S.B. No. 1188
AN ACT
relating to the medical assistance program and other health and
human services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. COMMUNITY COLLABORATION. Subchapter A, Chapter
531, Government Code, is amended by adding Section 531.020 to read
as follows:
Sec. 531.020. OFFICE OF COMMUNITY COLLABORATION. The
executive commissioner shall establish within the commission an
office of community collaboration. The office is responsible for:
(1) collaborating with community, state, and federal
stakeholders to improve the elements of the health care system that
are involved in the delivery of Medicaid services; and
(2) sharing with Medicaid providers, including
hospitals, any best practices, resources, or other information
regarding improvements to the health care system.
SECTION 2. MEDICAID FINANCING. (a) Subchapter B, Chapter
531, Government Code, is amended by adding Section 531.02113 to
read as follows:
Sec. 531.02113. OPTIMIZATION OF MEDICAID FINANCING. The
commission shall ensure that the Medicaid finance system is
optimized to:
(1) maximize the state's receipt of federal funds;
(2) create incentives for providers to use preventive
care;
(3) increase and retain providers in the system to
maintain an adequate provider network;
(4) more accurately reflect the costs borne by
providers; and
(5) encourage the improvement of the quality of care.
(b) Section 32.042, Human Resources Code, is amended by
amending Subsections (a), (b), (d), and (e) and adding Subsection
(b-1) to read as follows:
(a) An insurer shall maintain a file system that contains:
(1) the name, address, including claim submission
address, group policy number, employer's mailing address, social
security number, and date of birth of each enrollee, beneficiary,
subscriber, or policyholder covered by the insurer; and
(2) the name, address, including claim submission
address, and date of birth of each dependent of each enrollee,
beneficiary, subscriber, or policyholder covered by the insurer.
(b) The state's Medicaid third-party recovery division
shall identify state medical assistance recipients who have
third-party health coverage or insurance as provided by this
subsection. The department may:
(1) [shall] provide to an insurer Medicaid data tapes
that identify medical assistance recipients and request that the
insurer identify each enrollee, beneficiary, subscriber, or
policyholder of the insurer whose name also appears on the Medicaid
data tape; or
(2) request that an insurer provide to the department
identifying information for each enrollee, beneficiary,
subscriber, or policyholder of the insurer.An insurer shall comply with a request under this
subsection not later than the 60th day after the date the request
was made. An] insurer is only required [under this subsection] to
provide the department with the information maintained under
Subsection (a) by the insurer or made available to the insurer from
the plan. A plan administrator is subject to Subsection (b) and
shall provide information under that [this] subsection to the
extent the information [described in this subsection] is made
available to the plan administrator from the insurer or plan.
(d) An insurer shall provide the information required under
Subsection (b)(1) [this section] only if the department certifies
that the identified individuals are applicants for or recipients of
services under Medicaid or are legally responsible for an applicant
for or recipient of Medicaid services.
(e) The department shall enter into an agreement to
reimburse an insurer or plan administrator for necessary and
reasonable costs incurred in providing information requested under
Subsection (b)(1), not to exceed $5,000 for each data match made
under that subdivision. If the department makes a data match using
information provided under Subsection (b)(2), the department shall
reimburse the insurer or plan administrator for reasonable
administrative expenses incurred in providing the information. The
reimbursement for information under Subsection (b)(2) may not
exceed $5,000 for initially producing information with respect to a
person, or $200 for each subsequent production of information with
respect to the person [this section]. The department may enter into
an agreement with an insurer or plan administrator [insurers] that
provides procedures for requesting and providing information under
this section. An agreement under this subsection may not be
inconsistent with any law relating to the confidentiality or
privacy of personal information or medical records. The procedures
agreed to under this subsection must state the time and manner the
procedures take effect.
(c) The Health and Human Services Commission shall:
(1) examine the possibility of using existing state
funds, including existing state funds for the county indigent
health care program and the area health education centers in this
state, on health-related programs to maximize receipt of additional
federal Medicaid funds;
(2) subject to availability of funds, increase
Medicaid reimbursement rates for hospitals and physicians to better
align those rates with Medicare and private-pay reimbursement
rates;
(3) examine the possibility of a program under which
intergovernmental transfers are used to support graduate medical
education in support of the Medicaid program and, if
cost-effective, implement that program;
(4) examine the possibility of a program that includes
comprehensive outpatient rehabilitation facilities in the
prospective payment systems methodology and, if cost-effective,
implement that program;
(5) examine the possibility of developing Medicaid
waivers for intergovernmental transfers from local entities
similar to those used in the demonstration projects under Chapter
534, Government Code;
(6) examine the possibility of developing a Medicaid
waiver program to allow local governmental entities as well as
private employers to buy into the Medicaid or children's health
insurance programs and, if cost-effective, implement that program;
(7) examine the possibility of using employer
contributions and donations to expand eligibility and funding for
the Medicaid and children's health insurance programs and, if
cost-effective, implement that option; and
(8) examine the possibility of providing a tax
incentive in the form of an ad valorem, franchise, or sales tax
credit for employers to enable those employers to pay the state's
portion of the premiums for Medicaid or children's health insurance
for employees whose family income does not exceed 200 percent of the
federal poverty limit and, if cost-effective, implement that
option.
(d) If the Health and Human Services Commission chooses to
increase reimbursement rates for any providers under Subdivision
(2), Subsection (c) of this section, the commission shall give
priority to providers serving medically underserved areas, those
who treat a high volume of Medicaid patients, and those who provide
care that is an alternative to care in an emergency department.
SECTION 3. COLLECTION AND ANALYSIS OF INFORMATION.
(a) Subchapter B, Chapter 531, Government Code, is amended by
adding Section 531.02141 to read as follows:
Sec. 531.02141. MEDICAID INFORMATION COLLECTION AND
ANALYSIS. (a) The commission shall make every effort to improve
data analysis and integrate available information associated with
the Medicaid program. The commission shall use the decision
support system in the commission's center for strategic decision
support for this purpose and shall modify or redesign the system to
allow for the data collected by the Medicaid program to be used more
systematically and effectively for Medicaid program evaluation and
policy development. The commission shall develop or redesign the
system as necessary to ensure that the system:
(1) incorporates program enrollment, utilization, and
provider data that are currently collected;
(2) allows data manipulation and quick analysis to
address a large variety of questions concerning enrollment and
utilization patterns and trends within the program;
(3) is able to obtain consistent and accurate answers
to questions;
(4) allows for analysis of multiple issues within the
program to determine whether any programmatic or policy issues
overlap or are in conflict;
(5) includes predefined data reports on utilization of
high-cost services that allow program management to analyze and
determine the reasons for an increase or decrease in utilization
and immediately proceed with policy changes, if appropriate;
(6) includes any encounter data with respect to
recipients that a managed care organization that contracts with the
commission under Chapter 533 receives from a health care provider
under the organization's provider network; and
(7) links Medicaid and non-Medicaid data sets,
including data sets related to the Medicaid program, the Temporary
Assistance for Needy Families program, the Special Supplemental
Nutrition Program for Women, Infants, and Children, vital
statistics, and other public health programs.
