
13-9 developed under the waiver, the estimate of the amount of
13-10 resources, if any, the entity will transfer in each fiscal year to
13-11 the Texas Department of Health under the Medicaid disproportionate
13-12 share program; and
13-13 (C) any other necessary or equitable adjustment
13-14 as determined by the commission.
13-15 (g) The commission and the governing body of an entity that
13-16 makes resources available for matching to the commission under this
13-17 section may agree that the entity may make available for matching
13-18 resources or other funds in addition to those amounts computed
13-19 under Subsection (f) of this section. The additional resources or
13-20 funds may include an amount that reflects the costs associated with
13-21 the growth in the state Medicaid program as estimated in a federal
13-22 waiver application or other federal authorization that is required
13-23 to be submitted to implement the health care delivery system.
13-24 Additional amounts of resources or other funds made available for
13-25 matching by an entity under this subsection must be contained in
13-26 the final, binding matching funds agreement executed by the entity
13-27 under Subsections (i) and (j) of this section.
14-1 (h) The commission by rule shall determine the manner in
14-2 which an entity described by Subsection (d) or (e) of this section
14-3 shall make resources available for matching to the commission under
14-4 this section. If an intergovernmental initiative is formed under
14-5 Section 16B of this article, each entity listed under Subsection
14-6 (d) or (e) of this section that participates in the
14-7 intergovernmental initiative shall make its resources available for
14-8 matching to the commission by making its resources available to the
14-9 intergovernmental initiative, subject to federal approval.
14-10 (i) The commission shall prepare for an entity that makes
14-11 resources or other funds available for matching to the commission
14-12 under this section a proposed memorandum of understanding that
14-13 states the amount of resources and other funds available for
14-14 matching the entity will make available to the commission each year
14-15 under Subsections (f) and (g) of this section. The memorandum of
14-16 understanding serves as the basis for the negotiation of a final,
14-17 binding agreement called a "matching funds agreement" between the
14-18 governing body of the entity, the commissioners court, if
14-19 applicable, and the commission. The expiration date of the
14-20 matching funds agreement must be the same date as the expiration
14-21 date of a waiver authorizing the implementation of the health care
14-22 delivery system developed under this section and Sections 16B-16E
14-23 of this article. If the entity is a hospital district the tax rate
14-24 for which is set by the commissioners court of a county in which
14-25 the hospital district is located, the commissioners court must also
14-26 agree to the amount of resources or other funds available for
14-27 matching made available by the hospital district under Subsections
15-1 (f) and (g) of this section.
15-2 (j) A matching funds agreement for each entity must include
15-3 for each year the agreement is in effect:
15-4 (1) a statement of the amount of resources or other
15-5 funds available for matching the entity agrees to make available to
15-6 the commission under Subsections (f) and (g) of this section to
15-7 provide health care services to eligible individuals described by
15-8 the commission in the waiver application that a federal agency may
15-9 require to implement the health care delivery system;
15-10 (2) an estimate of the cost of providing services to
15-11 eligible individuals described by Subdivision (1) of this
15-12 subsection by category and by income level;
15-13 (3) an estimate of the number of eligible individuals
15-14 described by Subdivision (1) of this subsection who are being
15-15 served, by category and by income level;
15-16 (4) a description of the scope of services to be
15-17 provided to eligible individuals described by Subdivision (1) of
15-18 this subsection;
15-19 (5) a provision stating the requirement prescribed by
15-20 Subsection (a)(5) of this section;
15-21 (6) a provision stating that if the federal Health
15-22 Care Financing Administration and the commission modify the waiver
15-23 application submitted by the commission to implement the health
15-24 care delivery system with respect to financing, eligibility
15-25 criteria, or scope of services, the commission or an entity that
15-26 executes a matching funds agreement may request renegotiation or
15-27 modification of the terms of the agreement and the other party
16-1 shall make a good faith effort to renegotiate or modify the terms
16-2 of the agreement;
16-3 (7) a provision stating that if substantial changes in
16-4 the financing, eligibility criteria, or scope of services provided
16-5 to eligible individuals described by Subdivision (1) of this
16-6 subsection are mandated by federal or state law, the commission and
16-7 an entity that executes a matching funds agreement may mutually
16-8 agree to modify the agreement; and
16-9 (8) other information the commission may require.
16-10 (k) If a party to the matching funds agreement is an entity
16-11 located in a metropolitan statistical area as defined by the United
16-12 States Office of Management and Budget on the effective date of
16-13 this section, the matching funds agreement must be executed by the
16-14 entity and commission before the commission submits a waiver
16-15 application that a federal agency may require to implement the
16-16 health care delivery system unless the commission determines to
16-17 extend the agreement due date for an entity because of
16-18 extraordinary circumstances. The matching funds agreement entered
16-19 into by the commission and an entity located outside a metropolitan
16-20 statistical area may be executed after the waiver application is
16-21 approved. The commission by rule shall determine the time by which
16-22 the matching funds agreement of an entity located outside a
16-23 metropolitan statistical area on the effective date of this section
16-24 must be executed by that entity and the commission.
