By Madla S.B. No. 1574
75R9128 SAW-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the health care provider network of the state Medicaid
1-3 program health care delivery system.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 ARTICLE 1
1-6 SECTION 1.01. Section 16A(a), Article 4413(502), Vernon's
1-7 Texas Civil Statutes, as added by Chapter 444, Acts of the 74th
1-8 Legislature, Regular Session, 1995, is amended to read as follows:
1-9 (a) The commission shall develop a health care delivery
1-10 system that restructures the delivery of health care services
1-11 provided under the state Medicaid program. The commission shall
1-12 develop the health care delivery system only if the commission
1-13 obtains a waiver or other authorization from all necessary federal
1-14 agencies to implement the system. In developing the health care
1-15 delivery system, the commission shall:
1-16 (1) to the extent possible, design the system in a
1-17 manner that will:
1-18 (A) improve the health of Texans by:
1-19 (i) emphasizing prevention;
1-20 (ii) promoting continuity of care; and
1-21 (iii) providing a medical home for
1-22 Medicaid recipients; and
1-23 (B) ensure that each recipient can receive high
1-24 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;
2-26 (C) contributions by those children or other
2-27 persons or their families; or
3-1 (D) resources or other funds available for
3-2 matching;
3-3 (5) design the system to ensure that if the system
3-4 includes a method to finance the state Medicaid program by
3-5 obtaining federal matching funds for resources and other funds
3-6 available for matching, each entity listed in Subsection (d)(1),
3-7 (2), (3), (7), (8), or (9) or Subsection (e) of this section that
3-8 makes those resources and other funds available receives funds to
3-9 provide health care services to persons who are eligible for
3-10 Medicaid under the expanded eligibility criteria developed under
3-11 Subdivision (3) or (4) of this subsection in an amount that is at
3-12 least equal to the amount of resources or other funds available for
3-13 matching provided by that entity under this section;
3-14 (6) to the extent possible, provide for the entities
3-15 that make resources and other funds available for matching under
3-16 this section an option to operate the health care delivery system
3-17 within their regions including appropriate portions of the
3-18 eligibility determination process, subject to the standards of and
3-19 oversight by the commission;
3-20 (7) design the system to:
3-21 (A) include methods for ensuring accountability
3-22 to the state for the provision of health care services under the
3-23 state Medicaid program, including methods for financial reporting,
3-24 quality assurance, and utilization review;
3-25 (B) provide a single point of accountability for
3-26 collection of uniform data to assess, compile, and analyze outcome
3-27 quality and cost efficiency;
4-1 (C) conduct comparative analyses of compiled
4-2 data to assess the relative value of alternative health care
4-3 delivery systems and report to the governor, lieutenant governor,
4-4 and speaker of the house of representatives;
4-5 (D) oversee the methodology for setting
4-6 capitation and provider payment rates to ensure the cost-effective
4-7 provision of quality health care;
4-8 (E) ensure that both private and public health
4-9 care providers and managed care organizations, including a hospital
4-10 that has been designated as a disproportionate share hospital under
4-11 the state Medicaid program, will have an opportunity to participate
4-12 in the system;
4-13 (F) ensure, in adopting rules implementing the
4-14 system, that in developing the provider network for the system, the
4-15 commission, each intergovernmental initiative, and each managed
4-16 care organization, as applicable, give extra consideration to a
4-17 health care provider who has traditionally provided care to
4-18 Medicaid and charity care patients;
4-19 (G) give extra consideration to providers who
4-20 agree to assure continuity of care for Medicaid clients for 12
4-21 months beyond the period of eligibility; and
4-22 (H) require that the commission, each
4-23 intergovernmental initiative, and each managed care organization,
4-24 as applicable, include in its provider network, for not less than
4-25 three years after the date of implementation of managed care in a
4-26 service area, each health care provider in that area who:
4-27 (i) [previously] provided care to Medicaid
5-1 and charity care patients at a significant level, as prescribed by
5-2 the commission, during the 12 months preceding the date of
5-3 implementation;
5-4 (ii) agrees to accept the standard
5-5 provider reimbursement rate of the commission, the
