75R12895 SAW-F
By Coleman H.B. No. 3258
Substitute the following for H.B. No. 3258:
By Berlanga C.S.H.B. No. 3258
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the implementation of the Medicaid managed care
1-3 program.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subtitle I, Title 4, Government Code, is amended
1-6 by adding Chapter 533 to read as follows:
1-7 CHAPTER 533. IMPLEMENTATION OF MEDICAID
1-8 MANAGED CARE PROGRAM
1-9 SUBCHAPTER A. GENERAL PROVISIONS
1-10 Sec. 533.001. DEFINITIONS. In this chapter:
1-11 (1) "Commission" means the Health and Human Services
1-12 Commission or an agency operating part of the state Medicaid
1-13 managed care program, as appropriate.
1-14 (2) "Commissioner" means the commissioner of health
1-15 and human services.
1-16 (3) "Health and human services agencies" has the
1-17 meaning assigned by Section 531.001.
1-18 (4) "Managed care organization" means a person who is
1-19 authorized or otherwise permitted by law to arrange for or provide
1-20 a managed care plan.
1-21 (5) "Managed care plan" means a plan under which a
1-22 person undertakes to provide, arrange for, pay for, or reimburse
1-23 any part of the cost of any health care services. A part of the
1-24 plan must consist of arranging for or providing health care
2-1 services as distinguished from indemnification against the cost of
2-2 those services on a prepaid basis through insurance or otherwise.
2-3 The term does not include a plan that indemnifies a person for the
2-4 cost of health care services through insurance.
2-5 Sec. 533.002. PURPOSE. The commission shall implement the
2-6 Medicaid managed care program as part of the health care delivery
2-7 system developed under Chapter 532 by contracting with managed care
2-8 organizations in a manner that, to the extent possible:
2-9 (1) improves the health of Texans by:
2-10 (A) emphasizing prevention;
2-11 (B) promoting continuity of care; and
2-12 (C) providing a medical home for Medicaid
2-13 recipients;
2-14 (2) ensures that each Medicaid recipient receives high
2-15 quality, comprehensive health care services in the recipient's
2-16 local community;
2-17 (3) encourages the training of and access to primary
2-18 care physicians;
2-19 (4) maximizes cooperation with existing public health
2-20 entities, including local departments of health; and
2-21 (5) provides incentives to managed care organizations
2-22 to improve the quality of health care services provided to
2-23 Medicaid recipients.
2-24 Sec. 533.003. CONTRACTS WITH MANAGED CARE ORGANIZATIONS.
2-25 (a) In awarding contracts to managed care organizations, the
2-26 commission shall:
2-27 (1) give extra consideration to organizations that
3-1 agree to assure continuity of care for Medicaid recipients for at
3-2 least three months beyond the period of the recipients' Medicaid
3-3 eligibility; and
3-4 (2) consider the need to use different managed care
3-5 plans to meet the needs of different populations.
3-6 (b) A contract between a managed care organization and the
3-7 commission for the organization to provide health care services to
3-8 Medicaid recipients must contain:
3-9 (1) procedures to ensure accountability to the state
3-10 for the provision of health care services, including procedures for
3-11 financial reporting, quality assurance, utilization review, and
3-12 assurance of contract and subcontract compliance;
3-13 (2) capitation and provider payment rates that ensure
3-14 the cost-effective provision of high quality health care;
3-15 (3) a requirement that the managed care organization
3-16 seek participation in the organization's provider network from:
3-17 (A) each health care provider who has
3-18 traditionally provided care to Medicaid and charity care
3-19 recipients; and
3-20 (B) each hospital that has been designated as a
3-21 disproportionate share hospital under the state Medicaid program;
3-22 (4) a requirement that the managed care organization
3-23 include in its provider network, for not less than three years,
3-24 each health care provider who:
3-25 (A) previously provided care to Medicaid and
3-26 charity care recipients at a significant level as prescribed by the
3-27 commission;
4-1 (B) agrees to accept the prevailing provider
4-2 contract rate of the managed care organization; and
4-3 (C) has the credentials required by the managed
4-4 care organization, provided that lack of board certification or
4-5 accreditation by the Joint Commission on Accreditation of
4-6 Healthcare Organizations may not be the sole ground for exclusion
4-7 from the provider network;
4-8 (5) a requirement that the managed care organization
4-9 use, to the extent possible, a one-stop approach for client
4-10 information and referral, including access to a recipient advocate
4-11 to assist Medicaid recipients with enrollment, plan administration,
4-12 and payment; and
4-13 (6) a requirement that the managed care organization
4-14 pay providers for health care services not later than the 30th day
4-15 after the services are provided to a Medicaid recipient.
