79R5522 CLG-F
By: Nelson S.B. No. 871
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
adding Subdivision (5-a) to read as follows:
(5-a) "Medical home" means a primary care physician or
other 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.
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;
(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:
(A) recipients in obtaining health care
services; and
(B) physicians and other providers participating
in the state Medicaid program; and
(7) 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.
SECTION 3. Section 533.0025, Government Code, is amended by
amending Subsections (b), (c), and (d) and adding Subsections (c-1)
and (f) to read as follows:
(b) Except as otherwise provided by this section and
notwithstanding any other law, the commission shall provide medical
assistance [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 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.
(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 health
care 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 program
by physicians engaged in the private practice of medicine, home
health providers, and mental health services providers.
(c-1) Except as provided by Subchapter D, the commission may
not provide medical assistance in a certain area of this state or to
a certain population of recipients using a Medicaid managed care
model or arrangement as provided by this section unless the
commission provides an option for recipients in that area or
population 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 acute care] in a certain
area or to certain medical assistance recipients as prescribed by
this section, the commission shall provide medical assistance [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 to recipients in that area
through a different 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.
SECTION 4. 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 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; and
(4) aged, blind, or disabled persons who are not
residents of long-term care facilities.
(b) The integrated care management model developed under
the pilot project must include the following components:
(1) the assignment of recipients to a medical home;
(2) the establishment of a system for integrated care
management that addresses or provides for:
(A) acute or long-term care services, as
appropriate;
(B) the coordination and management of disease
management services; and
(C) case management, including case management
for recipients with chronic health conditions and management of
prescription drug use;
(3) the performance of health risk assessment
screenings on the initial enrollment of recipients in the pilot
project to identify those recipients who have or are at risk of
developing a chronic illness;
(4) a method for reporting the results of assessment
screenings described by Subdivision (3) to the recipient's medical
home;
(5) a method for reporting to physicians or other
appropriate health care providers at least quarterly on the use by
patients of:
(A) prescription drugs and the associated cost of
that use; and
(B) other health care services and the associated
cost of those uses;
(6) coordination by the patient's medical home of the
patient's support services, including home health services or
durable medical equipment;
(7) the establishment of a reimbursement system that
provides higher levels of payment for providers who:
(A) establish and maintain clinics to treat
recipients after normal business hours, as defined by rule of the
executive commissioner;
(B) incorporate early and periodic screening,
diagnosis, and treatment services into the medical home; and
(C) adhere to evidence-based, clinical
guidelines and performance measures that are developed by
physicians and subjected to a scientific peer review process;
(8) a comprehensive quality management program; and
(9) any other appropriate component the executive
commissioner determines will improve a recipient's health outcome
and is cost-effective.
(c) The commission shall implement the pilot project in at
least eight areas of this state, including both urban and rural
areas. At least one-half of the pilot project sites must be in
areas of this state in which a primary care case management model of
Medicaid managed care was being used to provide medical assistance
to recipients on January 1, 2005.
Sec. 533.062. TECHNOLOGICAL SUPPORT AND CARE COORDINATION.
(a) In implementing the integrated care management model of
Medicaid managed care under this subchapter, the commission shall
contract for technological support and care coordination as
necessary to assure appropriate use of services by and
cost-effective health outcomes for recipients.
(b) In awarding a contract under this section, the
commission shall:
(1) consider the effect of the contract on integrated
care management providers; and
(2) make a reasonable effort to reduce any
administrative barrier for those providers.
(c) The services provided under the contract should be
designed to enhance the ability of integrated care management
providers to be effective and responsive in making treatment
decisions.
Sec. 533.063. STATEWIDE ADVISORY COMMITTEE OF PROVIDERS.
(a) The executive commissioner shall appoint an advisory committee
of health care providers or representatives of those providers 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 under
Section 533.061.
(b) The committee consists of the following members:
(1) six primary care physicians who practice in
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 physician specialists;
(3) one representative of a federally qualified health
center, as defined by 42 U.S.C. Section 1396d(l)(2)(B);
(4) one representative of a rural health clinic; and
(5) one representative of hospitals.
(c) The advisory committee shall meet as necessary to
perform the duties required by this section.
(d) A member of the 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.
(e) The committee is not subject to Chapter 551, Government
Code.
Sec. 533.064. REGIONAL ADVISORY COMMITTEES. (a) In each
area of this state in which the commission plans to implement the
pilot project under Section 533.061, the executive commissioner
shall appoint an advisory committee for that area to assist with
the development and implementation of the integrated care
management model.
(b) A committee consists of individuals from the area with
respect to which the committee will provide advice and must include
the same number of members from each category of providers and
representatives of providers specified in Section 533.063(b).
(c) A committee is not subject to Chapter 551, Government
Code.
Sec. 533.065. REPORT. 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 report describing the results of the pilot
project implemented under Section 533.061. The report must
include:
(1) information regarding:
(A) recipient and provider satisfaction;
(B) recipient access to primary and specialty
care services;
(C) recipient outcomes, including health status
improvement; and
(D) the fiscal impact to political subdivisions
of this state in the areas in which the pilot project is
implemented, including any cost savings realized by those entities
from the implementation; and
(2) recommendations on whether to implement the pilot
project statewide.
Sec. 533.066. EXPIRATION OF SUBCHAPTER. This subchapter
expires September 1, 2009.
SECTION 5. 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 acute care] through the Medicaid managed care system
implemented under Chapter 533, Government Code.
SECTION 6. The executive commissioner of the Health and
Human Services Commission shall adopt rules to implement the pilot
project established under Section 533.061, Government Code, as
added by this Act, not later than December 1, 2005.
SECTION 7. To provide technological support and care
coordination services as required by Section 533.062, Government
Code, as added by this Act, the Health and Human Services Commission
may:
(1) if possible, modify an existing contract between
the commission and a contractor; or
(2) enter into an additional contract with a
contractor with which the commission has an existing contract.
SECTION 8. 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 9. 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.