16-25 (l) The liability of a county described by Subsection (d)(7)
16-26 of this section for health care services and assistance under
16-27 Subchapter B, Chapter 61, Health and Safety Code, is not affected
17-1 by this section.
17-2 (m) The commission by rule shall develop a methodology for
17-3 the distribution of special payments that may be made to a rural
17-4 hospital under Subsection (a)(15) of this section.
17-5 (n) This section expires September 1, 2001.
17-6 Sec. 16B. INTERGOVERNMENTAL INITIATIVES. (a) If a health
17-7 care delivery system developed under this section and Section 16A
17-8 and Sections 16C-16E of this article includes a method to finance
17-9 the state Medicaid program by obtaining federal matching funds for
17-10 local and state resources spent on or provided for indigent health
17-11 care, one or more of the entities listed in Section 16A(d) or (e)
17-12 of this article that make resources or other funds available for
17-13 matching under a matching funds agreement may form an
17-14 intergovernmental initiative to operate the health care delivery
17-15 system in a geographical area in accordance with this section.
17-16 (b) An intergovernmental initiative formed under this
17-17 section may serve more than one county. A county may not be served
17-18 by more than one intergovernmental initiative. The commission with
17-19 the consent of each entity that forms the intergovernmental
17-20 initiative may modify the geographical area the intergovernmental
17-21 initiative serves to:
17-22 (1) promote client access to health care services and
17-23 continuity of care; and
17-24 (2) move toward full regionalization of the health
17-25 care delivery system.
17-26 (c) An intergovernmental initiative must be formed as:
17-27 (1) a nonprofit corporation under the Texas Non-Profit
18-1 Corporation Act (Article 1396-1.01 et seq., Vernon's Texas Civil
18-2 Statutes); or
18-3 (2) any other nonstock, nonprofit entity that is
18-4 approved by the commission.
18-5 (d) An intergovernmental initiative formed under this
18-6 section is a governmental unit for purposes of Chapter 101, Civil
18-7 Practice and Remedies Code.
18-8 (e)(1) An intergovernmental initiative formed under this
18-9 section shall be governed as provided by this subsection.
18-10 (2) Each intergovernmental initiative has an executive
18-11 committee composed of representatives of each of the entities that
18-12 formed the intergovernmental initiative. The governing board of an
18-13 intergovernmental initiative is composed of the executive committee
18-14 and other persons or entities appointed by the executive committee
18-15 as prescribed by this subsection. The executive committee of an
18-16 intergovernmental initiative shall appoint to the governing board
18-17 of the intergovernmental initiative at least one person or entity
18-18 that represents each of the following groups located in the
18-19 geographical area the intergovernmental initiative serves:
18-20 (A) a representative of clients of the
18-21 intergovernmental initiative;
18-22 (B) a representative of a children's hospital or
18-23 the program director of an approved family practice residency
18-24 training program as defined by Section 61.501, Education Code, if
18-25 there is not a children's hospital located in the geographical area
18-26 served by the intergovernmental initiative;
18-27 (C) a physician or other individual health care
19-1 provider;
19-2 (D) a representative of a nonprofit hospital;
19-3 (E) a representative of a for-profit hospital;
19-4 (F) a representative of a managed care
19-5 organization that is licensed by the Texas Department of Insurance;
19-6 (G) a representative of each hospital, whether
19-7 public or private, that provided at least 14,000 low-income days of
19-8 care, as determined by the Texas Department of Health for purposes
19-9 of calculating eligibility for the Medicaid disproportionate share
19-10 program during the state fiscal year ending August 31, 1995, or at
19-11 least 14,000 low-income days of care in the state fiscal year
19-12 preceding the date of appointment as determined by the commission,
19-13 whichever is applicable; and
19-14 (H) a representative of a rural hospital that
19-15 received payments under the Medicaid disproportionate share program
19-16 during the hospital's fiscal year preceding the date of
19-17 appointment.
19-18 (3) It is a ground for removal from the governing
19-19 board if the group a member represents does not maintain during
19-20 service on the governing board the qualifications required for
19-21 inclusion on the board under Subdivision (2) of this subsection.
19-22 (4) A person appointed to the governing board by the
19-23 executive committee under Subdivision (2) of this subsection may be
19-24 appointed as a representative of more than one group listed in that
19-25 subdivision. If a group listed in that subdivision is not located
19-26 in the geographical area served by the intergovernmental
19-27 initiative, the executive committee is not required to appoint a
20-1 representative of that group to the governing board.
20-2 (5) If more than one entity forms an intergovernmental
20-3 initiative, the entities shall share governance of the executive
20-4 committee of the intergovernmental initiative in proportion to the
20-5 amount of resources and other funds they make available for
20-6 matching under the matching funds agreement.