4-16 (c) A contract between a managed care organization and the
4-17 commission for the organization to provide health care services to
4-18 Medicaid recipients in a health care service region that includes a
4-19 rural area must require that the organization include in its
4-20 provider network rural hospitals, physicians, home and community
4-21 support services agencies, and other rural health care providers
4-22 who:
4-23 (1) are sole community providers;
4-24 (2) provide a significant amount of care to Medicaid
4-25 and charity care recipients as prescribed by the commission; and
4-26 (3) agree to accept the prevailing provider contract
4-27 rate of the managed care organization.
5-1 Sec. 533.004. CONTRACT COMPLIANCE. (a) The commission
5-2 shall review each managed care organization that contracts with the
5-3 commission to provide health care services to Medicaid recipients
5-4 through a managed care plan issued by the organization to determine
5-5 whether the organization is prepared to meet its contractual
5-6 obligations.
5-7 (b) Each managed care organization that contracts with the
5-8 commission shall submit an implementation plan to the commission
5-9 not later than the 90th day before the date on which Medicaid
5-10 recipients may begin enrolling in the organization's managed care
5-11 plan.
5-12 (c) The commission shall provide a written response to an
5-13 implementation plan not later than the 10th day after a managed
5-14 care organization submits the plan if the plan reveals that the
5-15 organization may fail to meet its contractual obligations.
5-16 (d) The commission shall conduct further review not later
5-17 than the 60th day before the date on which Medicaid recipients may
5-18 begin enrolling in the organization's managed care plan.
5-19 (e) The review shall include an on-site inspection and tests
5-20 of service authorization and claims payment systems, complaint
5-21 processing systems, and any other process or system required by the
5-22 contract.
5-23 (f) The commission may delay enrollment of Medicaid
5-24 recipients in a managed care plan if the review reveals that the
5-25 managed care organization is not prepared to meet its contractual
5-26 obligations. The commission shall notify a managed care
5-27 organization of a decision to delay enrollment in a plan issued by
6-1 that organization.
6-2 (g) The commission shall identify and review the
6-3 administrative costs of each managed care organization that
6-4 contracts with the commission. The commission by rule may limit
6-5 these administrative costs.
6-6 Sec. 533.005. RECIPIENT ENROLLMENT. The commission shall:
6-7 (1) ensure that Medicaid recipients choose appropriate
6-8 managed care plans and primary health care providers by:
6-9 (A) providing initial information to recipients
6-10 and providers about the need for recipients to choose plans and
6-11 providers;
6-12 (B) providing follow-up information before
6-13 assignment of plans and providers and after assignment, if
6-14 necessary, to recipients who delay in choosing plans and providers;
6-15 and
6-16 (C) allowing plans and providers to provide
6-17 information directly to recipients under marketing guidelines
6-18 established by the commission;
6-19 (2) consider the following in assigning managed care
6-20 plans and primary health care providers to recipients who fail to
6-21 choose plans and providers:
6-22 (A) the importance of maintaining existing
6-23 physician-patient relationships;
6-24 (B) geographic convenience of plans and
6-25 providers for recipients;
6-26 (C) the types of value-added services offered by
6-27 plans and providers, including:
7-1 (i) child-care services;
7-2 (ii) continuity of care for at least three
7-3 months beyond the period of patients' eligibility for Medicaid;
7-4 (iii) coordination of services with other
7-5 providers who have traditionally provided health care services to
7-6 Medicaid recipients, including public health clinics;
7-7 (iv) essential public health services; and
7-8 (v) transportation; and
7-9 (D) to the extent possible, the quality of
7-10 services offered by plans or providers determined through outcome
7-11 measures of overall recipient health.
7-12 Sec. 533.006. SPECIAL DISEASE MANAGEMENT. (a) The
7-13 commission shall, to the extent possible, ensure that managed care
7-14 organizations under contract with the commission to provide health
7-15 care services to Medicaid recipients develop special disease
7-16 management programs to address chronic health conditions, including
7-17 asthma and diabetes.
7-18 (b) The commission may study, in conjunction with an
7-19 academic center, the benefits and costs of applying disease
7-20 management principles in the delivery of Medicaid managed care.
7-21 (Sections 533.007-533.020 reserved for expansion
7-22 SUBCHAPTER B. REGIONAL ADVISORY COMMITTEES
7-23 Sec. 533.021. APPOINTMENT. Not later than the 180th day
7-24 before the date the commission plans to implement Medicaid managed
7-25 care in a health care service region established under Section
7-26 16A(a)(10), Article 4413(502), Revised Statutes, the commission, in
7-27 consultation with health and human services agencies, shall appoint
8-1 a Medicaid managed care advisory committee for that region.
