1-1 AN ACT
1-2 relating to the state Medicaid program.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Section 32.024, Human Resources Code, is amended
1-5 by adding Subsections (x) and (y) to read as follows:
1-6 (x) In its rules and standards governing the vendor drug
1-7 program, and in accordance with Section 531.02106, Government Code,
1-8 the department shall provide for cost-sharing by recipients of
1-9 prescription drug benefits under the medical assistance program in
1-10 a manner that ensures that recipients with higher levels of income
1-11 are required to pay progressively higher percentages of the costs
1-12 of prescription drugs. In implementing cost-sharing provisions
1-13 required by this subsection, the department may not require a
1-14 pharmacy participating in the vendor drug program to collect
1-15 copayments or other cost-sharing payments from recipients for
1-16 remittance to the department, but shall allow the pharmacy to
1-17 retain the payments as a component of the reimbursement provided to
1-18 the pharmacy under the program.
1-19 (y) The department shall provide hyperbaric oxygen therapy
1-20 to the extent permitted by federal law.
1-21 SECTION 2. Subchapter B, Chapter 32, Human Resources Code,
1-22 is amended by adding Section 32.0247 to read as follows:
1-23 Sec. 32.0247. ELIGIBILITY OF CERTAIN ALIENS. (a) The
1-24 department shall provide medical assistance in accordance with 8
1-25 U.S.C. Section 1612(b), as amended, to a person who:
2-1 (1) is a qualified alien, as defined by 8 U.S.C.
2-2 Sections 1641(b) and (c), as amended;
2-3 (2) meets the eligibility requirements of the medical
2-4 assistance program;
2-5 (3) entered the United States on or after August 22,
2-6 1996; and
2-7 (4) has resided in the United States for a period of
2-8 five years after the date the person entered as a qualified alien.
2-9 (b) If authorized by federal law, the department shall
2-10 provide pregnancy-related medical assistance to the maximum extent
2-11 permitted by the federal law to a person who is pregnant and is a
2-12 lawfully present alien as defined by 8 C.F.R. Section 103.12, as
2-13 amended, including a battered alien under 8 U.S.C. Section 1641(c),
2-14 as amended, regardless of the date on which the person entered the
2-15 United States. The department shall comply with any prerequisite
2-16 imposed under the federal law for providing medical assistance
2-17 under this subsection.
2-18 SECTION 3. Subchapter B, Chapter 32, Human Resources Code,
2-19 is amended by adding Section 32.0252 to read as follows:
2-20 Sec. 32.0252. CONTRACT TO PROVIDE ELIGIBILITY DETERMINATION
2-21 SERVICES. (a) To the extent allowed by federal law, and except as
2-22 otherwise provided by this section, the department may contract for
2-23 the provision of medical assistance eligibility services with:
2-24 (1) a hospital district created under the authority of
2-25 Sections 4-11, Article IX, Texas Constitution;
2-26 (2) a hospital authority created under the authority
3-1 of Chapter 262 or 264, Health and Safety Code, that uses resources
3-2 to provide health care services to indigent persons to some extent;
3-3 (3) a hospital owned and operated by a municipality or
3-4 county or by a hospital authority created under Chapter 262 or 264,
3-5 Health and Safety Code;
3-6 (4) a medical school operated by this state;
3-7 (5) a medical school that receives state money under
3-8 Section 61.093, Education Code, or a chiropractic school that
3-9 receives state money under the General Appropriations Act;
3-10 (6) a teaching hospital operated by The University of
3-11 Texas System;
3-12 (7) a county that is required to provide health care
3-13 assistance to eligible county residents under Subchapter B, Chapter
3-14 61, Health and Safety Code;
3-15 (8) a governmental entity that is required to provide
3-16 money to a public hospital under Section 61.062, Health and Safety
3-17 Code;
3-18 (9) a county with a population of more than 400,000
3-19 that provides money to a public hospital and that is not included
3-20 in the boundaries of a hospital district;
3-21 (10) a hospital owned by a municipality and leased to
3-22 and operated by a nonprofit hospital for a public purpose;
3-23 (11) a hospital that receives Medicaid
3-24 disproportionate share payments;
3-25 (12) a community mental health and mental retardation
3-26 center;
4-1 (13) a local mental health or mental retardation
4-2 authority;
4-3 (14) a local health department or public health
4-4 district;
4-5 (15) a school-based health center;
4-6 (16) a community health center; and
4-7 (17) a federally qualified health center.
4-8 (b) The department may contract with an entity described by
4-9 Subsection (a) for the entity to designate one or more employees of
4-10 the entity to process medical assistance application forms and
4-11 conduct client interviews for eligibility determinations.
4-12 (c) Except as provided by Subsection (d), the contract must
4-13 require each designated employee to submit completed application
4-14 forms to the appropriate agency as determined by the department to
4-15 finally determine eligibility and to enroll eligible persons in the
4-16 program. A designated employee may not make a final determination
4-17 of eligibility or enroll an eligible person in the program.
4-18 (d) Notwithstanding Subsection (c), the commissioner may
4-19 apply for federal authorization to allow a designated employee of
4-20 an entity described by Subsection (a) to make a final determination
4-21 of eligibility or enroll an eligible person in the program.
4-22 (e) The department may:
4-23 (1) monitor the eligibility and application processing
4-24 program used by an entity with which the department contracts; and
4-25 (2) provide on-site supervision of the program for
4-26 quality control.
5-1 (f) The Health and Human Services Commission shall ensure
5-2 that there are adequate protections to avoid a conflict of interest
5-3 with an entity described by Subsection (a) that has a contract for
5-4 eligibility services and also has a contract, either directly or
5-5 through an affiliated entity, as a managed care organization for
5-6 the Medicaid program or for the child health plan program under
5-7 Chapter 62, Health and Safety Code. The commission shall ensure
5-8 that there are adequate protections for recipients to freely choose
5-9 a health plan without being inappropriately induced to join an
5-10 entity's health plan.
5-11 SECTION 4. Subchapter B, Chapter 32, Human Resources Code,
5-12 is amended by adding Section 32.0271 to read as follows:
5-13 Sec. 32.0271. SELECTION OF NURSE FIRST ASSISTANT. (a) In
5-14 this section, "nurse first assistant" means a registered nurse who:
5-15 (1) is certified in perioperative nursing by an
5-16 organization recognized by the Board of Nurse Examiners; and
5-17 (2) has completed a nurse first assistant educational
5-18 program approved by an organization recognized by the Board of
5-19 Nurse Examiners.
5-20 (b) The department shall ensure that a recipient of medical
5-21 assistance may select a nurse first assistant to perform any health
5-22 care service or procedure covered under the medical assistance
5-23 program if:
5-24 (1) the selected nurse first assistant is authorized
5-25 by law to perform the service or procedure; and
5-26 (2) the physician requests that the service or
6-1 procedure be performed by the nurse first assistant.
6-2 (c) A managed care organization or a managed care plan, as
6-3 those terms are defined by Section 533.001, Government Code, may
6-4 not by contract or any other method require a physician to use the
6-5 services of a nurse first assistant in providing care to a
6-6 recipient of medical assistance.
6-7 (d) The Board of Nurse Examiners may adopt rules governing
6-8 nurse first assistants for purposes of this section.
6-9 SECTION 5. Section 32.028, Human Resources Code, is amended
6-10 by adding Subsection (g) to read as follows:
6-11 (g) The department in its adoption of reasonable rules and
6-12 standards governing the allocation of any funds appropriated for
6-13 rate increases for physician services and outpatient hospital
6-14 services shall establish a provider reimbursement methodology that
6-15 recognizes and rewards high volume providers, with an emphasis on
6-16 providers located in areas of this state where medical assistance
6-17 payments are particularly vital to the health care delivery system.
6-18 SECTION 6. Section 32.029, Human Resources Code, is amended
6-19 by adding Subsection (f) to read as follows:
6-20 (f) The department or its designee may implement
6-21 demonstration projects designed to reduce medical assistance claims
6-22 processing costs.
6-23 SECTION 7. (a) Subchapter B, Chapter 32, Human Resources
6-24 Code, is amended by adding Section 32.0422 to read as follows:
6-25 Sec. 32.0422. HEALTH INSURANCE PREMIUM PAYMENT REIMBURSEMENT
6-26 PROGRAM FOR MEDICAL ASSISTANCE RECIPIENTS. (a) In this section:
7-1 (1) "Department" means the Texas Department of Health.
7-2 (2) "Group health benefit plan" has the meaning
7-3 assigned by Article 21.52K, Insurance Code.
7-4 (3) "Spouse" means a husband, who is a male, or a
7-5 wife, who is a female. A member of a civil union or similar
7-6 relationship entered into in another state between persons of the
7-7 same sex is not a spouse.
7-8 (b) The department shall identify individuals, otherwise
7-9 entitled to medical assistance, who are eligible to enroll in a
7-10 group health benefit plan. The department must include individuals
7-11 eligible for or receiving health care services under a Medicaid
7-12 managed care delivery system.
7-13 (c) The department may require an individual requesting
7-14 medical assistance to provide information as necessary relating to
7-15 the availability of a group health benefit plan to the individual
7-16 through an employer of the individual or an employer of the
7-17 individual's spouse or parent. The department may not leave
7-18 pending, consider incomplete, or otherwise delay an individual's
7-19 application for medical assistance or request for recertification
7-20 as a result of the requirement authorized by this subsection.
7-21 (d) For an individual identified under Subsection (b), the
7-22 department shall determine whether it is cost-effective to enroll
7-23 the individual in the group health benefit plan under this section.
7-24 (e) If the department determines that it is cost-effective
7-25 to enroll the individual in the group health benefit plan, the
7-26 department shall:
8-1 (1) require the individual to apply to enroll in the
8-2 group health benefit plan as a condition for eligibility under the
8-3 medical assistance program; and
8-4 (2) provide written notice to the issuer of the group
8-5 health benefit plan in accordance with Article 21.52K, Insurance
8-6 Code.
8-7 (f) The department shall provide for payment of:
8-8 (1) the employee's share of required premiums for
8-9 coverage of an individual enrolled in the group health benefit
8-10 plan; and
8-11 (2) any deductible, copayment, coinsurance, or other
8-12 cost-sharing obligation imposed on the enrolled individual for an
8-13 item or service otherwise covered under the medical assistance
8-14 program.
8-15 (g) A payment made by the department under Subsection (f) is
8-16 considered to be a payment for medical assistance.
8-17 (h) A payment of a premium for an individual who is a member
8-18 of the family of an individual enrolled in a group health benefit
8-19 plan under this section and who is not eligible for medical
8-20 assistance is considered to be a payment for medical assistance for
8-21 an eligible individual if:
8-22 (1) enrollment of the family members who are eligible
8-23 for medical assistance is not possible under the plan without also
8-24 enrolling members who are not eligible; and
8-25 (2) the department determines it to be cost-effective.
8-26 (i) A payment of any deductible, copayment, coinsurance, or
9-1 other cost-sharing obligation of a family member who is enrolled in
9-2 a group health benefit plan in accordance with Subsection (h) and
9-3 who is not eligible for medical assistance:
9-4 (1) may not be paid under this chapter; and
9-5 (2) is not considered to be a payment for medical
9-6 assistance for an eligible individual.