20-7 (6) Representation on the governing board and the
20-8 manner in which votes are apportioned among members of the
20-9 governing board who are not members of the executive committee must
20-10 be based primarily on the relative level of Medicaid and charity
20-11 care services, as defined by Section 311.031, Health and Safety
20-12 Code, provided by those non-executive committee members of the
20-13 governing board over the previous two years. The executive
20-14 committee must have at least 51 percent of the voting rights on the
20-15 governing board. The votes of the executive committee must be
20-16 apportioned in the manner described by Subdivision (5) of this
20-17 subsection.
20-18 (7) The executive committee of an intergovernmental
20-19 initiative has exclusive authority to manage the public funds of
20-20 the intergovernmental initiative, including the authority to
20-21 determine how those funds will be used in accordance with this
20-22 section and other applicable law. The governing board of an
20-23 intergovernmental initiative shall address health care delivery
20-24 system issues for the intergovernmental initiative, including the
20-25 preparation and negotiation of the proposed health care delivery
20-26 plan for the intergovernmental initiative under Subsection (i) of
20-27 this section.
21-1 (8) If an intergovernmental initiative formed under
21-2 this section includes a hospital district the tax rate for which is
21-3 set by the commissioners court of a county in the hospital
21-4 district, the commissioners court of that county must also agree to
21-5 the structure of governance of the intergovernmental initiative
21-6 within the requirements of this subsection. The commissioners
21-7 court shall take action required under this subdivision not later
21-8 than the date on which the health care delivery plan agreement for
21-9 the intergovernmental initiative is deemed approved or is rejected
21-10 by the commissioners court under Subsection (o) of this section.
21-11 (f) An intergovernmental initiative formed under this
21-12 section shall:
21-13 (1) operate the health care delivery system developed
21-14 under this section and Section 16A and Sections 16C-16E of this
21-15 article in the geographical area described by the health care
21-16 delivery plan agreement of the intergovernmental initiative subject
21-17 to the standards of and oversight by the commission and standards
21-18 and oversight contained in:
21-19 (A) applicable state and federal statutes and
21-20 rules;
21-21 (B) federal waivers or other federal
21-22 authorizations required to implement the health care delivery
21-23 system; and
21-24 (C) the health care delivery plan agreement
21-25 executed under this section by the entities forming the
21-26 intergovernmental initiative;
21-27 (2) perform the functions in operating the health care
22-1 delivery system that are prescribed by the health care delivery
22-2 plan agreement executed by the entities forming the
22-3 intergovernmental initiative and the commission;
22-4 (3) if applicable, make supplemental payments as
22-5 necessary to entities that make resources and other funds available
22-6 for matching to the intergovernmental initiative under Section 16A
22-7 of this article to satisfy the purpose of Section 16A(a)(5) of this
22-8 article and Subsection (m)(9) of this section;
22-9 (4) to the extent possible, manage care to lower the
22-10 cost of providing Medicaid services through the use of health care
22-11 delivery systems such as a primary care case management system,
22-12 partially capitated system, or fully capitated system or a
22-13 combination of one or more of those systems and use, where
22-14 possible, multiple, competing managed care organizations within
22-15 those systems;
22-16 (5) comply with Chapter 551, Government Code; and
22-17 (6) use any savings that accrue to the
22-18 intergovernmental initiative or the entities that form the
22-19 intergovernmental initiative through operation of the health care
22-20 delivery plan agreement solely for the purpose of delivering and
22-21 providing health care to indigent persons.
22-22 (g) An intergovernmental initiative formed under this
22-23 section may contract with any public or private entity to perform
22-24 any of the intergovernmental initiative's powers or duties. The
22-25 entities that form the intergovernmental initiative may contract,
22-26 collaborate, or enter into a joint venture with other entities as
22-27 necessary or appropriate to form or carry out the functions of or
23-1 provide services to the intergovernmental initiative. Any
23-2 contract, collaborative arrangement, or joint venture entered into
23-3 under this subsection by an entity that forms an intergovernmental
23-4 initiative is subject to the standards of and oversight by the
23-5 commission as authorized under this section and Section 16A and
23-6 Sections 16C-16E of this article.
23-7 (h) Not later than the 60th day after the date the
23-8 commission submits to the federal government an application for a
23-9 waiver or other authorization required to implement the health care
23-10 delivery system developed under this section and Section 16A and
23-11 Sections 16C-16E of this article, the entities listed in Section
23-12 16A(d) or (e) of this article that have executed a matching funds
23-13 agreement under Section 16A(k) of this article and that intend to
23-14 form an intergovernmental initiative shall submit to the commission
23-15 a letter of intent to form the intergovernmental initiative.
