By Nelson S.B. No. 1231
76R7318 KLA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to purchasing health care services for certain programs
1-3 operated by health and human services agencies.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter A, Chapter 533, Government Code, is
1-6 amended by adding Section 533.0025 to read as follows:
1-7 Sec. 533.0025. AWARD OF CONTRACTS. (a) The commission by
1-8 rule shall implement a system of selective contracting with managed
1-9 care organizations for the delivery of services through the
1-10 Medicaid managed care program. The commission may not use an
1-11 open-enrollment contracting system under which any managed care
1-12 organization that meets commission criteria is entitled to contract
1-13 with the commission.
1-14 (b) The commission may not publish a maximum capitation rate
1-15 in the minimum access and quality criteria included in a request
1-16 for proposals from managed care organizations.
1-17 (c) The commission shall periodically review and update the
1-18 minimum access and quality criteria included in a request for
1-19 proposals from managed care organizations.
1-20 SECTION 2. Section 533.003, Government Code, is amended to
1-21 read as follows:
1-22 Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. In
1-23 awarding contracts to managed care organizations, the commission
1-24 shall:
2-1 (1) give preference to organizations that have
2-2 significant participation in the organization's provider network
2-3 from each health care provider in the region who has traditionally
2-4 provided care to Medicaid and charity care patients;
2-5 (2) give extra consideration to organizations that
2-6 agree to assure continuity of care for at least three months beyond
2-7 the period of Medicaid eligibility for recipients; [and]
2-8 (3) consider the need to use different managed care
2-9 plans to meet the needs of different populations; and
2-10 (4) give preference to organizations that offer the
2-11 lowest capitation rates.
2-12 SECTION 3. Section 533.005, Government Code, is amended to
2-13 read as follows:
2-14 Sec. 533.005. [REQUIRED] CONTRACT PROVISIONS. (a) A
2-15 contract between a managed care organization and the commission for
2-16 the organization to provide health care services to recipients
2-17 must contain:
2-18 (1) procedures to ensure accountability to the state
2-19 for the provision of health care services, including procedures for
2-20 financial reporting, quality assurance, utilization review, and
2-21 assurance of contract and subcontract compliance;
2-22 (2) capitation and provider payment rates that ensure
2-23 the cost-effective provision of quality health care;
2-24 (3) a requirement that the managed care organization
2-25 provide ready access to a person who assists recipients in
2-26 resolving issues relating to enrollment, plan administration,
2-27 education and training, access to services, and grievance
3-1 procedures;
3-2 (4) a requirement that the managed care organization
3-3 provide ready access to a person who assists providers in resolving
3-4 issues relating to payment, plan administration, education and
3-5 training, and grievance procedures;
3-6 (5) a requirement that the managed care organization
3-7 provide information and referral about the availability of
3-8 educational, social, and other community services that could
3-9 benefit a recipient;
3-10 (6) procedures for recipient outreach and education;
3-11 (7) a requirement that the managed care organization
3-12 make payment to a physician or provider for health care services
3-13 rendered to a recipient under a managed care plan not later than
3-14 the 45th day after the date a claim for payment is received with
3-15 documentation reasonably necessary for the managed care
3-16 organization to process the claim, or within a period, not to
3-17 exceed 60 days, specified by a written agreement between the
3-18 physician or provider and the managed care organization;
3-19 (8) a requirement that the commission, on the date of
3-20 a recipient's enrollment in a managed care plan issued by the
3-21 managed care organization, inform the organization of the
3-22 recipient's Medicaid recertification date; and
3-23 (9) a requirement that the managed care organization
3-24 comply with Section 533.006 as a condition of contract retention
3-25 and renewal.
3-26 (b) A contract between a managed care organization and the
3-27 commission for the organization to provide health care services to
4-1 recipients of medical assistance may not contain a profit-sharing
4-2 requirement that requires the managed care organization to share a
4-3 percentage of its profits with a health and human services agency
4-4 or the commission.
