AN ACT
1-1 relating to the health care provider network of the state Medicaid
1-2 program health care delivery system.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 ARTICLE 1
1-5 SECTION 1.01. Subsection (a), Section 16A, Article
1-6 4413(502), Vernon's Texas Civil Statutes, as added by Chapter 444,
1-7 Acts of the 74th Legislature, 1995, is amended to read as follows:
1-8 (a) The commission shall develop a health care delivery
1-9 system that restructures the delivery of health care services
1-10 provided under the state Medicaid program. The commission shall
1-11 develop the health care delivery system only if the commission
1-12 obtains a waiver or other authorization from all necessary federal
1-13 agencies to implement the system. In developing the health care
1-14 delivery system, the commission shall:
1-15 (1) to the extent possible, design the system in a
1-16 manner that will:
1-17 (A) improve the health of Texans by:
1-18 (i) emphasizing prevention;
1-19 (ii) promoting continuity of care; and
1-20 (iii) providing a medical home for
1-21 Medicaid recipients; and
1-22 (B) ensure that each recipient can receive high
1-23 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 include 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;
3-1 (C) contributions by those children or other
3-2 persons or their families; or
3-3 (D) resources or other funds available for
3-4 matching;
3-5 (5) design the system to ensure that if the system
3-6 includes a method to finance the state Medicaid program by
3-7 obtaining federal matching funds for resources and other funds
3-8 available for matching, each entity listed in Subsection (d)(1),
3-9 (2), (3), (7), (8), or (9) or Subsection (e) of this section that
3-10 makes those resources and other funds available receives funds to
3-11 provide health care services to persons who are eligible for
3-12 Medicaid under the expanded eligibility criteria developed under
3-13 Subdivision (3) or (4) of this subsection in an amount that is at
3-14 least equal to the amount of resources or other funds available for
3-15 matching provided by that entity under this section;
3-16 (6) to the extent possible, provide for the entities
3-17 that make resources and other funds available for matching under
3-18 this section an option to operate the health care delivery system
3-19 within their regions including appropriate portions of the
3-20 eligibility determination process, subject to the standards of and
3-21 oversight by the commission;
3-22 (7) design the system to:
3-23 (A) include methods for ensuring accountability
3-24 to the state for the provision of health care services under the
3-25 state Medicaid program, including methods for financial reporting,
4-1 quality assurance, and utilization review;
4-2 (B) provide a single point of accountability for
4-3 collection of uniform data to assess, compile, and analyze outcome
4-4 quality and cost efficiency;
4-5 (C) conduct comparative analyses of compiled
4-6 data to assess the relative value of alternative health care
4-7 delivery systems and report to the governor, lieutenant governor,
4-8 and speaker of the house of representatives;
4-9 (D) oversee the methodology for setting
4-10 capitation and provider payment rates to ensure the cost-effective
4-11 provision of quality health care;
4-12 (E) ensure that both private and public health
4-13 care providers and managed care organizations, including a hospital
4-14 that has been designated as a disproportionate share hospital under
4-15 the state Medicaid program, will have an opportunity to participate
4-16 in the system;
4-17 (F) ensure, in adopting rules implementing the
4-18 system, that in developing the provider network for the system, the
4-19 commission, each intergovernmental initiative, and each managed
4-20 care organization, as applicable, give extra consideration to a
4-21 health care provider who has traditionally provided care to
4-22 Medicaid and charity care patients;
4-23 (G) give extra consideration to providers who
4-24 agree to assure continuity of care for Medicaid clients for 12
4-25 months beyond the period of eligibility; and
5-1 (H) require that the commission, each
5-2 intergovernmental initiative, and each managed care organization,
5-3 as applicable, include in its provider network, for not less than
5-4 three years after the date of implementation of managed care in a
5-5 service area for the current Medicaid population, each health care
5-6 provider in that area who:
5-7 (i) [previously] provided care to Medicaid
5-8 and charity care patients at a significant level, as prescribed by
5-9 the commission, during the 12 months preceding the date of
5-10 implementation;
5-11 (ii) agrees to accept the standard
5-12 provider reimbursement rate of the commission, the
5-13 intergovernmental initiative, or the managed care organization, as
5-14 applicable;
5-15 (iii) meets the credentialing requirements
5-16 under the system of the commission, the intergovernmental
5-17 initiative, or the managed care organization, as applicable,
5-18 provided that lack of board certification or accreditation by the
5-19 Joint Commission on Accreditation of Healthcare Organizations may
5-20 not be the sole grounds for exclusion from the provider network;
5-21 and
5-22 (iv) agrees to comply and does comply with
5-23 all of the terms and conditions of the standard provider agreement
5-24 of the commission, intergovernmental initiative, or managed care
5-25 organization, as applicable;
6-1 (8) design the system in a manner that, to the extent