(b) The commission shall ensure that all Medicaid data sets
created or identified by the decision support system are made
available on the Internet to the extent not prohibited by federal or
state laws regarding medical privacy or security. If privacy
concerns exist or arise with respect to making the data sets
available on the Internet, the system and the commission shall make
every effort to make the data available through that means either by
removing information by which particular individuals may be
identified or by aggregating the data in a manner so that individual
records cannot be associated with particular individuals.
(b) The Health and Human Services Commission shall allow for
sufficient opportunities for stakeholder input in the modification
or redesign of the decision support system in the commission's
center for strategic decision support as required by Section
531.02141, Government Code, as added by this section. The
commission may provide these opportunities through:
(1) existing mechanisms, such as regional advisory
committees or public forums; and
(2) meetings involving state and local agencies and
other entities involved in the planning, management, or delivery of
health and human services in this state.
SECTION 4. ADMINISTRATIVE PROCESSES AND AUDIT
REQUIREMENTS. (a) Subchapter B, Chapter 531, Government Code, is
amended by adding Sections 531.02411 and 531.02412 to read as
follows:
Sec. 531.02411. STREAMLINING ADMINISTRATIVE PROCESSES.
The commission shall make every effort using the commission's
existing resources to reduce the paperwork and other administrative
burdens placed on Medicaid recipients and providers and other
participants in the Medicaid program and shall use technology and
efficient business practices to decrease those burdens. In
addition, the commission shall make every effort to improve the
business practices associated with the administration of the
Medicaid program by any method the commission determines is
cost-effective, including:
(1) expanding the utilization of the electronic claims
payment system;
(2) developing an Internet portal system for prior
authorization requests;
(3) encouraging Medicaid providers to submit their
program participation applications electronically;
(4) ensuring that the Medicaid provider application is
easy to locate on the Internet so that providers may conveniently
apply to the program;
(5) working with federal partners to take advantage of
every opportunity to maximize additional federal funding for
technology in the Medicaid program; and
(6) encouraging the increased use of medical
technology by providers, including increasing their use of:
(A) electronic communications between patients
and their physicians or other health care providers;
(B) electronic prescribing tools that provide
up-to-date payer formulary information at the time a physician or
other health care practitioner writes a prescription and that
support the electronic transmission of a prescription;
(C) ambulatory computerized order entry systems
that facilitate physician and other health care practitioner orders
at the point of care for medications and laboratory and
radiological tests;
(D) inpatient computerized order entry systems
to reduce errors, improve health care quality, and lower costs in a
hospital setting;
(E) regional data-sharing to coordinate patient
care across a community for patients who are treated by multiple
providers; and
(F) electronic intensive care unit technology to
allow physicians to fully monitor hospital patients remotely.
Sec. 531.02412. SERVICE DELIVERY AUDIT MECHANISMS.
(a) The commission shall make every effort to ensure the integrity
of the Medicaid program. To ensure that integrity, the commission
shall:
(1) perform risk assessments of every element of the
Medicaid program and audit those elements of the program that are
determined to present the greatest risks;
(2) ensure that sufficient oversight is in place for
the Medicaid medical transportation program;
(3) ensure that a quality review assessment of the
Medicaid medical transportation program occurs; and
(4) evaluate the Medicaid program with respect to use
of the metrics developed through the Texas Health Steps performance
improvement plan to guide changes and improvements to the program.
(b) This section does not affect the duty of the Texas
Department of Transportation to manage the delivery of
transportation services, including the delivery of transportation
services for clients of health and human services programs.
(b) To further encourage the use of medical technology by
providers under the Medicaid program, the Health and Human Services
Commission may enter into a written agreement with a manufacturer,
as defined by Section 531.070, Government Code, to accept as a
program benefit in lieu of supplemental rebates, as defined by
Section 531.070, Government Code, the manufacturer's operation of a
pilot program under which the manufacturer supplies those providers
with a graphical electronic medical record system and evaluates the
benefits and cost-effectiveness of the system. The program must be
operated in a manner that is acceptable to the commission and must
be designed to test the benefits and cost-effectiveness on a
sufficiently large scale. The manufacturer shall report the
results of the program, including an analysis of the program's
benefits and cost-effectiveness, to the commission. The commission
shall report those results to the 80th Legislature not later than
January 15, 2007.
(c) The Health and Human Services Commission shall examine
options for standardizing and simplifying the interaction between
the Medicaid system and providers regardless of the service
delivery system through which a provider provides services and,
using existing resources, implement any options that are
anticipated to increase the quality of care and contain costs.
SECTION 5. LONG-TERM CARE SERVICES. (a) Subchapter B,
Chapter 531, Government Code, is amended by adding Sections 531.083
and 531.084 to read as follows:
Sec. 531.083. MEDICAID LONG-TERM CARE SYSTEM. The
commission shall ensure that the Medicaid long-term care system
provides the broadest array of choices possible for recipients
while ensuring that the services are delivered in a manner that is
cost-effective and makes the best use of available funds. The
commission shall also make every effort to improve the quality of
care for recipients of Medicaid long-term care services by:
(1) evaluating the need for expanding the provider
base for consumer-directed services and, if the commission
identifies a demand for that expansion, encouraging area agencies
on aging, independent living centers, and other potential long-term
care providers to become providers through contracts with the
Department of Aging and Disability Services;
(2) ensuring that all recipients who reside in a
nursing facility are provided information about end-of-life care
options and the importance of planning for end-of-life care; and
(3) developing policies to encourage a recipient who
resides in a nursing facility to receive treatment at that facility
whenever possible, while ensuring that the recipient receives an
appropriate continuum of care.
Sec. 531.084. MEDICAID LONG-TERM CARE COST CONTAINMENT
STRATEGIES. (a) The commission shall make every effort to achieve
cost efficiencies within the Medicaid long-term care program. To
achieve those efficiencies, the commission shall:
(1) establish a fee schedule for reimbursable incurred
medical expenses for dental services controlled in long-term care
facilities;
(2) implement a fee schedule for reimbursable incurred
medical expenses for durable medical equipment in nursing
facilities and ICF-MR facilities;
(3) implement a durable medical equipment fee schedule
action plan;
(4) establish a system for private contractors to
secure and coordinate the collection of Medicare funds for
recipients who are dually eligible for Medicare and Medicaid;
(5) create additional partnerships with
pharmaceutical companies to obtain discounted prescription drugs
for Medicaid recipients; and
(6) develop and implement a system for auditing the
Medicaid hospice care system that provides services in long-term
care facilities to ensure correct billing for pharmaceuticals.
(b) The executive commissioner and the commissioner of
aging and disability services shall jointly appoint persons to
serve on a work group to assist the commission in developing the fee
schedule required by Subsection (a)(1). The work group must
consist of providers of long-term care services, including dentists
and long-term care advocates.
(c) In developing the fee schedule required by Subsection
(a)(1), the commission shall consider:
(1) the need to ensure access to dental services for
residents of long-term care facilities who are unable to travel to a
dental office to obtain care;
(2) the most recent Comprehensive Fee Report published
by the National Dental Advisory Service;
(3) the difficulty of providing dental services in
long-term care facilities;
(4) the complexity of treating medically compromised
patients; and
(5) time-related and travel-related costs incurred by
dentists providing dental services in long-term care facilities.
(d) The commission shall annually update the fee schedule
required by Subsection (a)(1).
