77R16085 KKA/KLA-F
By Zaffirini, et al. S.B. No. 1156
Substitute the following for S.B. No. 1156:
By Coleman C.S.S.B. No. 1156
A BILL TO BE ENTITLED
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, the department may not limit benefits for the number of
1-8 medications prescribed to a recipient of prescription drug benefits
1-9 under the medical assistance program. In accordance with Section
1-10 531.02106, Government Code, the department also shall provide for
1-11 cost-sharing by recipients of prescription drug benefits under the
1-12 medical assistance program in a manner that ensures that recipients
1-13 with higher levels of income are required to pay progressively
1-14 higher percentages of the costs of prescription drugs. In
1-15 implementing cost-sharing provisions required by this subsection,
1-16 the department may not require a pharmacy participating in the
1-17 vendor drug program to collect copayments or other cost-sharing
1-18 payments from recipients for remittance to the department, but
1-19 shall allow the pharmacy to retain the payments as a component of
1-20 the reimbursement provided to the pharmacy under the program.
1-21 (y) The department shall provide medical assistance to a
1-22 person in need of treatment for breast or cervical cancer who is
1-23 eligible for that assistance under the Breast and Cervical Cancer
1-24 Prevention and Treatment Act of 2000 (Pub. L. No. 106-354) for a
2-1 continuous period during which the person requires that treatment.
2-2 The department shall simplify the provider enrollment process for a
2-3 provider of that medical assistance and shall adopt rules to
2-4 provide for certification of presumptive eligibility of a person
2-5 for that assistance. In determining a person's eligibility for
2-6 medical assistance under this subsection, the department, to the
2-7 extent allowed by federal law, may not require a personal
2-8 interview.
2-9 SECTION 2. (a) Subchapter B, Chapter 32, Human Resources
2-10 Code, is amended by adding Sections 32.0247 and 32.0248 to read as
2-11 follows:
2-12 Sec. 32.0247. ELIGIBILITY OF CERTAIN ALIENS. (a) The
2-13 department shall provide medical assistance in accordance with 8
2-14 U.S.C. Section 1612(b), as amended, to a person who:
2-15 (1) is a qualified alien, as defined by 8 U.S.C.
2-16 Sections 1641(b) and (c), as amended;
2-17 (2) meets the eligibility requirements of the medical
2-18 assistance program;
2-19 (3) entered the United States on or after August 22,
2-20 1996; and
2-21 (4) has resided in the United States for a period of
2-22 five years after the date the person entered as a qualified alien.
2-23 (b) If authorized by federal law, the department shall
2-24 provide pregnancy-related medical assistance to the maximum extent
2-25 permitted by the federal law to a person who is pregnant and is a
2-26 lawfully present alien as defined by 8 C.F.R. Section 103.12, as
2-27 amended, including a battered alien under 8 U.S.C. Section 1641(c),
3-1 as amended, regardless of the date on which the person entered the
3-2 United States. The department shall comply with any prerequisite
3-3 imposed under the federal law for providing medical assistance
3-4 under this subsection.
3-5 Sec. 32.0248. MEDICAL ASSISTANCE FOR CERTAIN PERSONS MAKING
3-6 TRANSITION FROM FOSTER CARE TO INDEPENDENT LIVING. (a) In this
3-7 section, "independent foster care adolescent" has the meaning
3-8 assigned by 42 U.S.C. Section 1396d(w)(1).
3-9 (b) The department shall provide medical assistance, in
3-10 accordance with department rules, to an independent foster care
3-11 adolescent who:
3-12 (1) is not otherwise eligible for medical assistance;
3-13 and
3-14 (2) is not covered by a health benefits plan offering
3-15 adequate benefits, as determined by the Health and Human Services
3-16 Commission.
3-17 (c) The department may not consider a person's income,
3-18 assets, or resources in determining whether the person is eligible
3-19 for medical assistance under this section.
3-20 (b) As soon as possible after the effective date of this
3-21 Act, the Health and Human Services Commission shall submit an
3-22 amendment to the state's Medicaid plan to include the provision of
3-23 medical assistance to independent foster care adolescents as
3-24 required by Section 32.0248, Human Resources Code, as added by this
3-25 Act.
3-26 SECTION 3. Subchapter B, Chapter 32, Human Resources Code, is
3-27 amended by adding Section 32.0252 to read as follows:
4-1 Sec. 32.0252. CONTRACT TO PROVIDE ELIGIBILITY DETERMINATION
4-2 SERVICES. (a) To the extent allowed by federal law, and except as
4-3 otherwise provided by this section, the department may contract for
4-4 the provision of medical assistance eligibility services with:
4-5 (1) a hospital district created under the authority of
4-6 Sections 4-11, Article IX, Texas Constitution;
4-7 (2) a hospital authority created under the authority
4-8 of Chapter 262 or 264, Health and Safety Code, that uses resources
4-9 to provide health care services to indigent persons to some extent;
4-10 (3) a hospital owned and operated by a municipality or
4-11 county or by a hospital authority created under Chapter 262 or 264,
4-12 Health and Safety Code;
4-13 (4) a medical school operated by this state;
4-14 (5) a medical school that receives state money under
4-15 Section 61.093, Education Code, or a chiropractic school that
4-16 receives state money under the General Appropriations Act;
4-17 (6) a teaching hospital operated by The University of
4-18 Texas System;
4-19 (7) a county that is required to provide health care
4-20 assistance to eligible county residents under Subchapter B, Chapter
4-21 61, Health and Safety Code;
4-22 (8) a governmental entity that is required to provide
4-23 money to a public hospital under Section 61.062, Health and Safety
4-24 Code;
4-25 (9) a county with a population of more than 400,000
4-26 that provides money to a public hospital and that is not included
4-27 in the boundaries of a hospital district;
5-1 (10) a hospital owned by a municipality and leased to
5-2 and operated by a nonprofit hospital for a public purpose;
5-3 (11) a hospital that receives Medicaid
5-4 disproportionate share payments;
5-5 (12) a community mental health and mental retardation
5-6 center;
5-7 (13) a local mental health or mental retardation
5-8 authority;
5-9 (14) a local health department or public health
5-10 district;
5-11 (15) a school-based health center;
5-12 (16) a community health center; and
5-13 (17) a federally qualified health center.
5-14 (b) The department may contract with an entity described by
5-15 Subsection (a) for the entity to designate one or more employees
5-16 of the entity to process medical assistance application forms and
5-17 conduct client interviews for eligibility determinations.
5-18 (c) The contract must require each designated employee to
5-19 submit completed application forms to the appropriate agency as
5-20 determined by the department to finally determine eligibility and
5-21 to enroll eligible persons in the program. A designated employee
5-22 may not make a final determination of eligibility or enroll an
5-23 eligible person in the program.
5-24 (d) The department may:
5-25 (1) monitor the eligibility and application processing
5-26 program used by an entity with which the department contracts; and
5-27 (2) provide on-site supervision of the program for
6-1 quality control.
6-2 (e) The Health and Human Services Commission shall ensure
6-3 that there are adequate protections to avoid a conflict of interest
6-4 with an entity described by Subsection (a) that has a contract for
6-5 eligibility services and also has a contract, either directly or
6-6 through an affiliated entity, as a managed care organization for
6-7 the Medicaid program or for the child health plan program under
6-8 Chapter 62, Health and Safety Code. The commission shall ensure
6-9 that there are adequate protections for recipients to freely choose
6-10 a health plan without being inappropriately induced to join an
6-11 entity's health plan.
6-12 SECTION 4. Subchapter B, Chapter 32, Human Resources Code, is
6-13 amended by adding Section 32.0271 to read as follows:
6-14 Sec. 32.0271. SELECTION OF NURSE FIRST ASSISTANT. (a) In
6-15 this section, "nurse first assistant" means a registered nurse who:
6-16 (1) is certified in perioperative nursing by an
6-17 organization recognized by the Board of Nurse Examiners; and
6-18 (2) has completed a nurse first assistant educational
6-19 program approved by an organization recognized by the Board of
6-20 Nurse Examiners.
6-21 (b) The department shall ensure that a recipient of medical
6-22 assistance may select a nurse first assistant to perform any health
6-23 care service or procedure covered under the medical assistance
6-24 program if:
6-25 (1) the selected nurse first assistant is authorized
6-26 by law to perform the service or procedure; and
6-27 (2) the physician requests that the service or
7-1 procedure be performed by the nurse first assistant.
7-2 (c) The Board of Nurse Examiners may adopt rules governing
7-3 nurse first assistants for purposes of this section.
7-4 SECTION 5. Section 32.029, Human Resources Code, is amended
7-5 by adding Subsection (f) to read as follows:
7-6 (f) The department or its designee may implement
7-7 demonstration projects designed to reduce medical assistance claims
7-8 processing costs.
7-9 SECTION 6. (a) Subchapter B, Chapter 32, Human Resources
7-10 Code, is amended by adding Section 32.0422 to read as follows:
7-11 Sec. 32.0422. HEALTH INSURANCE PREMIUM PAYMENT REIMBURSEMENT
7-12 PROGRAM FOR MEDICAL ASSISTANCE RECIPIENTS. (a) In this section:
7-13 (1) "Department" means the Texas Department of Health.
7-14 (2) "Group health benefit plan" has the meaning
7-15 assigned by Article 21.52K, Insurance Code.
7-16 (b) The department shall identify individuals, otherwise
7-17 entitled to medical assistance, who are eligible to enroll in a
7-18 group health benefit plan. The department must include individuals
7-19 eligible for or receiving health care services under a Medicaid
7-20 managed care delivery system.
7-21 (c) The department may require an individual requesting
7-22 medical assistance to provide information as necessary relating to
7-23 the availability of a group health benefit plan to the individual
7-24 through an employer of the individual or an employer of the
7-25 individual's spouse or parent. The department may not leave
7-26 pending, consider incomplete, or otherwise delay an individual's
7-27 application for medical assistance or request for recertification
8-1 as a result of the requirement authorized by this subsection.
8-2 (d) For an individual identified under Subsection (b), the
8-3 department shall determine whether it is cost-effective to enroll
8-4 the individual in the group health benefit plan under this section.
8-5 (e) If the department determines that it is cost-effective
8-6 to enroll the individual in the group health benefit plan, the
8-7 department shall:
8-8 (1) require the individual to apply to enroll in the
8-9 group health benefit plan as a condition for eligibility under the
8-10 medical assistance program; and
8-11 (2) provide written notice to the issuer of the group
8-12 health benefit plan in accordance with Article 21.52K, Insurance
8-13 Code.
8-14 (f) The department shall provide for payment of:
8-15 (1) the employee's share of required premiums for
8-16 coverage of an individual enrolled in the group health benefit
8-17 plan; and
8-18 (2) any deductible, copayment, coinsurance, or other
8-19 cost-sharing obligation imposed on the enrolled individual for an
8-20 item or service otherwise covered under the medical assistance
8-21 program.
8-22 (g) A payment made by the department under Subsection (f) is
8-23 considered to be a payment for medical assistance.
8-24 (h) A payment of a premium for an individual who is a member
8-25 of the family of an individual enrolled in a group health benefit
8-26 plan under this section and who is not eligible for medical
8-27 assistance is considered to be a payment for medical assistance for
9-1 an eligible individual if:
9-2 (1) enrollment of the family members who are eligible
9-3 for medical assistance is not possible under the plan without also
9-4 enrolling members who are not eligible; and
9-5 (2) the department determines it to be cost-effective.