4-5 SECTION 4. Section 533.0075, Government Code, is amended to
4-6 read as follows:
4-7 Sec. 533.0075. RECIPIENT ENROLLMENT. (a) The commission
4-8 shall:
4-9 (1) encourage recipients to choose appropriate managed
4-10 care plans and primary health care providers by:
4-11 (A) providing initial information to recipients
4-12 and providers in a region about the need for recipients to choose
4-13 plans and providers not later than the 90th day before the date on
4-14 which the commission plans to begin to provide health care services
4-15 to recipients in that region through managed care;
4-16 (B) providing follow-up information before
4-17 assignment of plans and providers and after assignment, if
4-18 necessary, to recipients who delay in choosing plans and providers;
4-19 and
4-20 (C) allowing plans and providers to provide
4-21 information to recipients or engage in marketing activities under
4-22 marketing guidelines established by the commission under Section
4-23 533.008 after the commission approves the information or
4-24 activities;
4-25 (2) except as provided by Subsection (b), assign
4-26 recipients who fail to choose plans and providers to a [consider
4-27 the following factors in assigning] managed care plan [plans] and
5-1 primary health care provider that offers the lowest capitation rate
5-2 available to the commission in the health care service region
5-3 [providers to recipients who fail to choose plans and providers:]
5-4 [(A) the importance of maintaining existing
5-5 provider-patient and physician-patient relationships, including
5-6 relationships with specialists, public health clinics, and
5-7 community health centers;]
5-8 [(B) to the extent possible, the need to assign
5-9 family members to the same providers and plans; and]
5-10 [(C) geographic convenience of plans and
5-11 providers for recipients]; and
5-12 (3) retain responsibility for enrollment and
5-13 disenrollment of recipients in managed care plans, except that the
5-14 commission may delegate the responsibility to an independent
5-15 contractor who receives no form of payment from, and has no
5-16 financial ties to, any managed care organization.
5-17 (b) The commission may consider other relevant factors in
5-18 assigning a recipient under Subsection (a)(2) to a managed care
5-19 plan and primary health care provider, including whether a family
5-20 member of the recipient is enrolled in a managed care plan other
5-21 than the plan in which the recipient would be enrolled under
5-22 Subsection(a)(2).
5-23 SECTION 5. Subchapter A, Chapter 533, Government Code, is
5-24 amended by adding Section 533.0095 to read as follows:
5-25 Sec. 533.0095. CASE MANAGEMENT SERVICES FOR CERTAIN
5-26 RECIPIENTS. The commission and the board of regents of The
5-27 University of Texas System by rule shall adopt a memorandum of
6-1 understanding under which The University of Texas M. D. Anderson
6-2 Cancer Center shall provide case management services to recipients
6-3 with advanced forms of cancer.
6-4 SECTION 6. Subchapter A, Chapter 533, Government Code, is
6-5 amended by adding Section 533.012 to read as follows:
6-6 Sec. 533.012. INFORMATION CLEARINGHOUSE. (a) The
6-7 commission shall establish and maintain an information
6-8 clearinghouse regarding the purchase of health care services
6-9 through managed care organizations, including:
6-10 (1) capitation rates offered by managed care
6-11 organizations; and
6-12 (2) benefits plans offered by managed care
6-13 organizations.
6-14 (b) The information clearinghouse must contain data
6-15 regarding managed care organizations that contract with:
6-16 (1) the commission; and
6-17 (2) the Employees Retirement System of Texas.
6-18 (c) The information clearinghouse may contain data regarding
6-19 managed care organizations that contract with:
6-20 (1) The University of Texas System;
6-21 (2) local governments; and
6-22 (3) private employers in this state.
6-23 (d) The Employees Retirement System of Texas shall cooperate
6-24 with the commission to provide the information required under
6-25 Subsection (b).
6-26 SECTION 7. Subchapter B, Chapter 32, Human Resources Code,
6-27 is amended by adding Section 32.0275 to read as follows:
7-1 Sec. 32.0275. CONTRACTS FOR CERTAIN SERVICES.
7-2 Notwithstanding Section 32.027, the department by rule shall
7-3 develop and implement a system of selective contracting for the
7-4 provision of laboratory services, home health services, eyeglass
7-5 services, and medical supplies under the medical assistance
7-6 program. The department may not use an open-enrollment contracting
7-7 system under which any person who meets department criteria is
7-8 entitled to contract with the department.
7-9 SECTION 8. Subchapter B, Chapter 32, Human Resources Code,
7-10 is amended by adding Section 32.052 to read as follows:
7-11 Sec. 32.052. COMPREHENSIVE CASE MANAGEMENT. (a) The
7-12 department by rule shall develop and implement a comprehensive case
7-13 management system to:
7-14 (1) provide oversight for the health care and
7-15 treatment plan of a recipient of medical assistance who has a
7-16 catastrophic illness or injury; and
7-17 (2) maximize the efficient use of department resources
7-18 while achieving the optimal patient outcome for the recipient.
7-19 (b) The comprehensive case management system may include:
7-20 (1) monitoring claims submitted by health care
7-21 providers for reimbursement for inpatient hospital services
7-22 provided to a recipient of medical assistance to identify a
7-23 recipient who has a catastrophic illness or injury; and
7-24 (2) developing a long-term plan of care for a
7-25 recipient identified under Subdivision (1) in cooperation with the
7-26 recipient and the recipient's health care providers and family.
7-27 SECTION 9. Subchapter E, Chapter 12, Health and Safety Code,
8-1 is amended by adding Section 12.057 to read as follows:
8-2 Sec. 12.057. CONTRACTS FOR CERTAIN HEALTH CARE SERVICES.