(b) The Health and Human Services Commission shall examine:
(1) the possibility of implementing a program to
expand Medicaid home health benefits to include speech pathology
services, intravenous therapy, and chemotherapy treatments and, if
cost-effective, implement that program;
(2) the possibility of implementing a program to
provide respite and other support services to individuals providing
daily assistance to persons with Alzheimer's disease or dementia to
reduce caregiver burnout and, if cost-effective, implement that
program;
(3) the possibility of implementing a program to offer
services through state schools to recipients who are living in the
community and a program to use funding for community-based services
to pay for the services from the state schools and, if
cost-effective, implement those programs;
(4) in conjunction with the Department of Aging and
Disability Services, the possibility of implementing a program to
simplify the administrative procedures for regulating nursing
facilities and, if cost-effective, implement that program; and
(5) the possibility of using fee schedules, prior
approval processes, and alternative service delivery options to
ensure appropriate utilization and payment for Medicaid services
and, if cost-effective, implement those schedules, processes, and
options.
(c) The Health and Human Services Commission shall study and
determine whether polypharmacy reviews for Medicaid recipients
receiving long-term care services could identify inappropriate
pharmaceutical usage patterns and lead to controlled costs.
(d) Prior to developing and adopting the fee schedule
required by Subdivision (1), Subsection (a), Section 531.084,
Government Code, as added by this section, the Health and Human
Services Commission shall make every effort to expedite the
approval of dental treatment plans and the approval and payment of
reimbursable incurred medical expenses for dental services
provided to residents of long-term care facilities.
SECTION 6. MEDICAID MANAGED CARE. (a) Section 533.005,
Government Code, is amended by amending Subsection (a) and adding
Subsection (c) to read as follows:
(a) A contract between a managed care organization and the
commission for the organization to provide health care services to
recipients must contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation [and provider payment] rates that
ensure the cost-effective provision of quality health care;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than the
45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to exceed
60 days, specified by a written agreement between the physician or
provider and the managed care organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the managed
care organization, inform the organization of the recipient's
Medicaid certification date;
(9) a requirement that the managed care organization
comply with Section 533.006 as a condition of contract retention
and renewal;
(10) a requirement that the managed care organization
provide the information required by Section 533.012 and otherwise
comply and cooperate with the commission's office of inspector
general [investigations and enforcement];
(11) a requirement that the managed care
organization's usages of out-of-network providers or groups of
out-of-network providers may not exceed limits for those usages
relating to total inpatient admissions, total outpatient services,
and emergency room admissions determined by the commission; [and]
(12) if the commission finds that a managed care
organization has violated Subdivision (11), a requirement that the
managed care organization reimburse an out-of-network provider for
health care services at a rate that is equal to the allowable rate
for those services, as determined under Sections 32.028 and
32.0281, Human Resources Code;
(13) a requirement that the organization use advanced
practice nurses in addition to physicians as primary care providers
to increase the availability of primary care providers in the
organization's provider network;
(14) a requirement that the managed care organization
reimburse a federally qualified health center or rural health
clinic for health care services provided to a recipient outside of
regular business hours, including on a weekend day or holiday, at a
rate that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician; and
(15) a requirement that the managed care organization
develop, implement, and maintain a system for tracking and
resolving all provider appeals related to claims payment, including
a process that will require:
(A) a tracking mechanism to document the status
and final disposition of each provider's claims payment appeal;
(B) the contracting with physicians who are not
network providers and who are of the same or related specialty as
the appealing physician to resolve claims disputes related to
denial on the basis of medical necessity that remain unresolved
subsequent to a provider appeal; and
(C) the determination of the physician resolving
the dispute to be binding on the managed care organization and
provider.
(c) The executive commissioner shall adopt rules regarding
the days, times of days, and holidays that are considered to be
outside of regular business hours for purposes of Subsection
(a)(14).
(b) Subchapter A, Chapter 533, Government Code, is amended
by adding Sections 533.0071 and 533.0072 to read as follows:
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission
shall make every effort to improve the administration of contracts
with managed care organizations. To improve the administration of
these contracts, the commission shall:
(1) ensure that the commission has appropriate
expertise and qualified staff to effectively manage contracts with
managed care organizations under the Medicaid managed care program;
(2) evaluate options for Medicaid payment recovery
from managed care organizations if the enrollee dies or is
incarcerated or if an enrollee is enrolled in more than one state
program or is covered by another liable third party insurer;
(3) maximize Medicaid payment recovery options by
contracting with private vendors to assist in the recovery of
capitation payments, payments from other liable third parties, and
other payments made to managed care organizations with respect to
enrollees who leave the managed care program;
(4) decrease the administrative burdens of managed
care for the state, the managed care organizations, and the
providers under managed care networks to the extent that those
changes are compatible with state law and existing Medicaid managed
care contracts, including decreasing those burdens by:
(A) where possible, decreasing the duplication
of administrative reporting requirements for the managed care
organizations, such as requirements for the submission of encounter
data, quality reports, historically underutilized business
reports, and claims payment summary reports;
(B) allowing managed care organizations to
provide updated address information directly to the commission for
correction in the state system;
(C) promoting consistency and uniformity among
managed care organization policies, including policies relating to
the preauthorization process, lengths of hospital stays, filing
deadlines, levels of care, and case management services; and
(D) reviewing the appropriateness of primary
care case management requirements in the admission and clinical
criteria process, such as requirements relating to including a
separate cover sheet for all communications, submitting
handwritten communications instead of electronic or typed review
processes, and admitting patients listed on separate
notifications; and
(5) reserve the right to amend the managed care
organization's process for resolving provider appeals of denials
based on medical necessity to include an independent review process
established by the commission for final determination of these
disputes.
Sec. 533.0072. INTERNET POSTING OF SANCTIONS IMPOSED FOR
CONTRACTUAL VIOLATIONS. (a) The commission shall prepare and
maintain a record of each enforcement action initiated by the
commission that results in a sanction, including a penalty, being
imposed against a managed care organization for failure to comply
with the terms of a contract to provide health care services to
recipients through a managed care plan issued by the organization.
(b) The record must include:
(1) the name and address of the organization;
(2) a description of the contractual obligation the
organization failed to meet;
(3) the date of determination of noncompliance;
(4) the date the sanction was imposed;
(5) the maximum sanction that may be imposed under the
contract for the violation; and
(6) the actual sanction imposed against the
organization.
(c) The commission shall post and maintain the records
required by this section on the commission's Internet website in
English and Spanish. The records must be posted in a format that is
readily accessible to and understandable by a member of the public.
The commission shall update the list of records on the website at
least quarterly.
(d) The commission may not post information under this
section that relates to a sanction while the sanction is the subject
of an administrative appeal or judicial review.
(e) A record prepared under this section may not include
information that is excepted from disclosure under Chapter 552.
(f) The executive commissioner shall adopt rules as
necessary to implement this section.
(c) The Health and Human Services Commission shall
reevaluate the case management fee used in the primary care case
management program and shall make recommendations to the
Legislative Budget Board if the commission finds that a different
rate is appropriate.
(d) The Health and Human Services Commission shall examine:
(1) the feasibility and cost-effectiveness of
establishing a sliding-scale case management fee for the primary
care case management program based on primary care provider
performance;
(2) the operational efficiency, health outcomes, case
management, and cost-effectiveness of the primary care case
management program and adopt any necessary changes to maximize
health outcomes and cost-effectiveness; and
(3) the mechanism used to encourage hospital
participation in the primary care case management program and adopt
alternative policies if current policies are determined to be
ineffective.