9-7 (j) The department shall treat coverage under the group
9-8 health benefit plan as a third party liability to the program.
9-9 Enrollment of an individual in a group health benefit plan under
9-10 this section does not affect the individual's eligibility for
9-11 medical assistance benefits, except that the state is entitled to
9-12 payment under Sections 32.033 and 32.038.
9-13 (k) The department may not require or permit an individual
9-14 who is enrolled in a group health benefit plan under this section
9-15 to participate in the Medicaid managed care program under Chapter
9-16 533, Government Code, or a Medicaid managed care demonstration
9-17 project under Section 32.041.
9-18 (l) The Texas Department of Human Services shall provide
9-19 information and otherwise cooperate with the department as
9-20 necessary to ensure the enrollment of eligible individuals in the
9-21 group health benefit plan under this section.
9-22 (m) The department shall adopt rules as necessary to
9-23 implement this section. In developing rules and related
9-24 procedures, the department shall consult with providers and other
9-25 interested persons to minimize the administrative complexity of the
9-26 program.
10-1 (b) Subchapter E, Chapter 21, Insurance Code, is amended by
10-2 adding Article 21.52K to read as follows:
10-3 Art. 21.52K. ENROLLMENT OF MEDICAL ASSISTANCE RECIPIENTS
10-4 Sec. 1. DEFINITION OF GROUP HEALTH BENEFIT PLAN. (a) In
10-5 this article, "group health benefit plan" means a plan that
10-6 provides benefits for medical or surgical expenses incurred as a
10-7 result of a health condition, accident, or sickness, including a
10-8 group, blanket, or franchise insurance policy or insurance
10-9 agreement, a group hospital service contract, or a group evidence
10-10 of coverage or similar group coverage document that is offered by:
10-11 (1) an insurance company;
10-12 (2) a group hospital service corporation operating
10-13 under Chapter 20 of this code;
10-14 (3) a fraternal benefit society operating under
10-15 Chapter 10 of this code;
10-16 (4) a stipulated premium insurance company operating
10-17 under Chapter 22 of this code;
10-18 (5) a reciprocal exchange operating under Chapter 19
10-19 of this code;
10-20 (6) a health maintenance organization operating under
10-21 the Texas Health Maintenance Organization Act (Chapter 20A,
10-22 Vernon's Texas Insurance Code);
10-23 (7) a multiple employer welfare arrangement that holds
10-24 a certificate of authority under Article 3.95-2 of this code; or
10-25 (8) an approved nonprofit health corporation that
10-26 holds a certificate of authority under Article 21.52F of this code.
11-1 (b) The term "group health benefit plan" includes:
11-2 (1) a small employer health benefit plan written under
11-3 Chapter 26 of this code; and
11-4 (2) a plan provided under the Texas Employees Uniform
11-5 Group Insurance Benefits Act (Article 3.50-2, Vernon's Texas
11-6 Insurance Code), the Texas State College and University Employees
11-7 Uniform Insurance Benefits Act (Article 3.50-3, Vernon's Texas
11-8 Insurance Code), the Texas Public School Employees Group Insurance
11-9 Act (Article 3.50-4, Insurance Code), or a successor of any of
11-10 those plans.
11-11 Sec. 2. ENROLLMENT REQUIRED. (a) The issuer of a group
11-12 health benefit plan, on receipt of written notice from the Texas
11-13 Department of Health or a designee of the Texas Department of
11-14 Health that states that an individual who is otherwise eligible for
11-15 enrollment in the plan is a recipient of medical assistance under
11-16 the state Medicaid program and is a participant in the health
11-17 insurance premium payment reimbursement program for medical
11-18 assistance recipients under Section 32.0422, Human Resources Code,
11-19 shall permit the individual to enroll in the plan without regard to
11-20 any enrollment period restriction.
11-21 (b) If an individual described by Subsection (a) of this
11-22 section is not eligible to enroll in the plan unless a family
11-23 member of the individual is also enrolled in the plan, the issuer,
11-24 on receipt of the written notice under Subsection (a) of this
11-25 section, shall enroll both the individual and the family member in
11-26 the plan.
12-1 (c) Unless enrollment occurs during an established
12-2 enrollment period, enrollment under this article takes effect on
12-3 the first day of the calendar month that begins at least 30 days
12-4 after the date written notice is received by the issuer under
12-5 Subsection (a) of this section.
12-6 (d) Notwithstanding any other requirement of the group
12-7 health benefit plan, the issuer of the plan shall permit an
12-8 individual who is enrolled in a group health benefit plan under
12-9 Subsection (a) of this section, and any family member of the
12-10 individual enrolled under Subsection (b) of this section, to
12-11 terminate enrollment in the plan not later than the 60th day after
12-12 the date on which the individual provides satisfactory proof to the
12-13 issuer that the individual is no longer:
12-14 (1) a recipient of medical assistance under the state
12-15 Medicaid program; or
12-16 (2) a participant in the health insurance premium
12-17 payment reimbursement program for medical assistance recipients
12-18 under Section 32.0422, Human Resources Code.
12-19 (c) Section 301.104, Labor Code, is amended to read as
12-20 follows:
12-21 Sec. 301.104. ELIGIBILITY. A person is eligible for the
12-22 refund for wages paid or incurred by the person, during each
12-23 calendar year for which the refund is claimed, only if:
12-24 (1) the wages paid or incurred by the person are for
12-25 services of an employee who is:
12-26 (A) a resident of this state; and
13-1 (B) a recipient of:
13-2 (i) financial assistance and services in
13-3 accordance with Chapter 31, Human Resources Code; or
13-4 (ii) medical assistance in accordance with
13-5 Chapter 32, Human Resources Code;
13-6 (2) the person satisfies the certification
13-7 requirements under Section 301.105; and
13-8 (3) the person provides and pays for the benefit of
13-9 the employee a part of the cost of coverage under:
13-10 (A) a health plan provided by a health
13-11 maintenance organization established under the Texas Health
13-12 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
13-13 Code);
13-14 (B) a health benefit plan approved by the
13-15 commissioner of insurance; [or]
13-16 (C) a self-funded or self-insured employee
13-17 welfare benefit plan that provides health benefits and is
13-18 established in accordance with the Employee Retirement Income
13-19 Security Act of 1974 (29 U.S.C. 1001 et seq.); or
13-20 (D) a medical savings account authorized under
13-21 the Health Insurance Portability and Accountability Act of 1996 (26
13-22 U.S.C. Section 220).
13-23 (d) Section 301.105, Labor Code, is amended to read as
13-24 follows:
13-25 Sec. 301.105. CERTIFICATION. A person is not eligible for
13-26 the refund for wages paid or incurred by the person unless the
14-1 person has received a written certification from the commission
14-2 that the employee is a recipient of financial assistance and
14-3 services or medical assistance on or before the day the employee
14-4 begins employment with the person.
14-5 (e) The changes in law made by this section take effect
14-6 August 31, 2001, and apply only to a group health benefit plan that
14-7 is delivered, issued for delivery, or renewed on or after that
14-8 date. A group health benefit plan that is delivered, issued for
14-9 delivery, or renewed before August 31, 2001, is governed by the law
14-10 as it existed immediately before that date, and that law is
14-11 continued in effect for that purpose.
14-12 (f) A person may claim a refund under Section 301.104, Labor
14-13 Code, as amended by this Act, only for wages paid or incurred on or
14-14 after the effective date of this Act.
14-15 SECTION 8. Subchapter B, Chapter 32, Human Resources Code,
14-16 is amended by adding Section 32.0471 to read as follows:
14-17 Sec. 32.0471. FAMILY PLANNING COUNSELING SERVICES; PROVIDER
14-18 QUALIFICATIONS. Notwithstanding Section 503.056, Occupations Code,
14-19 the department shall require that anyone who provides counseling
14-20 services related to family planning services provided under this
14-21 chapter must be:
14-22 (1) a licensed health care provider or a licensed
14-23 counseling professional; or
14-24 (2) under the supervision of a licensed health care
14-25 professional or a licensed counseling professional.
14-26 SECTION 9. (a) Subchapter B, Chapter 32, Human Resources
15-1 Code, is amended by adding Sections 32.053 through 32.056 to read
15-2 as follows:
15-3 Sec. 32.053. DEMONSTRATION PROJECT FOR CERTAIN MEDICATIONS
15-4 AND RELATED SERVICES. (a) The department shall establish a
15-5 demonstration project to provide to a person through the medical
15-6 assistance program psychotropic medications and related laboratory
15-7 and medical services necessary to conform to a prescribed medical
15-8 regime for those medications.
15-9 (b) A person is eligible to participate in the demonstration
15-10 project if the person:
15-11 (1) has been diagnosed as having a mental impairment,
15-12 including schizophrenia or bipolar disorder, that is expected to
15-13 cause the person to become a disabled individual, as defined by
15-14 Section 1614(a) of the federal Social Security Act (42 U.S.C.
15-15 Section 1382c), as amended;
15-16 (2) is at least 19 years of age, but not more than 64
15-17 years of age;
15-18 (3) has a net family income that is at or below 200
15-19 percent of the federal poverty level;
15-20 (4) is not covered by a health benefits plan offering
15-21 adequate coverage, as determined by the department; and
15-22 (5) is not otherwise eligible for medical assistance
15-23 at the time the person's eligibility for participation in the
15-24 demonstration project is determined.
15-25 (c) To the extent allowed by federal law, and except as
15-26 otherwise provided by this section, the department may contract for
16-1 the provision of eligibility services for the demonstration project
16-2 with a local mental health authority.
16-3 (d) Notwithstanding any other provision of this section, the
16-4 department shall provide each participant in the demonstration
16-5 project with a 12-month period of continuous eligibility for
16-6 participation in the project.
16-7 (e) Participation in the demonstration project does not
16-8 entitle a participant to other services provided under the medical
16-9 assistance program.
16-10 (f) The department shall establish an appropriate enrollment
16-11 limit for the demonstration project and may not allow participation
16-12 in the project to exceed that limit. Once the limit is reached,
16-13 the department shall establish a waiting list for enrollment in the
16-14 demonstration project.
16-15 (g) To the extent permitted by federal law, the department
16-16 may require a participant in the demonstration project to make
16-17 cost-sharing payments for services provided through the project.
16-18 (h) To the maximum extent possible, the department shall use
16-19 existing resources to fund the demonstration project.
16-20 (i) Not later than December 1 of each even-numbered year,
16-21 the department shall submit a biennial report to the legislature
16-22 regarding the department's progress in establishing and operating
16-23 the demonstration project.
16-24 (j) Not later than December 1, 2006, the department shall
16-25 evaluate the cost-effectiveness of the demonstration project,
16-26 including whether the preventive drug treatments and related
17-1 services provided under the project offset future long-term care
17-2 costs for project participants. If the results of the evaluation
17-3 indicate that the project is cost-effective, the department shall
17-4 incorporate a request for funding for the continuation of the
17-5 program in the department's budget request for the next state
17-6 fiscal biennium.
17-7 (k) This section expires September 1, 2012.