23-16 However, if all of the entities that intend to form an
23-17 intergovernmental initiative are located outside a metropolitan
23-18 statistical area, the commission by rule shall determine the time
23-19 by which those entities must submit to the commission a letter of
23-20 intent to form the intergovernmental initiative. The letter of
23-21 intent must include any information required by the commission,
23-22 including at a minimum the names and addresses of the entities that
23-23 intend to form the intergovernmental initiative and the
23-24 geographical area to be served by the intergovernmental initiative.
23-25 The letter of intent is not binding on the entities or the
23-26 commission and only serves to inform the commission of the areas of
23-27 the state that intend to be part of an intergovernmental
24-1 initiative.
24-2 (i) Within the time specified by the commission after the
24-3 date the federal government approves a waiver or gives federal
24-4 authorization required to implement the health care delivery system
24-5 developed under this section and Section 16A and Sections 16C-16E
24-6 of this article, the entities that have submitted a letter of
24-7 intent to form an intergovernmental initiative under this section
24-8 shall jointly submit to the commission a proposed health care
24-9 delivery plan that contains the information required by the
24-10 commission. The proposed health care delivery plan is not binding
24-11 on the entities or the commission but only serves as the basis for
24-12 negotiation of a final, binding agreement called a "health care
24-13 delivery plan agreement" between the entities and the commission.
24-14 The commission by rule shall set a reasonable date by which the
24-15 entities must submit and negotiate the proposed health care
24-16 delivery plan. The date must be based on the schedule in the
24-17 waiver developed by the commission for phasing in the health care
24-18 delivery system statewide. A negotiated health care delivery plan
24-19 agreement takes effect as provided by the terms of the agreement,
24-20 unless it is rejected by a commissioners court as provided by
24-21 Subsection (o) of this section.
24-22 (j) Before an intergovernmental initiative can operate the
24-23 health care delivery system developed under this section and
24-24 Section 16A and Sections 16C-16E of this article in accordance with
24-25 the health care delivery plan agreement, the commission must
24-26 approve the plan agreement, the structure of governance within the
24-27 requirements of Subsection (e) of this section, and the geographic
25-1 service area of the intergovernmental initiative but may do so only
25-2 after notice and public hearing held in the geographic service
25-3 area. The intergovernmental initiative shall determine the managed
25-4 care organizations with which the intergovernmental initiative may
25-5 contract under the plan agreement. Any contract entered into
25-6 between an intergovernmental initiative and a managed care
25-7 organization under this section and Section 16A and Sections
25-8 16C-16E of this article must comply with federal requirements and
25-9 the standards adopted under this section. Not later than the 30th
25-10 day after the date on which a contract described by this subsection
25-11 is executed, the intergovernmental initiative shall submit the
25-12 contract to the commission for review to ensure that the contract
25-13 complies with those requirements and standards. The commission on
25-14 review may require the intergovernmental initiative to modify the
25-15 contract to comply with federal requirements and state standards.
25-16 Some of the criteria on which the commission must base its decision
25-17 to approve a health care delivery plan agreement include:
25-18 (1) the cost-effectiveness of the health care delivery
25-19 plan;
25-20 (2) the opportunity for public and private managed
25-21 care organizations and providers to participate in the health care
25-22 delivery plan;
25-23 (3) access to quality health care services;
25-24 (4) any savings to the state; and
25-25 (5) whether the plan agreement contains the minimum
25-26 requirements prescribed by Subsection (m) of this section.
25-27 (k) The commission shall implement the health care delivery
26-1 system developed under this section and Section 16A and Sections
26-2 16C-16E of this article in a geographical area for which the
26-3 commission did not receive a letter of intent to form an
26-4 intergovernmental initiative or that is not covered by a health
26-5 care delivery plan agreement that has become final and binding by
26-6 the date specified by the commission under Subsection (i) of this
26-7 section. The commission, in performing its functions under this
26-8 subsection, is exempt from the Texas Health Maintenance
26-9 Organization Act (Chapter 20A, Vernon's Texas Insurance Code) and
26-10 Articles 21.07-6 and 21.58A, Insurance Code.
26-11 (l) The commission shall adopt rules regarding the health
26-12 care delivery plan agreement and requiring an intergovernmental
26-13 initiative to seek public input in the development and provisions
26-14 of the health care delivery plan agreement of the intergovernmental
26-15 initiative. In addition, the commission shall develop a model plan
26-16 agreement that includes the minimum requirements established by
26-17 rule for a health care delivery plan agreement.