5-6 intergovernmental initiative, or the managed care organization, as
5-7 applicable;
5-8 (iii) meets the credentialing requirements
5-9 under the system of the commission, the intergovernmental
5-10 initiative, or the managed care organization, as applicable,
5-11 provided that lack of board certification or accreditation by the
5-12 Joint Commission on Accreditation of Healthcare Organizations may
5-13 not be the sole grounds for exclusion from the provider network;
5-14 and
5-15 (iv) agrees to comply and does comply with
5-16 all of the terms and conditions of the standard provider agreement
5-17 of the commission, intergovernmental initiative, or managed care
5-18 organization, as applicable;
5-19 (8) design the system in a manner that, to the extent
5-20 possible, enables the state to manage care to lower the cost of
5-21 providing Medicaid services through the use of health care delivery
5-22 systems such as a primary care case management system, partially
5-23 capitated system, or fully capitated system or a combination of one
5-24 or more of those systems and use, where possible, multiple,
5-25 competing managed care organizations within those systems;
5-26 (9) design the system in a manner that enables the
5-27 state to:
6-1 (A) use different types of health care delivery
6-2 systems to meet the needs of different populations, including the
6-3 establishment of pilot programs to deliver health care services to
6-4 children with special health care needs;
6-5 (B) recognize the unique role of rural
6-6 hospitals, physicians, home and community support services
6-7 agencies, and other rural health care providers in providing access
6-8 to health care services for rural Texans; and
6-9 (C) review data from existing or new pilot
6-10 programs that cover all prescription drugs that are medically
6-11 indicated for a person by a licensed health care provider in
6-12 primary and preventive care and implement any changes in the state
6-13 Medicaid program that as a result of the review are determined to
6-14 be cost-effective and cost-neutral;
6-15 (10) establish geographic health care service regions
6-16 after consulting with local governmental entities that provide
6-17 resources or other funds available for matching under this section
6-18 and emphasize regional coordination in the provision of indigent
6-19 health care;
6-20 (11) simplify eligibility criteria and streamline
6-21 eligibility determination processes;
6-22 (12) to the extent possible, provide a one-stop
6-23 approach for client information and referral for managed care
6-24 services;
6-25 (13) to the extent possible, design the system in a
6-26 manner that encourages the training of and access to primary care
6-27 physicians;
7-1 (14) develop and prepare, after consulting with the
7-2 following entities, the waiver or other documents necessary to
7-3 obtain federal authorization for the system:
7-4 (A) governmental entities that provide health
7-5 care services and assistance to indigent persons in this state;
7-6 (B) consumer representatives;
7-7 (C) managed care organizations; and
7-8 (D) health care providers;
7-9 (15) design the system to ensure that if the system
7-10 includes a method to finance the state Medicaid program by
7-11 obtaining federal matching funds for resources and other funds
7-12 available for matching, an amount not to exceed $20 million a year
7-13 must be dedicated under the system as prescribed in the waiver for
7-14 special payments to rural hospitals that:
7-15 (A) are sole community providers and provide a
7-16 significant amount of care to Medicaid and charity care patients as
7-17 prescribed by the commission; and
7-18 (B) are located in a county in which the county
7-19 or another entity located in the county and described by Subsection
7-20 (d) or (e) of this section:
7-21 (i) has executed a matching funds
7-22 agreement with the commission under this section; and
7-23 (ii) participates in an intergovernmental
7-24 initiative under Section 16B of this article with a county that is
7-25 contiguous to the county in which the rural hospital is located or
7-26 with another entity described by Subsection (d) or (e) of this
7-27 section that is located in the contiguous county if the contiguous
8-1 county or the entity located in the contiguous county is one of the
8-2 entities that forms an intergovernmental initiative under Section
8-3 16B of this article;
8-4 (16) if necessary to ensure that all resources or
8-5 other funds available for matching are maximized in accordance with
8-6 Subdivision (3) of this subsection, design the system to ensure
8-7 that an amount determined by the commission is dedicated under the
8-8 system as prescribed in the waiver for special payments to
8-9 hospitals that provide at least 14,000 low-income patient days as