(e) The Health and Human Services Commission shall make
every effort to improve the delivery of health care services to
recipients enrolled in the Medicaid managed care program by
evaluating the following actions for a determination of
cost-effectiveness and pursuing those actions if they are
determined to be cost-effective:
(1) adding a Medicaid managed care contract
requirement that requires each managed care plan to work with the
commission and health care providers to improve the immunization
rate of Medicaid clients and the reporting of immunization
information for inclusion in ImmTrac;
(2) to the extent permitted by federal law, allowing
managed care organizations access to the previous claims history of
a new enrollee that is maintained by a claims administrator if the
new managed care organization enrollee was formerly a recipient
under the Medicaid fee for service or primary care case management
system;
(3) encouraging managed care organizations to operate
nurse triage telephone lines and to more effectively notify
enrollees that the lines exist and inform enrollees regarding how
to access those lines;
(4) creating more rigorous contract standards for
managed care organizations to ensure that children have clinically
appropriate alternatives to emergency room services outside of
regular office hours;
(5) developing more effective mechanisms to identify
and control the utilization of program services by enrollees who
are found to have abused the services; and
(6) studying the impact on the program of enrollees
who have a history of high or abusive use of program services and
incorporating the most effective methods of curtailing that
activity while assuring that those enrollees receive adequate
health services.
(f) Section 533.005, Government Code, as amended by this
section, applies only to a contract between the Health and Human
Services Commission and a managed care organization under Chapter
533, Government Code, that is entered into or renewed on or after
the effective date of this section. A contract between the
commission and an organization that is entered into or renewed
before the effective date of this section is governed by the law in
effect on the date the contract was entered into or renewed, and the
former law is continued in effect for that purpose.
(g) Section 533.0072, Government Code, as added by this
section, applies only to a sanction imposed on or after the
effective date of this section.
SECTION 7. SELECTION OF MEDICAL ASSISTANCE PROVIDERS.
(a) Section 32.027, Human Resources Code, is amended by amending
Subsection (f) and adding Subsection (l) to read as follows:
(f) The executive commissioner of the Health and Human
Services Commission [department] by rule may [shall] develop a
system of selective contracting with health care providers for the
provision of nonemergency inpatient hospital services to a
recipient of medical assistance under this chapter. In
implementing this subsection, the executive commissioner
[department] shall:
(1) seek input from consumer representatives and from
representatives of hospitals licensed under Chapter 241, Health and
Safety Code, and from organizations representing those hospitals;
and
(2) ensure that providers selected under the system
meet the needs of a recipient of medical assistance under this
chapter.
(l) Subject to appropriations, the department shall assure
that a recipient of medical assistance under this chapter may
select a licensed psychologist, a licensed marriage and family
therapist, as defined by Section 502.002, Occupations Code, a
licensed professional counselor, as defined by Section 503.002,
Occupations Code, or a licensed master social worker, as defined by
Section 505.002, Occupations Code, to perform any health care
service or procedure covered under the medical assistance program
if the selected person is authorized by law to perform the service
or procedure. This subsection shall be liberally construed.
(b) Subsection (e), Section 32.027, Human Resources Code,
as amended by Chapter 1251, Acts of the 78th Legislature, Regular
Session, 2003, is repealed.
SECTION 8. OPTIMIZATION OF CASE MANAGEMENT SYSTEMS.
(a) Subchapter B, Chapter 32, Human Resources Code, is amended by
adding Section 32.0551 to read as follows:
Sec. 32.0551. OPTIMIZATION OF CASE MANAGEMENT SYSTEMS. The
Health and Human Services Commission shall:
(1) create and coordinate staffing and other
administrative efficiencies for case management initiatives across
the commission and health and human services agencies, as defined
by Section 531.001, Government Code; and
(2) optimize federal funding revenue sources and
maximize the use of state funding resources for case management
initiatives across the commission and health and human services
agencies.
(b) The Health and Human Services Commission shall evaluate
the cost-effectiveness of developing intensive case management and
targeted interventions for all Medicaid recipients who are aged,
blind, or disabled.
(c) The Health and Human Services Commission shall identify
Medicaid programs or protocols in existence on the effective date
of this section that are not resulting in their anticipated cost
savings or quality outcomes. The commission shall enhance or
replace these programs or protocols with targeted strategies that
have demonstrated success in improving coordination of care and
cost savings within similar Medicaid recipient populations.
(d) The Health and Human Services Commission shall evaluate
the cost-effectiveness of including within Medicaid disease
management programs in existence on the effective date of this
section additional diseases, such as chronic kidney disease or
end-stage renal disease, additional chronic medical conditions,
such as severe pain that requires management, and other strategies,
such as home health services for children with chronic conditions
that are not included in the existing disease management programs
and the use of schools and school nurses to manage chronic medical
conditions of children. In evaluating the cost-effectiveness of
including other diseases, conditions, and strategies, the
commission may review existing data from the provider of disease
management services under Section 32.059, Human Resources Code, as
added by Chapter 208, Acts of the 78th Legislature, Regular
Session, 2003. The commission may also research the experiences of
other states, insurance companies, and managed care organizations
and review other sources of data the commission determines is
appropriate. The commission shall expand Medicaid disease
management programs and related programs to include the diseases,
conditions, and strategies that the commission determines under
this subsection will be cost-effective.
(e) The Health and Human Services Commission shall conduct a
study to determine the feasibility of combining the utilization
management, case management, care coordination, high-cost
targeting, provider incentives, and other quality and cost-control
measures implemented with respect to the Medicaid program under a
single federal waiver, which may be a waiver under Section 1915(c)
of the federal Social Security Act (42 U.S.C. Section 1396n(c)) or a
waiver under Section 1115(a) of that Act (42 U.S.C. Section
1315(a)). If the commission determines that the combination is
feasible, the commission shall develop the combined program and
seek the appropriate approval from the Centers for Medicare and
Medicaid Services. In conducting the study, the commission shall
solicit stakeholder input and consider information from any other
optimization-related projects currently being operated, including
the Consolidated Waiver Project authorized by 531.0219, Government
Code, former projects including the Mental Retardation Local
Authority program, and related information from projects in other
states.
SECTION 9. EDUCATION CAMPAIGN. (a) Subchapter B, Chapter
32, Human Resources Code, is amended by adding Section 32.071 to
read as follows:
Sec. 32.071. RECIPIENT AND PROVIDER EDUCATION. (a) The
department shall develop and implement a comprehensive medical
assistance education campaign for recipients and providers to
ensure that care is provided in such a way as to improve patient
outcomes and maximize cost-effectiveness. The department shall
ensure that educational information developed under this section is
demographically relevant and appropriate for each recipient or
provider to whom the information is provided.
(b) The comprehensive medical assistance education campaign
must include elements designed to encourage recipients to obtain,
maintain, and use a medical home and to reduce their use of
high-cost emergency department services for conditions that can be
treated through primary care or nonemergency physicians or other
providers. The campaign must include the dissemination of
educational information through newsletters and emergency
department staff members and at local health fairs, unless the
department determines that these methods of dissemination are not
effective in increasing recipients' appropriate use of the health
care system.
