By Berlanga, et al. H.B. No. 2913
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the authority of the Health and Human Services
1-3 Commission to administer and operate the Medicaid managed care
1-4 program.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Section 531.021, Government Code, is amended to
1-7 read as follows:
1-8 Sec. 531.021. ADMINISTRATION OF MEDICAID PROGRAM. (a) The
1-9 commission is the state agency designated to administer federal
1-10 medical assistance funds.
1-11 (b) The commission is responsible for adopting reasonable
1-12 rules and standards governing the determination of fees, charges,
1-13 and rates for medical assistance payments under Chapter 32, Human
1-14 Resources Code.
1-15 (c) The commission is responsible for the policy,
1-16 administration, evaluation, and operation of the Medicaid managed
1-17 care program.
1-18 (d) In discharging its duties relating to the Medicaid
1-19 managed care program, the commission shall consult with and
1-20 consider input from the advisory committee created under Section
1-21 531.047 and from each health and human services agency that
1-22 operates part of the Medicaid program.
1-23 (e) The commissioner or a person designated by the
1-24 commissioner shall supervise employees of health and human services
2-1 agencies in the performance of Medicaid managed care duties. The
2-2 commissioner or person designated by the commissioner may assign
2-3 duties to employees and require health and human services agencies
2-4 to assign duties to employees as necessary for the commission to
2-5 discharge its duties relating to the Medicaid managed care program.
2-6 SECTION 2. Subchapter B, Chapter 531, Government Code, is
2-7 amended by adding Section 531.047 to read as follows:
2-8 Sec. 531.047. MEDICAID MANAGED CARE INTERAGENCY ADVISORY
2-9 COMMITTEE. (a) An interagency advisory committee is created to
2-10 provide assistance and recommendations to the commission relating
2-11 to the policy, administration, evaluation, and operation of the
2-12 Medicaid managed care program. The advisory committee consists of:
2-13 (1) the commissioner or, if designated under
2-14 Subsection (b), the person acting as the state Medicaid director;
2-15 (2) a representative of the Texas Department of
2-16 Health, designated by the commissioner of public health;
2-17 (3) a representative of the Texas Department of Mental
2-18 Health and Mental Retardation, designated by the commissioner of
2-19 mental health and mental retardation;
2-20 (4) a representative of the Texas Department of Human
2-21 Services, designated by the commissioner of human services; and
2-22 (5) if considered appropriate by the commissioner, a
2-23 representative of any other state agency with duties relating to
2-24 the Medicaid managed care program, designated by the chief
2-25 administrative officer of that agency.
2-26 (b) The commissioner may designate the person acting as the
2-27 state Medicaid director to serve on the advisory committee on
3-1 behalf of the commissioner.
3-2 (c) A member of the advisory committee serves at the will of
3-3 the designating agency.
3-4 (d) The commissioner or the person acting as the state
3-5 Medicaid director, as applicable, serves as presiding officer of
3-6 the advisory committee, and members of the committee may elect
3-7 other necessary officers.
3-8 (e) The advisory committee shall meet at the call of the
3-9 presiding officer. The presiding officer shall call a meeting of
3-10 the committee at least once every two months.
3-11 (f) The designating agency is responsible for the expenses
3-12 of a member's service on the advisory committee. A member of the
3-13 advisory committee receives no additional compensation for serving
3-14 on the committee.
3-15 (g) The advisory committee is not subject to Article
3-16 6252-33, Revised Statutes.
3-17 SECTION 3. (a) Subtitle I, Title 4, Government Code, is
3-18 amended by adding Chapter 533 to read as follows:
3-19 CHAPTER 533. IMPLEMENTATION OF MEDICAID
3-20 MANAGED CARE PROGRAM
3-21 SUBCHAPTER A. GENERAL PROVISIONS
3-22 Sec. 533.001. DEFINITIONS. In this chapter:
3-23 (1) "Commission" means the Health and Human Services
3-24 Commission or an agency operating part of the state Medicaid
3-25 managed care program, as appropriate.
3-26 (2) "Commissioner" means the commissioner of health
3-27 and human services.
4-1 (3) "Health and human services agencies" has the
4-2 meaning assigned by Section 531.001.
4-3 (4) "Managed care organization" means a person who is
4-4 authorized or otherwise permitted by law to arrange for or provide
4-5 a managed care plan.