17-8 Sec. 32.054. DEMONSTRATION PROJECT FOR PERSONS WITH HIV
17-9 INFECTION OR AIDS. (a) In this section, "AIDS" and "HIV" have the
17-10 meanings assigned by Section 81.101, Health and Safety Code.
17-11 (b) The department shall establish a demonstration project
17-12 to provide a person with HIV infection or AIDS with the following
17-13 services and medications through the medical assistance program:
17-14 (1) services provided by a physician, physician
17-15 assistant, advanced practice nurse, or other health care provider
17-16 specified by the department;
17-17 (2) medications not included in the formulary for the
17-18 HIV medication program operated by the department, but determined
17-19 to be necessary for treatment of a condition related to HIV
17-20 infection or AIDS;
17-21 (3) vaccinations for hepatitis B and pneumonia;
17-22 (4) pap smears, colposcopy, and other diagnostic
17-23 procedures necessary to monitor gynecologic complications resulting
17-24 from HIV infection or AIDS in women;
17-25 (5) hospitalization;
17-26 (6) laboratory and other diagnostic services,
18-1 including periodic testing for CD4+ T-cell counts, viral load
18-2 determination, and phenotype or genotype testing if clinically
18-3 indicated; and
18-4 (7) other laboratory and radiological testing
18-5 necessary to monitor potential toxicity of therapy.
18-6 (c) The department shall establish the demonstration project
18-7 in at least two counties with a high prevalence of HIV infection
18-8 and AIDS. The department shall ensure that the demonstration
18-9 project is financed using funds made available by the counties in
18-10 which the department establishes the demonstration project. The
18-11 manner in which a county makes funds available may include an
18-12 option for the county to be able to certify the amount of funds
18-13 considered available instead of sending the funds to the state.
18-14 (d) A person is eligible to participate in the demonstration
18-15 project if the person:
18-16 (1) has been diagnosed with HIV infection or AIDS by a
18-17 physician;
18-18 (2) is under 65 years of age;
18-19 (3) has a net family income that is at or below 200
18-20 percent of the federal poverty level;
18-21 (4) is a resident of a county included in the project
18-22 or, subject to guidelines established by the department, is
18-23 receiving medical care for HIV infection or AIDS through a facility
18-24 located in a county included in the project;
18-25 (5) is not covered by a health benefits plan offering
18-26 adequate coverage, as determined by the department; and
19-1 (6) is not otherwise eligible for medical assistance
19-2 at the time the person's eligibility for participation in the
19-3 demonstration project is determined.
19-4 (e) Participation in the demonstration project does not
19-5 entitle a participant to other services provided under the medical
19-6 assistance program.
19-7 (f) The department shall establish an appropriate enrollment
19-8 limit for the demonstration project and may not allow participation
19-9 in the project to exceed that limit. Once the limit is reached,
19-10 the department:
19-11 (1) shall establish a waiting list for enrollment in
19-12 the demonstration project; and
19-13 (2) may allow eligible persons on the waiting list to
19-14 enroll solely in the HIV medication program operated by the
19-15 department.
19-16 (g) The department shall ensure that a participant in the
19-17 demonstration project is also enrolled in the HIV medication
19-18 program operated by the department.
19-19 (h) Notwithstanding any other provision of this section, the
19-20 department shall provide each participant in the project with a
19-21 six-month period of continuous eligibility for participation in the
19-22 project.
19-23 (i) Not later than December 1 of each even-numbered year,
19-24 the department shall submit a biennial report to the legislature
19-25 regarding the department's progress in establishing and operating
19-26 the demonstration project.
20-1 (j) Not later than December 1, 2006, the department shall
20-2 evaluate the cost-effectiveness of the demonstration project,
20-3 including whether the services and medications provided offset
20-4 future higher costs for project participants. If the results of
20-5 the evaluation indicate that the project is cost-effective, the
20-6 department shall incorporate a request for funding for the
20-7 expansion of the project into additional counties or throughout the
20-8 state, as appropriate, in the department's budget request for the
20-9 next state fiscal biennium.
20-10 (k) This section expires September 1, 2012.
20-11 Sec. 32.055. DEMONSTRATION PROJECTS FOR PROVISION OF MEDICAL
20-12 ASSISTANCE TO CERTAIN LOW-INCOME INDIVIDUALS. (a) The Health and
20-13 Human Services Commission shall establish demonstration projects to
20-14 provide medical assistance under this chapter to adult individuals
20-15 who are not otherwise eligible for medical assistance and whose
20-16 incomes are at or below 200 percent of the federal poverty level.
20-17 (b) The Health and Human Services Commission shall select
20-18 one or more municipalities or counties in which to implement the
20-19 demonstration projects.
20-20 (c) The Health and Human Services Commission, in conjunction
20-21 with local governmental entities that make funds available to the
20-22 commission in accordance with this section, shall design the
20-23 components of the demonstration project and shall ensure that:
20-24 (1) each demonstration project is financed using funds
20-25 made available by certain local governmental entities, through a
20-26 certification process, to the commission for matching purposes to
21-1 maximize federal funds for the medical assistance program; and
21-2 (2) a participant in a demonstration project is not
21-3 subject to a limitation imposed on prescription drug benefits under
21-4 the medical assistance program.
21-5 (d) The Health and Human Services Commission shall appoint
21-6 regional advisory committees to assist the commission in
21-7 establishing and implementing demonstration projects under this
21-8 section. An advisory committee must include health care providers,
21-9 employers, and local government officials.
21-10 Sec. 32.056. DEMONSTRATION PROJECT FOR WOMEN'S HEALTH CARE
21-11 SERVICES. (a) The department shall establish a five-year
21-12 demonstration project through the medical assistance program to
21-13 expand access to preventive health and family planning services for
21-14 women. A woman eligible under Subsection (b) to participate in the
21-15 demonstration project may receive preventive health and family
21-16 planning services, including:
21-17 (1) medical history;
21-18 (2) physical examinations;
21-19 (3) counseling and education on contraceptive methods
21-20 that includes:
21-21 (A) promoting abstinence as the preferred choice
21-22 of behavior related to all sexual activity for unmarried persons;
21-23 (B) emphasizing abstinence from sexual activity,
21-24 if used consistently and correctly, is the only method that is 100
21-25 percent effective in preventing pregnancy, sexually transmitted
21-26 diseases, infection with human immunodeficiency virus or acquired
22-1 immune deficiency syndrome, and the emotional trauma associated
22-2 with adolescent sexual activity; and
22-3 (C) informing single and divorced adults that
22-4 abstinence from sexual activity before marriage is the most
22-5 effective way to prevent pregnancy, sexually transmitted diseases,
22-6 and infection with human immunodeficiency virus or acquired immune
22-7 deficiency syndrome;
22-8 (4) provision of contraceptives;
22-9 (5) health screenings, including screening for:
22-10 (A) diabetes;
22-11 (B) cervical cancer;
22-12 (C) breast cancer;
22-13 (D) sexually transmitted diseases;
22-14 (E) hypertension;
22-15 (F) cholesterol; and
22-16 (G) tuberculosis;
22-17 (6) risk assessment; and
22-18 (7) referral of medical problems to appropriate
22-19 providers.
22-20 (b) A woman is eligible to participate in the demonstration
22-21 project if the woman:
22-22 (1) is 18 years of age or older;
22-23 (2) has a net family income that is at or below 185
22-24 percent of the federal poverty level; and
22-25 (3) is not otherwise eligible for the medical
22-26 assistance program.
23-1 (c) The department shall develop procedures for determining
23-2 and certifying presumptive eligibility for a woman eligible under
23-3 Subsection (b). The department shall integrate these procedures
23-4 with current procedures to minimize duplication of effort by
23-5 providers, the department, and other state agencies.
23-6 (d) The department shall provide for 12 months of continuous
23-7 eligibility for a woman eligible under Subsection (b).
23-8 (e) The department shall compile a list of potential funding
23-9 sources a client can use to help pay for treatment for health
23-10 problems:
23-11 (1) identified using services provided to the client
23-12 under the demonstration project; and
23-13 (2) for which the client is not eligible to receive
23-14 treatment under the medical assistance program.
23-15 (f) Not later than December 1 of each even-numbered year,
23-16 the department shall submit a report to the legislature that
23-17 includes a statement of the department's progress in establishing
23-18 and operating the demonstration project.
23-19 (g) The department shall ensure that money under the
23-20 demonstration project established by this section may not be used
23-21 for an abortion, as that term is defined by Section 245.002, Health
23-22 and Safety Code.
23-23 (h) To the extent required by federal budget neutrality
23-24 requirements, the department may establish an appropriate
23-25 enrollment limit for the demonstration project.
23-26 (i) This section expires September 1, 2007.
24-1 (b) The state agency responsible for implementing the
24-2 demonstration projects required by Sections 32.053 through 32.056,
24-3 Human Resources Code, as added by this Act, shall request and
24-4 actively pursue any necessary waivers or authorizations from the
24-5 Health Care Financing Administration or other appropriate entities
24-6 to enable the agency to implement the demonstration project not
24-7 later than September 1, 2002. The agency may delay implementing
24-8 the demonstration project until the necessary waivers or
24-9 authorizations are granted.
24-10 SECTION 10. (a) Subchapter B, Chapter 32, Human Resources
24-11 Code, is amended by adding Section 32.057 to read as follows:
24-12 Sec. 32.057. PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY
24-13 (PACE). (a) The department, as a part of the medical assistance
24-14 program, shall develop and implement a program of all-inclusive
24-15 care for the elderly (PACE) in accordance with Section 4802 of the
24-16 Balanced Budget Act of 1997 (Pub. L. No. 105-33), as amended. The
24-17 department shall provide medical assistance to a participant in the
24-18 PACE program in the manner and to the extent authorized by federal
24-19 law.
24-20 (b) The department shall adopt rules as necessary to
24-21 implement this section. In adopting rules, the department shall:
24-22 (1) use the Bienvivir Senior Health Services of El
24-23 Paso initiative as a model for the program; and
24-24 (2) ensure that a person is not required to hold a
24-25 certificate of authority as a health maintenance organization under
24-26 the Texas Health Maintenance Organization Act (Chapter 20A,
25-1 Vernon's Texas Insurance Code) to provide services under the PACE
25-2 program.
25-3 (c) The department may not contract with a person to provide
25-4 services under the PACE program unless the person:
25-5 (1) purchases reinsurance in an amount determined by
25-6 the department that is sufficient to ensure the person's continued
25-7 solvency; or
25-8 (2) has the financial resources sufficient to cover
25-9 expenses in the event of the person's insolvency.
25-10 (d) To demonstrate sufficiency of financial resources for
25-11 purposes of Subsection (c)(2), a person may use cash reserves, a
25-12 letter of credit, a guarantee of a company affiliated with the
25-13 person, or a combination of those arrangements. The amount of a
25-14 person's financial arrangement must be at least equal to the sum
25-15 of:
25-16 (1) the total capitation revenue for one month; and
25-17 (2) the average monthly payment of operating expenses.
25-18 (e) The department shall consult with the Texas Department
25-19 of Insurance in determining a person's sufficiency of financial
25-20 resources for continued solvency or to cover expenses in the event
25-21 of the person's insolvency as required by Subsection (c).
