Bill not drafted by TLC or Senate E&E.
Line and page numbers may not match official copy.
By Coleman H.B. No. 3258
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the implementation of Medicaid managed care.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Section 16A(a), Article 4413(502), Vernon's Texas
1-5 Civil Statutes, as added by Chapter 444, Acts of the 74th
1-6 Legislature, Regular Session, 1995, is amended to read as follows:
1-7 (a) The commission shall develop a health care delivery
1-8 system that restructures the delivery of health care services
1-9 provided under the state Medicaid program. The commission shall
1-10 develop the health care delivery system only if the commission
1-11 obtains a waiver or other authorization from all necessary federal
1-12 agencies to implement the system. In developing the health care
1-13 delivery system, the commission shall:
1-14 (1) to the extent possible, design the system in a
1-15 manner that will:
1-16 (A) improve the health of Texans by:
1-17 (i) emphasizing prevention;
1-18 (ii) promoting continuity of care; and
1-19 (iii) providing a medical home for
1-20 Medicaid recipients; and
1-21 (B) ensure that each recipient can receive high
1-22 quality, comprehensive health care services in the recipient's
1-23 local community;
1-24 (2) design the system in a manner that will enable the
2-1 state and the local governmental entities that make resources and
2-2 other funds available for matching to the commission under this
2-3 section to control the costs associated with the state Medicaid
2-4 program and, to the extent possible, will result in cost savings to
2-5 the state and those local governmental entities through health care
2-6 service delivery based on managed care;
2-7 (3) to the extent it is cost-effective to the state
2-8 and local governments, maximize the financing of the state Medicaid
2-9 program by obtaining federal matching funds for all resources and
2-10 other funds available for matching and expand Medicaid eligibility
2-11 to include persons who were eligible to receive indigent health
2-12 care services through the use of those resources or other funds
2-13 available for matching before expansion of eligibility, provided
2-14 that the commission shall give priority to expanding eligibility to
2-15 include children and their families;
2-16 (4) to the extent possible, develop a plan to expand
2-17 Medicaid eligibility to include children and other persons, other
2-18 than those persons described by Subdivision (3) of this subsection,
2-19 that is funded by using:
2-20 (A) appropriations that have previously been
2-21 made to other agencies or other programs to provide related health
2-22 care services to those children and other persons;
2-23 (B) earned federal funds;
2-24 (C) contributions by those children or other
2-25 persons or their families; or
2-26 (D) resources or other funds available for
2-27 matching;
2-28 (5) design the system to ensure that if the system
2-29 includes a method to finance the state Medicaid program by
2-30 obtaining federal matching funds for resources and other funds
3-1 available for matching, each entity listed in Subsection (d)(1),
3-2 (2), (3), (7), (8), or (9) or Subsection (e) of this section that
3-3 makes those resources and other funds available receives funds to
3-4 provide health care services to persons who are eligible for
3-5 Medicaid under the expanded eligibility criteria developed under
3-6 Subdivision (3) or (4) of this subsection in an amount that is at
3-7 least equal to the amount of resources or other funds available for
3-8 matching provided by that entity under this section;
3-9 (6) to the extent possible, provide for the entities
3-10 that make resources and other funds available for matching under
3-11 this section an option to operate the health care delivery system
3-12 within their regions including appropriate portions of the
3-13 eligibility determination process, subject to the standards of and
3-14 oversight by the commission;
3-15 (7) design the system to:
3-16 (A) include methods for ensuring accountability
3-17 to the state for the provision of health care services under the
3-18 state Medicaid program, including methods for financial reporting,
3-19 quality assurance, [and] utilization review[;], and contract
3-20 parameters;
3-21 (B) provide a single point of accountability for
3-22 collection of uniform data to assess, compile, and analyze outcome
3-23 quality and cost efficiency;
3-24 (C) conduct comparative analyses of compiled
3-25 data to assess the relative value of alternative health care
3-26 delivery systems and report to the governor, lieutenant governor,
3-27 and speaker of the house of representatives;
3-28 (D) oversee the methodology for setting
3-29 capitation and provider payment rates to ensure the cost-effective
3-30 provision of high quality health care;
4-1 (E) ensure that both private and public health