26-18 (m) The minimum requirements of a health care delivery plan
26-19 agreement must include provisions relating to:
26-20 (1) compliance with uniform criteria that are set in
26-21 the waiver described by Subsection (i) of this section for
26-22 establishing eligibility for persons receiving services under the
26-23 plan;
26-24 (2) compliance with a uniform description and
26-25 provision of services that is set in the waiver for persons covered
26-26 by the health care delivery plan;
26-27 (3) the assurance that, to the extent possible,
27-1 payments made to the intergovernmental initiative on a capitated
27-2 basis consider the geographic, risk-adjusted cost of providing care
27-3 to persons eligible for Medicaid;
27-4 (4) the development of a sufficient provider network
27-5 to ensure adequate access to quality health care services
27-6 consistent with the waiver and any standards prescribed by the
27-7 federal Health Care Financing Administration or the commission,
27-8 including standards relating to travel time and distance that are
27-9 designed to ensure access by patients to health care providers in
27-10 the patient's local community;
27-11 (5) the development and operation by each
27-12 intergovernmental initiative, managed care organization, and
27-13 provider that participates in the health care delivery system of
27-14 policies regarding financial management, quality assurance,
27-15 utilization review, and patient access in accordance with standards
27-16 consistent with the waiver and any standards prescribed by the
27-17 federal Health Care Financing Administration or the commission;
27-18 (6) the opportunity for participation of public and
27-19 private managed care organizations and providers in the health care
27-20 delivery system in accordance with standards established by the
27-21 commission, including provisions relating to:
27-22 (A) a methodology within the geographic service
27-23 area of an intergovernmental initiative for selection of
27-24 participating managed care organizations and providers, which must
27-25 provide added weight for additional services of value to the state
27-26 such as a continuum of care for Medicaid and charity care patients,
27-27 trauma, Level I emergency services, neonatal intensive care,
28-1 medical education, or other specialty services;
28-2 (B) a methodology within the geographic service
28-3 area of an intergovernmental initiative for establishing capitation
28-4 rates and provider payment rates, which rates may be supplemented
28-5 in exchange for the provision of specified additional services; and
28-6 (C) a methodology within the geographic service
28-7 area of an intergovernmental initiative to ensure recipients have
28-8 the choice of multiple managed care organizations where possible
28-9 and providers;
28-10 (7) maintenance of adequate stop-loss coverage of the
28-11 intergovernmental initiative or any managed care organization under
28-12 contract with the intergovernmental initiative, including
28-13 provisions to ensure that adequate stop-loss coverage is available;
28-14 (8) phasing in operation of the health care delivery
28-15 system, as appropriate to the area served by the intergovernmental
28-16 initiative, in accordance with any waiver application approval or
28-17 other federal authorization to implement the health care delivery
28-18 system, which may include provisions that include methods, such as
28-19 reserve funds, for phasing disproportionate share funds into
28-20 financing the system under the waiver;
28-21 (9) ensuring that the amount of funds each
28-22 participating entity listed in Section 16A(d)(1), (2), (3), (7),
28-23 (8), or (9) or Section 16A(e) of this article receives to provide
28-24 Medicaid health care services to persons who are eligible for
28-25 Medicaid as a result of the expanded eligibility criteria developed
28-26 under Section 16A(a)(3) or (4) of this article is at least equal to
28-27 the amount of resources and other funds made available for matching
29-1 to the commission by the entity;
29-2 (10) notice to health care providers of the procedures
29-3 used by the intergovernmental initiative or any managed care
29-4 organization under contract with the intergovernmental initiative
29-5 to solicit bids for the delivery of services by health care
29-6 providers;
29-7 (11) grievance and appeal procedures for persons who
29-8 are denied services or have a complaint regarding the quality of
29-9 services under the health care delivery plan;
29-10 (12) grievance and appeal procedures for health care
29-11 providers who are denied participation in the health care delivery
29-12 plan or who want to appeal the:
29-13 (A) calculation of payment rates under the plan;
29-14 (B) denial or reduction of supplemental payment
29-15 amounts; or
29-16 (C) denial or reduction of payment for services
29-17 provided or to be provided under the plan; and
29-18 (13) procedures for transactions made or contracts
29-19 entered into under the health care delivery plan agreement that
29-20 involve conflicts of interest, including procedures that:
29-21 (A) require members of an intergovernmental
29-22 initiative's governing board to disclose any financial or other
29-23 interest in entities with which the intergovernmental initiative
29-24 contracts;
29-25 (B) ensure compliance with the requirements
29-26 prescribed by Article 2.30, Texas Non-Profit Corporation Act
29-27 (Article 1396-2.30, Vernon's Texas Civil Statutes), and any other
30-1 applicable law; and
30-2 (C) at a minimum apply to a contract or
30-3 transaction between:
30-4 (i) an intergovernmental initiative and
30-5 one or more of the members of the intergovernmental initiative's
30-6 governing board;
30-7 (ii) an intergovernmental initiative and a
30-8 business entity in which one or more members of the
30-9 intergovernmental initiative's governing board are directors or
30-10 officers or have a financial interest; or
30-11 (iii) an intergovernmental initiative and
30-12 a business entity listed in Subsection (e)(2) of this section that
30-13 is represented on the intergovernmental initiative's governing
30-14 board.