25-22 (f) The department, with direction from the Health and Human
25-23 Services Commission, shall develop and implement a coordinated plan
25-24 to promote PACE program sites operating under this section. The
25-25 department shall adopt policies and procedures to ensure that
25-26 caseworkers and any other appropriate state agency staff discuss
26-1 the benefits of participating in the PACE program with long-term
26-2 care clients.
26-3 (b) The state agency administering the program of
26-4 all-inclusive care for the elderly (PACE) implemented under Section
26-5 32.057, Human Resources Code, as added by this Act, shall use its
26-6 best efforts to develop and support multiple PACE program sites.
26-7 (c) If before June 1, 2004, the state does not receive
26-8 federal approval for the operation of all PACE program sites for
26-9 which the state has applied solely because the federal limit on the
26-10 number of new PACE program sites allowed nationwide per year has
26-11 been attained, the Health and Human Services Commission and Texas
26-12 Department of Human Services, not later than September 1, 2004,
26-13 shall examine federal laws and regulations regarding PACE programs
26-14 and identify changes to law that would result in an increased
26-15 number of PACE programs in this state.
26-16 (d) Not later than December 1, 2004, the commissioner of
26-17 health and human services shall submit to the legislature a written
26-18 report concerning the results of the examination conducted under
26-19 Subsection (c) of this section. The report must include any
26-20 recommendations for memorializing the Congress of the United States
26-21 to request changes to federal laws or regulations.
26-22 (e) As soon as practicable after the effective date of this
26-23 Act, the Health and Human Services Commission shall submit an
26-24 amendment to the state's Medicaid plan authorizing the state to
26-25 implement the program of all-inclusive care for the elderly (PACE)
26-26 established under Section 32.057, Human Resources Code, as added by
27-1 this Act. The commission is not required to submit an additional
27-2 amendment to the state's Medicaid plan each time the state agency
27-3 administering the PACE program selects and enters into a proposed
27-4 agreement with a provider to deliver services under the program.
27-5 SECTION 11. (a) Subchapter B, Chapter 531, Government Code,
27-6 is amended by adding Sections 531.02101 through 531.02107 to read
27-7 as follows:
27-8 Sec. 531.02101. TRANSFER AUTHORITY RELATING TO
27-9 ADMINISTRATION OF MEDICAID PROGRAM. (a) To the extent that
27-10 reorganization is necessary to achieve the goals of increased
27-11 administrative efficiency, increased accountability, or cost
27-12 savings in the Medicaid program or to otherwise improve the health
27-13 of residents of this state, the commission, subject to Subsection
27-14 (b), may transfer any power, duty, function, program, activity,
27-15 obligation, right, contract, record, employee, property, or
27-16 appropriation or other money relating to administration of the
27-17 Medicaid program from a health and human services agency to the
27-18 commission.
27-19 (b) A transfer authorized by Subsection (a) may not take
27-20 effect unless approved by the Medicaid legislative oversight
27-21 committee created under Section 531.02102.
27-22 (c) The commission must notify the Legislative Budget Board
27-23 and the governor's office of budget and planning not later than the
27-24 30th day before the effective date of a transfer authorized by
27-25 Subsection (a).
27-26 Sec. 531.02102. MEDICAID LEGISLATIVE OVERSIGHT COMMITTEE.
28-1 (a) The Medicaid legislative oversight committee is composed of:
28-2 (1) five members of the senate appointed by the
28-3 lieutenant governor; and
28-4 (2) five members of the house of representatives
28-5 appointed by the speaker of the house of representatives.
28-6 (b) A member of the Medicaid legislative oversight committee
28-7 serves at the pleasure of the appointing official.
28-8 (c) The lieutenant governor and speaker of the house of
28-9 representatives shall appoint the presiding officer of the Medicaid
28-10 legislative oversight committee on an alternating basis. The
28-11 presiding officer shall serve a two-year term expiring February 1
28-12 of each odd-numbered year.
28-13 (d) The Medicaid legislative oversight committee shall:
28-14 (1) meet not more than quarterly at the call of the
28-15 presiding officer; and
28-16 (2) review and approve or reject any transfer proposed
28-17 by the commission of a power, duty, function, program, activity,
28-18 obligation, right, contract, record, employee, property, or
28-19 appropriation or other money relating to administration of the
28-20 Medicaid program from a health and human services agency to the
28-21 commission.
28-22 (e) The Medicaid legislative oversight committee may use
28-23 staff of standing committees in the senate and house of
28-24 representatives with appropriate jurisdiction, the Department of
28-25 Information Resources, the state auditor, the Texas Legislative
28-26 Council, and the Legislative Budget Board in carrying out its
29-1 responsibilities.
29-2 Sec. 531.02103. MEDICAID PROGRAM: STRATEGIES FOR IMPROVING
29-3 BUDGET CERTAINTY AND COST SAVINGS. (a) To achieve administrative
29-4 efficiency and cost savings in the Medicaid program, the commission
29-5 shall develop and implement strategies to improve management of the
29-6 cost, quality, and use of services provided under the program. The
29-7 strategies developed and implemented under this section may
29-8 include:
29-9 (1) expansion of an enhanced primary care case
29-10 management model to areas of the state and to populations currently
29-11 subject to fee-for-service arrangements;
29-12 (2) use of medical case management for complex medical
29-13 cases;
29-14 (3) mandatory enrollment of some or all Medicaid
29-15 recipients who receive Supplemental Security Income (SSI) (42
29-16 U.S.C. Section 1381 et seq.) into a STAR + Plus pilot program in an
29-17 area of the state served by a STAR pilot program as of January 1,
29-18 2001, or into an alternate managed care model developed by the
29-19 commission;
29-20 (4) use of telemedicine for children and other persons
29-21 with special health care needs;
29-22 (5) use of copayments and other mechanisms to
29-23 encourage responsible use of health care services under the
29-24 program, provided that implementation occurs in accordance with
29-25 Section 531.02106;
29-26 (6) use of procurement initiatives such as selective
30-1 contracting as a mechanism for obtaining provider services under
30-2 the program, provided that the initiatives may not apply to a Class
30-3 A community independent pharmacy or a Class A community chain
30-4 pharmacy with 10 or fewer pharmacies;
30-5 (7) expansion of the program of all-inclusive care for
30-6 the elderly (PACE), as authorized by Section 4802 of the Balanced
30-7 Budget Act of 1997 (Pub. L. No. 105-33), as amended, to additional
30-8 sites;
30-9 (8) use of disease management and drug therapy
30-10 management for Medicaid recipients with chronic diseases, including
30-11 congestive heart failure, chronic obstructive pulmonary disease,
30-12 asthma, and diabetes;
30-13 (9) use of cost controls in the provision of
30-14 pharmaceutical services as necessary to ensure appropriate pricing,
30-15 cost-effective use of pharmaceutical products, and the state's
30-16 greatest entitlement to rebates from pharmaceutical manufacturers;
30-17 (10) use of competitive pricing for medical equipment
30-18 and supplies, including vision care equipment and supplies;
30-19 (11) expansion of the health insurance premium payment
30-20 reimbursement system (HIPPS);
30-21 (12) reduction of hospital outlier payments; and
30-22 (13) any other strategy designed to improve the
30-23 quality and cost-effectiveness of the Medicaid program.
30-24 (b) The commission shall consult with local communities,
30-25 providers, consumers, and other affected parties in the development
30-26 and implementation of strategies under Subsection (a). The
31-1 commission shall use existing state or local advisory committees
31-2 for this purpose.
31-3 (c) The commission shall hold public hearings at least
31-4 quarterly regarding the development and implementation of
31-5 strategies under Subsection (a) and the development of agency
31-6 procedures and necessary state plan amendments or waivers. If the
31-7 commission proposes to adopt a rule necessary to implement a
31-8 strategy under Subsection (a), the commission shall adopt the rule
31-9 in accordance with Chapter 2001 and hold any public hearing
31-10 required by that chapter.
31-11 Sec. 531.02104. MEDICAID ELIGIBILITY AND ENROLLMENT. The
31-12 commission shall ensure that:
31-13 (1) the Medicaid eligibility policies, processes, and
31-14 time frames of the Texas Department of Human Services, including
31-15 policies, processes, and time frames relating to an applicant or
31-16 recipient whose eligibility status is on hold, are designed to
31-17 minimize the time that an applicant or recipient is required to
31-18 wait before the applicant or recipient begins receiving services or
31-19 is recertified;
31-20 (2) each state agency operating a part of the Medicaid
31-21 program conforms the Medicaid eligibility policies and related
31-22 processes and time frames, including any cutoff dates, of the
31-23 agency and any agency contractor to the Medicaid eligibility
31-24 policies, processes, and time frames of the Texas Department of
31-25 Human Services; and
31-26 (3) the Medicaid eligibility policies, processes, and
32-1 time frames of each agency operating a part of the Medicaid program
32-2 and any agency contractor are designed to minimize the time that an
32-3 applicant or recipient is required to wait before receiving
32-4 services.
32-5 Sec. 531.02105. TEXAS HEALTH STEPS PROGRAM. The commission
32-6 shall:
32-7 (1) take all actions necessary to simplify:
32-8 (A) provider enrollment in the Texas Health
32-9 Steps program;
32-10 (B) reporting requirements relating to the Texas
32-11 Health Steps program; and
32-12 (C) billing and coding procedures so that Texas
32-13 Health Steps program processes are more consistent with commercial
32-14 standards;
32-15 (2) in consultation with providers of Texas Health
32-16 Steps program services, develop mechanisms to promote accurate,
32-17 reliable, and timely reporting of examinations of children
32-18 conducted under the program to managed care organizations and other
32-19 appropriate entities;
32-20 (3) in consultation with providers of Texas Health
32-21 Steps program services, develop a mechanism to promote
32-22 incorporation of Texas Health Steps program services into a child's
32-23 medical home; and
32-24 (4) require the external quality monitoring
32-25 organization to evaluate the Texas Health Steps program using
32-26 information available from all relevant sources and prepare
33-1 periodic reports regarding the program for submission by the
33-2 commission to the legislature.
33-3 Sec. 531.02106. LIMITS ON MEDICAID COST-SHARING. Before
33-4 requiring Medicaid recipients to make copayments or comply with
33-5 other cost-sharing requirements, the commission by rule shall
33-6 establish monthly limits on total copayments and other cost-sharing
33-7 requirements.
33-8 Sec. 531.02107. AUTHORIZATION FOR EXPANDED MEDICAID
33-9 COST-SHARING. Notwithstanding any other law, the commissioner may
33-10 request federal authorization to require all Medicaid recipients to
33-11 make copayments or comply with other cost-sharing requirements for
33-12 all services provided under the program in accordance with that
33-13 authorization.
33-14 (b) As soon as possible after the effective date of this
33-15 Act, the lieutenant governor and the speaker of the house of
33-16 representatives shall appoint the members of the Medicaid
33-17 legislative oversight committee created by Section 531.02102,
33-18 Government Code, as added by this Act. The speaker of the house of
33-19 representatives shall appoint the initial presiding officer of the
33-20 committee.