4-6 (5) "Managed care plan" means a plan under which a
4-7 person undertakes to provide, arrange for, pay for, or reimburse
4-8 any part of the cost of any health care services. A part of the
4-9 plan must consist of arranging for or providing health care
4-10 services as distinguished from indemnification against the cost of
4-11 those services on a prepaid basis through insurance or otherwise.
4-12 The term includes a primary care case management provider network.
4-13 The term does not include a plan that indemnifies a person for the
4-14 cost of health care services through insurance.
4-15 (6) "Recipient" means a recipient of medical
4-16 assistance under Chapter 32, Human Resources Code.
4-17 Sec. 533.002. PURPOSE. The commission shall implement the
4-18 Medicaid managed care program as part of the health care delivery
4-19 system developed under Chapter 532 by contracting with managed care
4-20 organizations in a manner that, to the extent possible:
4-21 (1) improves the health of Texans by:
4-22 (A) emphasizing prevention;
4-23 (B) promoting continuity of care; and
4-24 (C) providing a medical home for recipients;
4-25 (2) ensures that each recipient receives high quality,
4-26 comprehensive health care services in the recipient's local
4-27 community;
5-1 (3) encourages the training of and access to primary
5-2 care physicians and providers;
5-3 (4) maximizes cooperation with existing public health
5-4 entities, including local departments of health;
5-5 (5) provides incentives to managed care organizations,
5-6 other than managed care organizations created by political
5-7 subdivisions with constitutional or statutory obligations to
5-8 provide health care to indigent patients, to improve the quality of
5-9 health care services for recipients by providing value-added
5-10 services; and
5-11 (6) reduces administrative and other nonfinancial
5-12 barriers for recipients in obtaining health care services.
5-13 Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. In
5-14 awarding contracts to managed care organizations, the commission
5-15 shall:
5-16 (1) give extra consideration to organizations that
5-17 agree to assure continuity of care for at least three months beyond
5-18 the period of Medicaid eligibility for recipients; and
5-19 (2) consider the need to use different managed care
5-20 plans to meet the needs of different populations.
5-21 Sec. 533.004. MANDATORY CONTRACTS. (a) In implementing
5-22 Medicaid managed care in a health care service region, the
5-23 commission shall contract with at least one managed care
5-24 organization in that region that:
5-25 (1) is created by a political subdivision with a
5-26 constitutional or statutory obligation to provide health care to
5-27 indigent patients;
6-1 (2) is licensed to provide health care in that region;
6-2 and
6-3 (3) demonstrates its ability to meet the contractual
6-4 obligations delineated in the commission's request for applications
6-5 to enter into a contract with the commission to provide health care
6-6 to recipients in that region.
6-7 (b) A contract with a managed care organization described in
6-8 Subsection (a) must contain the same requirements and capitation
6-9 rate as contracts with other managed care organizations to provide
6-10 health care services to recipients in that region.
6-11 (c) The commission may not contract with a managed care
6-12 organization created by a political subdivision under Subsection
6-13 (a)(1)(A) unless the political subdivision has entered into an
6-14 agreement with the state to provide funds for the expansion of
6-15 Medicaid for children as described by Chapter 444, Acts of the 74th
6-16 Legislature, Regular Session, 1995.
6-17 Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
6-18 between a managed care organization and the commission for the
6-19 organization to provide health care services to recipients must
6-20 contain:
6-21 (1) procedures to ensure accountability to the state
6-22 for the provision of health care services, including procedures for
6-23 financial reporting, quality assurance, utilization review, and
6-24 assurance of contract and subcontract compliance;
6-25 (2) capitation and provider payment rates that ensure
6-26 the cost-effective provision of high quality health care;
6-27 (3) a requirement that the managed care organization
7-1 provide ready access to a person who assists recipients in
7-2 resolving issues relating to enrollment, plan administration,
7-3 education and training, access to services, and grievance
7-4 procedures;
7-5 (4) a requirement that the managed care organization
7-6 provide ready access to a person who assists providers in resolving
7-7 issues relating to payment, plan administration, education and
7-8 training, and grievance procedures;
7-9 (5) a requirement that the managed care organization
7-10 provide information and referral about the availability of
7-11 educational, social, and other community services that could
7-12 benefit a recipient;
7-13 (6) procedures for recipient outreach and education;
7-14 and
7-15 (7) a requirement that the managed care organization
7-16 make payment to a physician or provider for health care services
7-17 rendered to a recipient under a managed care plan not later than
7-18 the 45th day after the date a claim for payment is received with
7-19 documentation reasonably necessary for the managed care
7-20 organization to process the claim, or within a period, not to
7-21 exceed 60 days, specified by a written agreement between the
7-22 physician or provider and the managed care organization.