30-15 (n) The health care delivery plan agreement for an
30-16 intergovernmental initiative must be completed before the
30-17 commission implements an approved waiver in the area covered by the
30-18 intergovernmental initiative. If an approved waiver is terminated,
30-19 the intergovernmental initiative or commission is entitled to
30-20 terminate the health care delivery plan agreement. If the waiver
30-21 is modified in a manner that affects the provision of services in
30-22 the area covered by the health care delivery plan agreement, the
30-23 intergovernmental initiative or the commission may request
30-24 renegotiation and modification of the plan agreement and the other
30-25 party shall make a good faith effort to renegotiate and modify the
30-26 agreement.
30-27 (o) If an intergovernmental initiative formed under this
31-1 section includes a hospital district the tax rate for which is set
31-2 by the commissioners court of a county in which the hospital
31-3 district is located, the intergovernmental initiative shall file
31-4 the negotiated health care delivery plan agreement with the
31-5 commissioners court. The negotiated agreement is deemed approved
31-6 by the commissioners court on the 30th day after the date on which
31-7 the intergovernmental initiative files the negotiated agreement
31-8 unless before the end of that 30-day period the commissioners court
31-9 adopts a resolution rejecting the negotiated agreement. The
31-10 commissioners court may adopt a resolution to delegate the
31-11 authority to reject the negotiated health care delivery plan
31-12 agreement to the board of directors of the hospital district.
31-13 (p) An intergovernmental initiative that operates a health
31-14 care delivery system in accordance with an approved health care
31-15 delivery plan agreement is exempt from the Texas Health Maintenance
31-16 Organization Act (Chapter 20A, Vernon's Texas Insurance Code) and
31-17 Articles 21.07-6 and 21.58A, Insurance Code, to the extent the
31-18 intergovernmental initiative:
31-19 (1) contracts to purchase services to operate the
31-20 health care delivery system through a managed care organization
31-21 that:
31-22 (A) is a health maintenance organization that
31-23 holds a certificate of authority to operate under the Texas Health
31-24 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
31-25 Code);
31-26 (B) is regulated by the Texas Department of
31-27 Insurance in a manner determined by the department to be
32-1 substantially similar in all material aspects to the manner in
32-2 which the department regulates health maintenance organizations; or
32-3 (C)(i) demonstrates to the satisfaction of the
32-4 Texas Department of Insurance that the managed care organization
32-5 has obtained insurance or other protection through an insurance
32-6 company licensed under the Insurance Code to guaranty the cost of
32-7 health care benefits or services to be provided by that managed
32-8 care organization and to provide coverage in the event of failure
32-9 of the managed care organization to meet its obligation under the
32-10 contract; and
32-11 (ii) satisfies federal law and regulations
32-12 relating to minimum solvency requirements applicable to entities or
32-13 persons contracting under the state Medicaid program; or
32-14 (2) receives capitated payments from the commission
32-15 under this section or Section 16A or Sections 16C-16E of this
32-16 article.
32-17 (q) A managed care organization that contracts with the
32-18 commission or with an intergovernmental initiative to provide or
32-19 arrange to provide health care benefits or services to Medicaid
32-20 eligible individuals must:
32-21 (1) be a health maintenance organization that holds a
32-22 certificate of authority to operate under the Texas Health
32-23 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
32-24 Code);
32-25 (2) be regulated by the Texas Department of Insurance
32-26 in a manner determined by the department to be substantially
32-27 similar in all material aspects to the manner in which the
33-1 department regulates health maintenance organizations; or
33-2 (3)(A) demonstrate to the satisfaction of the Texas
33-3 Department of Insurance that the managed care organization has
33-4 obtained insurance or other protection through an insurance company
33-5 licensed under the Insurance Code to guaranty the cost of health
33-6 care benefits or services to be provided by the managed care
33-7 organization and to provide coverage in the event of failure of the
33-8 managed care organization to meet its obligation under the
33-9 contract; and
33-10 (B) satisfy federal law and regulations relating
33-11 to minimum solvency requirements applicable to entities or persons
33-12 contracting under the state Medicaid program.
33-13 (r) Subsection (q) of this section does not affect the
33-14 requirement that any person or entity subject to Section 26(f)(2),
33-15 Texas Health Maintenance Organization Act (Article 20A.26, Vernon's
33-16 Texas Insurance Code), obtain a certificate of authority from the
33-17 commissioner of insurance. A state agency or intergovernmental
33-18 initiative may not contract with an entity or person subject to
33-19 Section 26(f)(2), Texas Health Maintenance Organization Act
33-20 (Article 20A.26, Vernon's Texas Insurance Code), unless that entity
33-21 or person holds a certificate of authority from the commissioner of
33-22 insurance.
33-23 (s) The commission may allow rates for services for Medicaid
33-24 eligible individuals to be established for categories of Medicaid
33-25 eligible individuals based on health status and other risk factors,
33-26 including age and sex.
33-27 (t) This section expires September 1, 2001.