33-21 SECTION 12. Subchapter B, Chapter 531, Government Code, is
33-22 amended by adding Section 531.02131 to read as follows:
33-23 Sec. 531.02131. COMMUNITY OUTREACH CAMPAIGN. (a) The
33-24 commission shall conduct a community outreach campaign to provide
33-25 information relating to the availability of Medicaid coverage for
33-26 children and adults and to promote enrollment of eligible children
34-1 and adults in Medicaid.
34-2 (b) The commission may combine the community outreach
34-3 campaign under this section with any other state outreach campaign
34-4 or educational activity relating to health care and available
34-5 health care coverage.
34-6 SECTION 13. Subsection (d), Section 531.0214, Government
34-7 Code, is amended to read as follows:
34-8 (d) The commission shall develop the database system in a
34-9 manner that will enable a complete analysis of the use of
34-10 prescription medications[, including information relating to:]
34-11 [(1) Medicaid clients for whom more than three
34-12 medications have been prescribed; and]
34-13 [(2) the medical effect denial of Medicaid coverage
34-14 for more than three medications has had on Medicaid clients].
34-15 SECTION 14. Subsection (a), Section 531.026, Government
34-16 Code, is amended to read as follows:
34-17 (a) The commission shall prepare and submit to the
34-18 lieutenant governor, the speaker of the house of representatives,
34-19 the comptroller, the Legislative Budget Board, [and] the governor's
34-20 office of budget and planning, each member of the appropriations
34-21 committees of the senate and house of representatives, and each
34-22 member of the standing committees of the senate and house of
34-23 representatives with responsibility for oversight of health and
34-24 human services issues [governor] a consolidated health and human
34-25 services budget recommendation not later than October 15 of each
34-26 even-numbered year.
35-1 SECTION 15. Subchapter B, Chapter 531, Government Code, is
35-2 amended by adding Section 531.0261 to read as follows:
35-3 Sec. 531.0261. CONSOLIDATED MEDICAID APPROPRIATIONS REQUEST.
35-4 (a) The commission shall include in the consolidated budget
35-5 recommendation required by Section 531.026 a consolidated Medicaid
35-6 appropriations request for the subsequent fiscal biennium.
35-7 (b) The commission shall:
35-8 (1) develop the consolidated Medicaid appropriations
35-9 request with input from the Legislative Budget Board and the
35-10 governor's office of budget and planning to ensure that relevant
35-11 information for acute and long-term care Medicaid programs relating
35-12 to caseloads, costs, measures, rates, waivers, and eligibility is
35-13 reflected; and
35-14 (2) provide assistance with the legislative
35-15 appropriations process by revising the consolidated Medicaid
35-16 appropriations request each time that revised caseload and cost
35-17 estimates relating to the Medicaid program are prepared.
35-18 SECTION 16. Subchapter B, Chapter 531, Government Code, is
35-19 amended by adding Section 531.0272 to read as follows:
35-20 Sec. 531.0272. COMPREHENSIVE MEDICAID OPERATING BUDGET;
35-21 QUARTERLY EXPENDITURE REPORTS. (a) The commission shall prepare a
35-22 comprehensive Medicaid operating budget at the beginning of each
35-23 fiscal year, with input as appropriate from each health and human
35-24 services agency that receives legislative appropriations relating
35-25 to the Medicaid program.
35-26 (b) The commission shall monitor all Medicaid expenditures
36-1 by the commission and health and human services agencies and submit
36-2 quarterly Medicaid expenditure reports to the lieutenant governor,
36-3 the speaker of the house of representatives, the comptroller, the
36-4 Legislative Budget Board, the governor's office of budget and
36-5 planning, each member of the appropriations committees of the
36-6 senate and house of representatives, and each member of the
36-7 standing committees of the senate and house of representatives with
36-8 responsibility for oversight of health and human services issues.
36-9 (c) The commission shall prepare the comprehensive Medicaid
36-10 operating budget and quarterly Medicaid expenditure reports with
36-11 input from the Legislative Budget Board and the governor's office
36-12 of budget and planning to ensure that the information described by
36-13 Section 531.0261(b)(1) is reflected.
36-14 SECTION 17. Subchapter B, Chapter 531, Government Code, is
36-15 amended by adding Section 531.055 to read as follows:
36-16 Sec. 531.055. MEDICAID REIMBURSEMENT RATES REPORT. Not
36-17 later than December 1 of each even-numbered year, the commission
36-18 shall prepare and deliver to the governor, lieutenant governor,
36-19 speaker of the house of representatives, and each member of the
36-20 legislature a report that:
36-21 (1) identifies the Medicaid reimbursement rates for
36-22 each county in this state; and
36-23 (2) compares the state's Medicaid reimbursement rates
36-24 to the Medicaid reimbursement rates of the top 15 industrial states
36-25 as ranked by the United States Department of Commerce Bureau of
36-26 Economic Analysis based on gross state product.
37-1 SECTION 18. (a) The purpose of this section is to pilot a
37-2 coordinated approach to addressing the needs of homeless people
37-3 with chronic illnesses who are recipients of medical assistance
37-4 under Chapter 32, Human Resources Code, so that homeless people may
37-5 learn to manage their illnesses and become productive members of
37-6 society. Current state, federal, and local agencies fund separate
37-7 programs that address only one aspect of the needs of homeless
37-8 people, such as housing, job training, and medical care. Homeless
37-9 people with chronic illnesses will benefit from a coordinated
37-10 approach that comprehensively addresses the needs of homeless
37-11 people.
37-12 (b) Subchapter B, Chapter 531, Government Code, is amended
37-13 by adding Section 531.057 to read as follows:
37-14 Sec. 531.057. PILOT CASE MANAGEMENT PROGRAM. (a) The
37-15 commission, in cooperation with the Texas Interagency Council for
37-16 the Homeless, shall develop a pilot case management program for
37-17 homeless people who have chronic illnesses, including diabetes and
37-18 HIV infection or AIDS, and who are recipients of medical assistance
37-19 under Chapter 32, Human Resources Code. The council in cooperation
37-20 with relevant state agencies shall administer the pilot program
37-21 under the direction of the commission.
37-22 (b) Using existing resources of the agencies composing the
37-23 Texas Interagency Council for the Homeless, the staff of the
37-24 council shall:
37-25 (1) select a county with a population of more than 2.8
37-26 million in which to implement the program;
38-1 (2) identify existing services provided through
38-2 programs of the agencies composing the council to homeless people
38-3 with chronic illnesses who are recipients of medical assistance;
38-4 (3) identify existing federal, state, county, and
38-5 local sources from which money may be available to fund the pilot
38-6 program; and
38-7 (4) create a pilot case management program for not
38-8 more than 75 homeless people with chronic illnesses who are
38-9 recipients of medical assistance using existing financial and
38-10 agency resources.
38-11 (c) The Texas Interagency Council for the Homeless shall
38-12 select, through competitive bidding, a nonprofit entity to
38-13 implement the pilot case management program for the homeless. The
38-14 pilot program established under this section must:
38-15 (1) provide case management services and existing
38-16 health-related education services to participants of the program;
38-17 and
38-18 (2) coordinate housing, medical, job training, and
38-19 other necessary services for the participants of the program.
38-20 (d) The commission shall identify programs available through
38-21 health and human services agencies through which homeless people
38-22 described by Subsection (a) may receive housing, medical, job
38-23 placement, or other services. The commission shall report to the
38-24 Texas Interagency Council for the Homeless information regarding
38-25 the identified programs, including the programs' sources of funding
38-26 and eligibility requirements.
39-1 (e) Not later than December 15 of each even-numbered year,
39-2 the Texas Interagency Council for the Homeless shall submit a
39-3 report to the governor, the lieutenant governor, and the speaker of
39-4 the house of representatives regarding the effectiveness of the
39-5 pilot program established under this section.
39-6 (f) This section expires September 1, 2005.
39-7 (c) The Health and Human Services Commission shall develop
39-8 and the Texas Interagency Council for the Homeless shall implement
39-9 the pilot program established under this section not later than
39-10 November 1, 2001.
39-11 SECTION 19. The heading to Chapter 533, Government Code, is
39-12 amended to read as follows:
39-13 CHAPTER 533. DEVELOPMENT AND IMPLEMENTATION
39-14 OF MEDICAID MANAGED CARE PROGRAM
39-15 SECTION 20. Subchapter A, Chapter 533, Government Code, is
39-16 amended by amending Sections 533.001 and 533.002 and adding
39-17 Sections 533.0021, 533.0022, 533.0023, and 533.0024 to read as
39-18 follows:
39-19 Sec. 533.001. Definitions. In this chapter:
39-20 (1) "Commission" means the Health and Human Services
39-21 Commission or an agency operating part of the state Medicaid
39-22 managed care program, as appropriate.
39-23 (2) "Commissioner" means the commissioner of health
39-24 and human services.
39-25 (3) "Health and human services agencies" has the
39-26 meaning assigned by Section 531.001.
40-1 (4) "Managed care organization" means a person who is
40-2 authorized or otherwise permitted by law to arrange for or provide
40-3 a managed care plan. The term includes a health care system
40-4 established under Chapter 20C, Insurance Code.
40-5 (5) "Managed care plan" means a plan under which a
40-6 person undertakes to provide, arrange for, pay for, or reimburse
40-7 any part of the cost of any health care services. A part of the
40-8 plan must consist of arranging for or providing health care
40-9 services as distinguished from indemnification against the cost of
40-10 those services on a prepaid basis through insurance or otherwise.
40-11 The term includes a primary care case management provider network
40-12 and a health care system established under Chapter 20C, Insurance
40-13 Code. The term does not include a plan that indemnifies a person
40-14 for the cost of health care services through insurance.
40-15 (6) "Recipient" means a recipient of medical
40-16 assistance under Chapter 32, Human Resources Code.
40-17 (7) "Health care service region" or "region" means a
40-18 Medicaid managed care service area as delineated by the commission.
40-19 Sec. 533.002. MEDICAID HEALTH CARE DELIVERY SYSTEM. The
40-20 commission may develop a health care delivery system that
40-21 restructures the delivery of health care services provided under
40-22 the state Medicaid program.
40-23 Sec. 533.0021. DESIGN AND DEVELOPMENT OF HEALTH CARE
40-24 DELIVERY SYSTEM. In developing the health care delivery system
40-25 under this chapter, the commission shall:
40-26 (1) design the system in a manner that:
41-1 (A) improves the health of the people of this
41-2 state by:
41-3 (i) emphasizing prevention;
41-4 (ii) promoting continuity of care; and
41-5 (iii) providing a medical home for
41-6 recipients;
41-7 (B) ensures that each recipient receives
41-8 high-quality, comprehensive health care services in the recipient's
41-9 local community; and
41-10 (C) ensures that the community is given an
41-11 opportunity to provide input and participate in the implementation
41-12 of the system in the health care service region by holding public
41-13 hearings in the community at which the commission takes public
41-14 comment from all persons interested in the implementation of the
41-15 system;
41-16 (2) to the extent that it is cost-effective to this
41-17 state and local governments:
41-18 (A) maximize the financing of the state Medicaid
41-19 program by obtaining federal matching funds for all resources or
41-20 other money available for matching;
41-21 (B) expand Medicaid eligibility to include
41-22 persons who were eligible to receive indigent health care services
41-23 through the use of those resources or other money available for
41-24 matching before expansion of eligibility; and
41-25 (C) develop a sliding scale copayment schedule
41-26 for recipients based on income and other factors determined by the
42-1 commissioner; and
42-2 (3) develop and prepare the waiver or other documents
42-3 necessary to obtain federal authorization for the system.
