79R11518 CLG-F
By: Delisi, Hill, McReynolds, Coleman, H.B. No. 1771
Truitt, et al.
A BILL TO BE ENTITLED
AN ACT
relating to the Medicaid managed care delivery system.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 533.001, Government Code, is amended by
amending Subdivisions (2) and (5) and adding Subdivisions (8), (9),
and (10) to read as follows:
(2) "Executive commissioner" ["Commissioner"] means
the executive commissioner of the Health and Human Services
Commission [health and human services].
(5) "Managed care plan" means a plan under which a
person undertakes to provide, arrange for, pay for, or reimburse
any part of the cost of any health care services. A part of the plan
must consist of arranging for or providing health care services as
distinguished from indemnification against the cost of those
services on a prepaid basis through insurance or otherwise. The
term includes a primary care case management provider network or an
integrated care management provider network. The term does not
include a plan that indemnifies a person for the cost of health care
services through insurance.
(8) "Case management" means the method of identifying,
assessing, planning, coordinating, and monitoring recipients with
complex, chronic, or high-cost health care needs and the
development of a plan of care to coordinate the medical and social
support services needed to achieve optimum recipient outcomes in a
cost-effective manner. The term includes disease management.
(9) "Medical home" means a primary care physician or
health care provider who:
(A) manages and coordinates all aspects of a
recipient's health care; and
(B) has a continuous and ongoing professional
relationship with the recipient.
(10) "Service coordination" means a process,
independent of providers, to link recipients with the spectrum of
medical, functional, and social support services and resources by
developing a plan of care to maximize the potential of the recipient
to achieve optimal health care, community integration and
inclusion, independence, and functionality.
SECTION 2. Section 533.002, Government Code, is amended to
read as follows:
Sec. 533.002. PURPOSE. The commission shall implement the
Medicaid managed care program as part of the health care delivery
system developed under Chapter 532 by contracting with managed care
organizations in a manner that, to the extent possible:
(1) improves the health of Texans by:
(A) emphasizing prevention;
(B) promoting continuity of care; [and]
(C) providing a medical home for recipients;
(D) providing long-term services and supports in
the most integrated setting possible; and
(E) promoting consumer control and
self-determination through consumer-directed services;
(2) ensures that each recipient receives high quality,
comprehensive health care services in the recipient's local
community;
(3) encourages the training of and access to primary
care physicians and providers;
(4) maximizes cooperation with existing public health
entities, including local departments of health;
(5) provides incentives to managed care organizations
to improve the quality of health care services for recipients by
providing value-added services; [and]
(6) reduces administrative and other nonfinancial
barriers for recipients in obtaining health care services;
(7) reduces administrative, financial, and
nonfinancial barriers for recipients and physicians and health care
providers participating in the state Medicaid program;
(8) minimizes expenditures not related to the
provision of direct care, unless those expenditures will result in
better care provided to and improved outcomes for recipients;
(9) ensures that each recipient who needs community
and long-term services and supports receives those services and
supports in the recipient's local community in accordance with
Section 531.0244 or 531.043, to the extent applicable; and
(10) promotes the integration, inclusion, and
independence of recipients by providing home and community-based
services.
SECTION 3. Section 533.0025, Government Code, is amended by
amending Subsections (b), (c), and (d) and adding Subsections
(b-1), (c-1), (c-2), (f), (g), and (h) to read as follows:
(b) Except as otherwise provided by this section and
notwithstanding any other law, the commission shall provide medical
assistance for health care and long-term services and supports [for
acute care] through the most cost-effective model of Medicaid
managed care as determined by the commission. If the commission
determines that it is more cost-effective, the commission may
provide medical assistance for health care and long-term services
and supports [for acute care] in a certain part of this state or to a
certain population of recipients using:
(1) a health maintenance organization model[,
including the acute care portion of Medicaid Star Plus pilot
programs];
(2) a primary care case management model;
(3) a prepaid health plan model;
(4) an exclusive provider organization model; or
(5) another Medicaid managed care model or
arrangement.
(b-1) The executive commissioner may not use a capitated
risk model for health care and long-term services and supports for
recipients who are aged, blind, or disabled, except in the acute and
long-term care integration pilot operating in Harris County on
August 31, 2005.