9-6 (i) A payment of any deductible, copayment, coinsurance, or
9-7 other cost-sharing obligation of a family member who is enrolled in
9-8 a group health benefit plan in accordance with Subsection (h) and
9-9 who is not eligible for medical assistance:
9-10 (1) may not be paid under this chapter; and
9-11 (2) is not considered to be a payment for medical
9-12 assistance for an eligible individual.
9-13 (j) The department shall treat coverage under the group
9-14 health benefit plan as a third party liability to the program.
9-15 Enrollment of an individual in a group health benefit plan under
9-16 this section does not affect the individual's eligibility for
9-17 medical assistance benefits, except that the state is entitled to
9-18 payment under Sections 32.033 and 32.038.
9-19 (k) The department may not require or permit an individual
9-20 who is enrolled in a group health benefit plan under this section
9-21 to participate in the Medicaid managed care program under Chapter
9-22 533, Government Code, or a Medicaid managed care demonstration
9-23 project under Section 32.041.
9-24 (l) The Texas Department of Human Services shall provide
9-25 information and otherwise cooperate with the department as
9-26 necessary to ensure the enrollment of eligible individuals in the
9-27 group health benefit plan under this section.
10-1 (m) The department shall adopt rules as necessary to
10-2 implement this section. In developing rules and related
10-3 procedures, the department shall consult with providers and other
10-4 interested persons to minimize the administrative complexity of the
10-5 program.
10-6 (b) Subchapter E, Chapter 21, Insurance Code, is amended by
10-7 adding Article 21.52K to read as follows:
10-8 Art. 21.52K. ENROLLMENT OF MEDICAL ASSISTANCE RECIPIENTS
10-9 Sec. 1. DEFINITION OF GROUP HEALTH BENEFIT PLAN. (a) In
10-10 this article, "group health benefit plan" means a plan that
10-11 provides benefits for medical or surgical expenses incurred as a
10-12 result of a health condition, accident, or sickness, including a
10-13 group, blanket, or franchise insurance policy or insurance
10-14 agreement, a group hospital service contract, or a group evidence
10-15 of coverage or similar group coverage document that is offered by:
10-16 (1) an insurance company;
10-17 (2) a group hospital service corporation operating
10-18 under Chapter 20 of this code;
10-19 (3) a fraternal benefit society operating under
10-20 Chapter 10 of this code;
10-21 (4) a stipulated premium insurance company operating
10-22 under Chapter 22 of this code;
10-23 (5) a reciprocal exchange operating under Chapter 19
10-24 of this code;
10-25 (6) a health maintenance organization operating under
10-26 the Texas Health Maintenance Organization Act (Chapter 20A,
10-27 Vernon's Texas Insurance Code);
11-1 (7) a multiple employer welfare arrangement that holds
11-2 a certificate of authority under Article 3.95-2 of this code; or
11-3 (8) an approved nonprofit health corporation that
11-4 holds a certificate of authority under Article 21.52F of this code.
11-5 (b) The term "group health benefit plan" includes:
11-6 (1) a small employer health benefit plan written under
11-7 Chapter 26 of this code; and
11-8 (2) a plan provided under the Texas Employees Uniform
11-9 Group Insurance Benefits Act (Article 3.50-2, Vernon's Texas
11-10 Insurance Code), the Texas State College and University Employees
11-11 Uniform Insurance Benefits Act (Article 3.50-3, Vernon's Texas
11-12 Insurance Code), the Texas Public School Employees Group Insurance
11-13 Act (Article 3.50-4, Vernon's Texas Insurance Code), or a successor
11-14 of any of those plans.
11-15 Sec. 2. ENROLLMENT REQUIRED. (a) The issuer of a group
11-16 health benefit plan, on receipt of written notice from the Texas
11-17 Department of Health or a designee of the Texas Department of
11-18 Health that states that an individual who is otherwise eligible for
11-19 enrollment in the plan is a recipient of medical assistance under
11-20 the state Medicaid program and is a participant in the health
11-21 insurance premium payment reimbursement program for medical
11-22 assistance recipients under Section 32.0422, Human Resources Code,
11-23 shall permit the individual to enroll in the plan without regard to
11-24 any enrollment period restriction.
11-25 (b) If an individual described by Subsection (a) of this
11-26 section is not eligible to enroll in the plan unless a family
11-27 member of the individual is also enrolled in the plan, the issuer,
12-1 on receipt of the written notice under Subsection (a) of this
12-2 section, shall enroll both the individual and the family member in
12-3 the plan.
12-4 (c) Unless enrollment occurs during an established
12-5 enrollment period, enrollment under this article takes effect on
12-6 the first day of the calendar month that begins at least 30 days
12-7 after the date written notice is received by the issuer under
12-8 Subsection (a) of this section.
12-9 (d) Notwithstanding any other requirement of the group
12-10 health benefit plan, the issuer of the plan shall permit an
12-11 individual who is enrolled in a group health benefit plan under
12-12 Subsection (a) of this section, and any family member of the
12-13 individual enrolled under Subsection (b) of this section, to
12-14 terminate enrollment in the plan not later than the 60th day after
12-15 the date on which the individual provides satisfactory proof to the
12-16 issuer that the individual is no longer:
12-17 (1) a recipient of medical assistance under the state
12-18 Medicaid program; or
12-19 (2) a participant in the health insurance premium
12-20 payment reimbursement program for medical assistance recipients
12-21 under Section 32.0422, Human Resources Code.
12-22 (c) The changes in law made by this section take effect
12-23 August 31, 2001, and apply only to a group health benefit plan that
12-24 is delivered, issued for delivery, or renewed on or after that
12-25 date. A group health benefit plan that is delivered, issued for
12-26 delivery, or renewed before August 31, 2001, is governed by the
12-27 law as it existed immediately before that date, and that law is
13-1 continued in effect for that purpose.
13-2 SECTION 7. (a) Subchapter B, Chapter 32, Human Resources
13-3 Code, is amended by adding Sections 32.053-32.056 to read as
13-4 follows:
13-5 Sec. 32.053. DEMONSTRATION PROJECT FOR CERTAIN MEDICATIONS
13-6 AND RELATED SERVICES. (a) The department shall establish a
13-7 demonstration project to provide to a person through the medical
13-8 assistance program psychotropic medications and related laboratory
13-9 and medical services necessary to conform to a prescribed medical
13-10 regime for those medications.
13-11 (b) A person is eligible to participate in the demonstration
13-12 project if the person:
13-13 (1) has been diagnosed as having a mental impairment,
13-14 including schizophrenia or bipolar disorder, that is expected to
13-15 cause the person to become a disabled individual, as defined by
13-16 Section 1614(a) of the federal Social Security Act (42 U.S.C.
13-17 Section 1382c), as amended;
13-18 (2) is at least 19 years of age, but not more than 64
13-19 years of age;
13-20 (3) has a net family income that is at or below 200
13-21 percent of the federal poverty level;
13-22 (4) is not covered by a health benefits plan offering
13-23 adequate coverage, as determined by the department; and
13-24 (5) is not otherwise eligible for medical assistance
13-25 at the time the person's eligibility for participation in the
13-26 demonstration project is determined.
13-27 (c) To the extent allowed by federal law, and except as
14-1 otherwise provided by this section, the department may contract for
14-2 the provision of eligibility services for the demonstration project
14-3 with a local mental health authority.
14-4 (d) Notwithstanding any other provision of this section, the
14-5 department shall provide each participant in the demonstration
14-6 project with a 12-month period of continuous eligibility for
14-7 participation in the project.
14-8 (e) Participation in the demonstration project does not
14-9 entitle a participant to other services provided under the medical
14-10 assistance program.
14-11 (f) The department shall establish an appropriate enrollment
14-12 limit for the demonstration project and may not allow participation
14-13 in the project to exceed that limit. Once the limit is reached,
14-14 the department shall establish a waiting list for enrollment in the
14-15 demonstration project.
14-16 (g) To the extent permitted by federal law, the department
14-17 may require a participant in the demonstration project to make
14-18 cost-sharing payments for services provided through the project.
14-19 (h) To the maximum extent possible, the department shall use
14-20 existing resources to fund the demonstration project.
14-21 (i) Not later than December 1 of each even-numbered year,
14-22 the department shall submit a biennial report to the legislature
14-23 regarding the department's progress in establishing and operating
14-24 the demonstration project.
14-25 (j) Not later than December 1, 2006, the department shall
14-26 evaluate the cost-effectiveness of the demonstration project,
14-27 including whether the preventive drug treatments and related
15-1 services provided under the project offset future long-term care
15-2 costs for project participants. If the results of the evaluation
15-3 indicate that the project is cost-effective, the department shall
15-4 incorporate a request for funding for the continuation of the
15-5 program in the department's budget request for the next state
15-6 fiscal biennium.
15-7 (k) This section expires September 1, 2012.
15-8 Sec. 32.054. DEMONSTRATION PROJECT FOR PERSONS WITH HIV
15-9 INFECTION OR AIDS. (a) In this section, "AIDS" and "HIV" have the
15-10 meanings assigned by Section 81.101, Health and Safety Code.
15-11 (b) The department shall establish a demonstration project
15-12 to provide a person with HIV infection or AIDS with the following
15-13 services and medications through the medical assistance program:
15-14 (1) services provided by a physician, physician
15-15 assistant, advanced practice nurse, or other health care provider
15-16 specified by the department;
15-17 (2) medications not included in the formulary for the
15-18 HIV medication program operated by the department, but determined
15-19 to be necessary for treatment of a condition related to HIV
15-20 infection or AIDS;
15-21 (3) vaccinations for hepatitis B and pneumonia;
15-22 (4) pap smears, colposcopy, and other diagnostic
15-23 procedures necessary to monitor gynecologic complications resulting
15-24 from HIV infection or AIDS in women;
15-25 (5) hospitalization;
15-26 (6) laboratory and other diagnostic services,
15-27 including periodic testing for CD4+ T-cell counts, viral load
16-1 determination, and phenotype or genotype testing if clinically
16-2 indicated; and
16-3 (7) other laboratory and radiological testing
16-4 necessary to monitor potential toxicity of therapy.
16-5 (c) The department shall establish the demonstration project
16-6 in at least two counties with a high prevalence of HIV infection
16-7 and AIDS. The department shall ensure that the demonstration
16-8 project is financed using funds made available by the counties in
16-9 which the department establishes the demonstration project. The
16-10 manner in which a county makes funds available may include an
16-11 option for the county to be able to certify the amount of funds
16-12 considered available instead of sending the funds to the state.
16-13 (d) A person is eligible to participate in the demonstration
16-14 project if the person:
16-15 (1) has been diagnosed with HIV infection or AIDS by a
16-16 physician;
16-17 (2) is under 65 years of age;
16-18 (3) has a net family income that is at or below 200
16-19 percent of the federal poverty level;
16-20 (4) is a resident of a county included in the project
16-21 or, subject to guidelines established by the department, is
16-22 receiving medical care for HIV infection or AIDS through a facility
16-23 located in a county included in the project;
16-24 (5) is not covered by a health benefits plan offering
16-25 adequate coverage, as determined by the department; and
16-26 (6) is not otherwise eligible for medical assistance
16-27 at the time the person's eligibility for participation in the
17-1 demonstration project is determined.
17-2 (e) Participation in the demonstration project does not
17-3 entitle a participant to other services provided under the medical
17-4 assistance program.
17-5 (f) The department shall establish an appropriate enrollment
17-6 limit for the demonstration project and may not allow participation
17-7 in the project to exceed that limit. Once the limit is reached,
17-8 the department:
17-9 (1) shall establish a waiting list for enrollment in
17-10 the demonstration project; and
17-11 (2) may allow eligible persons on the waiting list to
17-12 enroll solely in the HIV medication program operated by the
17-13 department.