4-2 care providers and managed care organizations, including a hospital
4-3 that has been designated as a disproportionate share hospital under
4-4 the state Medicaid program, will have an opportunity to participate
4-5 in the system;
4-6 (F) require [ensure], in adopting rules
4-7 implementing the system, that in developing the provider network
4-8 for the system, the commission, each intergovernmental initiative,
4-9 and each managed care organization, as applicable, seek
4-10 participation from each [give extra consideration to a] health care
4-11 provider who has traditionally provided care to Medicaid and
4-12 charity care patients;
4-13 (G) require that [give extra consideration to]
4-14 providers [who agree to] assure continuity of care for Medicaid
4-15 acute and long-term care clients for 12 months beyond the period of
4-16 eligibility; [and]
4-17 (H) require that the commission, each
4-18 intergovernmental initiative, and each managed care organization,
4-19 as applicable, include in its provider network, for not less than
4-20 three years, each health care provider who:
4-21 (i) previously provided care to Medicaid
4-22 and charity care patients at a significant level as prescribed by
4-23 the commission;
4-24 (ii) agrees to accept a reasonable [the
4-25 standard] provider reimbursement rate of the commission, the
4-26 intergovernmental initiative, or the managed care organization, as
4-27 applicable;
4-28 (iii) meets the credentialing requirements
4-29 under the system of the commission, the intergovernmental
4-30 initiative, or the managed care organization, as applicable,
5-1 provided that lack of board certification or accreditation by the
5-2 Joint Commission on Accreditation of Healthcare Organizations may
5-3 not be the sole grounds for exclusion from the provider network;
5-4 and
5-5 (iv) agrees to comply and does comply with
5-6 all of the terms and conditions of a reasonable [the standard]
5-7 provider agreement of the commission, intergovernmental initiative,
5-8 or managed care organization, as applicable; and
5-9 (I) maximize cooperation with existing public
5-10 health entities, including local departments of health;
5-11 (8) design the system in a manner that, to the extent
5-12 possible, enables the state to manage care to lower the cost of
5-13 providing Medicaid services through the use of health care delivery
5-14 systems such as a primary care case management system, partially
5-15 capitated system, or fully capitated system or a combination of one
5-16 or more of those systems and use, where possible, multiple,
5-17 competing managed care organizations within those systems;
5-18 (9) design the system in a manner that enables the
5-19 state to:
5-20 (A) use different types of health care delivery
5-21 systems to meet the needs of different populations, including the
5-22 establishment of pilot programs to deliver health care services to
5-23 children with special health care needs, adults with disabilities,
5-24 and persons with severe or persistent mental illness;
5-25 (B) recognize the unique role of rural
5-26 hospitals, physicians, home and community support services
5-27 agencies, and other rural health care providers in providing access
5-28 to health care services for rural Texans; [and]
5-29 (C) review data from existing or new pilot
5-30 programs that cover all prescription drugs that are medically
6-1 indicated for a person by a licensed health care provider in
6-2 primary and preventive care and implement any changes in the state
6-3 Medicaid program that as a result of the review are determined to
6-4 be cost-effective and cost-neutral; and
6-5 (D) allow recipients with special needs the
6-6 power to decide whether to participate in the managed care delivery
6-7 system;
6-8 (10) establish geographic health care service regions
6-9 after consulting with local governmental entities that provide
6-10 resources or other funds available for matching under this section
6-11 and emphasize regional coordination in the provision of indigent
6-12 health care;
6-13 (11) simplify eligibility criteria and streamline
6-14 eligibility determination processes;
6-15 (12) to the extent possible, provide a one-stop
6-16 approach for client information and referral for managed care
6-17 services;
6-18 (13) to the extent possible, design the system in a
6-19 manner that encourages the training of and access to primary care
6-20 physicians;
6-21 (14) develop and prepare, after consulting with the
6-22 following entities, the waiver or other documents necessary to
6-23 obtain federal authorization for the system:
6-24 (A) governmental entities that provide health
6-25 care services and assistance to indigent persons in this state;
6-26 (B) consumer representatives;
6-27 (C) managed care organizations; and
6-28 (D) health care providers;
6-29 (15) design the system to ensure that if the system
6-30 includes a method to finance the state Medicaid program by
7-1 obtaining federal matching funds for resources and other funds