7-23 Sec. 533.006. PROVIDER NETWORKS. (a) The commission shall
7-24 require that each managed care organization that contracts with the
7-25 commission to provide health care services to recipients in a
7-26 region:
7-27 (1) seek participation in the organization's provider
8-1 network from:
8-2 (A) each health care provider in the region who
8-3 has traditionally provided care to Medicaid and charity care
8-4 recipients; and
8-5 (B) each hospital in the region that has been
8-6 designated as a disproportionate share hospital under the state
8-7 Medicaid program; and
8-8 (2) include in its provider network for not less than
8-9 three years:
8-10 (A) each health care provider in the region who:
8-11 (i) previously provided care to Medicaid
8-12 and charity care recipients at a significant level as prescribed by
8-13 the commission;
8-14 (ii) agrees to accept the prevailing
8-15 provider contract rate of the managed care organization; and
8-16 (iii) has the credentials required by the
8-17 managed care organization, provided that lack of board
8-18 certification or accreditation by the Joint Commission on
8-19 Accreditation of Healthcare Organizations may not be the sole
8-20 ground for exclusion from the provider network;
8-21 (B) each accredited primary care residency
8-22 program in the region; and
8-23 (C) each disproportionate share hospital
8-24 designated by the commission as a statewide significant traditional
8-25 provider.
8-26 (b) A contract between a managed care organization and the
8-27 commission for the organization to provide health care services to
9-1 recipients in a health care service region that includes a rural
9-2 area must require that the organization include in its provider
9-3 network rural hospitals, physicians, home and community support
9-4 services agencies, and other rural health care providers who:
9-5 (1) are sole community providers;
9-6 (2) provide care to Medicaid and charity care
9-7 recipients at a significant level as prescribed by the commission;
9-8 (3) agree to accept the prevailing provider contract
9-9 rate of the managed care organization; and
9-10 (4) have the credentials required by the managed care
9-11 organization, provided that lack of board certification or
9-12 accreditation by the Joint Commission on Accreditation of
9-13 Healthcare Organizations may not be the sole ground for exclusion
9-14 from the provider network.
9-15 Sec. 533.007. CONTRACT COMPLIANCE. (a) The commission
9-16 shall review each managed care organization that contracts with the
9-17 commission to provide health care services to recipients through a
9-18 managed care plan issued by the organization to determine whether
9-19 the organization is prepared to meet its contractual obligations.
9-20 (b) Each managed care organization that contracts with the
9-21 commission to provide health care services to recipients in a
9-22 health care service region shall submit an implementation plan not
9-23 later than the 90th day before the date on which the commission
9-24 plans to begin to provide health care services to recipients in
9-25 that region through managed care. The implementation plan must
9-26 include:
9-27 (1) specific staffing patterns by function for all
10-1 operations, including enrollment, information systems, member
10-2 services, quality improvement, claims management, case management,
10-3 and provider and recipient training; and
10-4 (2) specific time frames for demonstrating
10-5 preparedness for implementation before the date on which the
10-6 commission plans to begin to provide health care services to
10-7 recipients in that region through managed care.
10-8 (c) The commission shall respond to an implementation plan
10-9 not later than the fifth day after the date a managed care
10-10 organization submits the plan if the plan does not adequately meet
10-11 preparedness guidelines.
10-12 (d) Each managed care organization that contracts with the
10-13 commission to provide health care services to recipients in a
10-14 region shall submit status reports on the implementation plan not
10-15 later than the 60th day and the 30th day before the date on which
10-16 the commission plans to begin to provide health care services to
10-17 recipients in that region through managed care and every 30th day
10-18 after that date until the 180th day after that date.
