By Coleman H.B. No. 2896
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the administration and operation of the Medicaid
1-3 program.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 533.002, Government Code, is amended to
1-6 read as follows:
1-7 Sec. 533.002. Purpose. The commission shall implement the
1-8 Medicaid managed care program as part of the health care delivery
1-9 system developed under Chapter 532 by contracting with managed care
1-10 organizations in a manner that, to the extent possible:
1-11 (1) improves the health of Texans by:
1-12 (A) emphasizing prevention;
1-13 (B) promoting continuity of care; [and]
1-14 (C) providing a medical home for recipients; and
1-15 (D) developing strategies to encourage more
1-16 personal responsibility in health care maintenance and decisions;
1-17 (2) ensures that each recipient receives high quality,
1-18 comprehensive health care services in the recipient's local
1-19 community;
1-20 (3) encourages the training of and access to primary
1-21 care physicians and providers;
2-1 (4) maximizes cooperation with existing public health
2-2 entities, including local departments of health;
2-3 (5) provides incentives to managed care organizations
2-4 to improve the quality of health care services for recipients by
2-5 providing value-added services; and
2-6 (6) reduces administrative and other nonfinancial
2-7 barriers for recipients in obtaining health care services.
2-8 SECTION 2. Section 533.003, Government Code, is amended to
2-9 read as follows:
2-10 Sec. 533.003. Considerations in Awarding Contracts. In
2-11 awarding contracts to managed care organizations, the commission
2-12 shall:
2-13 (1) give preference to organizations that have
2-14 significant participation in the organization's provider network
2-15 from each health care provider in the region who has traditionally
2-16 provided care to Medicaid and charity care patients;
2-17 (2) give extra consideration to organizations that
2-18 agree to assure continuity of care for at least three months beyond
2-19 the period of Medicaid eligibility for recipients; [and]
2-20 (3) consider the need to use different managed care
2-21 plans to meet the needs of different populations[.]; and
2-22 (4) give extra consideration to organizations that
2-23 demonstrate provider-friendly policies such as flexible
2-24 authorization periods and policies, electronic billing, and
2-25 electronic payment.
3-1 SECTION 3. Section 533.005, Government Code, is amended to
3-2 read as follows:
3-3 Sec. 533.005. Required Contract Provisions. A contract
3-4 between a managed care organization and the commission for the
3-5 organization to provide health care services to recipients must
3-6 contain:
3-7 (1) procedures to ensure accountability to the state
3-8 for the provision of health care services, including procedures for
3-9 financial reporting, quality assurance, utilization review, and
3-10 assurance of contract and subcontract compliance;
3-11 (2) capitation and provider payment rates that ensure
3-12 the cost-effective provision of quality health care;
3-13 (3) a requirement that the managed care organization
3-14 provide ready access to a person who assists recipients in
3-15 resolving issues relating to enrollment, plan administration,
3-16 education and training, access to services, and grievance
3-17 procedures;
3-18 (4) a requirement that the managed care organization
3-19 provide ready access to a person who assists providers in resolving
3-20 issues relating to payment, plan administration, education and
3-21 training, and grievance procedures;
3-22 (5) a requirement that the managed care organization
3-23 provide information and referral about the availability of
3-24 educational, social, and other community services that could
3-25 benefit a recipient;
4-1 (6) procedures for recipient outreach and education;
4-2 (7) a requirement that the managed care organization
4-3 make payment to a physician or provider for health care services
4-4 rendered to a recipient under a managed care plan not later than
4-5 the 45th day after the date a claim for payment is received with
4-6 documentation reasonably necessary for the managed care
4-7 organization to process the claim, or within a period, not to
4-8 exceed 60 days, specified by a written agreement between the
4-9 physician or provider and the managed care organization;
4-10 (8) a requirement that the commission, on the date of
4-11 a recipient's enrollment in a managed care plan issued by the
4-12 managed care organization, inform the organization of the
4-13 recipient's Medicaid recertification date; [and]
4-14 (9) a requirement that the managed care organization
4-15 comply with Section 533.006 as a condition of contract retention
4-16 and renewal[.];
4-17 (10) a prohibition that the managed care plan not
4-18 delegate any function or functions to a physician network that
4-19 includes exclusivity clauses in its contracts with physicians or
4-20 other providers; and
4-21 (11) a requirement that the managed care organization
4-22 provide patient education and referral through a 24-hour hotline
4-23 that:
4-24 (A) does not act as a gatekeeper to services;
4-25 (B) is answered by a bilingual nurse who has no
5-1 less than five years experience in critical or emergency room care;
5-2 and
5-3 (C) has a licensed physician available at all
5-4 times for advice.