7-2 available for matching, an amount not to exceed $20 million a year
7-3 must be dedicated under the system as prescribed in the waiver for
7-4 special payments to rural hospitals that:
7-5 (A) are sole community providers and provide a
7-6 significant amount of care to Medicaid and charity care patients as
7-7 prescribed by the commission; and
7-8 (B) are located in a county in which the county
7-9 or another entity located in the county and described by Subsection
7-10 (d) or (e) of this section:
7-11 (i) has executed a matching funds
7-12 agreement with the commission under this section; and
7-13 (ii) participates in an intergovernmental
7-14 initiative under Section 16B of this article with a county that is
7-15 contiguous to the county in which the rural hospital is located or
7-16 with another entity described by Subsection (d) or (e) of this
7-17 section that is located in the contiguous county if the contiguous
7-18 county or the entity located in the contiguous county is one of the
7-19 entities that forms an intergovernmental initiative under Section
7-20 16B of this article;
7-21 (16) if necessary to ensure that all resources or
7-22 other funds available for matching are maximized in accordance with
7-23 Subdivision (3) of this subsection, design the system to ensure
7-24 that an amount determined by the commission is dedicated under the
7-25 system as prescribed in the waiver for special payments to
7-26 hospitals that provide at least 14,000 low-income patient days as
7-27 determined by the commission under the methodology used for
7-28 calculating eligibility for the Medicaid disproportionate share
7-29 program;
7-30 (17) design a cost-neutral system to provide for a
8-1 sliding scale copayment system for individuals who are above 100
8-2 percent of the federal poverty level;
8-3 (18) to the extent possible and subject to the
8-4 availability of funds, design a cost-neutral system to allow the
8-5 development of a buy-in program with sliding scale premiums for
8-6 Medicaid recipients who are leaving the program and have incomes
8-7 between 150 percent and 250 percent of the federal poverty level;
8-8 (19) design the system in a manner that, to the extent
8-9 possible, will maintain administrative costs at a level not to
8-10 exceed five percent of the cost of the state Medicaid program; and
8-11 (20) develop and implement, in consultation with any
8-12 professional association representing 51 percent or more of the
8-13 licensed dentists in the state, a pilot program for child and adult
8-14 dental care and design the pilot program in a manner that enables:
8-15 (A) the program to be prevention-based;
8-16 (B) the choice of dentists to be at the
8-17 discretion of the eligible recipient, who will choose from a list
8-18 of qualified and participating providers or dental managed care
8-19 organizations; and
8-20 (C) the exploration of the use of local funds
8-21 currently spent on dental health care as a method for financing the
8-22 state share of the pilot program.
8-23 SECTION 2. Subtitle I, Title 4, Government Code, is amended
8-24 by adding Chapter 533 to read as follows:
8-25 CHAPTER 533. LEGISLATIVE OVERSIGHT COMMITTEE
8-26 Sec. 533.001. DEFINITIONS. In this chapter:
8-27 (1) "Commission" means the Health and Human Services
8-28 Commission.
8-29 (2) "Committee" means the Medicaid Managed Care
8-30 Legislative Oversight Committee.
9-1 Sec. 533.002. COMPOSITION OF COMMITTEE. The committee is
9-2 composed of:
9-3 (1) three members of the senate appointed by the
9-4 lieutenant governor; and
9-5 (2) three members of the house of representatives
9-6 appointed by the speaker of the house of representatives.
9-7 Sec. 533.003. COMMITTEE POWERS AND DUTIES. The committee
9-8 shall:
9-9 (1) meet quarterly with the commission;
9-10 (2) receive information about rules related to
9-11 Medicaid managed care proposed or adopted by the commission or a
9-12 health and human services agency; and
9-13 (3) review specific legislative recommendations
9-14 related to Medicaid managed care offered by the commission or a
9-15 health and human services agency.
9-16 Sec. 533.004. REPORT. (a) The committee shall report to
9-17 the governor, lieutenant governor, and speaker of the house of
9-18 representatives not later than December 31 of each even-numbered
9-19 year.
9-20 (b) The report must include:
9-21 (1) an examination of the effectiveness of Medicaid
9-22 managed care;
9-23 (2) identification of any problems with Medicaid
9-24 managed care; and
9-25 (3) recommendations for commission or legislative
9-26 action.
9-27 SECTION 3. This Act takes effect September 1, 1997.
9-28 SECTION 4. The importance of this legislation and the
9-29 crowded condition of the calendars in both houses create an
9-30 emergency and an imperative public necessity that the
10-1 constitutional rule requiring bills to be read on three several
10-2 days in each house be suspended, and this rule is hereby suspended.