6-2 possible, enables the state to manage care to lower the cost of
6-3 providing Medicaid services through the use of health care delivery
6-4 systems such as a primary care case management system, partially
6-5 capitated system, or fully capitated system or a combination of one
6-6 or more of those systems and use, where possible, multiple,
6-7 competing managed care organizations within those systems;
6-8 (9) design the system in a manner that enables the
6-9 state to:
6-10 (A) use different types of health care delivery
6-11 systems to meet the needs of different populations, including the
6-12 establishment of pilot programs to deliver health care services to
6-13 children with special health care needs;
6-14 (B) recognize the unique role of rural
6-15 hospitals, physicians, home and community support services
6-16 agencies, and other rural health care providers in providing access
6-17 to health care services for rural Texans; and
6-18 (C) review data from existing or new pilot
6-19 programs that cover all prescription drugs that are medically
6-20 indicated for a person by a licensed health care provider in
6-21 primary and preventive care and implement any changes in the state
6-22 Medicaid program that as a result of the review are determined to
6-23 be cost-effective and cost-neutral;
6-24 (10) establish geographic health care service regions
6-25 after consulting with local governmental entities that provide
7-1 resources or other funds available for matching under this section
7-2 and emphasize regional coordination in the provision of indigent
7-3 health care;
7-4 (11) simplify eligibility criteria and streamline
7-5 eligibility determination processes;
7-6 (12) to the extent possible, provide a one-stop
7-7 approach for client information and referral for managed care
7-8 services;
7-9 (13) to the extent possible, design the system in a
7-10 manner that encourages the training of and access to primary care
7-11 physicians;
7-12 (14) develop and prepare, after consulting with the
7-13 following entities, the waiver or other documents necessary to
7-14 obtain federal authorization for the system:
7-15 (A) governmental entities that provide health
7-16 care services and assistance to indigent persons in this state;
7-17 (B) consumer representatives;
7-18 (C) managed care organizations; and
7-19 (D) health care providers;
7-20 (15) design the system to ensure that if the system
7-21 includes a method to finance the state Medicaid program by
7-22 obtaining federal matching funds for resources and other funds
7-23 available for matching, an amount not to exceed $20 million a year
7-24 must be dedicated under the system as prescribed in the waiver for
7-25 special payments to rural hospitals that:
8-1 (A) are sole community providers and provide a
8-2 significant amount of care to Medicaid and charity care patients as
8-3 prescribed by the commission; and
8-4 (B) are located in a county in which the county
8-5 or another entity located in the county and described by Subsection
8-6 (d) or (e) of this section:
8-7 (i) has executed a matching funds
8-8 agreement with the commission under this section; and
8-9 (ii) participates in an intergovernmental
8-10 initiative under Section 16B of this article with a county that is
8-11 contiguous to the county in which the rural hospital is located or
8-12 with another entity described by Subsection (d) or (e) of this
8-13 section that is located in the contiguous county if the contiguous
8-14 county or the entity located in the contiguous county is one of the
8-15 entities that forms an intergovernmental initiative under Section
8-16 16B of this article;
8-17 (16) if necessary to ensure that all resources or
8-18 other funds available for matching are maximized in accordance with
8-19 Subdivision (3) of this subsection, design the system to ensure
8-20 that an amount determined by the commission is dedicated under the
8-21 system as prescribed in the waiver for special payments to
8-22 hospitals that provide at least 14,000 low-income patient days as
8-23 determined by the commission under the methodology used for
8-24 calculating eligibility for the Medicaid disproportionate share
8-25 program;
9-1 (17) design a cost-neutral system to provide for a
9-2 sliding scale copayment system for individuals who are above 100
9-3 percent of the federal poverty level;
9-4 (18) to the extent possible and subject to the
9-5 availability of funds, design a cost-neutral system to allow the
9-6 development of a buy-in program with sliding scale premiums for
9-7 Medicaid recipients who are leaving the program and have incomes
9-8 between 150 percent and 250 percent of the federal poverty level;
9-9 (19) design the system in a manner that, to the extent
9-10 possible, will maintain administrative costs at a level not to
9-11 exceed five percent of the cost of the state Medicaid program; and
9-12 (20) develop and implement, in consultation with any
9-13 professional association representing 51 percent or more of the
9-14 licensed dentists in the state, a pilot program for child and adult
9-15 dental care and design the pilot program in a manner that enables:
9-16 (A) the program to be prevention-based;
9-17 (B) the choice of dentists to be at the
9-18 discretion of the eligible recipient, who will choose from a list
9-19 of qualified and participating providers or dental managed care
9-20 organizations; and
9-21 (C) the exploration of the use of local funds
9-22 currently spent on dental health care as a method for financing the
9-23 state share of the pilot program.