5-5 SECTION 4. Subchapter A, Chapter 533, Government Code, is
5-6 amended by adding Section 533.0055 to read as follows:
5-7 Sec. 533.0055. EXTERNAL REVIEW OF CONTRACTS. (a) The
5-8 commission shall contract with an external entity to review
5-9 proposed contracts between the commission and managed care plans in
5-10 each region and comment on:
5-11 (1) proposed premium rates;
5-12 (2) sanctions for failure to meet performance goals;
5-13 and
5-14 (3) any other areas as directed by the commission.
5-15 (b) The commission shall enter into a contract with an
5-16 external entity not later than 120 days prior to the reenrollment
5-17 date for a region. The external entity shall report to the
5-18 commission not later than 60 days prior to the reenrollment date
5-19 for a region.
5-20 SECTION 5. Section 533.007, Government Code, is amended by
5-21 adding Subsection (g) to read as follows:
5-22 (g) The commission shall evaluate and report on the
5-23 performance of all managed care plans and any other contractors to
5-24 the state who participate in support of the Medicaid managed care
5-25 program and shall hold all managed care plans and any other
6-1 contractors to the state who participate in support of the Medicaid
6-2 managed care program to equal standards of accountability.
6-3 SECTION 6. Section 533.0075, Government Code, is amended to
6-4 read as follows:
6-5 Sec. 533.0075. Recipient Enrollment. The commission shall:
6-6 (1) encourage recipients to choose appropriate managed
6-7 care plans and primary health care providers by:
6-8 (A) providing initial information to recipients
6-9 and providers in a region about the need for recipients to choose
6-10 plans and providers not later than the 90th day before the date on
6-11 which the commission plans to begin to provide health care services
6-12 to recipients in that region through managed care;
6-13 (B) providing follow-up information before
6-14 assignment of plans and providers and after assignment, if
6-15 necessary, to recipients who delay in choosing plans and providers;
6-16 and
6-17 (C) allowing plans and providers to provide
6-18 information to recipients or engage in marketing activities under
6-19 marketing guidelines established by the commission under Section
6-20 533.008 after the commission approves the information or
6-21 activities;
6-22 (2) consider the following factors in assigning
6-23 managed care plans and primary health care providers to recipients
6-24 who fail to choose plans and providers:
6-25 (A) the importance of maintaining existing
7-1 provider-patient and physician-patient relationships, including
7-2 relationships with specialists, public health clinics, and
7-3 community health centers;
7-4 (B) to the extent possible, the need to assign
7-5 family members to the same providers and plans; and
7-6 (C) geographic convenience of plans and
7-7 providers for recipients; [and]
7-8 (3) retain responsibility for enrollment and
7-9 disenrollment of recipients in managed care plans, except that the
7-10 commission may delegate the responsibility to an independent
7-11 contractor who receives no form of payment from, and has no
7-12 financial ties to, any managed care organization[.]; and
7-13 (4) develop and implement an expedited process for
7-14 determining eligibility and enrolling pregnant women into Medicaid
7-15 and ensure immediate access to prenatal services.
7-16 SECTION 7. Subchapter A, Chapter 533, Government Code, is
7-17 amended by adding Sections 533.012-533.016 to read as follows:
7-18 Sec. 533.012. MORATORIUM ON IMPLEMENTATION; REVIEW; REPORT.