17-14 (g) The department shall ensure that a participant in the
17-15 demonstration project is also enrolled in the HIV medication
17-16 program operated by the department.
17-17 (h) Notwithstanding any other provision of this section, the
17-18 department shall provide each participant in the project with a
17-19 six-month period of continuous eligibility for participation in the
17-20 project.
17-21 (i) Not later than December 1 of each even-numbered year,
17-22 the department shall submit a biennial report to the legislature
17-23 regarding the department's progress in establishing and operating
17-24 the demonstration project.
17-25 (j) Not later than December 1, 2006, the department shall
17-26 evaluate the cost-effectiveness of the demonstration project,
17-27 including whether the services and medications provided offset
18-1 future higher costs for project participants. If the results of
18-2 the evaluation indicate that the project is cost-effective, the
18-3 department shall incorporate a request for funding for the
18-4 expansion of the project into additional counties or throughout the
18-5 state, as appropriate, in the department's budget request for the
18-6 next state fiscal biennium.
18-7 (k) This section expires September 1, 2012.
18-8 Sec. 32.055. DEMONSTRATION PROJECTS FOR PROVISION OF MEDICAL
18-9 ASSISTANCE TO CERTAIN LOW-INCOME INDIVIDUALS. (a) The Health and
18-10 Human Services Commission shall establish demonstration projects to
18-11 provide medical assistance under this chapter to adult individuals
18-12 who are not otherwise eligible for medical assistance and whose
18-13 incomes are at or below 200 percent of the federal poverty level.
18-14 (b) The Health and Human Services Commission shall select
18-15 one or more municipalities or counties in which to implement the
18-16 demonstration projects.
18-17 (c) The Health and Human Services Commission, in conjunction
18-18 with local governmental entities that make funds available to the
18-19 commission in accordance with this section, shall design the
18-20 components of the demonstration project and shall ensure that:
18-21 (1) each demonstration project is financed using funds
18-22 made available by certain local governmental entities, through a
18-23 certification process, to the commission for matching purposes to
18-24 maximize federal funds for the medical assistance program; and
18-25 (2) a participant in a demonstration project is not
18-26 subject to a limitation imposed on prescription drug benefits under
18-27 the medical assistance program.
19-1 (d) The Health and Human Services Commission shall appoint
19-2 regional advisory committees to assist the commission in
19-3 establishing and implementing demonstration projects under this
19-4 section. An advisory committee must include health care providers,
19-5 employers, and local government officials.
19-6 Sec. 32.056. DEMONSTRATION PROJECT FOR WOMEN'S HEALTH CARE
19-7 SERVICES. (a) The department shall establish a five-year
19-8 demonstration project through the medical assistance program to
19-9 expand access to preventive health and family planning services for
19-10 women. A woman eligible under Subsection (b) to participate in the
19-11 demonstration project may receive preventive health and family
19-12 planning services, including:
19-13 (1) medical history;
19-14 (2) physical examinations;
19-15 (3) counseling and education on contraceptive methods;
19-16 (4) provision of contraceptives;
19-17 (5) health screenings, including screening for:
19-18 (A) diabetes;
19-19 (B) cervical cancer;
19-20 (C) breast cancer;
19-21 (D) sexually transmitted diseases;
19-22 (E) hypertension;
19-23 (F) cholesterol; and
19-24 (G) tuberculosis;
19-25 (6) risk assessment; and
19-26 (7) referral of medical problems to appropriate
19-27 providers.
20-1 (b) A woman is eligible to participate in the demonstration
20-2 project if the woman:
20-3 (1) is of childbearing age, as determined by the
20-4 department;
20-5 (2) has a net family income that is at or below 185
20-6 percent of the federal poverty level; and
20-7 (3) is not otherwise eligible for the medical
20-8 assistance program.
20-9 (c) The department shall develop procedures for determining
20-10 and certifying presumptive eligibility for a woman eligible under
20-11 Subsection (b). The department shall integrate these procedures
20-12 with current procedures to minimize duplication of effort by
20-13 providers, the department, and other state agencies.
20-14 (d) The department shall provide for 12 months of continuous
20-15 eligibility for a woman eligible under Subsection (b).
20-16 (e) The department shall compile a list of potential funding
20-17 sources a client can use to help pay for treatment for health
20-18 problems:
20-19 (1) identified using services provided to the client
20-20 under the demonstration project; and
20-21 (2) for which the client is not eligible to receive
20-22 treatment under the medical assistance program.
20-23 (f) Not later than December 1 of each even-numbered year,
20-24 the department shall submit a report to the legislature that
20-25 includes a statement of the department's progress in establishing
20-26 and operating the demonstration project.
20-27 (g) The department shall ensure that money under the
21-1 demonstration project established by this section may not be used
21-2 for an abortion, as that term is defined by Section 245.002, Health
21-3 and Safety Code.
21-4 (h) To the extent required by federal budget neutrality
21-5 requirements, the department may establish an appropriate
21-6 enrollment limit for the demonstration project.
21-7 (i) This section expires September 1, 2007.
21-8 (b) The state agency responsible for implementing the
21-9 demonstration projects required by Sections 32.053-32.056, Human
21-10 Resources Code, as added by this Act, shall request and actively
21-11 pursue any necessary waivers or authorizations from the Health Care
21-12 Financing Administration or other appropriate entities to enable
21-13 the agency to implement the demonstration project not later than
21-14 September 1, 2002. The agency may delay implementing the
21-15 demonstration project until the necessary waivers or authorizations
21-16 are granted.
21-17 SECTION 8. (a) Subchapter B, Chapter 32, Human Resources
21-18 Code, is amended by adding Section 32.057 to read as follows:
21-19 Sec. 32.057. PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY
21-20 (PACE). (a) The department, as a part of the medical assistance
21-21 program, shall develop and implement a program of all-inclusive
21-22 care for the elderly (PACE) in accordance with Section 4802 of the
21-23 Balanced Budget Act of 1997 (Pub. L. No. 105-33), as amended. The
21-24 department shall provide medical assistance to a participant in the
21-25 PACE program in the manner and to the extent authorized by federal
21-26 law.
21-27 (b) The department shall adopt rules as necessary to
22-1 implement this section. In adopting rules, the department shall:
22-2 (1) use the Bienvivir Senior Health Services of El
22-3 Paso initiative as a model for the program; and
22-4 (2) ensure that a person is not required to hold a
22-5 certificate of authority as a health maintenance organization under
22-6 the Texas Health Maintenance Organization Act (Chapter 20A,
22-7 Vernon's Texas Insurance Code) to provide services under the PACE
22-8 program.
22-9 (c) The department may not contract with a person to provide
22-10 services under the PACE program unless the person:
22-11 (1) purchases reinsurance in an amount determined by
22-12 the department that is sufficient to ensure the person's continued
22-13 solvency; or
22-14 (2) has the financial resources sufficient to cover
22-15 expenses in the event of the person's insolvency.
22-16 (d) To demonstrate sufficiency of financial resources for
22-17 purposes of Subsection (c)(2), a person may use cash reserves, a
22-18 letter of credit, a guarantee of a company affiliated with the
22-19 person, or a combination of those arrangements. The amount of a
22-20 person's financial arrangement must be at least equal to the sum
22-21 of:
22-22 (1) the total capitation revenue for one month; and
22-23 (2) the average monthly payment of operating expenses.
22-24 (e) The department shall consult with the Texas Department
22-25 of Insurance in determining a person's sufficiency of financial
22-26 resources for continued solvency or to cover expenses in the event
22-27 of the person's insolvency as required by Subsection (c).
23-1 (f) The department, with direction from the Health and Human
23-2 Services Commission, shall develop and implement a coordinated plan
23-3 to promote PACE program sites operating under this section. The
23-4 department shall adopt policies and procedures to ensure that
23-5 caseworkers and any other appropriate state agency staff discuss
23-6 the benefits of participating in the PACE program with long-term
23-7 care clients.
23-8 (b) The state agency administering the program of
23-9 all-inclusive care for the elderly (PACE) implemented under Section
23-10 32.057, Human Resources Code, as added by this Act, shall use its
23-11 best efforts to develop and support multiple PACE program sites.
23-12 (c) If before June 1, 2004, the state does not receive
23-13 federal approval for the operation of all PACE program sites for
23-14 which the state has applied solely because the federal limit on the
23-15 number of new PACE program sites allowed nationwide per year has
23-16 been attained, the Health and Human Services Commission and Texas
23-17 Department of Human Services, not later than September 1, 2004,
23-18 shall examine federal laws and regulations regarding PACE programs
23-19 and identify changes to law that would result in an increased
23-20 number of PACE programs in this state.
23-21 (d) Not later than December 1, 2004, the commissioner of
23-22 health and human services shall submit to the legislature a written
23-23 report concerning the results of the examination conducted under
23-24 Subsection (c) of this section. The report must include any
23-25 recommendations for memorializing the Congress of the United States
23-26 to request changes to federal laws or regulations.
23-27 (e) As soon as practicable after the effective date of this
24-1 Act, the Health and Human Services Commission shall submit an
24-2 amendment to the state's Medicaid plan authorizing the state to
24-3 implement the program of all-inclusive care for the elderly (PACE)
24-4 established under Section 32.057, Human Resources Code, as added by
24-5 this Act. The commission is not required to submit an additional
24-6 amendment to the state's Medicaid plan each time the state agency
24-7 administering the PACE program selects and enters into a proposed
24-8 agreement with a provider to deliver services under the program.
24-9 SECTION 9. (a) Subchapter B, Chapter 531, Government Code,
24-10 is amended by adding Sections 531.02101-531.02106 to read as
24-11 follows:
24-12 Sec. 531.02101. TRANSFER AUTHORITY RELATING TO
24-13 ADMINISTRATION OF MEDICAID PROGRAM. (a) To the extent that
24-14 reorganization is necessary to achieve the goals of increased
24-15 administrative efficiency, increased accountability, or cost
24-16 savings in the Medicaid program or to otherwise improve the health
24-17 of residents of this state, the commission, subject to Subsection
24-18 (b), may transfer any power, duty, function, program, activity,
24-19 obligation, right, contract, record, employee, property, or
24-20 appropriation or other money relating to administration of the
24-21 Medicaid program from a health and human services agency to the
24-22 commission.
24-23 (b) A transfer authorized by Subsection (a) may not take
24-24 effect unless approved by the Medicaid legislative oversight
24-25 committee created under Section 531.02102.
24-26 (c) The commission must notify the Legislative Budget Board
24-27 and the governor's office of budget and planning not later than the
25-1 30th day before the effective date of a transfer authorized by
25-2 Subsection (a).
25-3 Sec. 531.02102. MEDICAID LEGISLATIVE OVERSIGHT COMMITTEE.
25-4 (a) The Medicaid legislative oversight committee is composed of:
25-5 (1) three members of the senate appointed by the
25-6 lieutenant governor; and
25-7 (2) three members of the house of representatives
25-8 appointed by the speaker of the house of representatives.
25-9 (b) A member of the Medicaid legislative oversight committee
25-10 serves at the pleasure of the appointing official.
25-11 (c) The lieutenant governor and speaker of the house of
25-12 representatives shall appoint the presiding officer of the Medicaid
25-13 legislative oversight committee on an alternating basis. The
25-14 presiding officer shall serve a two-year term expiring February 1
25-15 of each odd-numbered year.