(c) The department shall evaluate whether certain risk
groups may disproportionately increase their appropriate use of the
health care system as a result of targeted elements of an education
campaign. If the department determines that certain risk groups
will respond with more appropriate use of the system, the
department shall develop and implement the appropriate targeted
educational elements.
(d) The department shall develop a system for reviewing
recipient prescription drug use and educating providers with
respect to that drug use in a manner that emphasizes reducing
inappropriate prescription drug use and the possibility of adverse
drug interactions.
(e) The department shall coordinate the medical assistance
education campaign with area health education centers, federally
qualified health centers, as defined by 42 U.S.C. Section
1396d(l)(2)(B), and other stakeholders who use public funds to
educate recipients and providers about the health care system in
this state. The department shall make every effort to maximize
state funds by working through these partners to maximize receipt
of additional federal funding for administrative and other costs.
(f) The department shall coordinate with other state and
local agencies to ensure that community-based health workers,
health educators, state eligibility determination employees who
work in hospitals and other provider locations, and promoters are
used in the medical assistance education campaign, as appropriate.
(g) The department shall ensure that all state agencies that
work with recipients, all administrative persons who provide
eligibility determination and enrollment services, and all service
providers use the same curriculum for recipient and provider
education, as appropriate.
(b) In developing the comprehensive medical assistance
education campaign under Section 32.071, Human Resources Code, as
added by this section, the Health and Human Services Commission
shall ensure that private entities participating in the Medicaid
program, including vendors providing claims administration,
eligibility determination, enrollment services, and managed care
services, are involved to the extent those entities' participation
is useful.
(c) The Health and Human Services Commission shall identify
all funds being spent on the effective date of this section on
education for Medicaid recipients. The commission shall integrate
these funds into the comprehensive medical assistance education
campaign under Section 32.071, Human Resources Code, as added by
this section.
SECTION 10. OFFICE OF MEDICAL TECHNOLOGY. Subchapter A,
Chapter 531, Government Code, is amended by adding Section 531.0081
to read as follows:
Sec. 531.0081. OFFICE OF MEDICAL TECHNOLOGY. (a) In this
section, "office" means the office of medical technology.
(b) The commission shall establish the office of medical
technology within the commission. The office shall explore and
evaluate new developments in medical technology and propose
implementing the technology in the medical assistance program under
Chapter 32, Human Resources Code, if appropriate and
cost-effective.
(c) Office staff must have skills and experience in research
regarding health care technology.
SECTION 11. MEDICAID REIMBURSEMENT RATES. (a) Section
531.021, Government Code, is amended by adding Subsections (f) and
(g) to read as follows:
(f) In adopting rates for medical assistance payments under
Subsection (b)(2), the executive commissioner may adopt
reimbursement rates for appropriate nursing services provided to
recipients with certain health conditions if those services are
determined to provide a cost-effective alternative to
hospitalization. A physician must certify that the nursing
services are medically appropriate for the recipient for those
services to qualify for reimbursement under this subsection.
(g) In adopting rates for medical assistance payments under
Subsection (b)(2), the executive commissioner may adopt
cost-effective reimbursement rates for group appointments with
medical assistance providers for certain diseases and medical
conditions specified by rules of the executive commissioner.
(b) Subchapter B, Chapter 531, Government Code, is amended
by adding Section 531.02175 to read as follows:
Sec. 531.02175. REIMBURSEMENT FOR ONLINE MEDICAL
CONSULTATIONS. (a) In this section, "physician" means a person
licensed to practice medicine in this state under Subtitle B, Title
3, Occupations Code.
(b) Subject to the requirements of this subsection, the
executive commissioner by rule may require the commission and each
health and human services agency that administers a part of the
Medicaid program to provide Medicaid reimbursement for a medical
consultation that is provided by a physician or other health care
professional using the Internet as a cost-effective alternative to
an in-person consultation. The executive commissioner may require
the commission or a health and human services agency to provide the
reimbursement described by this subsection only if the Centers for
Medicare and Medicaid Services develop an appropriate Current
Procedural Terminology code for medical services provided using the
Internet.
(c) The executive commissioner may develop and implement a
pilot program in one or more sites chosen by the executive
commissioner under which Medicaid reimbursements are paid for
medical consultations provided by physicians or other health care
professionals using the Internet. The pilot program must be
designed to test whether an Internet medical consultation is a
cost-effective alternative to an in-person consultation under the
Medicaid program. The executive commissioner may modify the pilot
program as necessary throughout its implementation to maximize the
potential cost-effectiveness of Internet medical consultations.
If the executive commissioner determines from the pilot program
that Internet medical consultations are cost-effective, the
executive commissioner may expand the pilot program to additional
sites or may implement Medicaid reimbursements for Internet medical
consultations statewide.
(d) The executive commissioner is not required to implement
the pilot program authorized under Subsection (c) as a prerequisite
to providing Medicaid reimbursement authorized by Subsection (b) on
a statewide basis.
SECTION 12. HOSPITAL EMERGENCY ROOM USE REDUCTION.
(a) Subchapter B, Chapter 531, Government Code, is amended by
adding Section 531.085 to read as follows:
Sec. 531.085. HOSPITAL EMERGENCY ROOM USE REDUCTION
INITIATIVES. The commission shall develop and implement a
comprehensive plan to reduce the use of hospital emergency room
services by recipients under the medical assistance program. The
plan may include:
(1) a pilot program designed to facilitate program
participants in accessing an appropriate level of health care,
which may include as components:
(A) providing program participants access to
bilingual health services providers; and
(B) giving program participants information on
how to access primary care physicians, advanced practice nurses,
and local health clinics;
(2) a pilot program under which health care providers,
other than hospitals, are given financial incentives for treating
recipients outside of normal business hours to divert those
recipients from hospital emergency rooms;
(3) payment of a nominal referral fee to hospital
emergency rooms that perform an initial medical evaluation of a
recipient and subsequently refer the recipient, if medically
stable, to an appropriate level of health care, such as care
provided by a primary care physician, advanced practice nurse, or
local clinic;
(4) a program under which the commission or a managed
care organization that enters into a contract with the commission
under Chapter 533 contacts, by telephone or mail, a recipient who
accesses a hospital emergency room three times during a six-month
period and provides the recipient with information on ways the
recipient may secure a medical home to avoid unnecessary treatment
at hospital emergency rooms;
(5) a health care literacy program under which the
commission develops partnerships with other state agencies and
private entities to:
(A) assist the commission in developing
materials that:
(i) contain basic health care information
for parents of young children who are recipients under the medical
assistance program and who are participating in public or private
child-care or prekindergarten programs, including federal Head
Start programs; and
(ii) are written in a language
understandable to those parents and specifically tailored to be
applicable to the needs of those parents;
(B) distribute the materials developed under
Paragraph (A) to those parents; and
(C) otherwise teach those parents about the
health care needs of their children and ways to address those needs;
and
(6) other initiatives developed and implemented in
other states that have shown success in reducing the incidence of
unnecessary treatment in hospital emergency rooms.