(c) In determining whether a model or arrangement described
by Subsection (b) is more cost-effective, the executive
commissioner must consider:
(1) the scope, duration, and types of health benefits
or services to be provided in a certain part of this state or to a
certain population of recipients;
(2) administrative costs necessary to meet federal and
state statutory and regulatory requirements;
(3) the anticipated effect of market competition
associated with the configuration of Medicaid service delivery
models determined by the commission; [and]
(4) the gain or loss to this state of a tax collected
under Chapter 222 [Article 4.11], Insurance Code;
(5) the impact, including fiscal impact, to the
medical delivery infrastructure of political subdivisions of this
state that provide medical assistance, health care, or health care
services to recipients or indigent populations; and
(6) the long-term impact to the provider network of
the state Medicaid program, including participation in the network
by privately practicing physicians, home and community support
services agencies, mental health providers, providers of assisted
living services, and day activity health providers.
(c-1) The commission shall maintain any primary care case
management model implemented on or before January 1, 2005, until
the model is replaced by the integrated care management model as
provided by Subchapter D.
(c-2) If after January 1, 2005, the commission begins
initially providing medical assistance to recipients using a
Medicaid managed care model or arrangement, other than an
integrated care management model as provided by Subchapter D, the
commission must provide an option for those recipients to receive
medical assistance through a primary care case management model of
managed care.
(d) If the commission determines that it is not more
cost-effective to use a Medicaid managed care model to provide
certain types of medical assistance for health care and long-term
services and supports [for acute care] in a certain area or to
certain medical assistance recipients as prescribed by this
section, the commission shall provide medical assistance for health
care and long-term services and supports [for acute care] through a
traditional fee-for-service arrangement.
(f) Before the commission begins initially providing
medical assistance through a Medicaid managed care model or
arrangement to recipients residing in a certain area of this state,
or begins providing medical assistance through a different model or
arrangement to recipients in an area served by a Medicaid managed
care model or arrangement, the commission shall seek public
comments and hold a public hearing in the affected area at least six
months before the date the commission intends to begin providing
medical assistance through that model or arrangement.
(g) Before the commission begins initially providing
medical assistance to recipients through a Medicaid managed care
model or arrangement or begins providing medical assistance to
recipients through a different model or arrangement, the executive
commissioner shall provide to the governor, lieutenant governor,
and speaker of the house of representatives a report containing the
findings, determinations, evaluations, and weight given by the
executive commissioner to each provision the executive
commissioner is required to consider under Subsection (c) before
taking that action. A report submitted under this subsection must
be made available to the public on the commission's Internet
website.
(h) The implementation of any Medicaid managed care model or
arrangement does not preclude the operation of any program of
all-inclusive care for the elderly (PACE) site under Section
32.053, Human Resources Code.
SECTION 4. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.019 to read as follows:
Sec. 533.019. MEDICAL HOME FOR CERTAIN RECIPIENTS. A
recipient who is a child with special health care needs or who is a
child or adult with a disability may select a physician who is a
subspecialist to act as the recipient's medical home if the
subspecialist agrees to serve in that role.
SECTION 5. Chapter 533, Government Code, is amended by
adding Subchapter D to read as follows:
SUBCHAPTER D. INTEGRATED CARE MANAGEMENT MODEL
Sec. 533.061. ESTABLISHMENT OF AN INTEGRATED CARE
MANAGEMENT MODEL; PILOT PROJECT. (a) The executive commissioner
by rule shall establish, and the commission shall conduct and
evaluate, a pilot project to determine the cost savings, health
benefits, and effectiveness of providing medical assistance
through an integrated care management model to the following
populations of recipients:
(1) recipients of financial assistance under Chapter
31, Human Resources Code;
(2) pregnant women;
(3) children;
(4) recipients eligible to receive Supplemental
Security Income (SSI) benefits under 42 U.S.C. Section 1381 et
seq., who are not residents of long-term care facilities;
(5) recipients who are determined eligible for the
community-based alternative 1915(c) nursing home waiver services;
and
(6) recipients who are dually eligible for Medicaid
and Medicare.