10-1 ARTICLE 2
10-2 SECTION 2.01. Subsection (a), Section 532.102, Government
10-3 Code, as added by the Act of the 75th Legislature, Regular Session,
10-4 1997, relating to nonsubstantive additions to and corrections in
10-5 enacted codes, is amended to read as follows:
10-6 (a) In developing the health care delivery system under this
10-7 chapter, the commission shall:
10-8 (1) to the extent possible, design the system in a
10-9 manner that:
10-10 (A) improves the health of the people of this
10-11 state by:
10-12 (i) emphasizing prevention;
10-13 (ii) promoting continuity of care; and
10-14 (iii) providing a medical home for
10-15 Medicaid recipients; and
10-16 (B) ensures that each recipient can receive
10-17 high-quality, comprehensive health care services in the recipient's
10-18 local community;
10-19 (2) design the system in a manner that enables this
10-20 state and the local governmental entities that make resources and
10-21 other funds available for matching to the commission under this
10-22 subchapter to control the costs associated with the state Medicaid
10-23 program and that, to the extent possible, results in cost savings
10-24 to this state and those local governmental entities through health
10-25 care service delivery based on managed care;
11-1 (3) to the extent that it is cost-effective to this
11-2 state and local governments:
11-3 (A) maximize the financing of the state Medicaid
11-4 program by obtaining federal matching funds for all resources and
11-5 other funds available for matching; and
11-6 (B) expand Medicaid eligibility to include
11-7 persons who were eligible to receive indigent health care services
11-8 through the use of those resources or other funds available for
11-9 matching before expansion of eligibility, with priority to
11-10 expanding eligibility to children and their families;
11-11 (4) to the extent possible, develop a plan to expand
11-12 Medicaid eligibility to include children and other persons, other
11-13 than those persons described by Subdivision (3), that is funded by
11-14 using:
11-15 (A) appropriations that have previously been
11-16 made to other agencies or other programs to provide related health
11-17 care services to those children and other persons;
11-18 (B) earned federal funds;
11-19 (C) contributions by those children or other
11-20 persons or their families; or
11-21 (D) resources or other funds available for
11-22 matching;
11-23 (5) design the system to ensure that if the system
11-24 includes a method to finance the state Medicaid program by
11-25 obtaining federal matching funds for resources and other funds
12-1 available for matching, each entity listed in Section
12-2 532.104(a)(1), (2), (3), (7), (8), or (9) or Section 532.104(b)
12-3 that makes those resources and other funds available receives funds
12-4 to provide health care services to persons who are eligible for
12-5 Medicaid under the expanded eligibility criteria developed under
12-6 Subdivision (3) or (4) in an amount that is at least equal to the
12-7 amount of resources or other funds available for matching provided
12-8 by that entity under this chapter;
12-9 (6) to the extent possible, provide for each entity
12-10 that makes resources and other funds available for matching under
12-11 this subchapter an option to operate the health care delivery
12-12 system in its region, including appropriate portions of the
12-13 eligibility determination process, subject to the standards of and
12-14 oversight by the commission;
12-15 (7) design the system to:
12-16 (A) include methods for ensuring accountability
12-17 to this state for the provision of health care services under the
12-18 state Medicaid program, including methods for financial reporting,
12-19 quality assurance, and utilization review;
12-20 (B) provide a single point of accountability for
12-21 collection of uniform data to assess, compile, and analyze outcome
12-22 quality and cost efficiency;
12-23 (C) conduct comparative analyses of compiled
12-24 data to assess the relative value of alternative health care
12-25 delivery systems and report to the governor, lieutenant governor,
13-1 and speaker of the house of representatives;
13-2 (D) oversee the procedures for setting
13-3 capitation and provider payment rates to ensure the cost-effective
13-4 provision of quality health care;
13-5 (E) ensure that both private and public health
13-6 care providers and managed care organizations, including a hospital