25-16 (d) The Medicaid legislative oversight committee shall:
25-17 (1) meet not more than quarterly at the call of the
25-18 presiding officer; and
25-19 (2) review and approve or reject any transfer proposed
25-20 by the commission of a power, duty, function, program, activity,
25-21 obligation, right, contract, record, employee, property, or
25-22 appropriation or other money relating to administration of the
25-23 Medicaid program from a health and human services agency to the
25-24 commission.
25-25 (e) The Medicaid legislative oversight committee may use
25-26 staff of standing committees in the senate and house of
25-27 representatives with appropriate jurisdiction, the Department of
26-1 Information Resources, the state auditor, the Texas Legislative
26-2 Council, and the Legislative Budget Board in carrying out its
26-3 responsibilities.
26-4 Sec. 531.02103. MEDICAID PROGRAM: STRATEGIES FOR IMPROVING
26-5 BUDGET CERTAINTY AND COST SAVINGS. (a) To achieve administrative
26-6 efficiency and cost savings in the Medicaid program, the commission
26-7 shall develop and implement strategies to improve management of the
26-8 cost, quality, and use of services provided under the program. The
26-9 strategies developed and implemented under this section may
26-10 include:
26-11 (1) expansion of an enhanced primary care case
26-12 management model in areas of the state currently subject to
26-13 fee-for-service arrangements;
26-14 (2) use of medical case management for complex medical
26-15 cases;
26-16 (3) mandatory enrollment of some or all Medicaid
26-17 recipients who receive Supplemental Security Income (SSI) (42
26-18 U.S.C. Section 1381 et seq.) into a STAR + Plus pilot program in an
26-19 area of the state served by a STAR + Plus pilot program as of
26-20 January 1, 2001, or into an alternate managed care model developed
26-21 by the commission;
26-22 (4) use of telemedicine for children and other persons
26-23 with special health care needs;
26-24 (5) use of copayments and other mechanisms to
26-25 encourage responsible use of health care services under the
26-26 program, provided that implementation occurs in accordance with
26-27 Section 531.02106;
27-1 (6) use of procurement initiatives such as selective
27-2 contracting as a mechanism for obtaining provider services under
27-3 the program, provided that the initiatives may not apply to
27-4 pharmacies participating in the vendor drug program;
27-5 (7) expansion of the program of all-inclusive care for
27-6 the elderly (PACE), as authorized by Section 4802 of the Balanced
27-7 Budget Act of 1997 (Pub. L. No. 105-33), as amended, to additional
27-8 sites;
27-9 (8) use of disease management and drug therapy
27-10 management for Medicaid recipients with chronic diseases, including
27-11 congestive heart failure, chronic obstructive pulmonary disease,
27-12 asthma, and diabetes;
27-13 (9) use of cost controls in the provision of
27-14 pharmaceutical services as necessary to ensure appropriate pricing,
27-15 cost-effective use of pharmaceutical products, and the state's
27-16 greatest entitlement to rebates from pharmaceutical manufacturers;
27-17 (10) use of competitive pricing for medical equipment
27-18 and supplies, including vision care equipment and supplies;
27-19 (11) expansion of the health insurance premium payment
27-20 reimbursement system (HIPPS); and
27-21 (12) reduction of hospital outlier payments by not
27-22 more than five percent for cases that exceed the established rate
27-23 of reimbursement.
27-24 (b) The commission shall consult with local communities,
27-25 providers, consumers, and other affected parties in the development
27-26 and implementation of strategies under Subsection (a) and shall
27-27 solicit input on the need for and effect of those strategies. The
28-1 commission may use existing state or local advisory committees for
28-2 this purpose or may hold public hearings in the development of
28-3 agency rules and procedures and necessary state plan amendments or
28-4 waivers.
28-5 Sec. 531.02104. MEDICAID ELIGIBILITY AND ENROLLMENT. The
28-6 commission shall ensure that:
28-7 (1) the Medicaid eligibility policies, processes, and
28-8 time frames of the Texas Department of Human Services, including
28-9 policies, processes, and time frames relating to an applicant or
28-10 recipient whose eligibility status is on hold, are designed to
28-11 minimize the time that an applicant or recipient is required to
28-12 wait before the applicant or recipient begins receiving services or
28-13 is recertified;
28-14 (2) each state agency operating a part of the Medicaid
28-15 program conforms the Medicaid eligibility policies and related
28-16 processes and time frames, including any cutoff dates, of the
28-17 agency and any agency contractor to the Medicaid eligibility
28-18 policies, processes, and time frames of the Texas Department of
28-19 Human Services; and
28-20 (3) the Medicaid eligibility policies, processes, and
28-21 time frames of each agency operating a part of the Medicaid program
28-22 and any agency contractor are designed to minimize the time that an
28-23 applicant or recipient is required to wait before receiving
28-24 services.
28-25 Sec. 531.02105. TEXAS HEALTH STEPS PROGRAM. The commission
28-26 shall:
28-27 (1) take all actions necessary to simplify:
29-1 (A) provider enrollment in the Texas Health
29-2 Steps program;
29-3 (B) reporting requirements relating to the Texas
29-4 Health Steps program; and
29-5 (C) billing and coding procedures so that Texas
29-6 Health Steps program processes are more consistent with commercial
29-7 standards;
29-8 (2) in consultation with providers of Texas Health
29-9 Steps program services, develop mechanisms to promote accurate,
29-10 reliable, and timely reporting of examinations of children
29-11 conducted under the program to managed care organizations and other
29-12 appropriate entities;
29-13 (3) in consultation with providers of Texas Health
29-14 Steps program services, develop a mechanism to promote
29-15 incorporation of Texas Health Steps program services into a child's
29-16 medical home; and
29-17 (4) require the external quality monitoring
29-18 organization to evaluate the Texas Health Steps program using
29-19 information available from all relevant sources and prepare
29-20 periodic reports regarding the program for submission by the
29-21 commission to the legislature.
29-22 Sec. 531.02106. GUIDELINES FOR MEDICAID COST-SHARING. Before
29-23 requiring Medicaid recipients to make copayments or comply with
29-24 other cost-sharing requirements, the commission by rule shall:
29-25 (1) establish monthly limits on total copayments and
29-26 other cost-sharing requirements so that:
29-27 (A) a recipient with an income at or below the
30-1 federal poverty level is not required to pay more than the lesser
30-2 of $10 or five percent of the recipient's monthly household gross
30-3 income, and the total amount required to be paid by all members of
30-4 a household consisting only of recipients with incomes at or below
30-5 the federal poverty level does not exceed five percent of the
30-6 recipients' monthly household gross income; and
30-7 (B) a recipient with an income above the federal
30-8 poverty level is not required to pay more than five percent of the
30-9 recipient's monthly household gross income, and the total amount
30-10 required to be paid by all members of a household that includes a
30-11 recipient with an income above the federal poverty level does not
30-12 exceed five percent of the members' monthly household gross income;
30-13 and
30-14 (2) exempt preventive care services from any copayment
30-15 or other cost-sharing requirements.
30-16 (b) As soon as possible after the effective date of this
30-17 Act, the lieutenant governor and the speaker of the house of
30-18 representatives shall appoint the members of the Medicaid
30-19 legislative oversight committee created by Section 531.02102,
30-20 Government Code, as added by this Act. The speaker of the house of
30-21 representatives shall appoint the initial presiding officer of the
30-22 committee.
30-23 SECTION 10. Subchapter B, Chapter 531, Government Code, is
30-24 amended by adding Section 531.02131 to read as follows:
30-25 Sec. 531.02131. COMMUNITY OUTREACH CAMPAIGN. (a) The
30-26 commission shall conduct a community outreach campaign to provide
30-27 information relating to the availability of Medicaid coverage for
31-1 children and adults and to promote enrollment of eligible children
31-2 and adults in Medicaid.
31-3 (b) As a part of the community outreach campaign, the
31-4 commission shall inform potential Medicaid recipients of the
31-5 toll-free telephone assistance number required by Section 531.0213.
31-6 (c) The commission shall contract with community-based
31-7 organizations and other organizations, as appropriate, for
31-8 assistance in implementing the community outreach campaign.
31-9 (d) In designing the community outreach campaign, the
31-10 commission shall include components similar to components of the
31-11 community outreach campaign required under Section 62.056, Health
31-12 and Safety Code.
31-13 (e) To the extent feasible and appropriate, the commission
31-14 may combine the community outreach campaign required by this
31-15 section with any other state outreach campaign or educational
31-16 activity relating to health care and available health care
31-17 coverage.
31-18 SECTION 11. Subsection (d), Section 531.0214, Government
31-19 Code, is amended to read as follows:
31-20 (d) The commission shall develop the database system in a
31-21 manner that will enable a complete analysis of the use of
31-22 prescription medications[, including information relating to:]
31-23 [(1) Medicaid clients for whom more than three
31-24 medications have been prescribed; and]
31-25 [(2) the medical effect denial of Medicaid coverage
31-26 for more than three medications has had on Medicaid clients].
31-27 SECTION 12. Subsection (a), Section 531.026, Government
32-1 Code, is amended to read as follows:
32-2 (a) The commission shall prepare and submit to the
32-3 lieutenant governor, the speaker of the house of representatives,
32-4 the comptroller, the Legislative Budget Board, [and] the governor's
32-5 office of budget and planning, each member of the appropriations
32-6 committees of the senate and house of representatives, and each
32-7 member of the standing committees of the senate and house of
32-8 representatives with responsibility for oversight of health and
32-9 human services issues [governor] a consolidated health and human
32-10 services budget recommendation not later than October 15 of each
32-11 even-numbered year.
32-12 SECTION 13. Subchapter B, Chapter 531, Government Code, is
32-13 amended by adding Section 531.0261 to read as follows:
32-14 Sec. 531.0261. CONSOLIDATED MEDICAID APPROPRIATIONS REQUEST.
32-15 (a) The commission shall include in the consolidated budget
32-16 recommendation required by Section 531.026 a consolidated Medicaid
32-17 appropriations request for the subsequent fiscal biennium.
32-18 (b) The commission shall:
32-19 (1) develop the consolidated Medicaid appropriations
32-20 request with input from the Legislative Budget Board and the
32-21 governor's office of budget and planning to ensure that relevant
32-22 information for acute and long-term care Medicaid programs relating
32-23 to caseloads, costs, measures, rates, waivers, and eligibility is
32-24 reflected; and
32-25 (2) provide assistance with the legislative
32-26 appropriations process by revising the consolidated Medicaid
32-27 appropriations request each time that revised caseload and cost
33-1 estimates relating to the Medicaid program are prepared.
33-2 SECTION 14. Subchapter B, Chapter 531, Government Code, is
33-3 amended by adding Section 531.0272 to read as follows:
33-4 Sec. 531.0272. COMPREHENSIVE MEDICAID OPERATING BUDGET;
33-5 QUARTERLY EXPENDITURE REPORTS. (a) The commission shall prepare a
33-6 comprehensive Medicaid operating budget at the beginning of each
33-7 fiscal year, with input as appropriate from each health and human
33-8 services agency that receives legislative appropriations relating
33-9 to the Medicaid program.
33-10 (b) The commission shall monitor all Medicaid expenditures
33-11 by the commission and health and human services agencies and submit
33-12 quarterly Medicaid expenditure reports to the lieutenant governor,
33-13 the speaker of the house of representatives, the comptroller, the
33-14 Legislative Budget Board, the governor's office of budget and
33-15 planning, each member of the appropriations committees of the
33-16 senate and house of representatives, and each member of the
33-17 standing committees of the senate and house of representatives with
33-18 responsibility for oversight of health and human services issues.