(b) The Health and Human Services Commission may develop the
health care literacy component of the comprehensive plan to reduce
the use of hospital emergency room services required by Subdivision
(5), Section 531.085, Government Code, as added by this section, so
that the health care literacy component operates in a manner
similar to the manner in which the Johnson & Johnson/UCLA Health
Care Institute operates its health care training program that is
designed to teach parents to better address the health care needs of
their children.
SECTION 13. PERFORMANCE BONUS PILOT PROGRAM. Subchapter B,
Chapter 531, Government Code, is amended by adding Section 531.086
to read as follows:
Sec. 531.086. PERFORMANCE BONUS PILOT PROGRAM. (a) The
commission shall develop a proposal for providing higher
reimbursement rates to primary care case management providers under
the Medicaid program who treat program recipients with chronic
health conditions in accordance with evidence-based, nationally
accepted best practices and standards of care.
(b) The commission shall define the parameters of the
proposed program, including:
(1) the types of chronic health conditions the program
would target;
(2) the best practices and standards of care that must
be followed for a provider to obtain a higher reimbursement rate
under the proposed program; and
(3) the types of providers to whom the higher
reimbursement rate would be offered under the proposed program.
(c) Not later than December 1, 2006, the Health and Human
Services Commission shall report to the standing committees of the
senate and the house of representatives having primary jurisdiction
over welfare programs regarding the proposed program under this
section. The report must include:
(1) the anticipated effect of the higher reimbursement
rates to be offered under the program on the quality of care
provided and the health outcomes for program recipients;
(2) a determination of whether the program would be
cost-effective; and
(3) a recommendation regarding implementation of the
program.
(d) This section expires September 1, 2007.
SECTION 14. RETURN OF UNUSED DRUGS. Section 562.1085,
Occupations Code, is amended by amending Subsection (a) and adding
Subsection (f) to read as follows:
(a) A pharmacist who practices in or serves as a consultant
for a health care facility in this state may return to a pharmacy
certain unused drugs, other than a controlled substance as defined
by Chapter 481, Health and Safety Code, purchased from the pharmacy
as provided by board rule. The unused drugs must:
(1) be approved by the federal Food and Drug
Administration and be:
(A) sealed in [the manufacturer's original]
unopened tamper-evident packaging and either individually packaged
or packaged in unit-dose packaging;
(B) oral or parenteral medication in sealed
single-dose containers approved by the federal Food and Drug
Administration;
(C) topical or inhalant drugs in sealed
units-of-use containers approved by the federal Food and Drug
Administration; or
(D) parenteral medications in sealed
multiple-dose containers approved by the federal Food and Drug
Administration from which doses have not been withdrawn; and
(2) not be the subject of a mandatory recall by a state
or federal agency or a voluntary recall by a drug seller or
manufacturer.
(f) The tamper-evident packaging required under Subsection
(a)(1) for the return of unused drugs is not required to be the
manufacturer's original packaging unless that packaging is
required by federal law.
SECTION 15. MEDICAL INFORMATION TELEPHONE HOTLINE.
(a) Subchapter B, Chapter 531, Government Code, is amended by
adding Section 531.02131 to read as follows:
Sec. 531.02131. MEDICAID MEDICAL INFORMATION TELEPHONE
HOTLINE PILOT PROGRAM. (a) In this section, "net cost-savings"
means the total projected cost of Medicaid benefits for an area
served under the pilot program minus the actual cost of Medicaid
benefits for the area.
(b) The commission shall evaluate the cost-effectiveness,
in regard to preventing unnecessary emergency room visits and
ensuring that Medicaid recipients seek medical treatment in the
most medically appropriate and cost-effective setting, of
developing a Medicaid medical information telephone hotline pilot
program under which physicians are available by telephone to answer
medical questions and provide medical information for recipients.
If the commission determines that the pilot program is likely to
result in net cost-savings, the commission shall develop the pilot
program.
(c) The commission shall select the area in which to
implement the pilot program. The selected area must include:
(1) at least two counties; and
(2) not more than 100,000 Medicaid recipients, with
approximately 50 percent of the recipients enrolled in a managed
care program in which the recipients receive services from a health
maintenance organization.
(d) The commission shall request proposals from private
vendors for the operation of a telephone hotline under the pilot
program. The commission may not award a contract to a vendor unless
the vendor agrees to contractual terms:
(1) requiring the vendor to answer medical questions
and provide medical information by telephone to recipients using
only physicians;
(2) providing that the value of the contract is
contingent on achievement of net cost-savings in the area served by
the vendor; and
(3) permitting the commission to terminate the
contract after a reasonable period if the vendor's services do not
result in net cost-savings in the area served by the vendor.
(e) The commission shall periodically determine whether the
pilot program is resulting in net cost-savings. The commission
shall discontinue the pilot program if the commission determines
that the pilot program is not resulting in net cost-savings after a
reasonable period.
(f) Notwithstanding any other provision of this section,
including Subsection (b), the commission is not required to develop
the pilot program if suitable private vendors are not available to
operate the telephone hotline.
(g) The executive commissioner shall adopt rules necessary
for implementation of this section.
(b) Not later than December 1, 2005, the Health and Human
Services Commission shall determine whether the pilot program
described by Section 531.02131, Government Code, as added by this
section, is likely to result in net cost-savings. If the
determination indicates that net cost-savings are likely, the
commission shall take the action required by Subsections (c), (d),
and (e) of this section.
(c) Not later than January 1, 2006, the Health and Human
Services Commission shall select the counties in which the pilot
program will be implemented.
(d) Not later than February 1, 2006, the Health and Human
Services Commission shall request proposals from private vendors
for the operation of a medical information telephone hotline. The
commission shall evaluate the proposals and choose one or more
vendors as soon as possible after the receipt of the proposals.
(e) Not later than January 1, 2007, the Health and Human
Services Commission shall report to the governor, the lieutenant
governor, and the speaker of the house of representatives regarding
the pilot program. The report must include:
(1) a description of the status of the pilot program,
including whether the commission was unable to contract with a
suitable vendor;
(2) if the pilot program has been implemented:
(A) an evaluation of the effects of the pilot
program on emergency room visits by program participants; and
(B) a description of cost savings in the area
included in the pilot program; and
(3) recommendations regarding expanding or revising
the pilot program.
SECTION 16. PRESCRIPTION DRUGS. (a) Section 531.070,
Government Code, is amended by amending Subsection (l) and adding
Subsection (n) to read as follows:
(l) Each year the commission shall provide a written report
to the legislature and the governor. The report shall cover:
(1) the cost of administering the preferred drug lists
adopted under Section 531.072;
(2) an analysis of the utilization trends for medical
services provided by the state and any correlation to the preferred
drug lists;
(3) an analysis of the effect on health outcomes and
results for recipients; [and]
(4) statistical information related to the number of
approvals granted or denied; and
(5) an analysis of the effect during the preceding
year of the implementation of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Pub. L. No. 108-173) on
the preferred drug list adopted under Section 531.072 and the prior
authorization requirements under Section 531.073 applicable under
the Medicaid vendor drug program.
(n) Prior to or during supplemental rebate agreement
negotiations for drugs being considered for the preferred drug
list, the commission shall disclose to pharmaceutical
manufacturers any clinical edits or clinical protocols that may be
imposed on drugs within a particular drug category that are placed
on the preferred list during the contract period. Clinical edits
will not be imposed for a preferred drug during the contract period
unless the above disclosure is made.