13-7 that has been designated as a disproportionate share hospital under
13-8 the state Medicaid program, have an opportunity to participate in
13-9 the system;
13-10 (F) ensure, in adopting rules implementing the
13-11 system, that in developing the provider network for the system, the
13-12 commission, each intergovernmental initiative, and each managed
13-13 care organization, as applicable, give extra consideration to a
13-14 health care provider who has traditionally provided care to
13-15 Medicaid and charity care patients;
13-16 (G) give extra consideration to providers who
13-17 agree to ensure continuity of care for Medicaid clients for 12
13-18 months beyond the period of eligibility; and
13-19 (H) require that the commission, each
13-20 intergovernmental initiative, and each managed care organization,
13-21 as applicable, include in its provider network, for not less than
13-22 three years after the date of implementation of managed care in a
13-23 service area, each health care provider in that area who:
13-24 (i) provided care to Medicaid and charity
13-25 care patients at a significant level, as prescribed by the
14-1 commission, during the 12 months preceding the date of
14-2 implementation;
14-3 (ii) agrees to accept the standard
14-4 provider reimbursement rate of the commission, the
14-5 intergovernmental initiative, or the managed care organization, as
14-6 applicable;
14-7 (iii) meets the credentialing requirements
14-8 under the system of the commission, the intergovernmental
14-9 initiative, or the managed care organization, as applicable,
14-10 provided that lack of board certification or accreditation by the
14-11 Joint Commission on Accreditation of Healthcare Organizations may
14-12 not be the sole grounds for exclusion from the provider network;
14-13 and
14-14 (iv) agrees to comply and does comply with
14-15 all of the terms of the standard provider agreement of the
14-16 commission, intergovernmental initiative, or managed care
14-17 organization, as applicable;
14-18 (8) design the system in a manner that, to the extent
14-19 possible, enables the state to manage care to lower the cost of
14-20 providing Medicaid services through the use of health care delivery
14-21 systems such as a primary care case management system, partially
14-22 capitated system, or fully capitated system or a combination of one
14-23 or more of those systems and use, if possible, multiple, competing
14-24 managed care organizations in those systems;
14-25 (9) design the system in a manner that enables the
15-1 state to:
15-2 (A) use different types of health care delivery
15-3 systems to meet the needs of different populations, including the
15-4 establishment of pilot programs to deliver health care services to
15-5 children with special health care needs;
15-6 (B) recognize the unique role of rural
15-7 hospitals, physicians, home and community support services
15-8 agencies, and other rural health care providers in providing access
15-9 to health care services for persons who live in rural areas of this
15-10 state; and
15-11 (C) review data from existing or new pilot
15-12 programs that cover all prescription drugs that are medically
15-13 indicated for a person by a licensed health care provider in
15-14 primary and preventive care and implement any changes in the state
15-15 Medicaid program that as a result of the review are determined to
15-16 be cost-effective and cost-neutral;
15-17 (10) establish geographic health care service regions
15-18 after consulting with local governmental entities that provide
15-19 resources or other funds available for matching under this section
15-20 and emphasize regional coordination in the provision of indigent
15-21 health care;
15-22 (11) simplify eligibility criteria and streamline
15-23 eligibility determination processes;
15-24 (12) to the extent possible, provide a one-stop
15-25 approach for client information and referral for managed care
16-1 services;
16-2 (13) to the extent possible, design the system in a
16-3 manner that encourages the training of and access to primary care
16-4 physicians;
16-5 (14) develop and prepare, after consulting with the
16-6 following entities, the waiver or other documents necessary to
16-7 obtain federal authorization for the system:
16-8 (A) governmental entities that provide health
16-9 care services and assistance to indigent persons in this state;
16-10 (B) consumer representatives;