34-1 Sec. 16C. IMPLEMENTATION OF HEALTH CARE DELIVERY SYSTEM;
34-2 ENFORCEMENT. (a) In accordance with this article and other
34-3 applicable state and federal statutes, the commission shall:
34-4 (1) implement a health care delivery system developed
34-5 under this section and Sections 16A, 16B, 16D, and 16E of this
34-6 article; and
34-7 (2) monitor compliance with and take any action as
34-8 necessary or appropriate, including the use of administrative
34-9 penalties, to enforce this section and Sections 16A, 16B, 16D, and
34-10 16E of this article and related rules, federal waivers, or orders
34-11 and decisions of the commission.
34-12 (b) The commission and the Texas Department of Insurance, to
34-13 the extent not prohibited by federal law, shall share confidential
34-14 information, including financial data, that relates to or affects
34-15 an entity that may contract with the commission or an
34-16 intergovernmental initiative to carry out the purposes of this
34-17 section and Sections 16A, 16B, 16D, and 16E of this article.
34-18 (c) This section expires September 1, 2001.
34-19 Sec. 16D. RULES FOR HEALTH CARE DELIVERY SYSTEM. (a) The
34-20 commission shall adopt rules as necessary or appropriate to carry
34-21 out its functions under Sections 16A, 16B, 16C, and 16E of this
34-22 article.
34-23 (b) The commissioner of insurance shall adopt rules as
34-24 necessary or appropriate to carry out functions of the Texas
34-25 Department of Insurance under Sections 16B and 16C of this article.
34-26 (c) The commission may require a health and human services
34-27 agency that operates a part of the state Medicaid program to adopt,
35-1 with the approval of the commission, rules under Subsection (a) of
35-2 this section as necessary or appropriate to implement Sections 16A,
35-3 16B, 16C, and 16E of this article.
35-4 (d) This section expires September 1, 2001.
35-5 Sec. 16E. DELEGATION OF AUTHORITY. (a) The commission may
35-6 delegate to a health and human services agency that operates a part
35-7 of the state Medicaid program the authority to exercise all or part
35-8 of its functions, powers, and duties under Sections 16A, 16B, and
35-9 16C of this article.
35-10 (b) This section expires September 1, 2001.
35-11 Sec. 16F. CONFLICT WITH OTHER LAW. (a) To the extent of
35-12 conflict between Sections 16A-16E of this article and any other
35-13 provision of state law, Sections 16A-16E of this article prevail.
35-14 (b) This section expires September 1, 2001.
35-15 Sec. 16G. AWARD FOR REPORTING MEDICAID FRAUD, MISUSE, OR
35-16 OVERCHARGES. (a) The commission may grant an award to an
35-17 individual who reports activity that constitutes fraud or misuse of
35-18 funds in the state Medicaid program or reports overcharges in the
35-19 program if the commission determines that the disclosure results in
35-20 the recovery of an overcharge or in the termination of the
35-21 fraudulent activity or misuse of funds.
35-22 (b) The commission shall determine the amount of an award,
35-23 provided that the award must be equal to not less than 10 percent
35-24 of the savings to the state that result from the individual's
35-25 disclosure. In determining the amount of the award, the commission
35-26 shall consider how important the disclosure is in ensuring the
35-27 fiscal integrity of the program.
36-1 (c) An award under this section is subject to appropriation.
36-2 The award must be paid from money appropriated to or otherwise
36-3 available to the commission, and additional money may not be
36-4 appropriated to the commission for the purpose of paying the award.
36-5 (d) Payment of an award under this section from federal
36-6 funds is subject to the permissible use under federal law of funds
36-7 for this purpose.
36-8 SECTION 2. Section 1, Article 4413(502), Revised Statutes,
36-9 is amended to read as follows:
36-10 Sec. 1. DEFINITIONS. In this article:
36-11 (1) "Commission" means the Health and Human Services
36-12 Commission.
36-13 (2) "Commissioner" means the commissioner of health
36-14 and human services.
36-15 (3) "Managed care organization" means any entity or
36-16 person that is authorized or otherwise permitted by law to arrange
36-17 for or provide a managed care plan.
36-18 (4) "Managed care plan" means any plan under which an
36-19 entity or person undertakes to provide, arrange for, pay for, or
36-20 reimburse any part of the cost of any health care services,
36-21 provided, however, that a part of the plan must consist of
36-22 arranging for or providing health care services as distinguished
36-23 from indemnification against the cost of those services, on a
36-24 pre-paid basis through insurance or otherwise. The term does not
36-25 include a plan that indemnifies a person for the cost of health
36-26 care services through insurance.
36-27 (5) "Resources" means:
37-1 (A) for an entity listed in Section 16A(d)(1),
37-2 (2), (3), (7), (8), or (9) or Section 16A(e) of this article, tax
37-3 or other public revenues spent on indigent health care; and
37-4 (B) for an entity listed in Section 16A(d)(4),
37-5 (5), or (6) of this article, the value of unsponsored charity care
37-6 as described by the General Appropriations Act provided by or on
37-7 behalf of that entity to indigent persons and general revenue or
37-8 other funds used for matching under the Medicaid disproportionate
37-9 share program.
