Amend CSHB 3258 by striking all below the enacting clause and
substituting the following:
SECTION 1. Section 531.021, Government Code, is amended to
read as follows:
Sec. 531.021. ADMINISTRATION OF MEDICAID PROGRAM. (a) The
commission is the state agency designated to administer federal
medical assistance funds.
(b) The commission is responsible for the policy,
administration, evaluation, and operation of the Medicaid managed
care program.
(c) In discharging its duties relating to the Medicaid
managed care program, the commission shall consult with and
consider input from the advisory committee created under Section
531.047 and from each health and human services agency that
operates part of the Medicaid program.
(d) The commissioner or a person designated by the
commissioner shall supervise employees of health and human services
agencies in the performance of Medicaid managed care duties. The
commissioner or person designated by the commissioner may assign
duties to employees and require health and human services agencies
to assign duties to employees as necessary for the commission to
discharge its duties relating to the Medicaid managed care program.
SECTION 2. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.047 to read as follows:
Sec. 531.047. MEDICAID MANAGED CARE INTERAGENCY ADVISORY
COMMITTEE. (a) An interagency advisory committee is created to
provide assistance and recommendations to the commission relating
to the policy, administration, evaluation, and operation of the
Medicaid managed care program. The advisory committee consists of:
(1) the commissioner or, if designated under
Subsection (b), the person acting as the state Medicaid director;
(2) a representative of the Texas Department of
Health, designated by the commissioner of public health;
(3) a representative of the Texas Department of Mental
Health and Mental Retardation, designated by the commissioner of
mental health and mental retardation;
(4) a representative of the Texas Department of Human
Services, designated by the commissioner of human services; and
(5) if considered appropriate by the commissioner, a
representative of any other state agency with duties relating to
the Medicaid managed care program, designated by the chief
administrative officer of that agency.
(b) The commissioner may designate the person acting as the
state Medicaid director to serve on the advisory committee on
behalf of the commissioner.
(c) A member of the advisory committee serves at the will of
the designating agency.
(d) The commissioner or the person acting as the state
Medicaid director, as applicable, serves as presiding officer of
the advisory committee, and members of the committee may elect
other necessary officers.
(e) The advisory committee shall meet at the call of the
presiding officer. The presiding officer shall call a meeting of
the committee at least once every two months.
(f) The designating agency is responsible for the expenses
of a member's service on the advisory committee. A member of the
advisory committee receives no additional compensation for serving
on the committee.
(g) The advisory committee is not subject to Article
6252-33, Revised Statutes.
SECTION 3. Subtitle I, Title 4, Government Code, is amended
by adding Chapter 533 to read as follows:
CHAPTER 533. IMPLEMENTATION OF MEDICAID
MANAGED CARE PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 533.001. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services
Commission or an agency operating part of the state Medicaid
managed care program, as appropriate.
(2) "Commissioner" means the commissioner of health
and human services.
(3) "Health and human services agencies" has the
meaning assigned by Section 531.001.
(4) "Managed care organization" means a person who is
authorized or otherwise permitted by law to arrange for or provide
a managed care plan.
(5) "Managed care plan" means a plan under which a
person undertakes to provide, arrange for, pay for, or reimburse
any part of the cost of any health care services. A part of the
plan must consist of arranging for or providing health care
services as distinguished from indemnification against the cost of
those services on a prepaid basis through insurance or otherwise.
The term includes a primary care case management provider network.
The term does not include a plan that indemnifies a person for the
cost of health care services through insurance.
(6) "Recipient" means a recipient of medical
assistance under Chapter 32, Human Resources Code.
Sec. 533.002. PURPOSE. The commission shall implement the
Medicaid managed care program as part of the health care delivery
system developed under Chapter 532 by contracting with managed care
organizations in a manner that, to the extent possible:
(1) improves the health of Texans by:
(A) emphasizing prevention;
(B) promoting continuity of care; and
(C) providing a medical home for recipients;
(2) ensures that each recipient receives high quality,
comprehensive health care services in the recipient's local
community;
(3) encourages the training of and access to primary
care physicians and providers;
(4) maximizes cooperation with existing public health
entities, including local departments of health;
(5) provides incentives to managed care organizations,
other than managed care organizations created by political
subdivisions with constitutional or statutory obligations to
provide health care to indigent patients, to improve the quality of
health care services for recipients by providing value-added
services, including services listed in Section 533.008(2)(D); and
(6) reduces administrative and other nonfinancial
barriers for recipients in obtaining health care services.
Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. In
awarding contracts to managed care organizations, the commission
shall:
(1) give extra consideration to organizations that
agree to assure continuity of care for at least three months beyond
the period of Medicaid eligibility for recipients; and
(2) consider the need to use different managed care
plans to meet the needs of different populations.
Sec. 533.004. MANDATORY CONTRACTS. (a) In implementing
Medicaid managed care in a health care service region, the
commission shall contract with at least one managed care
organization in that region that:
(1) is created by a political subdivision with a
constitutional or statutory obligation to provide health care to
indigent patients;
(2) is licensed to provide health care in that region;
and
(3) demonstrates its ability to meet the contractual
obligations delineated in the commission's request for applications
to enter into a contract with the commission to provide health care
to recipients in that region.
(b) A contract with a managed care organization described in
Subsection (a) must contain the same requirements and capitation
rate as contracts with other managed care organizations to provide
health care services to recipients in that region.
Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
between a managed care organization and the commission for the
organization to provide health care services to recipients must
contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation and provider payment rates that ensure
the cost-effective provision of high quality health care;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
and
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than
the 45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to
exceed 60 days, specified by a written agreement between the
physician or provider and the managed care organization.
Sec. 533.006. PROVIDER NETWORKS. (a) The commission shall
require that each managed care organization that contracts with the
commission to provide health care services to recipients in a
region:
(1) seek participation in the organization's provider
network from:
(A) each health care provider in the region who
has traditionally provided care to Medicaid and charity care
recipients; and
(B) each hospital in the region that has been
designated as a disproportionate share hospital under the state
Medicaid program; and
(2) include in its provider network for not less than
three years:
(A) each health care provider in the region who:
(i) previously provided care to Medicaid
and charity care recipients at a significant level as prescribed by
the commission;
(ii) agrees to accept the prevailing
provider contract rate of the managed care organization; and
(iii) has the credentials required by the
managed care organization, provided that lack of board
certification or accreditation by the Joint Commission on
Accreditation of Healthcare Organizations may not be the sole
ground for exclusion from the provider network; and
(B) each accredited primary care residency
program in the region.
(b) A contract between a managed care organization and the
commission for the organization to provide health care services to
recipients in a health care service region that includes a rural
area must require that the organization include in its provider
network rural hospitals, physicians, home and community support
services agencies, and other rural health care providers who:
(1) are sole community providers;
(2) provide care to Medicaid and charity care
recipients at a significant level as prescribed by the commission;
(3) agree to accept the prevailing provider contract
rate of the managed care organization; and
(4) have the credentials required by the managed care
organization, provided that lack of board certification or
accreditation by the Joint Commission on Accreditation of
Healthcare Organizations may not be the sole ground for exclusion
from the provider network.
Sec. 533.007. CONTRACT COMPLIANCE. (a) The commission
shall review each managed care organization that contracts with the
commission to provide health care services to recipients through a
managed care plan issued by the organization to determine whether
the organization is prepared to meet its contractual obligations.
(b) Each managed care organization that contracts with the
commission to provide health care services to recipients in a
health care service region shall submit an implementation plan not
later than the 90th day before the date on which the commission
plans to begin to provide health care services to recipients in
that region through managed care. The implementation plan must
include:
(1) specific staffing patterns by function for all
operations, including enrollment, information systems, member
services, quality improvement, claims management, case management,
and provider and recipient training; and
(2) specific time frames for demonstrating
preparedness for implementation before the date on which the
commission plans to begin to provide health care services to
recipients in that region through managed care.
(c) The commission shall respond to an implementation plan
not later than the fifth day after the date a managed care
organization submits the plan if the plan does not adequately meet
preparedness guidelines.
(d) Each managed care organization that contracts with the
commission to provide health care services to recipients in a
region shall submit status reports on the implementation plan not
later than the 60th day and the 30th day before the date on which
the commission plans to begin to provide health care services to
recipients in that region through managed care and every 30th day
after that date until the 180th day after that date.