42-4 Sec. 533.0022. PURPOSE. The commission shall implement the
42-5 Medicaid managed care program as part of the health care delivery
42-6 system developed under this chapter [Chapter 532] by contracting
42-7 with managed care organizations in a manner that, to the extent
42-8 possible:
42-9 (1) accomplishes the goals described by Section
42-10 533.0021 [improves the health of Texans by:]
42-11 [(A) emphasizing prevention;]
42-12 [(B) promoting continuity of care; and]
42-13 [(C) providing a medical home for recipients;]
42-14 [(2) ensures that each recipient receives high
42-15 quality, comprehensive health care services in the recipient's
42-16 local community];
42-17 (2) [(3)] encourages the training of and access to
42-18 primary care physicians and providers;
42-19 (3) [(4)] maximizes cooperation with existing public
42-20 health entities, including local departments of health and
42-21 community mental health and mental retardation centers established
42-22 under Chapter 534, Health and Safety Code;
42-23 (4) [(5)] provides incentives to managed care
42-24 organizations to improve the quality of health care services for
42-25 recipients by providing value-added services; [and]
42-26 (5) [(6)] reduces administrative and other
43-1 nonfinancial barriers for recipients in obtaining health care
43-2 services; and
43-3 (6) controls the costs associated with the state
43-4 Medicaid program.
43-5 Sec. 533.0023. RULES FOR HEALTH CARE DELIVERY SYSTEM.
43-6 (a) The commissioner of insurance shall adopt rules as necessary
43-7 or appropriate to carry out the functions of the Texas Department
43-8 of Insurance under this chapter.
43-9 (b) The commissioner of health and human services shall
43-10 adopt rules and obtain public input in accordance with Chapter 2001
43-11 before making substantive changes to policies or programs under the
43-12 Medicaid managed care program.
43-13 Sec. 533.0024. RESOLUTION OF IMPLEMENTATION ISSUES. The
43-14 commission shall conduct a meeting at least quarterly with managed
43-15 care organizations that contract with the commission under this
43-16 chapter and health care providers to identify and resolve
43-17 implementation issues with respect to the Medicaid managed care
43-18 program.
43-19 SECTION 21. Subchapter A, Chapter 533, Government Code, is
43-20 amended by adding Section 533.0035 to read as follows:
43-21 Sec. 533.0035. LIMITATION ON NUMBER OF CONTRACTS AWARDED.
43-22 The commission shall:
43-23 (1) evaluate the number of managed care organizations
43-24 with which the commission contracts to provide health care services
43-25 in each health care service region, focusing particularly on the
43-26 market share of those managed care organizations; and
44-1 (2) limit the number of contracts awarded to managed
44-2 care organizations under this chapter in a manner that promotes the
44-3 successful implementation of the delivery of health care services
44-4 through the state Medicaid managed care program.
44-5 SECTION 22. (a) Section 533.005, Government Code, is
44-6 amended to read as follows:
44-7 Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
44-8 between a managed care organization and the commission for the
44-9 organization to provide health care services to recipients must
44-10 contain:
44-11 (1) procedures to ensure accountability to the state
44-12 for the provision of health care services, including procedures for
44-13 financial reporting, quality assurance, utilization review, and
44-14 assurance of contract and subcontract compliance;
44-15 (2) capitation and provider payment rates that ensure
44-16 the cost-effective provision of quality health care;
44-17 (3) a requirement that the managed care organization
44-18 provide ready access to a person who assists recipients in
44-19 resolving issues relating to enrollment, plan administration,
44-20 education and training, access to services, and grievance
44-21 procedures;
44-22 (4) a requirement that the managed care organization
44-23 provide ready access to a person who assists providers in resolving
44-24 issues relating to payment, plan administration, education and
44-25 training, and grievance procedures;
44-26 (5) a requirement that the managed care organization
45-1 provide information and referral about the availability of
45-2 educational, social, and other community services that could
45-3 benefit a recipient;
45-4 (6) procedures for recipient outreach and education;
45-5 (7) a requirement that the managed care organization
45-6 make payment to a physician or provider for health care services
45-7 rendered to a recipient under a managed care plan not later than
45-8 the 45th day after the date a claim for payment is received with
45-9 documentation reasonably necessary for the managed care
45-10 organization to process the claim, or within a period, not to
45-11 exceed 60 days, specified by a written agreement between the
45-12 physician or provider and the managed care organization;
45-13 (8) a requirement that the commission, on the date of
45-14 a recipient's enrollment in a managed care plan issued by the
45-15 managed care organization, inform the organization of the
45-16 recipient's Medicaid certification date;
45-17 (9) a requirement that the managed care organization
45-18 comply with Section 533.006 as a condition of contract retention
45-19 and renewal; [and]
45-20 (10) a requirement that the managed care organization
45-21 provide the information required by Section 533.012 and otherwise
45-22 comply and cooperate with the commission's office of investigations
45-23 and enforcement;
45-24 (11) a process by which the commission is required to:
45-25 (A) provide in writing to the managed care
45-26 organization the projected fiscal impact on the state and managed
46-1 care organizations that contract with the commission under this
46-2 chapter of proposed Medicaid managed care program, benefit, or
46-3 contract changes; and
46-4 (B) negotiate in good faith regarding
46-5 appropriate operational and financial changes to the contract with
46-6 the managed care organization before implementing those changes;
46-7 (12) a requirement that the managed care organization
46-8 providing services to recipients under a Medicaid STAR + Plus pilot
46-9 program:
46-10 (A) have an appropriate number of clinically
46-11 trained case managers within the Medicaid STAR + Plus pilot program
46-12 service delivery area to manage medically complex patients; and
46-13 (B) implement disease management programs that
46-14 address the medical conditions of the Medicaid STAR + Plus pilot
46-15 program population, including persons with HIV infection, AIDS, or
46-16 sickle cell anemia;
46-17 (13) a requirement that the renewal date of the
46-18 contract coincide with the beginning of the state fiscal year; and
46-19 (14) a requirement that the managed care organization
46-20 reimburse health care providers for an appropriate emergency
46-21 medical screening that is within the capability of the hospital's
46-22 emergency department, including ancillary services routinely
46-23 available to the emergency department, and that is provided to
46-24 determine whether:
46-25 (A) an emergency medical or psychiatric
46-26 condition exists; and
47-1 (B) additional medical examination and treatment
47-2 is required to stabilize the emergency medical or psychiatric
47-3 condition.
47-4 (b) The changes in law made by Section 533.005, Government
47-5 Code, as amended by this Act, apply to a contract between the
47-6 Health and Human Services Commission and a managed care
47-7 organization under Chapter 533, Government Code, that is entered
47-8 into or renewed on or after the effective date of this Act. A
47-9 contract that is entered into or renewed before the effective date
47-10 of this Act is governed by the law in effect on the date the
47-11 contract was entered into or renewed, and the former law is
47-12 continued in effect for that purpose.
47-13 SECTION 23. (a) Subchapter A, Chapter 533, Government Code,
47-14 is amended by adding Sections 533.0051, 533.0076, 533.0091,
47-15 533.0131, and 533.016 through 533.0207 to read as follows:
47-16 Sec. 533.0051. CONTRACT RENEWAL. Before renewing a contract
47-17 with a managed care organization under this chapter, the commission
47-18 shall consider:
47-19 (1) the managed care organization's:
47-20 (A) overall contract compliance;
47-21 (B) implementation of simplified administrative
47-22 processes for health care providers and recipients;
47-23 (C) compliance with statutory requirements to
47-24 promptly reimburse health care providers for covered services
47-25 provided under the Medicaid managed care program;
47-26 (D) compliance with the requirements under
48-1 Article 3.70-3C, Insurance Code, as added by Chapter 1260, Acts of
48-2 the 75th Legislature, Regular Session, 1997, and Section 14, Texas
48-3 Health Maintenance Organization Act (Article 20A.14, Vernon's Texas
48-4 Insurance Code), to identify advanced practice nurses and physician
48-5 assistants as providers in the managed care organization's provider
48-6 network;
48-7 (E) financial performance; and
48-8 (F) participation in the state child health plan
48-9 under Chapter 62, Health and Safety Code; and
48-10 (2) the level of satisfaction of recipients and health
48-11 care providers with the managed care organization.
48-12 Sec. 533.0076. LIMITATIONS ON RECIPIENT DISENROLLMENT.
48-13 (a) Except as provided by Subsections (b) and (c), and to the
48-14 extent permitted by federal law, the commission may prohibit a
48-15 recipient from disenrolling in a managed care plan under this
48-16 chapter and enrolling in another managed care plan during the
48-17 12-month period after the date the recipient initially enrolls in a
48-18 plan.
48-19 (b) At any time before the 91st day after the date of a
48-20 recipient's initial enrollment in a managed care plan under this
48-21 chapter, the recipient may disenroll in that plan for any reason
48-22 and enroll in another managed care plan under this chapter.
48-23 (c) The commission shall allow a recipient who is enrolled
48-24 in a managed care plan under this chapter to disenroll in that plan
48-25 at any time for cause in accordance with federal law.
48-26 Sec. 533.0091. UNIFORM STANDARDS FOR IDENTIFYING RECIPIENTS
49-1 WITH DISABILITIES OR CHRONIC CONDITIONS. (a) The commission shall
49-2 collaborate with managed care organizations that contract with the
49-3 commission under this chapter to develop a uniform screening tool
49-4 to be used by the managed care organizations to identify adult
49-5 recipients with disabilities or chronic health conditions and
49-6 assist those recipients in accessing health care services.
49-7 (b) The commission, in cooperation with the Texas Department
49-8 of Health, by rule shall adopt criteria by which to classify a
49-9 child with certain health conditions as a child with special health
49-10 care needs. In adopting the criteria, the commission must include
49-11 children who have:
49-12 (1) severe disabilities;
49-13 (2) severe mental or emotional disorders;
49-14 (3) medically complex or fragile health conditions; or
49-15 (4) rare or chronic health conditions that are likely
49-16 to last at least one year and result in limitations on the child's
49-17 functioning and activities when compared to other children of the
49-18 same age who do not have those conditions.
49-19 (c) The commission, in cooperation with the Texas Department
49-20 of Health, shall:
49-21 (1) monitor and assess health care services provided
49-22 under the state Medicaid managed care program and the medical
49-23 assistance program under Chapter 32, Human Resources Code, to
49-24 children with special health care needs as determined by the
49-25 criteria adopted under Subsection (b);
49-26 (2) adopt specific quality of care standards
50-1 applicable to health care services provided under the state
50-2 Medicaid managed care program to children described by Subdivision
50-3 (1); and
50-4 (3) undertake initiatives to develop, test, and
50-5 implement optimum methods for the delivery of appropriate,
50-6 comprehensive, and cost-effective health care services under the
50-7 state Medicaid managed care program to children described by
50-8 Subdivision (1), including initiatives to:
50-9 (A) coordinate health care services with
50-10 educational programs and other social and community services; and
50-11 (B) promote family involvement and support.
