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79R17633 KLA-D
By: Nelson S.B. No. 1188
Substitute the following for S.B. No. 1188:
By: Dawson C.S.S.B. No. 1188
A BILL TO BE ENTITLED
AN ACT
relating to the medical assistance program and the provision of
related 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) Subchapter B, Chapter 32, Human Resources Code, is
amended by adding Section 32.0424 to read as follows:
Sec. 32.0424. CLAIMS FOR REIMBURSEMENT TO MEDICAL
ASSISTANCE PROGRAM. (a) In this section, "insurer" and "plan
administrator" have the meanings assigned by Section 32.042.
(b) An insurer or plan administrator may not apply a point
of sale, timely filing, or out-of-network limitation, restriction,
or provision, or any other plan limitation, restriction, or
provision, that results in the rejection or denial of a claim by the
medical assistance program for reimbursement as authorized by
federal or state law for a health care benefit paid by the program.
(c) An insurer or plan administrator that may have primary
liability with respect to a health care benefit provided under the
medical assistance program to a person may not impose on the
department or a designee of the department any kind of fee, charge,
or expense to process a claim by the program for reimbursement for
the benefit.
(d) 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.
(e) If the Health and Human Services Commission chooses to
increase reimbursement rates for any providers under Subsection
(d)(2) 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; and
(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.
(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; and
(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.
(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;
(3) maximize Medicaid payment recovery options by
contracting with private vendors to assist in the recovery of
capitation payments and other payments made to managed care
organizations with respect to enrollees who leave the managed care
program; and
(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) requiring 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.
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.
Subsection (f), Section 32.027, Human Resources Code, is amended 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.
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.
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. 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 11. 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 subsection and
Subsection (d) of this section, 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 12. EFFECTIVE DATE. This Act takes effect
September 1, 2005.