(e) The commission shall conduct a compliance and readiness
review of each managed care organization that contracts with the
commission not later than the 15th day before the date on which the
commission plans to begin the enrollment process in a region and
again not later than the 15th day before the date on which the
commission plans to begin to provide health care services to
recipients in that region through managed care. The review must
include an on-site inspection and tests of service authorization
and claims payment systems, complaint processing systems, and any
other process or system required by the contract.
(f) The commission may delay enrollment of recipients in a
managed care plan issued by a managed care organization if the
review reveals that the managed care organization is not prepared
to meet its contractual obligations. The commission shall notify a
managed care organization of a decision to delay enrollment in a
plan issued by that organization.
Sec. 533.008. RECIPIENT ENROLLMENT. The commission shall:
(1) encourage recipients to choose appropriate managed
care plans and primary health care providers by:
(A) providing initial information to recipients
and providers in a region about the need for recipients to choose
plans and providers not later than the 90th day before the date on
which the commission plans to begin to provide health care services
to recipients in that region through managed care;
(B) providing follow-up information before
assignment of plans and providers and after assignment, if
necessary, to recipients who delay in choosing plans and providers;
and
(C) allowing plans and providers to provide
information to recipients or engage in marketing activities under
marketing guidelines established by the commission under Section
533.009 after the commission approves the information or
activities;
(2) consider the following factors, in the order
listed, in assigning managed care plans and primary health care
providers to recipients who fail to choose plans and providers:
(A) the importance of maintaining existing
physician-patient relationships, including relationships with
specialists, public health clinics, and community health centers;
(B) to the extent possible, the need to assign
family members to the same providers and plans;
(C) geographic convenience of plans and
providers for recipients;
(D) to the extent possible, the types of
value-added services offered by plans that meet the needs of
recipients and their families, including:
(i) continuity of care for at least three
months beyond the period of Medicaid eligibility for recipients;
(ii) coordination of services with other
providers who have traditionally provided health care services to
Medicaid recipients, including public health clinics and community
health centers;
(iii) essential public health services;
and
(iv) transportation; and
(E) to the extent possible, the quality of
services offered by plans or providers determined through outcome
measures of overall recipient health; and
(3) retain responsibility for enrollment and
disenrollment of recipients in managed care plans, except that the
commission may delegate the responsibility to an independent
contractor who receives no form of payment from, and has no
financial ties to, any managed care organization.
Sec. 533.009. MARKETING GUIDELINES. The commission shall
establish marketing guidelines for managed care organizations that
contract with the commission to provide health care services to
recipients, including guidelines that prohibit:
(1) door-to-door marketing to recipients by managed
care organizations or agents of those organizations;
(2) the use of marketing materials with inaccurate or
misleading information;
(3) misrepresentations to recipients or providers;
(4) offering recipients material or financial
incentives to choose a managed care plan other than nominal gifts
or free health screenings approved by the commission that the
managed care organization offers to all recipients regardless of
whether the recipients enroll in the managed care plan;
(5) marketing at public assistance offices; and
(6) the use of marketing agents who are paid solely by
the commission.
Sec. 533.010. SPECIAL DISEASE MANAGEMENT. (a) The
commission shall, to the extent possible, ensure that managed care
organizations under contract with the commission to provide health
care services to recipients develop special disease management
programs to address chronic health conditions, including asthma and
diabetes.
(b) The commission may study, in conjunction with an
academic center, the benefits and costs of applying disease
management principles in the delivery of Medicaid managed care.
Sec. 533.011. SPECIAL PROTOCOLS. In conjunction with an
academic center, the commission may study the treatment of indigent
populations to develop special protocols for managed care
organizations to use in providing health care services to
recipients.
Sections 533.012-533.020 reserved for expansion
SUBCHAPTER B. REGIONAL ADVISORY COMMITTEES
Sec. 533.021. APPOINTMENT. Not later than the 180th day
before the date the commission plans to begin to provide health
care services to recipients in a health care service region through
managed care, the commission, in consultation with health and human
services agencies, shall appoint a Medicaid managed care advisory
committee for that region.
Sec. 533.022. COMPOSITION. A committee consists of
representatives from entities and communities in the region as
considered necessary by the commission to ensure representation of
interested persons, including representatives of:
(1) hospitals;
(2) managed care organizations;
(3) primary care providers;
(4) state agencies;
(5) consumer advocates;
(6) recipients; and
(7) rural providers.
