By: Delisi, et al. (Senate Sponsor - Nelson) H.B. No. 1771
(In the Senate - Received from the House April 28, 2005;
April 29, 2005, read first time and referred to Committee on
Finance; May 23, 2005, reported adversely, with favorable
Committee Substitute by the following vote: Yeas 10, Nays 0;
May 23, 2005, sent to printer.)
COMMITTEE SUBSTITUTE FOR H.B. No. 1771 By: Nelson
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. Chapter 533, Government Code, is amended by
adding Subchapter D to read as follows:
SUBCHAPTER D. INTEGRATED CARE MANAGEMENT MODEL
Sec. 533.061. INTEGRATED CARE MANAGEMENT MODEL. (a) The
executive commissioner, by rule, shall develop an integrated care
management model of Medicaid managed care. The "integrated care
management model" is a noncapitated primary care case management
model of Medicaid managed care with enhanced components to:
(1) improve patient health and social outcomes;
(2) improve access to care;
(3) constrain health care costs; and
(4) integrate the spectrum of acute care and long-term
care services and supports.
(b) In developing the integrated care management model, the
executive commissioner shall ensure that the integrated care
management model utilizes managed care principles and strategies to
assure proper utilization of acute care and long-term care services
and supports. The components of the model must include:
(1) the assignment of recipients to a medical home;
(2) utilization management to assure appropriate
access and utilization of services, including prescription drugs;
(3) health risk or functional needs assessment;
(4) a method for reporting to medical homes and other
appropriate health care providers on the utilization by recipients
of health care services and the associated cost of utilization of
those services;
(5) mechanisms to reduce inappropriate emergency
department utilization by recipients, including the provision of
after-hours primary care;
(6) mechanisms that ensure a robust system of care
coordination for assessing, planning, coordinating, and monitoring
recipients with complex, chronic, or high-cost health care or
social support needs, including attendant care and other services
needed to remain in the community;
(7) implementation of a comprehensive,
community-based initiative to educate recipients about effective
use of the health care delivery system;
(8) strategies to prevent or delay
institutionalization of recipients through the effective
utilization of home and community-based support services; and
(9) any other components the executive commissioner
determines will improve a recipient's health outcome and are
cost-effective.
(c) For purposes of this chapter, the integrated care
management model is a managed care plan.
Sec. 533.062. CONTRACTING FOR INTEGRATED CARE MANAGEMENT.
(a) The commission may contract with one or more administrative
services organizations to perform the coordination of care and
other services and functions of the integrated care management
model developed under Section 533.061.
(b) The commission may require that each administrative
services organization contracting with the commission under this
section assume responsibility for exceeding administrative costs
and not meeting performance standards in connection with the
provision of acute care and long-term care services and supports
under the terms of the contract.
(c) The commission may include in a contract awarded under
this section a written guarantee of state savings on Medicaid
expenditures for recipients receiving services provided under the
integrated care management model developed under Section 533.061.
(d) The commission may require that each administrative
services organization contracting with the commission under this
section establish pay-for-performance incentives for providers to
improve patient outcomes.
(e) In this section, "administrative services organization"
means an entity that performs administrative and management
functions, such as the development of a physician and provider
network, care coordination, service coordination, utilization
review and management, quality management, and patient and provider
education, for a noncapitated system of health care services,
medical services, or long-term care services and supports.
Sec. 533.063. STATEWIDE INTEGRATED CARE MANAGEMENT
ADVISORY COMMITTEE. (a) The executive commissioner may appoint an
advisory committee to assist the executive commissioner in the
development and implementation of the integrated care management
model.
(b) The advisory committee is subject to Chapter 551.
SECTION 2. (a) The Health and Human Services Commission
shall require each administrative services organization
contracting with the commission to perform services under Section
533.062, Government Code, as added by this Act, to coordinate with,
use, and otherwise interface with the fee-for-service claims
payment contractor operating in this state on August 31, 2005,
until the date the claims payment contract expires, subject to
renewal of the contract.
(b) The commission may require each administrative services
organization contracting with the commission to perform services
under Section 533.062, Government Code, as added by this Act, to
incorporate disease management into the integrated care management
model established under Section 533.061, Government Code, as added
by this Act, utilizing the Medicaid disease management contractor
operating in this state on November 1, 2004, until the date the
disease management contract expires, subject to renewal of the
contract.
SECTION 3. 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 4. If any provision of this Act conflicts with a
statute enacted by the 79th Legislature, Regular Session, 2005, the
provision of this Act controls.
SECTION 5. 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.
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