16-11 (C) managed care organizations; and
16-12 (D) health care providers;
16-13 (15) design the system to ensure that if the system
16-14 includes a method to finance the state Medicaid program by
16-15 obtaining federal matching funds for resources and other funds
16-16 available for matching, an amount not to exceed $20 million a year
16-17 must be dedicated under the system as prescribed in the waiver for
16-18 special payments to rural hospitals that:
16-19 (A) are sole community providers and provide a
16-20 significant amount of care to Medicaid and charity care patients as
16-21 prescribed by the commission; and
16-22 (B) are located in a county in which the county,
16-23 or another entity located in the county and described by Section
16-24 532.104:
16-25 (i) has executed a matching funds
17-1 agreement with the commission under this subchapter; and
17-2 (ii) participates in an intergovernmental
17-3 initiative under Subchapter C with a county that is contiguous to
17-4 the county in which the rural hospital is located or with another
17-5 entity described by Section 532.104 that is located in the
17-6 contiguous county if the contiguous county or the entity located in
17-7 the contiguous county is one of the entities that forms an
17-8 intergovernmental initiative under Subchapter C;
17-9 (16) if necessary to ensure that all resources or
17-10 other funds available for matching are maximized in accordance with
17-11 Subdivision (3), design the system to ensure that an amount
17-12 determined by the commission is dedicated under the system as
17-13 prescribed in the waiver for special payments to hospitals that
17-14 provide at least 14,000 low-income patient days as determined by
17-15 the commission under the procedures used for determining
17-16 eligibility for the Medicaid disproportionate share program;
17-17 (17) design a cost-neutral system to provide for a
17-18 sliding scale copayment system for individuals who are above 100
17-19 percent of the federal poverty level;
17-20 (18) to the extent possible and subject to the
17-21 availability of funds, design a cost-neutral system to allow the
17-22 development of a buy-in program with sliding scale premiums for
17-23 Medicaid recipients who are leaving the program and have incomes
17-24 between 150 percent and 250 percent of the federal poverty level;
17-25 (19) design the system in a manner that, to the extent
18-1 possible, maintains administrative costs at a level not to exceed
18-2 five percent of the cost of the state Medicaid program; and
18-3 (20) develop and implement, in consultation with a
18-4 professional association representing 51 percent or more of the
18-5 licensed dentists in this state, a pilot program for child and
18-6 adult dental care that:
18-7 (A) is prevention-based;
18-8 (B) allows the choice of dentists to be at the
18-9 discretion of the eligible recipient, who chooses from a list of
18-10 qualified and participating providers or dental managed care
18-11 organizations; and
18-12 (C) explores the use of local funds spent on
18-13 dental health care in the period before June 13, 1995, as a method
18-14 for financing the state share of the pilot program.
18-15 ARTICLE 3
18-16 SECTION 3.01. This Act takes effect September 1, 1997.
18-17 SECTION 3.02. Article 1 takes effect only if the Act of the
18-18 75th Legislature, Regular Session, 1997, relating to nonsubstantive
18-19 additions to and corrections in enacted codes, does not take
18-20 effect.
18-21 SECTION 3.03. Article 2 takes effect only if the Act of the
18-22 75th Legislature, Regular Session, 1997, relating to nonsubstantive
18-23 additions to and corrections in enacted codes, takes effect.
18-24 SECTION 3.04. The importance of this legislation and the
18-25 crowded condition of the calendars in both houses create an
19-1 emergency and an imperative public necessity that the
19-2 constitutional rule requiring bills to be read on three several
19-3 days in each house be suspended, and this rule is hereby suspended.
_______________________________ _______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 1574 passed the Senate on
April 17, 1997, by a viva-voce vote.
_______________________________
Secretary of the Senate
I hereby certify that S.B. No. 1574 passed the House on
May 16, 1997, by a non-record vote.
_______________________________
Chief Clerk of the House
Approved:
_______________________________
Date
_______________________________
Governor