Sec. 533.023. PRESIDING OFFICER; SUBCOMMITTEES. The
commissioner or the commissioner's designated representative serves
as the presiding officer of a committee. The presiding officer may
appoint subcommittees as necessary.
Sec. 533.024. MEETINGS. (a) A committee shall meet at
least quarterly for the first year after appointment of the
committee and at least annually after that time.
(b) A committee is subject to Chapter 551, Government Code.
Sec. 533.025. POWERS AND DUTIES. A committee shall:
(1) comment on the implementation of Medicaid managed
care in the region;
(2) provide recommendations to the commission on the
improvement of Medicaid managed care in the region not later than
the 30th day after the date of each committee meeting; and
(3) seek input from the public, including public
comment at each committee meeting.
Sec. 533.026. INFORMATION FROM COMMISSION. On request, the
commission shall provide to a committee information relating to
recipient enrollment and disenrollment, recipient and provider
complaints, administrative procedures, program expenditures, and
education and training procedures.
Sec. 533.027. COMPENSATION; REIMBURSEMENT. (a) A member of
a committee other than a representative of a health and human
services agency is not entitled to receive compensation or
reimbursement for travel expenses.
(b) A member of a committee who is an agency representative
is entitled to reimbursement for expenses incurred in the
performance of committee duties by the appointing agency in
accordance with the travel provisions for state employees in the
General Appropriations Act.
Sec. 533.028. OTHER LAW. Except as provided by this
chapter, a committee is subject to Article 6252-33, Revised
Statutes.
SECTION 4. Not later than September 1, 1997, the Health and
Human Services Commission shall direct the Texas Department of
Health and the Texas Department of Human Services to submit to the
governor and the Legislative Budget Board a plan to realize cost
savings for the state by simplifying eligibility criteria and
streamlining eligibility determination processes for recipients of
financial assistance under Chapter 31, Human Resources Code,
recipients of medical assistance under Chapter 32, Human Resources
Code, and recipients of other public assistance.
SECTION 5. Not later than December 1, 1998, the Health and
Human Services Commission shall submit a report to the governor,
the lieutenant governor, and the speaker of the house of
representatives on the impact of Medicaid managed care on the
public health sector.
SECTION 6. Not later than the first anniversary of the date
on which Medicaid recipients in a health care service region begin
to receive health care services through Medicaid managed care, the
Health and Human Services Commission, in cooperation with the
Medicaid managed care advisory committee for that region created
under Subchapter B, Chapter 533, Government Code, as added by this
Act, shall submit a report to the governor, lieutenant governor,
and speaker of the house of representatives on the implementation
of Medicaid managed care in that region. If Medicaid recipients in
a region began to receive health care services through managed care
before September 1, 1996, the commission is required to submit a
report on the implementation of Medicaid managed care in that
region as soon as possible after the effective date of this Act.
The commission may consolidate a report with any other report
relating to the same subject that the commission is required to
submit under other law.
SECTION 7. (a) Section 533.007, Government Code, as added
by this Act, applies only to a contract with a managed care
organization that the commission enters into or renews on or after
the effective date of this Act. A contract with a managed care
organization that the commission enters into or renews before the
effective date of this Act is governed by the law as it existed
immediately before that date, and that law is continued in effect
for that purpose.
(b) Section 533.004, Government Code, as added by this Act,
does not affect the expansion of medical assistance for children
described in H.C.R. No. 189, 75th Legislature, Regular Session,
1997.
(c) If Medicaid recipients in a health care service region
began to receive health care services through managed care before
the effective date of this Act, the commission shall appoint a
Medicaid managed care advisory committee for that region in
accordance with Subchapter B, Chapter 533, Government Code, as
added by this Act, as soon as possible after the effective date of
this Act.
(d) For purposes of this section, "commission" means the
Health and Human Services Commission or an agency operating part of
the state Medicaid managed care program, as appropriate.
SECTION 8. The importance of this legislation and the
crowded condition of the calendars in both houses create an
emergency and an imperative public necessity that the
constitutional rule requiring bills to be read on three several
days in each house be suspended, and this rule is hereby suspended,
and that this Act take effect and be in force from and after its
passage, and it is so enacted.