8-10 determined by the commission under the methodology used for
8-11 calculating eligibility for the Medicaid disproportionate share
8-12 program;
8-13 (17) design a cost-neutral system to provide for a
8-14 sliding scale copayment system for individuals who are above 100
8-15 percent of the federal poverty level;
8-16 (18) to the extent possible and subject to the
8-17 availability of funds, design a cost-neutral system to allow the
8-18 development of a buy-in program with sliding scale premiums for
8-19 Medicaid recipients who are leaving the program and have incomes
8-20 between 150 percent and 250 percent of the federal poverty level;
8-21 (19) design the system in a manner that, to the extent
8-22 possible, will maintain administrative costs at a level not to
8-23 exceed five percent of the cost of the state Medicaid program; and
8-24 (20) develop and implement, in consultation with any
8-25 professional association representing 51 percent or more of the
8-26 licensed dentists in the state, a pilot program for child and adult
8-27 dental care and design the pilot program in a manner that enables:
9-1 (A) the program to be prevention-based;
9-2 (B) the choice of dentists to be at the
9-3 discretion of the eligible recipient, who will choose from a list
9-4 of qualified and participating providers or dental managed care
9-5 organizations; and
9-6 (C) the exploration of the use of local funds
9-7 currently spent on dental health care as a method for financing the
9-8 state share of the pilot program.
9-9 ARTICLE 2
9-10 SECTION 2.01. Section 532.102(a), Government Code, as added
9-11 by the Act of the 75th Legislature, Regular Session, 1997, relating
9-12 to nonsubstantive additions to and corrections in enacted codes, is
9-13 amended to read as follows:
9-14 (a) In developing the health care delivery system under this
9-15 chapter, the commission shall:
9-16 (1) to the extent possible, design the system in a
9-17 manner that:
9-18 (A) improves the health of the people of this
9-19 state by:
9-20 (i) emphasizing prevention;
9-21 (ii) promoting continuity of care; and
9-22 (iii) providing a medical home for
9-23 Medicaid recipients; and
9-24 (B) ensures that each recipient can receive high
9-25 quality, comprehensive health care services in the recipient's
9-26 local community;
9-27 (2) design the system in a manner that enables this
10-1 state and the local governmental entities that make resources and
10-2 other funds available for matching to the commission under this
10-3 subchapter to control the costs associated with the state Medicaid
10-4 program and, to the extent possible, results in cost savings to
10-5 this state and those local governmental entities through health
10-6 care service delivery based on managed care;
10-7 (3) to the extent it is cost-effective to this state
10-8 and local governments:
10-9 (A) maximize the financing of the state Medicaid
10-10 program by obtaining federal matching funds for all resources and
10-11 other funds available for matching; and
10-12 (B) expand Medicaid eligibility to include
10-13 persons who were eligible to receive indigent health care services
10-14 through the use of those resources or other funds available for
10-15 matching before expansion of eligibility, with priority to
10-16 expanding eligibility to children and their families;
10-17 (4) to the extent possible, develop a plan to expand
10-18 Medicaid eligibility to include children and other persons, other
10-19 than those persons described by Subdivision (3), that is funded by
10-20 using:
10-21 (A) appropriations that have previously been
10-22 made to other agencies or other programs to provide related health
10-23 care services to those children and other persons;
10-24 (B) earned federal funds;
10-25 (C) contributions by those children or other
10-26 persons or their families; or
10-27 (D) resources or other funds available for
11-1 matching;
11-2 (5) design the system to ensure that if the system
11-3 includes a method to finance the state Medicaid program by
11-4 obtaining federal matching funds for resources and other funds
11-5 available for matching, each entity listed in Section
11-6 532.104(a)(1), (2), (3), (7), (8), or (9) or Section 532.104(b)
11-7 that makes those resources and other funds available receives funds
11-8 to provide health care services to persons who are eligible for
11-9 Medicaid under the expanded eligibility criteria developed under
11-10 Subdivision (3) or (4) in an amount that is at least equal to the
11-11 amount of resources or other funds available for matching provided
11-12 by that entity under this chapter;
11-13 (6) to the extent possible, provide for each entity
11-14 that makes resources and other funds available for matching under
11-15 this subchapter an option to operate the health care delivery