50-12 Sec. 533.0131. USE OF ENCOUNTER DATA IN DETERMINING PREMIUM
50-13 PAYMENT RATES. (a) In determining premium payment rates and other
50-14 amounts paid to managed care organizations under a managed care
50-15 plan, the commission may not base or derive the rates or amounts on
50-16 or from encounter data, or incorporate in the determination an
50-17 analysis of encounter data, unless a certifier of encounter data
50-18 certifies that:
50-19 (1) the encounter data for the most recent state
50-20 fiscal year is complete, accurate, and reliable; and
50-21 (2) there is no statistically significant variability
50-22 in the encounter data attributable to incompleteness, inaccuracy,
50-23 or another deficiency as compared to equivalent data for similar
50-24 populations and when evaluated against professionally accepted
50-25 standards.
50-26 (b) For purposes of determining whether data is equivalent
51-1 data for similar populations under Subsection (a)(2), a certifier
51-2 of encounter data shall, at a minimum, consider:
51-3 (1) the regional variation in utilization patterns of
51-4 recipients and costs of health care services;
51-5 (2) the range and type of health care services to be
51-6 covered by premium payment rates;
51-7 (3) the number of managed care plans in the region;
51-8 and
51-9 (4) the current number of recipients in each region,
51-10 including the number for each category of recipient.
51-11 Sec. 533.016. INTERAGENCY SHARING OF INFORMATION. (a) The
51-12 commission shall require a health and human services agency
51-13 implementing the Medicaid managed care program to provide to each
51-14 other health and human services agency implementing the program
51-15 information reported to the agency by a managed care organization
51-16 or health care provider providing services to recipients.
51-17 (b) Except as prohibited by federal law, the commission,
51-18 each health and human services agency implementing the Medicaid
51-19 managed care program, and the Texas Department of Insurance shall
51-20 share confidential information, including financial data, that
51-21 relates to or affects a person who proposes to contract with or has
51-22 contracted with a state agency or a contractor of a state agency
51-23 for the purposes of this chapter.
51-24 (c) Information shared between agencies under Subsection (b)
51-25 remains confidential and is not subject to disclosure under Chapter
51-26 552.
52-1 Sec. 533.017. REDUCTION AND COORDINATION OF REPORTING
52-2 REQUIREMENTS AND INSPECTION PROCEDURES. (a) The commission shall:
52-3 (1) streamline on-site inspection procedures of
52-4 managed care organizations contracting with the commission under
52-5 this chapter;
52-6 (2) streamline reporting requirements for managed care
52-7 organizations contracting with the commission under this chapter,
52-8 including:
52-9 (A) combining information required to be
52-10 reported into a quarterly management report;
52-11 (B) eliminating unnecessary or duplicative
52-12 reporting requirements; and
52-13 (C) to the extent feasible, allowing managed
52-14 care organizations contracting with the commission under this
52-15 chapter to submit reports electronically;
52-16 (3) require managed care organizations contracting
52-17 with the commission under this chapter to streamline administrative
52-18 processes required of health care providers, including:
52-19 (A) simplifying and standardizing, to the extent
52-20 reasonably feasible, the forms providers are required to complete,
52-21 including forms for preauthorization for covered services;
52-22 (B) eliminating unnecessary or duplicative
52-23 reporting requirements; and
52-24 (C) encouraging the adoption of collaboratively
52-25 developed uniform forms; and
52-26 (4) designate one entity to which managed care
53-1 organizations contracting with the commission under this chapter
53-2 may report encounter data.
53-3 (b) Except as provided by Subsection (d), the commission and
53-4 the Texas Department of Insurance and contractors of the commission
53-5 or department may not schedule, initiate, prepare for, or conduct a
53-6 documentary, electronic, or on-site review, a readiness,
53-7 compliance, or performance review, or any other review, audit, or
53-8 examination of a managed care organization contracting with the
53-9 commission under this chapter until:
53-10 (1) the commission, the department, and, if
53-11 appropriate, each health and human services agency implementing a
53-12 part of the Medicaid managed care program enter into a memorandum
53-13 of understanding under Section 533.018; and
53-14 (2) the agencies described by Subdivision (1) provide
53-15 that memorandum to the managed care organization.
53-16 (c) Notwithstanding Subsection (b), the commission or the
53-17 Texas Department of Insurance may take any action:
53-18 (1) otherwise authorized by law to protect the safety
53-19 of a recipient; or
53-20 (2) with respect to a managed care organization
53-21 determined to be in a hazardous financial condition.
53-22 (d) The commission and the Texas Department of Insurance may
53-23 review monthly, quarterly, or annual reports required to be filed
53-24 by managed care organizations contracting with the commission under
53-25 this chapter.
53-26 Sec. 533.018. MEMORANDUM OF UNDERSTANDING REGARDING
54-1 COORDINATION OF REPORTING REQUIREMENTS AND INSPECTION PROCEDURES.
54-2 (a) The commission, the Texas Department of Insurance, and, if
54-3 appropriate, each health and human services agency implementing a
54-4 part of the Medicaid managed care program shall enter into a
54-5 memorandum of understanding that outlines methods to:
54-6 (1) maximize interagency coordination in conducting
54-7 reviews of managed care organizations contracting with the
54-8 commission under this chapter; and
54-9 (2) eliminate and prevent duplicative monitoring,
54-10 reporting, reviewing of forms, regulation, and enforcement policies
54-11 and processes with respect to those managed care organizations.
54-12 (b) The memorandum of understanding under this section must:
54-13 (1) maximize the use of electronic filing of
54-14 information by managed care organizations contracting with the
54-15 commission under this chapter;
54-16 (2) specify the process by which the commission and
54-17 the Texas Department of Insurance will jointly schedule a single
54-18 on-site visit that satisfies the requirements of all state agencies
54-19 regarding regularly scheduled, comprehensive compliance monitoring
54-20 of and enforcement efforts with respect to managed care
54-21 organizations contracting with the commission under this chapter;
54-22 (3) require that interagency orientation and training
54-23 are scheduled and conducted to ensure that agency staff members are
54-24 familiar with the obligation to eliminate and prevent duplicative
54-25 monitoring and enforcement activities; and
54-26 (4) ensure coordination to eliminate and prevent
55-1 duplication regarding policy development and implementation,
55-2 procurement, cost estimates, electronic systems issues, and
55-3 monitoring and enforcement activities with respect to managed care
55-4 organizations that serve recipients as well as enrollees in the
55-5 state child health plan under Chapter 62, Health and Safety Code.
55-6 Sec. 533.019. INTEGRATED OPERATIONAL AND FINANCIAL AUDIT
55-7 INSTRUMENT. (a) The commission and the Texas Department of
55-8 Insurance shall develop and use an integrated operational and
55-9 financial audit instrument for regularly scheduled, comprehensive,
55-10 on-site readiness, performance, or compliance reviews, or other
55-11 reviews, audits, or examinations of managed care organizations that
55-12 contract with the commission under this chapter.
55-13 (b) In developing the integrated operational and financial
55-14 audit instrument, the commission and the Texas Department of
55-15 Insurance must include:
55-16 (1) a method to assess compliance with each applicable
55-17 federal and state law and each applicable accreditation and
55-18 contractual requirement, including financial, actuarial,
55-19 operational, and quality of care requirements, the agencies are
55-20 authorized to enforce at least on a periodic basis;
55-21 (2) a method to assess compliance of documents,
55-22 records, and electronic files the commission or the Texas
55-23 Department of Insurance requires managed care organizations that
55-24 contract with the commission under this chapter to submit for
55-25 review, either before or as an alternative to an on-site review,
55-26 audit, or examination; and
56-1 (3) a method to assess compliance through on-site
56-2 reviews, audits, and examinations, including document review,
56-3 electronic systems testing or review, and observation and
56-4 interviews of managed care organization employees.
56-5 (c) The commission and the Texas Department of Insurance may
56-6 contract on a competitive bid basis with a consultant not
56-7 affiliated with the commission or department to develop the
56-8 integrated operational and financial audit instrument required by
56-9 this section.
56-10 Sec. 533.020. PREAUTHORIZATION FOR CERTAIN SERVICES NOT
56-11 REQUIRED. The commission, in consultation with physicians,
56-12 hospitals, and managed care organizations contracting with the
56-13 commission under this chapter, shall develop:
56-14 (1) a process by which the managed care organizations
56-15 eliminate preauthorization processes for covered services that are
56-16 considered to be routine services; and
56-17 (2) a process by which to notify health care providers
56-18 of covered services under the Medicaid managed care program for
56-19 which preauthorization is not required.
56-20 Sec. 533.0201. UTILIZATION REVIEW UNDER PRIMARY CARE CASE
56-21 MANAGEMENT NETWORK. To the extent allowed by federal law, the
56-22 commission shall require a managed care organization that contracts
56-23 with the commission under this chapter and that provides health
56-24 care services to recipients through a primary care case management
56-25 network to conduct utilization review of those services in
56-26 accordance with Article 21.58A, Insurance Code.
57-1 Sec. 533.0202. NOTICE OF DETERMINATIONS MADE BY UTILIZATION
57-2 REVIEW AGENTS. (a) In this section, "utilization review agent"
57-3 has the meaning assigned by Section 2, Article 21.58A, Insurance
57-4 Code.
57-5 (b) A utilization review agent shall notify a recipient or a
57-6 person acting on behalf of the recipient and the recipient's health
57-7 care provider of a utilization review determination in accordance
57-8 with this section and Section 5(a), Article 21.58A, Insurance Code,
57-9 with respect to services provided under the state Medicaid managed
57-10 care program.
57-11 (c) If the utilization review agent makes an adverse
57-12 determination, the notice required by this section must include:
57-13 (1) the principal reasons for the adverse
57-14 determination;
57-15 (2) the clinical basis for the adverse determination;
57-16 (3) a description or the source of the screening
57-17 criteria used as guidelines in making the determination; and
57-18 (4) a description of the procedure for the complaint
57-19 and appeal process, including a description provided to the
57-20 recipient of:
57-21 (A) the recipient's right to a Medicaid fair
57-22 hearing at any time; and
57-23 (B) the procedures for appealing an adverse
57-24 determination at a Medicaid fair hearing.
57-25 (d) The utilization review agent must provide notice of an
57-26 adverse determination:
58-1 (1) to the recipient and the recipient's health care
58-2 provider of record by telephone or electronic transmission not
58-3 later than the next business day after the date the determination
58-4 is made if the recipient is hospitalized when the determination is
58-5 made, to be followed not later than the third business day after
58-6 the date the determination is made by a written notice of the
58-7 determination;
58-8 (2) to the recipient and the recipient's health care
58-9 provider of record by written notice not later than the third
58-10 business day after the date the determination is made if the
58-11 recipient is not hospitalized when the determination is made; or
58-12 (3) to the recipient's treating physician or health
58-13 care provider within the time appropriate to the circumstances that
58-14 relate to the delivery of the services and the condition of the
58-15 patient, but not later than one hour after the recipient's treating
58-16 physician or provider requests poststabilization care following
58-17 emergency treatment.
58-18 (e) The commissioner shall adopt rules to implement this
58-19 section.