(b) For purposes of this section, "integrated care
management" includes:
(1) the development and maintenance of a comprehensive
network of physicians, hospitals, community clinics, public health
providers, home and community support providers, and other
providers, as appropriate, to meet the diverse needs of recipients
described by Subsection (a) who are participating in the pilot
project;
(2) the assignment of recipients to a medical home;
(3) recipient-level reporting, at least quarterly, to
physicians or appropriate health care providers of the utilization
and costs of health care services, including prescription drug
utilization and costs, of recipients described by Subsection (a)
who are participating in the pilot project;
(4) health risk assessment screenings for recipients
on enrollment in the pilot project and annually after enrollment to
identify recipients who have chronic illnesses or diseases or who
are at risk of developing chronic illnesses or diseases and the
reporting of the results of the assessment screenings to the
recipient's medical home;
(5) care coordination with the recipients' medical
home, including the provision of home health services or durable
medical equipment;
(6) case management, including coordination of
disease management for recipients identified as having chronic
health conditions, and prescription drug management;
(7) a mechanism to provide for increased levels of
payment to providers who:
(A) adhere to physician-developed,
evidence-based, and peer-reviewed clinical guidelines and
performance measures;
(B) incorporate early and periodic screening,
diagnosis, and treatment services into the medical home;
(C) establish and maintain clinics to treat
recipients after normal business hours, as defined by rule of the
executive commissioner; and
(D) implement measures to improve patient
safety;
(8) a comprehensive quality management program;
(9) outreach initiatives to recruit physicians and
health care providers to participate in the Medicaid program;
(10) cost-effective utilization of telemedicine
medical services or telehealth services, particularly to improve
the management of chronic conditions;
(11) mechanisms to assist recipients to easily
identify participating physicians and health care providers,
including the posting of a list of participating providers on the
Internet;
(12) implementation of a clinically based after-hours
nurse telephone hotline;
(13) a functional needs assessment, performed on
enrollment and at least annually after enrollment in the most
cost-effective manner, to determine community and social support
services needed by recipients;
(14) a mechanism to link case management and service
coordinators to assure timely communication and care plan
collaboration regarding the recipient's medical, functional, and
social support needs to maximize optimal health care, independence,
and functionality;
(15) aggressive efforts to prevent or delay
institutionalization of recipients through the effective
utilization of home and community-based support services;
(16) implementation of the Promoting Independence
initiative for children and adults to identify persons who wish to
leave a nursing facility or other institution and to reside in the
community;
(17) the provision of services in the most integrated
setting possible that promotes community integration, inclusion,
and independence; and
(18) any other features the executive commissioner,
with advice from the advisory committee under Section 533.064,
determines will improve a recipient's health outcome and are
cost-effective.
(c) The Department of Aging and Disability Services is
responsible for the development of policies for the long-term care
provisions of the integrated care management model.
(d) In establishing the integrated care management model,
the commission shall implement the pilot project in the eight
Medicaid managed care service delivery areas of this state where
Star Plus would have otherwise been implemented.
Sec. 533.062. CONTRACTING FOR INTEGRATED CARE MANAGEMENT.
(a) The commission shall contract with a managed care organization
or other qualified organization to perform the components of the
integrated care management model specified in Section 533.061(b) to
achieve the following goals:
(1) assure proper utilization of services;
(2) promote cost-effective outcomes;
(3) enhance the ability of physicians and health care
providers to be effective and responsive in making treatment
decisions; and
(4) ensure that services for persons with functional
limitations or medical needs and their families assist those
persons in achieving and maintaining the greatest possible
independence, autonomy, and quality of life through
consumer-directed services and self-determination.
(b) In contracting under this section, the commission
shall:
(1) require the integrated care management contractor
to use fee-for-service billing systems in existence on August 31,
2005;
(2) incorporate disease management into the
integrated care management model utilizing the Medicaid disease
management contractor operating in the state as of November 1,
2004, and through the expiration or renewal of the disease
management contract in effect on August 31, 2005;
(3) consider the effect a transition to a new
contractor will have on the recipients and physicians and health
care providers participating in the state Medicaid program; and
(4) make every reasonable attempt to minimize any
administrative burden and expense on the physicians and health care
providers participating in the pilot project.
(c) The commission may amend contracts to the extent allowed
by law.
Sec. 533.063. COST-EFFECTIVENESS OF THE INTEGRATED CARE
MANAGEMENT MODEL. (a) In determining whether the integrated care
management model achieves cost savings, the commission shall
consider:
(1) any savings achieved through disease management
programs established under Section 32.059, Human Resources Code, as
added by Chapter 208, Acts of the 78th Legislature, Regular
Session, 2003;
(2) the appropriate utilization of prescription
medications by recipients;
(3) appropriate case management and care coordination
by utilization of a medical home;
(4) reductions in inappropriate utilization of
emergency rooms by recipients; and
(5) appropriate utilization of home and
community-based services by recipients to reduce the need for
more-expensive hospital care or long-term institutional care.
(b) The comptroller shall verify the findings of the
commission in evaluating the cost savings of the integrated care
management model.
(c) Projected cost savings are not to be achieved by
reducing eligibility for long-term services below what is currently
available in the existing integrated managed care long-term service
system.
Sec. 533.064. STATEWIDE INTEGRATED CARE MANAGEMENT
ADVISORY COMMITTEE. (a) The executive commissioner shall appoint
an advisory committee to assist the executive commissioner in
developing the integrated care management model. The executive
commissioner shall consult the advisory committee throughout the
development of the model, including in relation to the development
of proposed rules regarding the components of the integrated care
management model specified in Section 533.061(b).