8-3 (a) In this section, "center of excellence" means a health care
8-4 facility that specializes in the diagnosis and treatment of a
8-5 particular illness or injury, or of a series of related illnesses
8-6 or injuries, and that has a history of providing high-quality
8-7 health care services.
8-8 (b) If the department determines that a center of excellence
8-9 can provide high-cost health care services at a comparable or lower
8-10 cost than the department would otherwise pay to another health care
8-11 provider, the department shall contract with such a center to
8-12 provide services to a person who voluntarily participates in the
8-13 program and who:
8-14 (1) is a recipient of medical assistance under Chapter
8-15 32, Human Resources Code;
8-16 (2) is eligible for kidney care services under Chapter
8-17 42; or
8-18 (3) is eligible for services under the Chronically Ill
8-19 and Disabled Children's Services program.
8-20 (c) The health care services for which the department may
8-21 contract under Subsection (b) must include:
8-22 (1) organ transplantation services;
8-23 (2) neonatal intensive care services; and
8-24 (3) intensive cardiac care services.
8-25 (d) The department may contract with a center of excellence
8-26 to provide other high-cost health care services as determined by
8-27 the department.
9-1 SECTION 10. (a) The Health and Human Services Commission
9-2 shall conduct a study regarding the applicability of and
9-3 feasibility of using medical savings accounts authorized under the
9-4 Internal Revenue Code of 1986, as amended, for the delivery of
9-5 services to Medicaid recipients.
9-6 (b) The commission shall report the results of the study
9-7 required by Subsection (a) to the 77th Legislature.
9-8 SECTION 11. (a) Not later than January 1, 2000, the Health
9-9 and Human Services Commission shall develop and implement the
9-10 system of selective contracting required by Section 533.0025,
9-11 Government Code, as added by this Act.
9-12 (b) Notwithstanding Section 533.0025, Government Code, as
9-13 added by this Act, the Health and Human Services Commission may
9-14 continue to use an open-enrollment contracting system with managed
9-15 care organizations for the delivery of services through the
9-16 Medicaid managed care program until the system of selective
9-17 contracting is implemented.
9-18 (c) The change in law made by Section 533.0025, Government
9-19 Code, as added by this Act, applies only to a contract that is
9-20 entered into or renewed on or after the effective date of this Act.
9-21 A contract entered into before the effective date of this Act is
9-22 governed by the law in effect at the time the contract was entered
9-23 into, and that law is continued in effect for that purpose.
9-24 SECTION 12. (a) Not later than January 1, 2000, the Texas
9-25 Department of Health shall develop and implement the selective
9-26 contracting system required by Section 32.0275, Human Resources
9-27 Code, as added by this Act. In developing the system, the
10-1 department shall compare a cost-benefit analysis between using a
10-2 statewide versus a regional competitive bidding process and shall
10-3 implement the most cost-effective system.
10-4 (b) Notwithstanding Section 32.0275, Human Resources Code,
10-5 as added by this Act:
10-6 (1) the department may continue to use an
10-7 open-enrollment contracting system for the provision of laboratory
10-8 services, home health services, eyeglass services, and medical
10-9 supplies under the medical assistance program; and
10-10 (2) a person under a contract executed before the
10-11 effective date of this Act may continue to provide services in
10-12 accordance with the contract until the contract expires or is
10-13 lawfully terminated.
10-14 (c) The change in law made by Section 32.0275, Human
10-15 Resources Code, as added by this Act, applies only to a contract
10-16 that is entered into or renewed on or after the effective date of
10-17 this Act. A contract entered into before the effective date of
10-18 this Act is governed by the law in effect at the time the contract
10-19 was entered into, and that law is continued in effect for that
10-20 purpose.
10-21 SECTION 13. Not later than January 1, 2000, the Texas
10-22 Department of Health shall develop and implement the comprehensive
10-23 case management system required under Section 32.052, Human
10-24 Resources Code, as added by this Act.
10-25 SECTION 14. The Texas Department of Health shall enter into
10-26 the contracts required by Section 12.057, Health and Safety Code,
10-27 as added by this Act, for a contract term to begin not later than
11-1 September 1, 2001.
11-2 SECTION 15. If before implementing any provision of this Act
11-3 a state agency determines that a waiver or authorization from a
11-4 federal agency is necessary for implementation of that provision,
11-5 the agency affected by the provision shall request the waiver or
11-6 authorization and may delay implementing that provision until the
11-7 waiver or authorization is granted.
11-8 SECTION 16. This Act takes effect September 1, 1999.
11-9 SECTION 17. The importance of this legislation and the
11-10 crowded condition of the calendars in both houses create an
11-11 emergency and an imperative public necessity that the
11-12 constitutional rule requiring bills to be read on three several
11-13 days in each house be suspended, and this rule is hereby suspended.