33-19 (c) The commission shall prepare the comprehensive Medicaid
33-20 operating budget and quarterly Medicaid expenditure reports with
33-21 input from the Legislative Budget Board and the governor's office
33-22 of budget and planning to ensure that the information described by
33-23 Section 531.0261(b)(1) is reflected.
33-24 SECTION 15. Subchapter B, Chapter 531, Government Code, is
33-25 amended by adding Sections 531.055 and 531.056 to read as follows:
33-26 Sec. 531.055. MEDICAID REIMBURSEMENT RATES REPORT. Not later
33-27 than December 1 of each even-numbered year, the commission shall
34-1 prepare and deliver to the governor, the lieutenant governor, the
34-2 speaker of the house of representatives, and each member of the
34-3 legislature a report that:
34-4 (1) identifies the Medicaid provider reimbursement
34-5 rates established by rule for each county in this state and the
34-6 rates paid to providers by managed care organizations contracting
34-7 with the commission under Chapter 533 in each affected area of the
34-8 state;
34-9 (2) compares the rates identified under Subdivision
34-10 (1) to:
34-11 (A) the rates paid by other health care payors,
34-12 including Medicare, in the same county or affected area of the
34-13 state for comparable services provided to comparable populations;
34-14 and
34-15 (B) the appropriate Medicaid rates of the top 15
34-16 industrial states as ranked by the United States Department of
34-17 Commerce Bureau of Economic Analysis based on gross state product;
34-18 (3) includes information necessary to permit an
34-19 accurate comparison of reimbursement provided to pharmacies
34-20 participating in the vendor drug program, including information
34-21 relating to dispensing fees, brand name drug product cost
34-22 definitions, generic drug product cost definitions, any other
34-23 reimbursements or deductions, and total reimbursements for the top
34-24 25 brand name drug prescriptions and for the top 25 generic drug
34-25 prescriptions; and
34-26 (4) includes information resulting from cost reports
34-27 obtained from a statistically valid sample of pharmacies
35-1 participating in the vendor drug program that specify the costs of
35-2 the pharmacies in preparing and dispensing prescriptions and
35-3 providing other pharmacy services, including drug therapy
35-4 management.
35-5 Sec. 531.056. MIGRANT CARE NETWORK STUDY; PILOT PROGRAM. (a)
35-6 In this section, "migrant or seasonal agricultural worker" means an
35-7 individual who:
35-8 (1) is working or available for work seasonally or
35-9 temporarily in primarily an agricultural or agriculture-related
35-10 industry; and
35-11 (2) moves one or more times from one place to another
35-12 to perform seasonal or temporary employment or to be available for
35-13 seasonal or temporary employment.
35-14 (b) The commission shall conduct a study regarding the
35-15 feasibility of contracting with one or more existing networks of
35-16 health care providers located in this state and in other states to
35-17 establish a migrant care network to provide health care services to
35-18 children of migrant or seasonal agricultural workers who are
35-19 residents of this state and intend to return to this state at the
35-20 conclusion of temporary or seasonal employment in another state and
35-21 who are:
35-22 (1) recipients of medical assistance under Chapter 32,
35-23 Human Resources Code; or
35-24 (2) enrollees in the child health plan program under
35-25 Chapter 62, Health and Safety Code, or the health benefits plan
35-26 program under Chapter 63, Health and Safety Code.
35-27 (c) In conducting the study under this section, the
36-1 commission shall:
36-2 (1) consider migrant work patterns to determine in
36-3 which states the migrant care network is most needed to adequately
36-4 provide the medical assistance, child health plan coverage, or
36-5 health benefits plan coverage;
36-6 (2) examine the necessity and fiscal effect of
36-7 entering into interstate agreements to establish the migrant care
36-8 network; and
36-9 (3) determine whether ensuring the provision of health
36-10 care services under the medical assistance program, the child
36-11 health plan program, and the health benefits plan program for
36-12 children of migrant or seasonal agricultural workers during the
36-13 time in which a child is outside of this state is necessary to
36-14 maintain continuity of care for the child.
36-15 (d) If, based on the results of the study under this
36-16 section, the commission determines that the establishment of a
36-17 migrant care network is feasible, the commission shall develop and
36-18 implement a pilot program for that purpose. The commission by rule
36-19 shall establish eligibility criteria for participation in the pilot
36-20 program.
36-21 (e) The commission shall report its findings and
36-22 recommendations regarding the establishment of a migrant care
36-23 network to the governor, the lieutenant governor, and the standing
36-24 committees of the senate and house of representatives having
36-25 primary jurisdiction over the commission. The commission shall
36-26 make the report:
36-27 (1) on completion of the study required by this
37-1 section if the commission determines that the establishment of the
37-2 migrant care network is not feasible; or
37-3 (2) on implementation of the pilot program required by
37-4 this section if the commission determines that the establishment of
37-5 the migrant care network is feasible.
37-6 (f) This section expires September 1, 2003.
37-7 SECTION 16. (a) The purpose of this section is to pilot a
37-8 coordinated approach to addressing the needs of homeless people
37-9 with chronic illnesses who are recipients of medical assistance
37-10 under Chapter 32, Human Resources Code, so that homeless people may
37-11 learn to manage their illnesses and become productive members of
37-12 society. Current state, federal, and local agencies fund separate
37-13 programs that address only one aspect of the needs of homeless
37-14 people, such as housing, job training, and medical care. Homeless
37-15 people with chronic illnesses will benefit from a coordinated
37-16 approach that comprehensively addresses the needs of homeless
37-17 people.
37-18 (b) Subchapter B, Chapter 531, Government Code, is amended
37-19 by adding Section 531.057 to read as follows:
37-20 Sec. 531.057. PILOT CASE MANAGEMENT PROGRAM. (a) The
37-21 commission, in cooperation with the Texas Interagency Council for
37-22 the Homeless, shall develop a pilot case management program for
37-23 homeless people who have chronic illnesses, including diabetes and
37-24 HIV infection or AIDS, and who are recipients of medical assistance
37-25 under Chapter 32, Human Resources Code. The council in cooperation
37-26 with relevant state agencies shall administer the pilot program
37-27 under the direction of the commission.
38-1 (b) Using existing resources of the agencies composing the
38-2 council, the staff of the council shall:
38-3 (1) select a county with a population of more than 2.8
38-4 million in which to implement the program;
38-5 (2) identify existing services provided through
38-6 programs of the agencies composing the council to homeless people
38-7 with chronic illnesses who are recipients of medical assistance;
38-8 (3) identify existing federal, state, county, and
38-9 local sources from which money may be available to fund the pilot
38-10 program; and
38-11 (4) create a pilot case management program for not
38-12 more than 75 homeless people with chronic illnesses who are
38-13 recipients of medical assistance using existing financial and
38-14 agency resources.
38-15 (c) The council shall select, through competitive bidding, a
38-16 nonprofit entity to implement the pilot case management program for
38-17 the homeless. The pilot program established under this section
38-18 must:
38-19 (1) provide case management services and existing
38-20 health-related education services to participants of the program;
38-21 and
38-22 (2) coordinate housing, medical, job training, and
38-23 other necessary services for the participants of the program.
38-24 (d) The commission shall identify programs available through
38-25 health and human services agencies through which homeless people
38-26 described by Subsection (a) may receive housing, medical, job
38-27 placement, or other services. The commission shall report to the
39-1 council information regarding the identified programs, including
39-2 the programs' sources of funding and eligibility requirements.
39-3 (e) Not later than December 15 of each even-numbered year,
39-4 the council shall submit a report to the governor, the lieutenant
39-5 governor, and the speaker of the house of representatives regarding
39-6 the effectiveness of the pilot program established under this
39-7 section.
39-8 (f) This section expires September 1, 2005.
39-9 (c) The Health and Human Services Commission shall develop
39-10 and the Texas Interagency Council for the Homeless shall implement
39-11 the pilot program established under this section not later than
39-12 November 1, 2001.
39-13 SECTION 17. The heading to Chapter 533, Government Code, is
39-14 amended to read as follows:
39-15 CHAPTER 533. DEVELOPMENT AND IMPLEMENTATION
39-16 OF MEDICAID MANAGED CARE PROGRAM
39-17 SECTION 18. Subchapter A, Chapter 533, Government Code, is
39-18 amended by amending Sections 533.001 and 533.002 and adding
39-19 Sections 533.0021, 533.0022, and 533.0023 to read as follows:
39-20 Sec. 533.001. Definitions. In this chapter:
39-21 (1) "Commission" means the Health and Human Services
39-22 Commission or an agency operating part of the state Medicaid
39-23 managed care program, as appropriate.
39-24 (2) "Commissioner" means the commissioner of health
39-25 and human services.
39-26 (3) "Health and human services agencies" has the
39-27 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:
40-27 (A) improves the health of the people of this
41-1 state by:
41-2 (i) emphasizing prevention;
41-3 (ii) promoting continuity of care; and
41-4 (iii) providing a medical home for
41-5 recipients;
41-6 (B) ensures that each recipient receives
41-7 high-quality, comprehensive health care services in the recipient's
41-8 local community; and
41-9 (C) ensures that the community supports the
41-10 implementation of the system in the health care service region, to
41-11 be ascertained through a public hearing in the community at which
41-12 the commission takes public comment from health care consumers and
41-13 physicians and other health care providers;
41-14 (2) to the extent that it is cost-effective to this
41-15 state and local governments:
41-16 (A) maximize the financing of the state Medicaid
41-17 program by obtaining federal matching funds for all resources or
41-18 other money available for matching; and
41-19 (B) expand Medicaid eligibility to include
41-20 persons who were eligible to receive indigent health care services
41-21 through the use of those resources or other money available for
41-22 matching before expansion of eligibility; and
41-23 (3) develop and prepare the waiver or other documents
41-24 necessary to obtain federal authorization for the system.
41-25 Sec. 533.0022. PURPOSE. The commission shall implement the
41-26 Medicaid managed care program as part of the health care delivery
41-27 system developed under this chapter [Chapter 532] by contracting
42-1 with managed care organizations in a manner that, to the extent
42-2 possible:
42-3 (1) accomplishes the goals described by Section
42-4 533.0021 [improves the health of Texans by:]
42-5 [(A) emphasizing prevention;]
42-6 [(B) promoting continuity of care; and]
42-7 [(C) providing a medical home for recipients;]
42-8 [(2) ensures that each recipient receives high
42-9 quality, comprehensive health care services in the recipient's
42-10 local community];
42-11 (2) [(3)] encourages the training of and access to
42-12 primary care physicians and providers;
42-13 (3) [(4)] maximizes cooperation with existing public
42-14 health entities, including local departments of health and
42-15 community mental health and mental retardation centers established
42-16 under Chapter 534, Health and Safety Code;
42-17 (4) [(5)] provides incentives to managed care
42-18 organizations to improve the quality of health care services for
42-19 recipients by providing value-added services; [and]
42-20 (5) [(6)] reduces administrative and other
42-21 nonfinancial barriers for recipients in obtaining health care
42-22 services; and
42-23 (6) controls the costs associated with the state
42-24 Medicaid program.
42-25 Sec. 533.0023. RULES FOR HEALTH CARE DELIVERY SYSTEM. The
42-26 commissioner of insurance shall adopt rules as necessary or
42-27 appropriate to carry out the functions of the Texas Department of
43-1 Insurance under this chapter.