(b) Subsection (n), Section 531.070, Government Code, as
added by this section, applies only to a supplemental rebate
agreement that is entered into or renewed on or after the effective
date of this Act. A supplemental rebate agreement that is entered
into or renewed before the effective date of this Act is governed by
the law in effect on the date the agreement was entered into or
renewed, and the former law is continued in effect for that purpose.
SECTION 17. PHARMACEUTICAL AND THERAPEUTICS COMMITTEE.
Section 531.074, Government Code, is amended by adding Subsection
(m) to read as follows:
(m) The commission or the commission's agent shall publicly
disclose each specific drug recommended for preferred drug list
status for each drug class included in the preferred drug list for
the Medicaid vendor drug program. The disclosure must be made in
writing after the conclusion of committee deliberations that result
in recommendations made to the executive commissioner regarding the
placement of drugs on the preferred drug list.
SECTION 18. FRAUD, ABUSE, OR OVERCHARGES. (a) Section
531.102, Government Code, is amended by adding Subsections (j) and
(k) to read as follows:
(j) The office shall prepare a final report on each audit or
investigation conducted under this section. The final report must
include:
(1) a summary of the activities performed by the
office in conducting the audit or investigation;
(2) a statement regarding whether the audit or
investigation resulted in a finding of any wrongdoing; and
(3) a description of any findings of wrongdoing.
(k) A final report on an audit or investigation is subject
to required disclosure under Chapter 552. All information and
materials compiled during the audit or investigation remain
confidential and not subject to required disclosure in accordance
with Section 531.1021(g).
(b) Section 531.1021, Government Code, is amended by
amending Subsection (g) and adding Subsection (h) to read as
follows:
(g) All information and materials subpoenaed or compiled by
the office in connection with an audit or investigation are
confidential and not subject to disclosure under Chapter 552, and
not subject to disclosure, discovery, subpoena, or other means of
legal compulsion for their release to anyone other than the office
or its employees or agents involved in the audit or investigation
conducted by the office, except that this information may be
disclosed to the office of the attorney general, the state
auditor's office, and law enforcement agencies.
(h) A person who receives information under Subsection (g)
may disclose the information only in accordance with Subsection (g)
and in a manner that is consistent with the authorized purpose for
which the person first received the information.
SECTION 19. MEDICAID DISEASE MANAGEMENT PROGRAMS.
(a) Section 533.009, Government Code, is amended by adding
Subsection (f) to read as follows:
(f) The executive commissioner, by rule, shall prescribe
the minimum requirements that a managed care organization, in
providing a disease management program, must meet to be eligible to
receive a contract under this section. The managed care
organization must, at a minimum, be required to:
(1) provide disease management services that have
performance measures for particular diseases that are comparable to
the relevant performance measures applicable to a provider of
disease management services under Section 32.059, Human Resources
Code, as added by Chapter 208, Acts of the 78th Legislature, Regular
Session, 2003; and
(2) show evidence of ability to manage complex
diseases in the Medicaid population.
(b) Section 32.059, Human Resources Code, as added by
Chapter 208, Acts of the 78th Legislature, Regular Session, 2003,
is amended by amending Subsection (c) and adding Subsection (c-1)
to read as follows:
(c) The executive commissioner of the Health and Human
Services Commission [department], by rule, shall prescribe the
minimum requirements a provider of a disease management program
must meet to be eligible to receive a contract under this section.
The provider must, at a minimum, be required to:
(1) use disease management approaches that are based
on evidence-supported models, [minimum] standards of care in the
medical community, and clinical outcomes; and
(2) ensure that a recipient's primary care physician
and other appropriate specialty physicians, or registered nurses,
advanced practice nurses, or physician assistants specified and
directed or supervised in accordance with applicable law by the
recipient's primary care physician or other appropriate specialty
physicians, become directly involved in the disease management
program through which the recipient receives services.
(c-1) A managed care health plan that develops and
implements a disease management program under Section 533.009,
Government Code, and a provider of a disease management program
under this section shall coordinate during a transition period
beneficiary care for patients that move from one disease management
program to another program.
(c) The executive commissioner of the Health and Human
Services Commission may use a provider of a disease management
program under Section 32.059, Human Resources Code, as added by
Chapter 208, Acts of the 78th Legislature, Regular Session, 2003,
as amended by this section, to provide disease management services
if the executive commissioner determines that the use of that
provider will be more cost-effective to the Medicaid program than
using a provider of a disease management program under Section
533.009, Government Code, as amended by this section. A Medicaid
recipient currently in a disease management program provided under
Section 32.059, Human Resources Code, as added by Chapter 208, Acts
of the 78th Legislature, Regular Session, 2003, in a service area
that is subject to a Medicaid managed care expansion may remain
enrolled in the recipient's current disease management program if
the executive commissioner determines that allowing those
recipients to remain is cost-effective.
SECTION 20. INTEGRATED CARE MANAGEMENT MODEL. (a) 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.
(b) 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 section, 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.
(c) 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 section,
to incorporate disease management into the integrated care
management model established under Section 533.061, Government
Code, as added by this section, 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.
(d) If any provision of this section conflicts with another
statute enacted by the 79th Legislature, Regular Session, 2005, the
provision of this section controls.
SECTION 21. DISPENSATION OF PRESCRIPTION DRUGS.
(a) Subsections (o) and (p), Section 481.074, Health and Safety
Code, are amended to read as follows:
(o) A pharmacist may dispense a Schedule II controlled
substance pursuant to a facsimile copy of an official prescription
completed in the manner required by Section 481.075 and transmitted
by the practitioner or the practitioner's agent to the pharmacy if:
(1) the prescription is written for:
(A) a Schedule II narcotic or nonnarcotic
substance for a patient in a long-term care facility (LTCF), and the
practitioner notes on the prescription "LTCF patient";
(B) a Schedule II narcotic product to be
compounded for the direct administration to a patient by
parenteral, intravenous, intramuscular, subcutaneous, or
intraspinal infusion; or
(C) a Schedule II narcotic substance for a
patient with a medical diagnosis documenting a terminal illness or
a patient enrolled in a hospice care program certified or paid for
by Medicare under Title XVIII, Social Security Act (42 U.S.C.
Section 1395 et seq.), as amended, by Medicaid, or by a hospice
program that is licensed under Chapter 142, and the practitioner or
the practitioner's agent notes on the prescription "terminally ill"
or "hospice patient"; and
(2) after transmitting the prescription, the
prescribing practitioner or the practitioner's agent:
(A) writes across the face of the official
prescription "VOID--sent by fax to (name and telephone number of
receiving pharmacy)"; and
(B) files the official prescription in the
patient's medical records instead of delivering it to the patient
[promptly complies with Subsection (p)].
(p) [Not later than the seventh day after the date a
prescribing practitioner transmits the facsimile copy of the
official prescription to the pharmacy, the prescribing
practitioner shall deliver in person or mail the official written
prescription to the dispensing pharmacist at the pharmacy where the
prescription was dispensed. The envelope of a prescription
delivered by mail must be postmarked not later than the seventh day
after the date the official prescription was written.] On receipt
of the prescription, the dispensing pharmacy shall file the
facsimile copy of the prescription [with the official prescription]
and shall send information to the director as required by Section
481.075.