10-19 (e) The commission shall conduct a compliance and readiness
10-20 review of each managed care organization that contracts with the
10-21 commission not later than the 15th day before the date on which the
10-22 commission plans to begin the enrollment process in a region and
10-23 again not later than the 15th day before the date on which the
10-24 commission plans to begin to provide health care services to
10-25 recipients in that region through managed care. The review must
10-26 include an on-site inspection and tests of service authorization
10-27 and claims payment systems, complaint processing systems, and any
11-1 other process or system required by the contract.
11-2 (f) The commission may delay enrollment of recipients in a
11-3 managed care plan issued by a managed care organization if the
11-4 review reveals that the managed care organization is not prepared
11-5 to meet its contractual obligations. The commission shall notify a
11-6 managed care organization of a decision to delay enrollment in a
11-7 plan issued by that organization.
11-8 Sec. 533.008. MARKETING GUIDELINES. The commission shall
11-9 establish marketing guidelines for managed care organizations that
11-10 contract with the commission to provide health care services to
11-11 recipients, including guidelines that prohibit:
11-12 (1) door-to-door marketing to recipients by managed
11-13 care organizations or agents of those organizations;
11-14 (2) the use of marketing materials with inaccurate or
11-15 misleading information;
11-16 (3) misrepresentations to recipients or providers;
11-17 (4) offering recipients material or financial
11-18 incentives to choose a managed care plan other than nominal gifts
11-19 or free health screenings approved by the commission that the
11-20 managed care organization offers to all recipients regardless of
11-21 whether the recipients enroll in the managed care plan;
11-22 (5) marketing at public assistance offices; and
11-23 (6) the use of marketing agents who are paid solely by
11-24 the commission.
11-25 Sec. 533.009. SPECIAL DISEASE MANAGEMENT. (a) The
11-26 commission shall, to the extent possible, ensure that managed care
11-27 organizations under contract with the commission to provide health
12-1 care services to recipients develop special disease management
12-2 programs to address chronic health conditions, including asthma and
12-3 diabetes.
12-4 (b) The commission may study, in conjunction with an
12-5 academic center, the benefits and costs of applying disease
12-6 management principles in the delivery of Medicaid managed care.
12-7 Sec. 533.010. SPECIAL PROTOCOLS. In conjunction with an
12-8 academic center, the commission may study the treatment of indigent
12-9 populations to develop special protocols for managed care
12-10 organizations to use in providing health care services to
12-11 recipients.
12-12 (Sections 533.011-533.020 reserved for expansion
12-13 SUBCHAPTER B. REGIONAL ADVISORY COMMITTEES
12-14 Sec. 533.021. APPOINTMENT. Not later than the 180th day
12-15 before the date the commission plans to begin to provide health
12-16 care services to recipients in a health care service region through
12-17 managed care, the commission, in consultation with health and human
12-18 services agencies, shall appoint a Medicaid managed care advisory
12-19 committee for that region.
12-20 Sec. 533.022. COMPOSITION. A committee consists of
12-21 representatives from entities and communities in the region as
12-22 considered necessary by the commission to ensure representation of
12-23 interested persons, including representatives of:
12-24 (1) hospitals;
12-25 (2) managed care organizations;
12-26 (3) primary care providers;
12-27 (4) state agencies;
13-1 (5) consumer advocates;
13-2 (6) recipients; and
13-3 (7) rural providers.
13-4 Sec. 533.023. PRESIDING OFFICER; SUBCOMMITTEES. The
13-5 commissioner or the commissioner's designated representative serves
13-6 as the presiding officer of a committee. The presiding officer may
13-7 appoint subcommittees as necessary.
13-8 Sec. 533.024. MEETINGS. (a) A committee shall meet at
13-9 least quarterly for the first year after appointment of the
13-10 committee and at least annually after that time.
13-11 (b) A committee is subject to Chapter 551, Government Code.
13-12 Sec. 533.025. POWERS AND DUTIES. A committee shall:
13-13 (1) comment on the implementation of Medicaid managed
13-14 care in the region;
13-15 (2) provide recommendations to the commission on the
13-16 improvement of Medicaid managed care in the region not later than
13-17 the 30th day after the date of each committee meeting; and
13-18 (3) seek input from the public, including public
13-19 comment at each committee meeting.
