76R16016 CLG-F By Moncrief S.B. No. 1331 Substitute the following for S.B. No. 1331: By Maxey C.S.S.B. No. 1331 A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to an assessment of the effectiveness of Medicaid managed 1-3 care contracts. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. Subchapter B, Chapter 12, Health and Safety Code, 1-6 is amended by adding Section 12.0123 to read as follows: 1-7 Sec. 12.0123. EXTERNAL AUDITS OF CERTAIN MEDICAID 1-8 CONTRACTORS. (a) In this section, "Medicaid contractor" means an 1-9 entity that: 1-10 (1) is not a health and human services agency as 1-11 defined by Section 531.001, Government Code; and 1-12 (2) under contract with or otherwise on behalf of the 1-13 department, performs one or more administrative services in 1-14 relation to the department's operation of a part of the state 1-15 Medicaid program, such as claims processing, utilization review, 1-16 client enrollment, provider enrollment, quality monitoring, or 1-17 payment of claims. 1-18 (b) The department shall contract with an independent 1-19 auditor to perform annual independent external financial and 1-20 performance audits of any Medicaid contractor used by the 1-21 department in the department's operation of a part of the state 1-22 Medicaid program. 1-23 (c) The department shall ensure that audit procedures 2-1 related to financial audits and performance audits are used 2-2 consistently in audits under this section. 2-3 (d) An audit required by this section must be completed 2-4 before the end of the fiscal year immediately following the fiscal 2-5 year for which the audit is performed. 2-6 SECTION 2. Subchapter A, Chapter 533, Government Code, is 2-7 amended by adding Section 533.012 to read as follows: 2-8 Sec. 533.012. MORATORIUM ON IMPLEMENTATION OF CERTAIN PILOT 2-9 PROGRAMS; REVIEW; REPORT. (a) Notwithstanding any other law, the 2-10 commission may not implement Medicaid managed care pilot programs, 2-11 Medicaid behavioral health pilot programs, or Medicaid Star + Plus 2-12 pilot programs in a region for which the commission has not: 2-13 (1) received a bid from a managed care organization to 2-14 provide health care services to recipients in the region through a 2-15 managed care plan; or 2-16 (2) entered into a contract with a managed care 2-17 organization to provide health care services to recipients in the 2-18 region through a managed care plan. 2-19 (b) The commission shall: 2-20 (1) review any outstanding administrative and 2-21 financial issues with respect to Medicaid managed care pilot 2-22 programs, Medicaid behavioral health pilot programs, and Medicaid 2-23 Star + Plus pilot programs implemented in health care service 2-24 regions; and 2-25 (2) review the impact of the Medicaid managed care 2-26 delivery system, including managed care organizations, prepaid 2-27 health plans, and primary care case management, on: 3-1 (A) physical access and program-related access 3-2 to appropriate services by recipients, including recipients who 3-3 have special health care needs; 3-4 (B) quality of health care delivery and patient 3-5 outcomes; 3-6 (C) utilization patterns of recipients; 3-7 (D) statewide Medicaid costs; 3-8 (E) coordination of care and care coordination 3-9 in Medicaid Star + Plus pilot programs; 3-10 (F) the level of administrative complexity for 3-11 providers, recipients, and managed care organizations; 3-12 (G) public hospitals, medical schools, and other 3-13 traditional providers of indigent health care; and 3-14 (H) competition in the marketplace and network 3-15 retention. 3-16 (c) In performing its duties and functions under Subsection 3-17 (b), the commission shall consult with Medicaid providers, medical 3-18 professional organizations, managed care organizations, consumers, 3-19 state agencies, and political subdivisions with a constitutional or 3-20 statutory obligation to provide health care for indigent persons. 3-21 The commission may coordinate the review required under Subsection 3-22 (b) with any other study or review the commission is required to 3-23 complete. 3-24 (d) Notwithstanding Subsection (a), the commission may 3-25 implement Medicaid managed care pilot programs, Medicaid behavioral 3-26 health pilot programs, and Medicaid Star + Plus pilot programs in a 3-27 region described by that subsection if the commission finds that: 4-1 (1) outstanding administrative and financial issues 4-2 with respect to the implementation of those programs in health care 4-3 service regions have been resolved; and 4-4 (2) implementation of those programs in a region 4-5 described by Subsection (a) would benefit both recipients and 4-6 providers. 4-7 (e) Not later than November 1, 2000, the commission shall 4-8 submit a report to the governor and the legislature that: 4-9 (1) states whether the outstanding administrative and 4-10 financial issues with respect to the pilot programs described by 4-11 Subsection (b)(1) have been sufficiently resolved; 4-12 (2) summarizes the findings of the review conducted 4-13 under Subsection (b); 4-14 (3) recommends which elements of the Medicaid managed 4-15 care delivery system should be applied to the traditional 4-16 fee-for-service component of the state Medicaid program to achieve 4-17 the goals specified in Section 533.002(1); and 4-18 (4) recommends whether Medicaid managed care pilot 4-19 programs, Medicaid behavioral health pilot programs, or Medicaid 4-20 Star + Plus pilot programs should be implemented in health care 4-21 service regions described by Subsection (a). 4-22 (f) To the extent practicable, this section may not be 4-23 construed to affect the duty of the commission to plan the 4-24 continued expansion of Medicaid managed care pilot programs, 4-25 Medicaid behavioral health pilot programs, and Medicaid Star + Plus 4-26 pilot programs in health care service regions described by 4-27 Subsection (a) after July 1, 2001. 5-1 (g) This section expires July 1, 2001. 5-2 SECTION 3. If before implementing any provision of this Act 5-3 a state agency determines that a waiver or other authorization from 5-4 a federal agency is necessary for implementation, the Health and 5-5 Human Services Commission shall request the waiver or authorization 5-6 and may delay implementing that provision until the waiver or 5-7 authorization is granted. 5-8 SECTION 4. The importance of this legislation and the 5-9 crowded condition of the calendars in both houses create an 5-10 emergency and an imperative public necessity that the 5-11 constitutional rule requiring bills to be read on three several 5-12 days in each house be suspended, and this rule is hereby suspended, 5-13 and that this Act take effect and be in force from and after its 5-14 passage, and it is so enacted.