43-2 SECTION 19. Section 533.003, Government Code, is amended to
43-3 read as follows:
43-4 Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. (a) In
43-5 awarding contracts to managed care organizations, the commission
43-6 shall:
43-7 (1) give preference to organizations that have
43-8 significant participation in the organization's provider network
43-9 from each health care provider in the region who has traditionally
43-10 provided care to Medicaid and charity care patients;
43-11 (2) give extra consideration to organizations that
43-12 agree to assure continuity of care for at least three months beyond
43-13 the period of Medicaid eligibility for recipients;
43-14 (3) consider the need to use different managed care
43-15 plans to meet the needs of different populations; and
43-16 (4) consider the ability of organizations to process
43-17 Medicaid claims electronically.
43-18 (b) The commission may not award a contract to or renew a
43-19 contract with a managed care organization that, after July 1, 2001,
43-20 has a policy that the usual and customary reimbursement rate for a
43-21 health care provider who is outside the organization's provider
43-22 network is equal to the lowest contracted rate the organization has
43-23 negotiated with a provider who is in the network in the same health
43-24 care service region.
43-25 SECTION 20. Subchapter A, Chapter 533, Government Code, is
43-26 amended by adding Section 533.0035 to read as follows:
43-27 Sec. 533.0035. LIMITATION ON NUMBER OF CONTRACTS AWARDED.
44-1 The commission shall:
44-2 (1) evaluate the number of managed care organizations
44-3 with which the commission contracts to provide health care services
44-4 in each health care service region, focusing particularly on the
44-5 market share of those managed care organizations; and
44-6 (2) limit the number of contracts awarded to managed
44-7 care organizations under this chapter in a manner that promotes the
44-8 successful implementation of the delivery of health care services
44-9 through the state Medicaid managed care program.
44-10 SECTION 21. (a) Section 533.005, Government Code, is
44-11 amended to read as follows:
44-12 Sec. 533.005. REQUIRED CONTRACT PROVISIONS. A contract
44-13 between a managed care organization and the commission for the
44-14 organization to provide health care services to recipients must
44-15 contain:
44-16 (1) procedures to ensure accountability to the state
44-17 for the provision of health care services, including procedures for
44-18 financial reporting, quality assurance, utilization review, and
44-19 assurance of contract and subcontract compliance;
44-20 (2) capitation and provider payment rates that ensure
44-21 the cost-effective provision of quality health care;
44-22 (3) a requirement that the managed care organization
44-23 provide ready access to a person who assists recipients in
44-24 resolving issues relating to enrollment, plan administration,
44-25 education and training, access to services, and grievance
44-26 procedures;
44-27 (4) a requirement that the managed care organization
45-1 provide ready access to a person who assists providers in resolving
45-2 issues relating to payment, plan administration, education and
45-3 training, and grievance procedures;
45-4 (5) a requirement that the managed care organization
45-5 provide information and referral about the availability of
45-6 educational, social, and other community services that could
45-7 benefit a recipient;
45-8 (6) procedures for recipient outreach and education;
45-9 (7) a requirement that the managed care organization
45-10 make payment to a physician or provider for health care services
45-11 rendered to a recipient under a managed care plan not later than
45-12 the 45th day after the date a claim for payment is received with
45-13 documentation reasonably necessary for the managed care
45-14 organization to process the claim, or within a period, not to
45-15 exceed 60 days, specified by a written agreement between the
45-16 physician or provider and the managed care organization;
45-17 (8) a requirement that the commission, on the date of
45-18 a recipient's enrollment in a managed care plan issued by the
45-19 managed care organization, inform the organization of the
45-20 recipient's Medicaid certification date;
45-21 (9) a requirement that the managed care organization
45-22 comply with Section 533.006 as a condition of contract retention
45-23 and renewal; [and]
45-24 (10) a requirement that the managed care organization
45-25 provide the information required by Section 533.012 and otherwise
45-26 comply and cooperate with the commission's office of investigations
45-27 and enforcement;
46-1 (11) a requirement that the managed care organization
46-2 or managed care plan reimburse health care providers for medical
46-3 screening and stabilization of an emergency medical or psychiatric
46-4 condition and not use a triage method of reimbursement; and
46-5 (12) a process by which the commission is required to:
46-6 (A) provide in writing to the managed care
46-7 organization the projected fiscal impact on the state and managed
46-8 care organizations that contract with the commission under this
46-9 chapter of proposed Medicaid managed care program, benefit, or
46-10 contract changes; and
46-11 (B) negotiate in good faith regarding
46-12 appropriate operational and financial changes to the contract with
46-13 the managed care organization before implementing those changes.
46-14 (b) The changes in law made by Section 533.005, Government
46-15 Code, as amended by this Act, apply to a contract between the
46-16 Health and Human Services Commission and a managed care
46-17 organization under Chapter 533, Government Code, that is entered
46-18 into or renewed on or after the effective date of this Act. A
46-19 contract that is entered into or renewed before the effective date
46-20 of this Act is governed by the law in effect on the date the
46-21 contract was entered into or renewed, and the former law is
46-22 continued in effect for that purpose.
46-23 SECTION 22. (a) Subchapter A, Chapter 533, Government Code,
46-24 is amended by adding Sections 533.0051, 533.0076, 533.0091,
46-25 533.0131, and 533.016-533.0208 to read as follows:
46-26 Sec. 533.0051. CONTRACT RENEWAL. Before renewing a contract
46-27 with a managed care organization under this chapter, the commission
47-1 shall consider:
47-2 (1) the managed care organization's:
47-3 (A) overall contract compliance;
47-4 (B) implementation of simplified administrative
47-5 processes for health care providers and recipients;
47-6 (C) compliance with statutory requirements to
47-7 promptly reimburse health care providers for covered services
47-8 provided under the Medicaid managed care program;
47-9 (D) compliance with the requirements under
47-10 Article 3.70-3C, Insurance Code, as added by Chapter 1260, Acts of
47-11 the 75th Legislature, Regular Session, 1997, and Section 14, Texas
47-12 Health Maintenance Organization Act (Article 20A.14, Vernon's Texas
47-13 Insurance Code), to identify advanced practice nurses and physician
47-14 assistants as providers in the managed care organization's provider
47-15 network;
47-16 (E) financial performance; and
47-17 (F) participation in the state child health plan
47-18 under Chapter 62, Health and Safety Code; and
47-19 (2) the level of satisfaction of recipients and health
47-20 care providers with the managed care organization.
47-21 Sec. 533.0076. LIMITATIONS ON RECIPIENT DISENROLLMENT. (a)
47-22 Except as provided by Subsections (b) and (c), and to the extent
47-23 permitted by federal law, the commission may prohibit a recipient
47-24 from disenrolling in a managed care plan under this chapter and
47-25 enrolling in another managed care plan during the 12-month period
47-26 after the date the recipient initially enrolls in a plan.
47-27 (b) At any time before the 91st day after the date of a
48-1 recipient's initial enrollment in a managed care plan under this
48-2 chapter, the recipient may disenroll in that plan for any reason
48-3 and enroll in another managed care plan under this chapter.
48-4 (c) The commission shall allow a recipient who is enrolled
48-5 in a managed care plan under this chapter to disenroll in that plan
48-6 at any time for cause in accordance with federal law.
48-7 Sec. 533.0091. UNIFORM STANDARDS FOR IDENTIFYING RECIPIENTS
48-8 WITH DISABILITIES OR CHRONIC CONDITIONS. (a) The commission shall
48-9 collaborate with managed care organizations that contract with the
48-10 commission under this chapter to develop a uniform screening tool
48-11 to be used by the managed care organizations to identify adult
48-12 recipients with disabilities or chronic health conditions and
48-13 assist those recipients in accessing health care services.
48-14 (b) The commission, in cooperation with the Texas Department
48-15 of Health, by rule shall adopt criteria by which to classify a
48-16 child with certain health conditions as a child with special health
48-17 care needs. In adopting the criteria, the commission must include
48-18 children who have:
48-19 (1) severe disabilities;
48-20 (2) severe mental or emotional disorders;
48-21 (3) medically complex or fragile health conditions; or
48-22 (4) rare or chronic health conditions that are likely
48-23 to last at least one year and result in limitations on the child's
48-24 functioning and activities when compared to other children of the
48-25 same age who do not have those conditions.
48-26 (c) The commission, in cooperation with the Texas Department
48-27 of Health, shall:
49-1 (1) monitor and assess health care services provided
49-2 under the state Medicaid managed care program and the medical
49-3 assistance program under Chapter 32, Human Resources Code, to
49-4 children with special health care needs as determined by the
49-5 criteria adopted under Subsection (b);
49-6 (2) adopt specific quality of care standards
49-7 applicable to health care services provided under the state
49-8 Medicaid managed care program to children described by Subdivision
49-9 (1); and
49-10 (3) undertake initiatives to develop, test, and
49-11 implement optimum methods for the delivery of appropriate,
49-12 comprehensive, and cost-effective health care services under the
49-13 state Medicaid managed care program to children described by
49-14 Subdivision (1), including initiatives to:
49-15 (A) coordinate health care services with
49-16 educational programs and other social and community services; and
49-17 (B) promote family involvement and support.
49-18 Sec. 533.0131. USE OF ENCOUNTER DATA IN DETERMINING PREMIUM
49-19 PAYMENT RATES. (a) In determining premium payment rates and other
49-20 amounts paid to managed care organizations under a managed care
49-21 plan, the commission may not base or derive the rates or amounts on
49-22 or from encounter data, or incorporate in the determination an
49-23 analysis of encounter data, unless a certifier of encounter data
49-24 certifies that:
49-25 (1) the encounter data for the most recent state
49-26 fiscal year is complete, accurate, and reliable; and
49-27 (2) there is no statistically significant variability
50-1 in the encounter data attributable to incompleteness, inaccuracy,
50-2 or another deficiency as compared to equivalent data for similar
50-3 populations and when evaluated against professionally accepted
50-4 standards.
50-5 (b) For purposes of determining whether data is equivalent
50-6 data for similar populations under Subsection (a)(2), a certifier
50-7 of encounter data shall, at a minimum, consider:
50-8 (1) the regional variation in utilization patterns of
50-9 recipients and costs of health care services;
50-10 (2) the range and type of health care services to be
50-11 covered by premium payment rates;
50-12 (3) the number of managed care plans in the region;
50-13 and
50-14 (4) the current number of recipients in each region,
50-15 including the number for each category of recipient.
50-16 Sec. 533.016. INTERAGENCY SHARING OF INFORMATION. (a) The
50-17 commission shall require a health and human services agency
50-18 implementing the Medicaid managed care program to provide to each
50-19 other health and human services agency implementing the program
50-20 information reported to the agency by a managed care organization
50-21 or health care provider providing services to recipients.
50-22 (b) Except as prohibited by federal law, the commission,
50-23 each health and human services agency implementing the Medicaid
50-24 managed care program, and the Texas Department of Insurance shall
50-25 share confidential information, including financial data, that
50-26 relates to or affects a person who proposes to contract with or has
50-27 contracted with a state agency or a contractor of a state agency
51-1 for the purposes of this chapter.
51-2 (c) Information shared between agencies under Subsection (b)
51-3 remains confidential and is not subject to disclosure under Chapter
51-4 552.