13-20 Sec. 533.026. INFORMATION FROM COMMISSION. On request, the
13-21 commission shall provide to a committee information relating to
13-22 recipient enrollment and disenrollment, recipient and provider
13-23 complaints, administrative procedures, program expenditures, and
13-24 education and training procedures.
13-25 Sec. 533.027. COMPENSATION; REIMBURSEMENT. (a) A member of
13-26 a committee other than a representative of a health and human
13-27 services agency is not entitled to receive compensation or
14-1 reimbursement for travel expenses.
14-2 (b) A member of a committee who is an agency representative
14-3 is entitled to reimbursement for expenses incurred in the
14-4 performance of committee duties by the appointing agency in
14-5 accordance with the travel provisions for state employees in the
14-6 General Appropriations Act.
14-7 Sec. 533.028. OTHER LAW. Except as provided by this
14-8 chapter, a committee is subject to Article 6252-33, Revised
14-9 Statutes.
14-10 (b) Not later than September 1, 1997, the Health and Human
14-11 Services Commission shall direct the Texas Department of Health and
14-12 the Texas Department of Human Services to submit to the governor
14-13 and the Legislative Budget Board a plan to realize cost savings for
14-14 the state by simplifying eligibility criteria and streamlining
14-15 eligibility determination processes for recipients of financial
14-16 assistance under Chapter 31, Human Resources Code, recipients of
14-17 medical assistance under Chapter 32, Human Resources Code, and
14-18 recipients of other public assistance.
14-19 (c) Not later than December 1, 1998, the Health and Human
14-20 Services Commission shall submit a report to the governor, the
14-21 lieutenant governor, and the speaker of the house of
14-22 representatives on the impact of Medicaid managed care on the
14-23 public health sector.
14-24 (d) Not later than the first anniversary of the date on
14-25 which Medicaid recipients in a health care service region begin to
14-26 receive health care services through Medicaid managed care, the
14-27 Health and Human Services Commission, in cooperation with the
15-1 Medicaid managed care advisory committee for that region created
15-2 under Subchapter B, Chapter 533, Government Code, as added by this
15-3 Act, shall submit a report to the governor, lieutenant governor,
15-4 and speaker of the house of representatives on the implementation
15-5 of Medicaid managed care in that region. If Medicaid recipients in
15-6 a region began to receive health care services through managed care
15-7 before September 1, 1996, the commission is required to submit a
15-8 report on the implementation of Medicaid managed care in that
15-9 region as soon as possible after the effective date of this Act.
15-10 The commission may consolidate a report with any other report
15-11 relating to the same subject that the commission is required to
15-12 submit under other law.
15-13 (e) Section 533.007, Government Code, as added by this Act,
15-14 applies only to a contract with a managed care organization that
15-15 the Health and Human Services Commission or an agency operating
15-16 part of the Medicaid managed care program enters into or renews on
15-17 or after the effective date of this Act. A contract with a managed
15-18 care organization that the Health and Human Services Commission or
15-19 an agency operating part of the Medicaid managed care program
15-20 enters into or renews before the effective date of this Act is
15-21 governed by the law as it existed immediately before that date, and
15-22 that law is continued in effect for that purpose.
15-23 (f) Section 533.004, Government Code, as added by this Act,
15-24 does not affect the expansion of medical assistance for children
15-25 described in H.C.R. No. 189, 75th Legislature, Regular Session,
15-26 1997.
15-27 (g) If Medicaid recipients in a health care service region
16-1 began to receive health care services through managed care before
16-2 the effective date of this Act, the Health and Human Services
16-3 Commission or an agency operating part of the Medicaid managed care
16-4 program shall appoint a Medicaid managed care advisory committee
16-5 for that region in accordance with Subchapter B, Chapter 533,
16-6 Government Code, as added by this Act, as soon as possible after
16-7 the effective date of this Act.
16-8 (h) This section takes effect immediately.
16-9 SECTION 4. This Act takes effect September 1, 1997, except
16-10 that Section 3 of this Act takes effect immediately.
16-11 SECTION 5. The importance of this legislation and the
16-12 crowded condition of the calendars in both houses create an
16-13 emergency and an imperative public necessity that the
16-14 constitutional rule requiring bills to be read on three several
16-15 days in each house be suspended, and this rule is hereby suspended,
16-16 and that this Act take effect and be in force according to its
16-17 terms, and it is so enacted.