37-10 (6) "Resources or other funds available for matching"
37-11 or "resources and other funds available for matching" means
37-12 resources and other funds made available by an entity listed in
37-13 Section 16A(d) or (e) of this article that the federal government
37-14 has determined are acceptable for matching under a waiver submitted
37-15 to develop and implement the health care delivery system developed
37-16 under Sections 16A-16E of this article.
37-17 SECTION 3. Chapter 285, Health and Safety Code, is amended
37-18 by adding Subchapter H to read as follows:
37-19 SUBCHAPTER H. CONTRACTS, COLLABORATIONS, AND JOINT VENTURES
37-20 Sec. 285.091. HOSPITAL DISTRICT CONTRACTS, COLLABORATIONS,
37-21 AND JOINT VENTURES. A hospital district created under general or
37-22 special law may contract, collaborate, or enter into a joint
37-23 venture with any public or private entity as necessary to form or
37-24 carry out the functions of or provide services to an
37-25 intergovernmental initiative under Section 16B, Article 4413(502),
37-26 Revised Statutes.
37-27 SECTION 4. (a) The Health and Human Services Commission or
38-1 a health and human services agency that operates a part of the
38-2 state Medicaid program may not implement Sections 16A through 16E,
38-3 Article 4413(502), Revised Statutes, as added by this Act, unless
38-4 the commission has obtained a waiver or other authorization from
38-5 all necessary federal agencies to implement those provisions.
38-6 (b) Except as provided by Subsection (c) of this section,
38-7 the Health and Human Services Commission, not later than August 31,
38-8 1995, shall submit to the federal government the waiver or other
38-9 authorizations required to develop or implement the health care
38-10 delivery system developed by the commission under Sections 16A
38-11 through 16E, Article 4413(502), Revised Statutes, as added by this
38-12 Act, unless both the governor and the Legislative Budget Board
38-13 determine that the expenditure of funds under the health care
38-14 delivery system as designed will not enable the state to control
38-15 the costs associated with the state Medicaid program.
38-16 (c) If the Health and Human Services Commission finds that
38-17 it is not practical or feasible to submit the waiver described by
38-18 Subsection (a) of this section by August 31, 1995, the commission
38-19 shall certify its findings to the governor not later than August
38-20 15, 1995. On receipt of the commission's certification, the
38-21 governor by executive order may postpone the date the waiver is
38-22 required to be submitted under this Act and establish an alternate
38-23 submission date that may not be later than September 30, 1995.
38-24 SECTION 5. (a) The Health and Human Services Commission by
38-25 rule shall establish a pilot program to provide for telephone
38-26 health care systems for persons currently receiving Medicaid within
38-27 a capitated managed care organization or other managed care
39-1 initiatives during the 1996-1997 biennium. The purpose of the
39-2 program is to study the efficiency and cost-effectiveness of a
39-3 telephone-based health care system.
39-4 (b) The commission may encourage private and public entities
39-5 to participate in the program.
39-6 (c) During the time the pilot program is operating, the
39-7 state auditor shall conduct quarterly reviews and assessments of
39-8 the program.
39-9 (d) Not later than February 1, 1997, the commission shall
39-10 report to the 75th Legislature concerning the efficiency and
39-11 cost-effectiveness of the pilot program.
39-12 (e) If before implementing this section, the commission
39-13 determines that a waiver or authorization from a federal agency is
39-14 necessary for implementation, the commission shall request the
39-15 waiver or authorization and may delay implementing those provisions
39-16 until the waiver or authorization is granted.
39-17 SECTION 6. (a) The Health and Human Services Commission
39-18 shall begin the process of establishing additional Medicaid managed
39-19 care pilot programs not later than the date on which the commission
39-20 submits the waiver application to the federal government.
39-21 (b) If a federal waiver or other authorization is not
39-22 obtained from all necessary federal agencies to implement the
39-23 health care delivery system developed under Sections 16A through
39-24 16E, Article 4413(502), Revised Statutes, as added by this Act, the
39-25 Health and Human Services Commission shall continue to establish
39-26 additional Medicaid managed care pilot programs statewide to
39-27 decrease the cost to the state of providing Medicaid services while
40-1 improving access to health care services for Medicaid recipients.
40-2 (c) The Health and Human Services Commission may contract
40-3 with public or private entities as necessary for the commission to
40-4 perform its functions under this section.
40-5 SECTION 7. The importance of this legislation and the
40-6 crowded condition of the calendars in both houses create an
40-7 emergency and an imperative public necessity that the
40-8 constitutional rule requiring bills to be read on three several
40-9 days in each house be suspended, and this rule is hereby suspended,
40-10 and that this Act take effect and be in force from and after its
40-11 passage, and it is so enacted.