51-5 Sec. 533.017. REDUCTION AND COORDINATION OF REPORTING
51-6 REQUIREMENTS AND INSPECTION PROCEDURES. (a) The commission shall:
51-7 (1) streamline on-site inspection procedures of
51-8 managed care organizations contracting with the commission under
51-9 this chapter;
51-10 (2) streamline reporting requirements for managed care
51-11 organizations contracting with the commission under this chapter,
51-12 including:
51-13 (A) combining information required to be
51-14 reported into a quarterly management report;
51-15 (B) eliminating unnecessary or duplicative
51-16 reporting requirements; and
51-17 (C) to the extent feasible, allowing managed
51-18 care organizations contracting with the commission under this
51-19 chapter to submit reports electronically;
51-20 (3) require managed care organizations contracting
51-21 with the commission under this chapter to streamline administrative
51-22 processes required of health care providers, including:
51-23 (A) simplifying and standardizing, to the extent
51-24 reasonably feasible, the forms providers are required to complete,
51-25 including forms for preauthorization for covered services;
51-26 (B) eliminating unnecessary or duplicative
51-27 reporting requirements; and
52-1 (C) encouraging the adoption of collaboratively
52-2 developed uniform forms; and
52-3 (4) designate one entity to which managed care
52-4 organizations contracting with the commission under this chapter
52-5 may report encounter data.
52-6 (b) Except as provided by Subsection (d), the commission and
52-7 the Texas Department of Insurance and contractors of the commission
52-8 or department may not schedule, initiate, prepare for, or conduct a
52-9 documentary, electronic, or on-site review, a readiness,
52-10 compliance, or performance review, or any other review, audit, or
52-11 examination of a managed care organization contracting with the
52-12 commission under this chapter until:
52-13 (1) the commission, the department, and, if
52-14 appropriate, each health and human services agency implementing a
52-15 part of the Medicaid managed care program enter into a memorandum
52-16 of understanding under Section 533.018; and
52-17 (2) the agencies described by Subdivision (1) provide
52-18 that memorandum to the managed care organization.
52-19 (c) Notwithstanding Subsection (b), the commission or the
52-20 Texas Department of Insurance may take any action:
52-21 (1) otherwise authorized by law to protect the safety
52-22 of a recipient; or
52-23 (2) with respect to a managed care organization
52-24 determined to be in a hazardous financial condition.
52-25 (d) The commission and the Texas Department of Insurance may
52-26 review monthly, quarterly, or annual reports required to be filed
52-27 by managed care organizations contracting with the commission under
53-1 this chapter.
53-2 Sec. 533.018. MEMORANDUM OF UNDERSTANDING REGARDING
53-3 COORDINATION OF REPORTING REQUIREMENTS AND INSPECTION PROCEDURES.
53-4 (a) The commission, the Texas Department of Insurance, and, if
53-5 appropriate, each health and human services agency implementing a
53-6 part of the Medicaid managed care program shall enter into a
53-7 memorandum of understanding that outlines methods to:
53-8 (1) maximize interagency coordination in conducting
53-9 reviews of managed care organizations contracting with the
53-10 commission under this chapter; and
53-11 (2) eliminate and prevent duplicative monitoring,
53-12 regulation, and enforcement policies and processes with respect to
53-13 those managed care organizations.
53-14 (b) The memorandum of understanding under this section must:
53-15 (1) ensure that managed care organizations contracting
53-16 with the commission under this chapter are not required to file the
53-17 same or similar information with more than one state agency;
53-18 (2) maximize the use of electronic filing of
53-19 information by managed care organizations contracting with the
53-20 commission under this chapter;
53-21 (3) specifically identify all information, documents,
53-22 and reports that managed care organizations contracting with the
53-23 commission under this chapter are required to file with state
53-24 agencies, either electronically or otherwise, and describe the
53-25 information, documents, or reports and the authority for the filing
53-26 requirement;
53-27 (4) ensure that regularly scheduled, comprehensive
54-1 compliance monitoring of and enforcement efforts with respect to
54-2 managed care organizations contracting with the commission under
54-3 this chapter:
54-4 (A) are highly coordinated between the agencies
54-5 entering into the memorandum of understanding and consolidate
54-6 similar monitoring and enforcement functions of each agency in a
54-7 unified, streamlined process; and
54-8 (B) do not require duplication of efforts of
54-9 agency employees or contractors or the managed care organizations;
54-10 (5) include as an attachment the operational and
54-11 financial audit instrument to be developed under Section 533.019;
54-12 (6) specify in detail the process by which the
54-13 commission and the Texas Department of Insurance will amend the
54-14 operational and financial audit instrument developed under Section
54-15 533.019;
54-16 (7) specify in detail the process by which the
54-17 commission and the Texas Department of Insurance will jointly
54-18 schedule a single on-site visit that satisfies the requirements of
54-19 all state agencies regarding regularly scheduled, comprehensive
54-20 compliance monitoring of and enforcement efforts with respect to
54-21 managed care organizations contracting with the commission under
54-22 this chapter;
54-23 (8) specify in detail the process by which the
54-24 commission and the Texas Department of Insurance will coordinate
54-25 with respect to:
54-26 (A) focus studies, market conduct
54-27 investigations, data calls, and any type of ad hoc requests for
55-1 information from or performance reviews of a managed care
55-2 organization that contracts with the commission under this chapter;
55-3 (B) investigations of complaints regarding a
55-4 managed care organization that contracts with the commission under
55-5 this chapter, both before and during the investigation; and
55-6 (C) the development and implementation of
55-7 corrective action plans for and enforcement actions against a
55-8 managed care organization that contracts with the commission under
55-9 this chapter;
55-10 (9) specify the manner in which the commission and the
55-11 Texas Department of Insurance will:
55-12 (A) ensure the regular exchange of information
55-13 between the commission, the department, and each health and human
55-14 services agency that operates a part of the Medicaid managed care
55-15 program, including information regarding:
55-16 (i) the names of and contact information
55-17 for agency staff members having monitoring and enforcement
55-18 responsibilities with respect to managed care organizations that
55-19 contract with the commission under this chapter; and
55-20 (ii) each agency staff member responsible
55-21 for collecting and distributing information to be exchanged and the
55-22 frequency with which that information will be exchanged;
55-23 (B) schedule and conduct regular, periodic
55-24 interagency briefings by electronic notice or otherwise to assist
55-25 agency staff members in:
55-26 (i) remaining informed regarding current
55-27 monitoring and enforcement activities; and
56-1 (ii) coordinating monitoring and
56-2 enforcement activities, including coordinating persons who will
56-3 participate in the activities, and the frequency with which the
56-4 activities will be conducted;
56-5 (C) schedule and conduct interagency orientation
56-6 and training to ensure that agency staff members are familiar with:
56-7 (i) the obligation to eliminate and
56-8 prevent duplicative monitoring and enforcement activities;
56-9 (ii) the general regulatory
56-10 responsibilities of each agency; and
56-11 (iii) resources for maintaining
56-12 coordination between the agencies;
56-13 (D) ensure that the agencies eliminate and
56-14 prevent duplication of efforts by agency employees and contractors
56-15 and managed care organizations that contract with the commission
56-16 under this chapter with respect to the activities of contractors
56-17 who communicate or interact with the managed care organizations;
56-18 and
56-19 (E) ensure coordination to eliminate and prevent
56-20 duplication regarding policy development and implementation,
56-21 procurement, cost estimates, electronic systems issues, and
56-22 monitoring and enforcement activities with respect to managed care
56-23 organizations that serve recipients as well as enrollees in the
56-24 state child health plan under Chapter 62, Health and Safety Code;
56-25 and
56-26 (10) describe the process by which the commission and
56-27 the Texas Department of Insurance will collaborate to:
57-1 (A) identify statutory barriers to eliminating
57-2 or preventing duplicative public and private monitoring and
57-3 enforcement activities with respect to managed care organizations
57-4 that contract with the commission under this chapter; and
57-5 (B) develop recommendations for legislation
57-6 regarding removing the barriers described by Paragraph (A).
57-7 Sec. 533.019. OPERATIONAL AND FINANCIAL AUDIT INSTRUMENT.
57-8 (a) The commission and the Texas Department of Insurance shall
57-9 develop and use an operational and financial audit instrument for
57-10 regularly scheduled, comprehensive, on-site readiness, performance,
57-11 or compliance reviews, or other reviews, audits, or examinations of
57-12 managed care organizations that contract with the commission under
57-13 this chapter.
57-14 (b) In developing the operational and financial audit
57-15 instrument, the commission and the Texas Department of Insurance
57-16 must include:
57-17 (1) a method to assess compliance with each applicable
57-18 federal and state law and each applicable accreditation and
57-19 contractual requirement, including financial, actuarial,
57-20 operational, and quality of care requirements, the agencies are
57-21 authorized to enforce at least on a periodic basis;
57-22 (2) a method to assess compliance of documents,
57-23 records, and electronic files the commission or the Texas
57-24 Department of Insurance requires managed care organizations that
57-25 contract with the commission under this chapter to submit for
57-26 review, either before or as an alternative to an on-site review,
57-27 audit, or examination; and
58-1 (3) a method to assess compliance through on-site
58-2 reviews, audits, and examinations, including document review,
58-3 electronic systems testing or review, and observation and
58-4 interviews of managed care organization employees.
58-5 (c) The commission and the Texas Department of Insurance may
58-6 contract on a competitive bid basis with a consultant not
58-7 affiliated with the commission or department to develop the
58-8 operational and financial audit instrument required by this
58-9 section.
58-10 Sec. 533.020. PREAUTHORIZATION FOR CERTAIN SERVICES NOT
58-11 REQUIRED. The commission, in consultation with physicians,
58-12 hospitals, and managed care organizations contracting with the
58-13 commission under this chapter, shall develop:
58-14 (1) a process by which the managed care organizations
58-15 eliminate preauthorization processes for covered services that are
58-16 considered to be routine services; and
58-17 (2) a process by which to notify health care providers
58-18 of covered services under the Medicaid managed care program for
58-19 which preauthorization is not required.
58-20 Sec. 533.0201. UTILIZATION REVIEW UNDER PRIMARY CARE CASE
58-21 MANAGEMENT NETWORK. To the extent allowed by federal law, the
58-22 commission shall require a managed care organization that contracts
58-23 with the commission under this chapter and that provides health
58-24 care services to recipients through a primary care case management
58-25 network to conduct utilization review of those services in
58-26 accordance with Article 21.58A, Insurance Code.
58-27 Sec. 533.0202. NOTICE OF DETERMINATIONS MADE BY UTILIZATION
59-1 REVIEW AGENTS. (a) In this section, "utilization review agent" has
59-2 the meaning assigned by Section 2, Article 21.58A, Insurance Code.
59-3 (b) A utilization review agent shall notify a recipient or a
59-4 person acting on behalf of the recipient and the recipient's health
59-5 care provider of a utilization review determination in accordance
59-6 with this section and Section 5(a), Article 21.58A, Insurance Code,
59-7 with respect to services provided under the state Medicaid managed
59-8 care program.
59-9 (c) If the utilization review agent makes an adverse
59-10 determination, the notice required by this section must include:
59-11 (1) the principal reasons for the adverse
59-12 determination;
59-13 (2) the clinical basis for the adverse determination;
59-14 (3) a description or the source of the screening
59-15 criteria used as guidelines in making the determination; and
59-16 (4) a description of the procedure for the complaint
59-17 and appeal process, including a description provided to the
59-18 recipient of:
59-19 (A) the recipient's right to a Medicaid fair
59-20 hearing at any time; and
59-21 (B) the procedures for appealing an adverse
59-22 determination at a Medicaid fair hearing.