7-19 (a) The commission shall not implement Medicaid managed care or
7-20 Medicaid long-term care pilot programs in any additional regions
7-21 after implementation of Medicaid managed care or Medicaid long-term
7-22 care pilot programs in currently bid and contracted regions until:
7-23 (1) the commission reviews:
7-24 (A) the outstanding administrative and financial
7-25 issues in the Medicaid managed care program; and
8-1 (B) the Medicaid long-term care pilot programs
8-2 with respect to patient outcomes, coordination of care, access to
8-3 care, and types of providers included in the pilot programs;
8-4 (2) the commission submits a report to the governor
8-5 and the 77th Legislature that:
8-6 (A) demonstrates that outstanding administrative
8-7 and financial issues with Medicaid managed care and Medicaid
8-8 long-term care pilot programs are sufficiently resolved; and
8-9 (B) recommends whether Medicaid managed care and
8-10 Medicaid long-term care pilot programs should be implemented in
8-11 additional regions.
8-12 (b) The commission shall submit the report required in
8-13 Subsection (a) by January 1, 2001.
8-14 Sec. 533.013. PREMIUM RATE DETERMINATION; REVIEW AND
8-15 COMMENT. (a) In determining premium rates paid to managed care
8-16 plans, the commission shall consider:
8-17 (1) regional cost variation of health care services;
8-18 (2) the range and type of health care services to be
8-19 included in the premium rate;
8-20 (3) the number of managed care plans in a region;
8-21 (4) the current and projected caseload mix in a
8-22 region; and
8-23 (5) the ability of managed care plans to meet their
8-24 costs of operation under the proposed rates.
8-25 (b) The Texas Department of Insurance shall concurrently
9-1 review and comment on the premium rates developed by the commission
9-2 with special focus on the requirements of Subsection (a)(4) above.
9-3 Sec. 533.014. PROFIT SHARING. (a) The commission shall
9-4 develop rules regarding the sharing of annual profit earned by
9-5 managed care plans under the Medicaid program. The rules shall
9-6 provide that:
9-7 (1) the managed care plan shall retain the first three
9-8 percent of annual profit generated by the plan;
9-9 (2) the managed care plan shall share evenly with the
9-10 state any annual profit generated above three percent and below ten
9-11 percent; and
9-12 (3) the managed care plan shall return to the state
9-13 all annual profit generated above ten percent.
9-14 (b) All annual profit shared with the state or returned to
9-15 the state under this Section shall be deposited in the state's
9-16 general revenue fund.
9-17 Sec. 533.015. UNIFORM DOCUMENT REVIEW. The commission shall
9-18 develop and administer a single uniform procedure for review and
9-19 approval or disapproval each document that the state requires a
9-20 managed care organization to submit for state approval, and require
9-21 that each agency involved in administering Medicaid managed care
9-22 for acute or long-term care use this system.
9-23 Sec. 533.016. COORDINATION OF MEDICAID LONG-TERM CARE
9-24 PILOTS. If the commission delegates all or part of its functions,
9-25 powers, and duties under Section 532.002, Subchapter B, or
10-1 Subchapter C related to long-term care, including but not limited
10-2 to the operation of pilot projects, it shall designate a single
10-3 lead agency to ameliorate the impact of multiple agencies
10-4 responsible for the functions related to long-term care, and shall
10-5 ensure that long-term care is administered as efficiently and
10-6 effectively as if it were administered by a single state agency.
10-7 SECTION 8. Acts 1997, 75th Legislature, Chapter 1153,
10-8 Section 2.07, is repealed.
10-9 SECTION 9. The importance of this legislation and the
10-10 crowded condition of the calendars in both houses create an
10-11 emergency and an imperative public necessity that the
10-12 constitutional rule requiring bills to be read on three several
10-13 days in each house be suspended, and this rule is hereby suspended,
10-14 and that this Act take effect and be in force from and after its
10-15 passage, and it is so enacted.