58-20 Sec. 533.0203. COMPLAINT INFORMATION. (a) The commission,
58-21 in cooperation with the Texas Department of Insurance and any other
58-22 appropriate entity, shall collect complaint data, including
58-23 complaint resolution rates, regarding managed care organizations
58-24 contracting with the commission under this chapter. In entering
58-25 into or renewing a contract with a managed care organization under
58-26 this chapter, the commission may include provisions in the contract
59-1 to accomplish the purposes of this section.
59-2 (b) The commission shall report on a quarterly basis the
59-3 complaint data collected under Subsection (a) to the state Medicaid
59-4 managed care advisory committee under Subchapter C.
59-5 (c) Not later than December 1 of each even-numbered year,
59-6 the commission shall report to the legislature the complaint data
59-7 collected under Subsection (a). The report may be consolidated
59-8 with any other report relating to the same subject matter the
59-9 commission is required to submit under other law.
59-10 Sec. 533.0204. PROVIDER REPORTING OF ENCOUNTER DATA. The
59-11 commission shall collaborate with managed care organizations that
59-12 contract with the commission and health care providers under the
59-13 organizations' provider networks to develop incentives and
59-14 mechanisms to encourage providers to report complete and accurate
59-15 encounter data to managed care organizations in a timely manner.
59-16 Sec. 533.0205. QUALIFICATIONS OF CERTIFIER OF ENCOUNTER
59-17 DATA. (a) The person acting as the state Medicaid director shall
59-18 appoint a person as the certifier of encounter data.
59-19 (b) The certifier of encounter data must have:
59-20 (1) demonstrated expertise in estimating premium
59-21 payment rates paid to a managed care organization under a managed
59-22 care plan; and
59-23 (2) access to actuarial expertise, including expertise
59-24 in estimating premium payment rates paid to a managed care
59-25 organization under a managed care plan.
59-26 (c) A person may not be appointed under this section as the
60-1 certifier of encounter data if the person participated with the
60-2 commission in developing premium payment rates for managed care
60-3 organizations under managed care plans in this state during the
60-4 three-year period before the date the certifier is appointed.
60-5 Sec. 533.0206. CERTIFICATION OF ENCOUNTER DATA. (a) The
60-6 certifier of encounter data shall certify the completeness,
60-7 accuracy, and reliability of encounter data for each state fiscal
60-8 year.
60-9 (b) The commission shall make available to the certifier all
60-10 records and data the certifier considers appropriate for evaluating
60-11 whether to certify the encounter data. The commission shall
60-12 provide to the certifier selected resources and assistance in
60-13 obtaining, compiling, and interpreting the records and data.
60-14 Sec. 533.0207. IMPLEMENTATION OF CERTAIN MANAGED CARE PLANS
60-15 IN CERTAIN COUNTIES. (a) Notwithstanding any other law, before
60-16 implementing a Medicaid managed care plan that uses capitation as a
60-17 method of payment in a county with a population of less than
60-18 100,000, the commission must determine that implementation is
60-19 economically efficient.
60-20 (b) Notwithstanding Subsection (a), the commission may
60-21 continue implementation of a Medicaid managed care plan described
60-22 by Subsection (a) in a county with a population of less than
60-23 100,000 if implementation of the plan in the county was in progress
60-24 on January 1, 2001.
60-25 (b) Not later than March 1, 2002, the Health and Human
60-26 Services Commission and each appropriate health and human services
61-1 agency implementing part of the Medicaid managed care program under
61-2 Chapter 533, Government Code, shall complete the requirements for
61-3 reducing and coordinating reporting requirements and inspection
61-4 procedures as required by Section 533.017, Government Code, as
61-5 added by this Act.
61-6 (c) Not later than March 1, 2002, the Health and Human
61-7 Services Commission, the Texas Department of Insurance, and each
61-8 appropriate health and human services agency implementing a part of
61-9 the Medicaid managed care program under Chapter 533, Government
61-10 Code, shall enter into the memorandum of understanding required by
61-11 Section 533.018, Government Code, as added by this Act.
61-12 (d) Not later than March 1, 2002, the Health and Human
61-13 Services Commission and the Texas Department of Insurance shall
61-14 develop the integrated operational and financial audit instrument
61-15 required by Section 533.019, Government Code, as added by this Act.
61-16 (e) The changes in law made by Section 533.0202, Government
61-17 Code, as added by this Act, apply to a contract between the Health
61-18 and Human Services Commission and a managed care organization under
61-19 Chapter 533, Government Code, that is entered into or renewed on or
61-20 after the effective date of this Act. A contract that is entered
61-21 into or renewed before the effective date of this Act is governed
61-22 by the law in effect on the date the contract was entered into or
61-23 renewed, and the former law is continued in effect for that
61-24 purpose.
61-25 (f) Not later than January 1, 2002, the person acting as the
61-26 state Medicaid director shall appoint the certifier of Medicaid
62-1 managed care encounter data required by Section 533.0205,
62-2 Government Code, as added by this Act.
62-3 SECTION 24. Subsection (a), Section 533.041, Government
62-4 Code, is amended to read as follows:
62-5 (a) The commission shall appoint a state Medicaid managed
62-6 care advisory committee. The advisory committee consists of
62-7 representatives of:
62-8 (1) hospitals;
62-9 (2) managed care organizations;
62-10 (3) primary care providers;
62-11 (4) state agencies;
62-12 (5) consumer advocates representing low-income
62-13 recipients;
62-14 (6) consumer advocates representing recipients with a
62-15 disability;
62-16 (7) parents of children who are recipients;
62-17 (8) rural providers;
62-18 (9) advocates for children with special health care
62-19 needs;
62-20 (10) pediatric health care providers, including
62-21 specialty providers;
62-22 (11) long-term care providers, including nursing home
62-23 providers;
62-24 (12) obstetrical care providers;
62-25 (13) community-based organizations serving low-income
62-26 children and their families; [and]
63-1 (14) community-based organizations engaged in
63-2 perinatal services and outreach;
63-3 (15) medically underserved communities; and
63-4 (16) community mental health and mental retardation
63-5 centers established under Subchapter A, Chapter 534, Health and
63-6 Safety Code.
63-7 SECTION 25. Notwithstanding S.B. No. 1, Acts of the 77th
63-8 Legislature, Regular Session, 2001 (the General Appropriations
63-9 Act), the annual salary of the executive director of the
63-10 Interagency Council on Early Childhood Intervention during the
63-11 state fiscal biennium beginning September 1, 2001, is $72,000.
63-12 SECTION 26. (a) The commissioner of health and human
63-13 services shall conduct a study regarding the feasibility of
63-14 expanding the medical assistance program under Chapter 32, Human
63-15 Resources Code, to provide medical assistance to disabled children
63-16 18 years of age or younger in accordance with 42 U.S.C. Section
63-17 1396a(e)(3), as amended.
63-18 (b) In conducting the study, the commissioner of health and
63-19 human services shall evaluate:
63-20 (1) the number of children who would be eligible for
63-21 medical assistance under the expanded program and who would be
63-22 likely to enroll;
63-23 (2) the effect of other health insurance coverage
63-24 provided for children who would be eligible under the expanded
63-25 medical assistance program on the cost of expanding the program;
63-26 (3) utilization patterns of similar populations of
64-1 disabled children under similar programs in this state and other
64-2 states;
64-3 (4) the cost to the state of inappropriate
64-4 institutionalization of disabled children resulting from
64-5 unavailability of health insurance coverage for those children; and
64-6 (5) options for setting an income eligibility cap for
64-7 the expanded medical assistance program.
64-8 (c) Not later than December 1, 2002, the commissioner of
64-9 health and human services shall submit a report to the legislature
64-10 regarding the results of the study conducted under this section.
64-11 The report must include a recommendation regarding expanding the
64-12 medical assistance program to provide that assistance to disabled
64-13 children in accordance with 42 U.S.C. Section 1396a(e)(3), as
64-14 amended.
64-15 SECTION 27. The commissioner of health and human services
64-16 shall examine the reimbursement methodology for air ambulance
64-17 services purchased under the medical assistance program and may
64-18 implement any changes necessary to maintain a viable air ambulance
64-19 system through the state.
64-20 SECTION 28. On January 1, 2002, or on an earlier date
64-21 specified by the Health and Human Services Commission:
64-22 (1) all powers, duties, functions, activities,
64-23 obligations, rights, contracts, records, employees, property, and
64-24 appropriations and other money of the Texas Department of Health
64-25 that are determined by the commissioner of health and human
64-26 services to be essential to the administration of Medicaid acute
65-1 care services or the Medicaid vendor drug program are transferred
65-2 to the Health and Human Services Commission;
65-3 (2) a rule or form adopted by the Texas Department of
65-4 Health that relates to a transferred component of the Medicaid
65-5 program is a rule or form of the Health and Human Services
65-6 Commission and remains in effect until altered by the commission;
65-7 (3) a reference in law or an administrative rule to
65-8 the Texas Department of Health that relates to a transferred
65-9 component of the Medicaid program means the Health and Human
65-10 Services Commission;
65-11 (4) a license, permit, or certification in effect that
65-12 was issued by the Texas Department of Health that relates to a
65-13 transferred component of the Medicaid program is continued in
65-14 effect as a license, permit, or certification of the Health and
65-15 Human Services Commission; and
65-16 (5) a complaint, investigation, or other proceeding
65-17 pending before the Texas Department of Health that relates to a
65-18 transferred component of the Medicaid program is transferred
65-19 without change in status to the Health and Human Services
65-20 Commission.
65-21 SECTION 29. (a) Subject to Subsection (b) of this section,
65-22 if before implementing any provision of this Act a state agency
65-23 determines that a waiver or authorization from a federal agency is
65-24 necessary for implementation of that provision, the agency affected
65-25 by the provision shall request the waiver or authorization and may
65-26 delay implementing that provision until the waiver or authorization
66-1 is granted.
66-2 (b) Implementation of Sections 32.053 through 32.056, Human
66-3 Resources Code, as added by this Act, is governed by Section 9 of
66-4 this Act. Implementation of Section 32.057, Human Resources Code,
66-5 as added by this Act, is governed by Section 10 of this Act.
66-6 SECTION 30. Except as otherwise provided by this Act, this
66-7 Act takes effect September 1, 2001, and applies to a person
66-8 receiving medical assistance on or after that date regardless of
66-9 the date on which the person began receiving that medical
66-10 assistance.
S.B. No. 1156
_______________________________ _______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 1156 passed the Senate on
April 24, 2001, by the following vote: Yeas 29, Nays 0, one
present not voting; May 23, 2001, Senate refused to concur in House
amendments and requested appointment of Conference Committee;
May 24, 2001, House granted request of the Senate; May 27, 2001,
Senate adopted Conference Committee Report by a viva-voce vote.
_______________________________
Secretary of the Senate
I hereby certify that S.B. No. 1156 passed the House, with
amendments, on May 22, 2001, by a non-record vote; May 24, 2001,
House granted request of the Senate for appointment of Conference
Committee; May 27, 2001, House adopted Conference Committee Report
by a non-record vote.
_______________________________
Chief Clerk of the House
Approved:
_______________________________
Date
_______________________________
Governor