59-23 (d) The utilization review agent must provide notice of an
59-24 adverse determination:
59-25 (1) to the recipient and the recipient's health care
59-26 provider of record by telephone or electronic transmission not
59-27 later than the next business day after the date the determination
60-1 is made if the recipient is hospitalized when the determination is
60-2 made, to be followed not later than the third business day after
60-3 the date the determination is made by a written notice of the
60-4 determination;
60-5 (2) to the recipient and the recipient's health care
60-6 provider of record by written notice not later than the third
60-7 business day after the date the determination is made if the
60-8 recipient is not hospitalized when the determination is made; or
60-9 (3) to the recipient's treating physician or health
60-10 care provider within the time appropriate to the circumstances that
60-11 relate to the delivery of the services and the condition of the
60-12 patient, but not later than one hour after the recipient's treating
60-13 physician or provider requests poststabilization care following
60-14 emergency treatment.
60-15 (e) The commissioner shall adopt rules to implement this
60-16 section.
60-17 Sec. 533.0203. COMPLAINT INFORMATION. (a) The commission,
60-18 in cooperation with the Texas Department of Insurance and any other
60-19 appropriate entity, shall collect complaint data, including
60-20 complaint resolution rates, regarding managed care organizations
60-21 contracting with the commission under this chapter. In entering
60-22 into or renewing a contract with a managed care organization under
60-23 this chapter, the commission may include provisions in the contract
60-24 to accomplish the purposes of this section.
60-25 (b) The commission shall report on a quarterly basis the
60-26 complaint data collected under Subsection (a) to the state Medicaid
60-27 managed care advisory committee under Subchapter C.
61-1 (c) Not later than December 1 of each even-numbered year,
61-2 the commission shall report to the legislature the complaint data
61-3 collected under Subsection (a). The report may be consolidated
61-4 with any other report relating to the same subject matter the
61-5 commission is required to submit under other law.
61-6 Sec. 533.0204. PROVIDER REPORTING OF ENCOUNTER DATA. The
61-7 commission shall collaborate with managed care organizations that
61-8 contract with the commission and health care providers under the
61-9 organizations' provider networks to develop incentives and
61-10 mechanisms to encourage providers to report complete and accurate
61-11 encounter data to managed care organizations in a timely manner.
61-12 Sec. 533.0205. QUALIFICATIONS OF CERTIFIER OF ENCOUNTER
61-13 DATA. (a) The person acting as the state Medicaid director shall
61-14 appoint a person as the certifier of encounter data.
61-15 (b) The certifier of encounter data must have:
61-16 (1) demonstrated expertise in estimating premium
61-17 payment rates paid to a managed care organization under a managed
61-18 care plan; and
61-19 (2) access to actuarial expertise, including expertise
61-20 in estimating premium payment rates paid to a managed care
61-21 organization under a managed care plan.
61-22 (c) A person may not be appointed under this section as the
61-23 certifier of encounter data if the person participated with the
61-24 commission in developing premium payment rates for managed care
61-25 organizations under managed care plans in this state during the
61-26 three-year period before the date the certifier is appointed.
61-27 Sec. 533.0206. CERTIFICATION OF ENCOUNTER DATA. (a) The
62-1 certifier of encounter data shall certify the completeness,
62-2 accuracy, and reliability of encounter data for each state fiscal
62-3 year.
62-4 (b) The commission shall make available to the certifier all
62-5 records and data the certifier considers appropriate for evaluating
62-6 whether to certify the encounter data. The commission shall
62-7 provide to the certifier selected resources and assistance in
62-8 obtaining, compiling, and interpreting the records and data.
62-9 Sec. 533.0207. IMPLEMENTATION OF CERTAIN MANAGED CARE PLANS
62-10 IN CERTAIN COUNTIES. (a) Notwithstanding any other law, before
62-11 implementing a Medicaid managed care plan that uses capitation as a
62-12 method of payment in a county with a population of less than
62-13 100,000, the commission must determine that implementation is
62-14 economically efficient.
62-15 (b) Notwithstanding Subsection (a), the commission may
62-16 continue implementation of a Medicaid managed care plan described
62-17 by Subsection (a) in a county with a population of less than
62-18 100,000 if implementation of the plan in the county was in progress
62-19 on January 1, 2001.
62-20 Sec. 533.0208. INTEGRATED MENTAL HEALTH FUNDING TO LOCAL
62-21 MHMR AUTHORITIES. (a) The commission and the Texas Department of
62-22 Mental Health and Mental Retardation may establish a program that
62-23 uses direct contracting with units of local government that the
62-24 department designates as local mental health and mental retardation
62-25 authorities to allow the authorities to manage all federal, state,
62-26 and local matching funds for community mental health services to
62-27 provide more customer choice, an improved array of services at the
63-1 provider level, improved quality of services, and more
63-2 cost-effective services.
63-3 (b) A local mental health and mental retardation authority
63-4 shall:
63-5 (1) establish an effective process for planning,
63-6 policy development, and monitoring of the local program that
63-7 includes consumers and family members; and
63-8 (2) maintain an effective local process for planning,
63-9 policy development, resource management, service contracting, and
63-10 coordination with other local agencies, including local jails.
63-11 (c) The Texas Department of Mental Health and Mental
63-12 Retardation shall adopt rules to implement the program.
63-13 (b) Not later than March 1, 2002, the Health and Human
63-14 Services Commission, the Texas Department of Insurance, and each
63-15 appropriate health and human services agency implementing a part of
63-16 the Medicaid managed care program under Chapter 533, Government
63-17 Code, shall enter into the memorandum of understanding required by
63-18 Section 533.018, Government Code, as added by this Act.
63-19 (c) Not later than March 1, 2002, the Health and Human
63-20 Services Commission and the Texas Department of Insurance shall
63-21 develop the operational and financial audit instrument required by
63-22 Section 533.019, Government Code, as added by this Act.
63-23 (d) The changes in law made by Section 533.0202, Government
63-24 Code, as added by this Act, apply to a contract between the Health
63-25 and Human Services Commission and a managed care organization under
63-26 Chapter 533, Government Code, that is entered into or renewed on or
63-27 after the effective date of this Act. A contract that is entered
64-1 into or renewed before the effective date of this Act is governed
64-2 by the law in effect on the date the contract was entered into or
64-3 renewed, and the former law is continued in effect for that
64-4 purpose.
64-5 (e) Not later than January 1, 2002, the person acting as the
64-6 state Medicaid director shall appoint the certifier of Medicaid
64-7 managed care encounter data required by Section 533.0205,
64-8 Government Code, as added by this Act.
64-9 (f) The agencies responsible for implementing Section
64-10 533.0208, Government Code, as added by this Act, shall request and
64-11 actively pursue any necessary waivers or authorizations from the
64-12 Health Care Financing Administration or other appropriate entities
64-13 to enable the agencies to implement that section not later than
64-14 September 1, 2002. The agencies may delay implementing Section
64-15 533.0208, Government Code, as added by this Act, until the
64-16 necessary waivers or authorizations are granted.
64-17 SECTION 23. Subsection (a), Section 533.041, Government
64-18 Code, is amended to read as follows:
64-19 (a) The commission shall appoint a state Medicaid managed
64-20 care advisory committee. The advisory committee consists of
64-21 representatives of:
64-22 (1) hospitals;
64-23 (2) managed care organizations;
64-24 (3) primary care providers;
64-25 (4) state agencies;
64-26 (5) consumer advocates representing low-income
64-27 recipients;
65-1 (6) consumer advocates representing recipients with a
65-2 disability;
65-3 (7) parents of children who are recipients;
65-4 (8) rural providers;
65-5 (9) advocates for children with special health care
65-6 needs;
65-7 (10) pediatric health care providers, including
65-8 specialty providers;
65-9 (11) long-term care providers, including nursing home
65-10 providers;
65-11 (12) obstetrical care providers;
65-12 (13) community-based organizations serving low-income
65-13 children and their families; [and]
65-14 (14) community-based organizations engaged in
65-15 perinatal services and outreach;
65-16 (15) medically underserved communities; and
65-17 (16) community mental health and mental retardation
65-18 centers established under Subchapter A, Chapter 534, Health and
65-19 Safety Code.
65-20 SECTION 24. (a) The commissioner of health and human
65-21 services shall conduct a study regarding the feasibility of
65-22 expanding the medical assistance program under Chapter 32, Human
65-23 Resources Code, to provide medical assistance to disabled children
65-24 18 years of age or younger in accordance with 42 U.S.C. Section
65-25 1396a(e)(3), as amended.
65-26 (b) In conducting the study, the commissioner shall
65-27 evaluate:
66-1 (1) the number of children who would be eligible for
66-2 medical assistance under the expanded program and who would be
66-3 likely to enroll;
66-4 (2) the effect of other health insurance coverage
66-5 provided for children who would be eligible under the expanded
66-6 medical assistance program on the cost of expanding the program;
66-7 (3) utilization patterns of similar populations of
66-8 disabled children under similar programs in this state and other
66-9 states;
66-10 (4) the cost to the state of inappropriate
66-11 institutionalization of disabled children resulting from
66-12 unavailability of health insurance coverage for those children; and
66-13 (5) options for setting an income eligibility cap for
66-14 the expanded medical assistance program.
66-15 (c) Not later than December 1, 2002, the commissioner shall
66-16 submit a report to the legislature regarding the results of the
66-17 study conducted under this section. The report must include a
66-18 recommendation regarding expanding the medical assistance program
66-19 to provide that assistance to disabled children in accordance with
66-20 42 U.S.C. Section 1396a(e)(3), as amended.
66-21 SECTION 25. On January 1, 2002, or on an earlier date
66-22 specified by the Health and Human Services Commission:
66-23 (1) all powers, duties, functions, activities,
66-24 obligations, rights, contracts, records, employees, property, and
66-25 appropriations and other money of the Texas Department of Health
66-26 that are determined by the commissioner of health and human
66-27 services to be essential to the administration of Medicaid acute
67-1 care services or the Medicaid vendor drug program are transferred
67-2 to the Health and Human Services Commission;
67-3 (2) a rule or form adopted by the Texas Department of
67-4 Health that relates to a transferred component of the Medicaid
67-5 program is a rule or form of the Health and Human Services
67-6 Commission and remains in effect until altered by the commission;
67-7 (3) a reference in law or an administrative rule to
67-8 the Texas Department of Health that relates to a transferred
67-9 component of the Medicaid program means the Health and Human
67-10 Services Commission;
67-11 (4) a license, permit, or certification in effect that
67-12 was issued by the Texas Department of Health that relates to a
67-13 transferred component of the Medicaid program is continued in
67-14 effect as a license, permit, or certification of the Health and
67-15 Human Services Commission; and
67-16 (5) a complaint, investigation, or other proceeding
67-17 pending before the Texas Department of Health that relates to a
67-18 transferred component of the Medicaid program is transferred
67-19 without change in status to the Health and Human Services
67-20 Commission.
67-21 SECTION 26. (a) Subject to Subsection (b) of this section,
67-22 if before implementing any provision of this Act a state agency
67-23 determines that a waiver or authorization from a federal agency is
67-24 necessary for implementation of that provision, the agency affected
67-25 by the provision shall request the waiver or authorization and may
67-26 delay implementing that provision until the waiver or authorization
67-27 is granted.
68-1 (b) Implementation of Sections 32.053-32.056, Human
68-2 Resources Code, as added by this Act, is governed by Section 7 of
68-3 this Act. Implementation of Section 32.057, Human Resources Code,
68-4 as added by this Act, is governed by Section 8 of this Act.
68-5 Implementation of Section 533.0208, Government Code, as added by
68-6 this Act, is governed by Section 22 of this Act.
68-7 SECTION 27. Except as otherwise provided by this Act, this
68-8 Act takes effect September 1, 2001, and applies to a person
68-9 receiving medical assistance on or after that date regardless of
68-10 the date on which the person began receiving that medical
68-11 assistance.