8-2 Sec. 533.022. COMPOSITION. A committee consists of:
8-3 (1) a representative from each of the following
8-4 entities located in the region:
8-5 (A) a hospital district;
8-6 (B) a nonprofit hospital;
8-7 (C) a for-profit hospital;
8-8 (D) a managed care organization; and
8-9 (E) a children's hospital, if available;
8-10 (2) a regional representative from each of the
8-11 following agencies:
8-12 (A) the Texas Department of Health;
8-13 (B) the Texas Department of Human Services; and
8-14 (C) the Texas Department of Mental Health and
8-15 Mental Retardation;
8-16 (3) three representatives of the Medicaid recipient
8-17 community in the region, at least one of whom must be a
8-18 representative of the community of mental health care recipients;
8-19 (4) a physician in the region;
8-20 (5) a rural health care provider or a provider from a
8-21 medically underserved area in the region, as appropriate; and
8-22 (6) representatives of other entities or communities
8-23 in the region as considered necessary by the commission to ensure
8-24 appropriate representation of interested parties and representation
8-25 of rural areas by at least two committee members.
8-26 Sec. 533.023. PRESIDING OFFICER; SUBCOMMITTEES. The
8-27 commissioner or the commissioner's designated representative serves
9-1 as the presiding officer of a committee. The presiding officer may
9-2 appoint subcommittees as necessary.
9-3 Sec. 533.024. MEETINGS. A committee shall meet at least
9-4 quarterly for the first year after appointment of the committee and
9-5 at least annually after that time.
9-6 Sec. 533.025. POWERS AND DUTIES. A committee shall:
9-7 (1) review and comment on readiness review of managed
9-8 care organizations that have contracted with the commission to
9-9 provide services to Medicaid recipients in the region;
9-10 (2) review and comment on the implementation of
9-11 Medicaid managed care in the region; and
9-12 (3) provide recommendations to the commission on the
9-13 improvement of Medicaid managed care in the region.
9-14 Sec. 533.026. COMPENSATION; REIMBURSEMENT. (a) A member of
9-15 a committee other than a representative of a health and human
9-16 services agency is not entitled to receive compensation or
9-17 reimbursement for travel expenses.
9-18 (b) A member of a committee who is an agency representative
9-19 is entitled to reimbursement for expenses incurred in the
9-20 performance of committee duties by the appointing agency in
9-21 accordance with the travel provisions for state employees in the
9-22 General Appropriations Act.
9-23 Sec. 533.027. OTHER LAW. Except as provided by this
9-24 chapter, a committee is subject to Article 6252-33, Revised
9-25 Statutes.
9-26 SECTION 2. Not later than September 1, 1997, the Health and
9-27 Human Services Commission shall direct the Texas Department of
10-1 Health and the Texas Department of Human Services to submit to the
10-2 governor and the Legislative Budget Board a plan to realize cost
10-3 savings for the state by simplifying eligibility criteria and
10-4 streamlining eligibility determination processes for recipients of
10-5 financial assistance under Chapter 31, Human Resources Code,
10-6 recipients of medical assistance under Chapter 32, Human Resources
10-7 Code, and recipients of other public assistance.
10-8 SECTION 3. Not later than December 1, 1998, the Health and
10-9 Human Services Commission shall submit a report to the governor,
10-10 the lieutenant governor, and the speaker of the house of
10-11 representatives on the impact of Medicaid managed care on the
10-12 public health sector.
10-13 SECTION 4. (a) Not later than the first anniversary of the
10-14 date on which Medicaid recipients in a health care service region
10-15 begin enrolling in Medicaid managed care plans, the Health and
10-16 Human Services Commission, in cooperation with the Medicaid managed
10-17 care advisory committee for that region created under Chapter 533,
10-18 Government Code, as added by this Act, shall submit a report to the
10-19 governor, lieutenant governor, and speaker of the house of
10-20 representatives on the implementation of Medicaid managed care in
10-21 that region.
10-22 (b) As soon as possible after the effective date of this
10-23 Act, the commission is required to submit a report on the
10-24 implementation of Medicaid managed care in a region if Medicaid
10-25 recipients in that region began enrolling in Medicaid managed care
10-26 plans before September 1, 1996.
10-27 SECTION 5. (a) Except as provided by Subsection (b) of this
11-1 section, this Act takes effect immediately.
11-2 (b) Section 533.004, Government Code, as added by this Act,
11-3 takes effect September 1, 1997, and applies only to a contract with
11-4 a managed care organization that the commission enters into or
11-5 renews on or after that date. A contract with a managed care
11-6 organization that the commission enters into or renews before
11-7 September 1, 1997, is governed by the law as it existed immediately
11-8 before that date, and that law is continued in effect for that
11-9 purpose.
11-10 (c) For purposes of this section, "commission" means the
11-11 Health and Human Services Commission or an agency operating part of
11-12 the state Medicaid managed care program, as appropriate.
11-13 SECTION 6. The importance of this legislation and the
11-14 crowded condition of the calendars in both houses create an
11-15 emergency and an imperative public necessity that the
11-16 constitutional rule requiring bills to be read on three several
11-17 days in each house be suspended, and this rule is hereby suspended,
11-18 and that this Act take effect and be in force according to its
11-19 terms, and it is so enacted.