11-16 system in its region, including appropriate portions of the
11-17 eligibility determination process, subject to the standards of and
11-18 oversight by the commission;
11-19 (7) design the system to:
11-20 (A) include methods for ensuring accountability
11-21 to this state for the provision of health care services under the
11-22 state Medicaid program, including methods for financial reporting,
11-23 quality assurance, and utilization review;
11-24 (B) provide a single point of accountability for
11-25 collection of uniform data to assess, compile, and analyze outcome
11-26 quality and cost efficiency;
11-27 (C) conduct comparative analyses of compiled
12-1 data to assess the relative value of alternative health care
12-2 delivery systems and report to the governor, lieutenant governor,
12-3 and speaker of the house of representatives;
12-4 (D) oversee the procedures for setting
12-5 capitation and provider payment rates to ensure the cost-effective
12-6 provision of quality health care;
12-7 (E) ensure that both private and public health
12-8 care providers and managed care organizations, including a hospital
12-9 that has been designated as a disproportionate share hospital under
12-10 the state Medicaid program, have an opportunity to participate in
12-11 the system;
12-12 (F) ensure, in adopting rules implementing the
12-13 system, that in developing the provider network for the system, the
12-14 commission, each intergovernmental initiative, and each managed
12-15 care organization, as applicable, give extra consideration to a
12-16 health care provider who has traditionally provided care to
12-17 Medicaid and charity care patients;
12-18 (G) give extra consideration to providers who
12-19 agree to ensure continuity of care for Medicaid clients for 12
12-20 months beyond the period of eligibility; and
12-21 (H) require that the commission, each
12-22 intergovernmental initiative, and each managed care organization,
12-23 as applicable, include in its provider network, for not less than
12-24 three years after the date of implementation of managed care in a
12-25 service area, each health care provider in that area who:
12-26 (i) provided care to Medicaid and charity
12-27 care patients at a significant level, as prescribed by the
13-1 commission, during the 12 months preceding the date of
13-2 implementation;
13-3 (ii) agrees to accept the standard
13-4 provider reimbursement rate of the commission, the
13-5 intergovernmental initiative, or the managed care organization, as
13-6 applicable;
13-7 (iii) meets the credentialing requirements
13-8 under the system of the commission, the intergovernmental
13-9 initiative, or the managed care organization, as applicable,
13-10 provided that lack of board certification or accreditation by the
13-11 Joint Commission on Accreditation of Healthcare Organizations may
13-12 not be the sole grounds for exclusion from the provider network;
13-13 and
13-14 (iv) agrees to comply and does comply with
13-15 all of the terms of the standard provider agreement of the
13-16 commission, intergovernmental initiative, or managed care
13-17 organization, as applicable;
13-18 (8) design the system in a manner that, to the extent
13-19 possible, enables the state to manage care to lower the cost of
13-20 providing Medicaid services through the use of health care delivery
13-21 systems such as a primary care case management system, partially
13-22 capitated system, or fully capitated system or a combination of one
13-23 or more of those systems and use, if possible, multiple, competing
13-24 managed care organizations in those systems;
13-25 (9) design the system in a manner that enables the
13-26 state to:
13-27 (A) use different types of health care delivery
14-1 systems to meet the needs of different populations, including the
14-2 establishment of pilot programs to deliver health care services to
14-3 children with special health care needs;
14-4 (B) recognize the unique role of rural
14-5 hospitals, physicians, home and community support services
14-6 agencies, and other rural health care providers in providing access
14-7 to health care services for persons who live in rural areas of this
14-8 state; and
14-9 (C) review data from existing or new pilot
14-10 programs that cover all prescription drugs that are medically
14-11 indicated for a person by a licensed health care provider in
14-12 primary and preventive care and implement any changes in the state
14-13 Medicaid program that as a result of the review are determined to
14-14 be cost-effective and cost-neutral;
14-15 (10) establish geographic health care service regions
14-16 after consulting with local governmental entities that provide
14-17 resources or other funds available for matching under this section