(b) This section takes effect immediately if this Act
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 section takes effect September 1, 2005.
SECTION 22. PROVISION OF CERTAIN PRESCRIPTION DRUGS
PROHIBITED. Section 32.024, Human Resources Code, is amended by
adding Subsection (bb) to read as follows:
(bb) The department may not provide an erectile dysfunction
medication under the Medicaid vendor drug program to a person
required to register as a sex offender under Chapter 62, Code of
Criminal Procedure, to the maximum extent federal law allows the
department to deny that medication.
SECTION 23. CONTINUOUS ELIGIBILITY. Section 32.0261, Human
Resources Code, is amended to read as follows:
Sec. 32.0261. CONTINUOUS ELIGIBILITY. The department shall
adopt rules in accordance with 42 U.S.C. Section 1396a(e)(12), as
amended, to provide for a period of continuous eligibility for a
child under 19 years of age who is determined to be eligible for
medical assistance under this chapter. The rules shall provide
that the child remains eligible for medical assistance, without
additional review by the department and regardless of changes in
the child's resources or income, until the earlier of:
(1) the end of the six-month period following [first
anniversary of] the date on which the child's eligibility was
determined; or
(2) the child's 19th birthday.
SECTION 24. NOTICE OF AVAILABILITY OF CERTAIN BENEFITS.
Chapter 159, Occupations Code, is amended by adding Section 159.010
to read as follows:
Sec. 159.010. NOTICE OF BENEFITS UNDER STATE CHILD HEALTH
PLAN. A physician who provides Medicaid health care services to a
pregnant woman shall inform the woman of the health benefits for
which the woman or the woman's child may be eligible under the state
child health plan under Chapter 62, Health and Safety Code.
SECTION 25. MEDICAID COVERAGE FOR HEALTH INSURANCE PREMIUMS
AND LONG-TERM CARE NEEDS. (a) The Health and Human Services
Commission shall explore the commission's authority under federal
law to offer, and the cost and feasibility of offering:
(1) a stipend paid by the Medicaid program to a person
to cover the cost of a private health insurance plan as an
alternative to providing traditional Medicaid services for the
person;
(2) premium payment assistance through the Medicaid
program for long-term care insurance for a person with a health
condition that increases the likelihood that the person will need
long-term care in the future; and
(3) a long-term care partnership between the Medicaid
program and a person under which the person pays the premiums for
long-term care insurance and the Medicaid program provides
continued coverage after benefits under that insurance are
exhausted.
(b) In exploring the feasibility of the options described by
Subsection (a) of this section, the Health and Human Services
Commission shall consider whether other state incentives that could
encourage persons to purchase health insurance plans or long-term
care insurance are feasible. The incentives may include offering
tax credits to businesses to increase the availability of
affordable insurance.
(c) If the Health and Human Services Commission determines
that any of the options described by Subsection (a) of this section
are feasible and cost-effective, the commission shall make efforts
to implement those options to the extent they are authorized by
federal law. The commission shall request any necessary waivers
from the Centers for Medicare and Medicaid Services as soon as
possible after determining that an option is feasible and
cost-effective. If the commission determines that legislative
changes are necessary to implement an option, the commission shall
report to the 80th Legislature and specify the changes that are
needed.
SECTION 26. MAXIMIZATION OF FEDERAL RESOURCES. The Health
and Human Services Commission shall make every effort to maximize
the receipt and use of federal health and human services resources
for the office of community collaboration established under Section
531.020, Government Code, as added by this Act, and the decision
support system in the commission's center for strategic decision
support.
SECTION 27. ABOLITION OF LONG-TERM CARE LEGISLATIVE
OVERSIGHT COMMITTEE; INTERIM REPORT ON LONG-TERM CARE. (a) On the
effective date of this Act, Subchapter O, Chapter 242, Health and
Safety Code, is repealed, and the long-term care legislative
oversight committee established under that subchapter is
abolished.
(b) All records in the custody of the long-term care
legislative oversight committee that are related to a duty,
function, or activity of the committee shall be transferred on the
effective date of this Act to the standing committees of the senate
and house of representatives having primary jurisdiction over
long-term care services.
SECTION 28. ABOLITION OF HEALTH AND HUMAN SERVICES
TRANSITION LEGISLATIVE OVERSIGHT COMMITTEE. The Health and Human
Services Transition Legislative Oversight Committee established
under Section 1.22, Chapter 198, Acts of the 78th Legislature,
Regular Session, 2003, is abolished on the effective date of this
Act.
SECTION 29. ABOLITION OF INTERAGENCY COUNCIL ON
PHARMACEUTICALS BULK PURCHASING. On September 1, 2007, the
Interagency Council on Pharmaceuticals Bulk Purchasing is
abolished, and Chapter 111, Health and Safety Code, and Subsection
(e), Section 431.116, and Subsection (d), Section 431.208, Health
and Safety Code, are repealed.
SECTION 30. IMPLEMENTATION; WAIVER. (a) The Health and
Human Services Commission shall make every effort to take each
action and implement each reform required by this Act as soon as
possible. Except as otherwise provided by this Act, the commission
shall take each action and implement each reform required by this
Act not later than September 1, 2007. Any action of the commission
taken to justify implementing or ignoring the reforms required by
this Act must be defensible, but need not be exhaustive.
(b) Not later than December 1, 2005, the Health and Human
Services Commission shall submit a report to the governor and to the
presiding officers of the standing committees of the senate and
house of representatives having primary jurisdiction over health
and human services that specifies the strategies the commission or
an appropriate health and human services agency, as defined by
Section 531.001, Government Code, will use to examine, study,
evaluate, or otherwise make a determination relating to a reform or
take another action required by this Act.
(c) Except as provided by Subsection (b) of this section,
for each provision of this Act that requires the Health and Human
Services Commission or a health and human services agency, as
defined by Section 531.001, Government Code, to examine the
possibility of making changes to the Medicaid program, to study an
aspect of the Medicaid program, to evaluate the cost-effectiveness
of a proposed reform, or to otherwise make a determination before
implementing a reform, the Health and Human Services Commission
shall submit a report to the governor and to the presiding officers
of the standing committees of the senate and house of
representatives having primary jurisdiction over health and human
services that includes the criteria used and the results obtained
by the commission or health and human services agency in taking the
required action. The report must be delivered not later than
September 1, 2007.
(d) If before implementing any provision of this Act a state
agency determines that a waiver or 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 31. EFFECTIVE DATE. Except as otherwise provided
by this Act, this Act takes effect September 1, 2005.
______________________________ ______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 1188 passed the Senate on
April 26, 2005, by the following vote: Yeas 31, Nays 0;
May 27, 2005, Senate refused to concur in House amendments and
requested appointment of Conference Committee; May 28, 2005, House
granted request of the Senate; May 29, 2005, Senate adopted
Conference Committee Report by the following vote: Yeas 31,
Nays 0.
______________________________
Secretary of the Senate
I hereby certify that S.B. No. 1188 passed the House, with
amendments, on May 25, 2005, by the following vote: Yeas 143,
Nays 0, two present not voting; May 28, 2005, House granted request
of the Senate for appointment of Conference Committee;
May 29, 2005, House adopted Conference Committee Report by a
non-record vote.
______________________________
Chief Clerk of the House
Approved:
______________________________
Date
______________________________
Governor