(b) The advisory committee consists of the following
members:
(1) three practicing primary care physicians from
different geographic areas of this state, including at least two
physicians with experience practicing under a primary care case
management model of Medicaid managed care;
(2) three practicing subspecialty care physicians
with:
(A) one subspecialist having expertise in
treating adults with disabilities;
(B) one subspecialist having expertise in
treating children with special health care needs; and
(C) one subspecialist having expertise in
chronic care management;
(3) one representative of a federally qualified health
center, as defined by 42 U.S.C. Section 1396d(l)(2)(B);
(4) two representatives of hospital districts located
in urban areas;
(5) one representative of a children's hospital;
(6) one representative of a home and community support
services agency;
(7) one provider of assisted living services;
(8) one consumer representative who is knowledgeable
regarding issues affecting pregnant women, children, and families
eligible for Medicaid;
(9) one consumer representative who is knowledgeable
regarding issues affecting recipients who are dually eligible for
Medicaid and Medicare; and
(10) one consumer representative who is knowledgeable
regarding issues affecting recipients who are aged, blind, or
disabled.
(c) The advisory committee shall establish the following
subcommittees composed of one or more members of the advisory
committee and one or more persons who do not serve on the advisory
committee:
(1) one subcommittee to provide advice and assistance
to the executive commissioner and advisory committee on the
specific medical, social, and functional support services and needs
of children;
(2) one subcommittee to provide advice and assistance
to the executive commissioner and advisory committee on the
specific medical, social, and functional support services and needs
of adults with disabilities; and
(3) any other subcommittees the advisory committee
considers necessary to provide advice and assistance to the
executive commissioner and advisory committee on operational and
design issues relating to the development and implementation of the
integrated care management model.
(d) In making appointments to the subcommittees under
Subsection (c), the advisory committee shall assure that each
subcommittee provides representation of the broad range of
appropriate acute care providers, long-term care providers, and
consumers to assure inclusive and diverse input into the
development and design of the integrated care management model.
(e) The advisory committee shall meet as necessary to
perform the duties required by this section.
(f) A member of the advisory committee may not receive
compensation for serving on the committee but is entitled to
reimbursement for reasonable and necessary travel expenses
incurred by the member while conducting the business of the
committee, as provided by the General Appropriations Act.
(g) The advisory committee is not subject to Chapter 551.
Sec. 533.065. REPORT REGARDING INTEGRATED CARE MANAGEMENT
MODEL. Not later than January 5, 2007, the commission shall submit
to the Legislative Budget Board, the lieutenant governor, and the
speaker of the house of representatives a preliminary report
containing the commission's findings regarding the implementation
of the integrated care management model developed under Section
533.061. The report must include:
(1) information regarding:
(A) recipient and provider satisfaction;
(B) recipient access to primary and subspecialty
care services;
(C) recipient access to community and social
support services;
(D) recipient outcomes, including health status
improvement;
(E) recipient outcomes relating to the Promoting
Independence initiative for children and adults;
(F) any cost savings realized from the
implementation; and
(G) the fiscal impact to political subdivisions
of this state in the areas in which the model is implemented,
including any cost savings realized by those entities from the
implementation;
(2) recommendations for improvement of the model; and
(3) recommendations on whether to implement the pilot
project in other areas of this state.
Sec. 533.066. EXPIRATION OF SUBCHAPTER. This subchapter
expires September 1, 2009.
SECTION 6. Section 32.0212, Human Resources Code, is
amended to read as follows:
Sec. 32.0212. DELIVERY OF MEDICAL ASSISTANCE.
Notwithstanding any other law and subject to Section 533.0025,
Government Code, the department shall provide medical assistance
for health care and long-term services and supports [for acute
care] through the Medicaid managed care system implemented under
Chapter 533, Government Code.
SECTION 7. (a) The executive commissioner of the Health and
Human Services Commission shall adopt rules to implement the
integrated care management model pilot project established under
Section 533.061, Government Code, as added by this Act, not later
than December 1, 2005.
(b) Not later than September 1, 2006, the Health and Human
Services Commission shall implement the integrated care management
pilot project established under Section 533.061, Government Code,
as added by this Act.
SECTION 8. The executive commissioner of the Health and
Human Services Commission shall appoint the members of the
statewide integrated care management advisory committee created
under Section 533.064, Government Code, as added by this Act, not
later than September 2, 2005.
SECTION 9. If before implementing any provision of this Act
a state agency determines that a waiver or other authorization from
a federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 10. This Act takes effect immediately if it
receives a vote of two-thirds of all the members elected to each
house, as provided by Section 39, Article III, Texas Constitution.
If this Act does not receive the vote necessary for immediate
effect, this Act takes effect September 1, 2005.