14-18 and emphasize regional coordination in the provision of indigent
14-19 health care;
14-20 (11) simplify eligibility criteria and streamline
14-21 eligibility determination processes;
14-22 (12) to the extent possible, provide a one-stop
14-23 approach for client information and referral for managed care
14-24 services;
14-25 (13) to the extent possible, design the system in a
14-26 manner that encourages the training of and access to primary care
14-27 physicians;
15-1 (14) develop and prepare, after consulting with the
15-2 following entities, the waiver or other documents necessary to
15-3 obtain federal authorization for the system:
15-4 (A) governmental entities that provide health
15-5 care services and assistance to indigent persons in this state;
15-6 (B) consumer representatives;
15-7 (C) managed care organizations; and
15-8 (D) health care providers;
15-9 (15) design the system to ensure that if the system
15-10 includes a method to finance the state Medicaid program by
15-11 obtaining federal matching funds for resources and other funds
15-12 available for matching, an amount not to exceed $20 million a year
15-13 must be dedicated under the system as prescribed in the waiver for
15-14 special payments to rural hospitals that:
15-15 (A) are sole community providers and provide a
15-16 significant amount of care to Medicaid and charity care patients as
15-17 prescribed by the commission; and
15-18 (B) are located in a county in which the county,
15-19 or another entity located in the county and described by Section
15-20 532.104:
15-21 (i) has executed a matching funds
15-22 agreement with the commission under this subchapter; and
15-23 (ii) participates in an intergovernmental
15-24 initiative under Subchapter C with a county that is contiguous to
15-25 the county in which the rural hospital is located or with another
15-26 entity described by Section 532.104 that is located in the
15-27 contiguous county if the contiguous county or the entity located in
16-1 the contiguous county is one of the entities that forms an
16-2 intergovernmental initiative under Subchapter C;
16-3 (16) if necessary to ensure that all resources or
16-4 other funds available for matching are maximized in accordance with
16-5 Subdivision (3), design the system to ensure that an amount
16-6 determined by the commission is dedicated under the system as
16-7 prescribed in the waiver for special payments to hospitals that
16-8 provide at least 14,000 low-income patient days as determined by
16-9 the commission under the procedures used for determining
16-10 eligibility for the Medicaid disproportionate share program;
16-11 (17) design a cost-neutral system to provide for a
16-12 sliding scale copayment system for individuals who are above 100
16-13 percent of the federal poverty level;
16-14 (18) to the extent possible and subject to the
16-15 availability of funds, design a cost-neutral system to allow the
16-16 development of a buy-in program with sliding scale premiums for
16-17 Medicaid recipients who are leaving the program and have incomes
16-18 between 150 percent and 250 percent of the federal poverty level;
16-19 (19) design the system in a manner that, to the extent
16-20 possible, maintains administrative costs at a level not to exceed
16-21 five percent of the cost of the state Medicaid program; and
16-22 (20) develop and implement, in consultation with a
16-23 professional association representing 51 percent or more of the
16-24 licensed dentists in this state, a pilot program for child and
16-25 adult dental care that:
16-26 (A) is prevention-based;
16-27 (B) allows the choice of dentists to be at the
17-1 discretion of the eligible recipient, who chooses from a list of
17-2 qualified and participating providers or dental managed care
17-3 organizations; and
17-4 (C) explores the use of local funds spent on
17-5 dental health care in the period before June 13, 1995, as a method
17-6 for financing the state share of the pilot program.
17-7 ARTICLE 3
17-8 SECTION 3.01. This Act takes effect September 1, 1997.
17-9 SECTION 3.02. Article 1 takes effect only if the Act of the
17-10 75th Legislature, Regular Session, 1997, relating to nonsubstantive
17-11 additions to and corrections in enacted codes, does not take
17-12 effect.
17-13 SECTION 3.03. Article 2 takes effect only if the Act of the
17-14 75th Legislature, Regular Session, 1997, relating to nonsubstantive
17-15 additions to and corrections in enacted codes, takes effect.
17-16 SECTION 3.04. The importance of this legislation and the
17-17 crowded condition of the calendars in both houses create an
17-18 emergency and an imperative public necessity that the
17-19 constitutional rule requiring bills to be read on three several
17-20 days in each house be suspended, and this rule is hereby suspended.