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79R8923 KLA-F
By: Nelson S.B. No. 1188
A BILL TO BE ENTITLED
AN ACT
relating to the medical assistance and children's health insurance
programs.
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 Sections 531.02113 and
531.082 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.
Sec. 531.082. ENHANCED REIMBURSEMENT RATES FOR CERTAIN
MEDICAL ASSISTANCE PROVIDERS. (a) In adopting standards for rates
for medical assistance payments under Chapter 32, Human Resources
Code, as required by Section 531.021(b)(2), the executive
commissioner shall establish a program under which providers under
the medical assistance program are offered enhanced reimbursement
rates in accordance with this section for implementing
technological improvements or participating in other quality
improvement activities.
(b) A physician, health clinic, hospital, or other provider
under the medical assistance program may receive a reimbursement
rate that is two percent higher than the rate for medical assistance
payments that the provider would otherwise receive if the
physician, clinic, hospital, or other provider uses a system by
which medical records are maintained in an electronic format,
rather than in the hard-copy format traditionally used by health
care providers. The use of general electronic recordkeeping
systems or practice management applications is not sufficient to
qualify a provider for the enhanced reimbursement rate under this
subsection.
(c) A physician, health clinic, hospital, or other provider
under the medical assistance program may receive a reimbursement
rate that is two percent higher than the rate for medical assistance
payments that the provider would otherwise receive if the
physician, clinic, hospital, or other provider uses a computerized
physician order-entry system for pharmaceuticals and other
pharmacy orders. To be eligible for the enhanced reimbursement
rate under this subsection, a provider must use a system that is
designed to allow the prescribing physician to directly enter the
orders into the system.
(d) A health clinic or hospital that is a provider under the
medical assistance program may receive a reimbursement rate that is
three percent higher than the rate for medical assistance payments
that the provider would otherwise receive if the provider uses a
computerized physician order-entry system described by Subsection
(c) and a system by which administration of pharmaceuticals is
verified electronically using bar-coded or other electronically
coded pharmaceutical containers and corresponding identifiers that
are affixed to the patient, including identification cards or
wristbands.
(e) A physician, health clinic, hospital, or other provider
under the medical assistance program may receive a reimbursement
rate that is three percent higher than the rate for medical
assistance payments that the provider would otherwise receive if
the physician, clinic, hospital, or other provider participates in
quality improvement or monitoring initiatives designated by rules
adopted by the executive commissioner.
(b) 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.
(c) If the Health and Human Services Commission chooses to
increase reimbursement rates for any providers under Subsection
(b)(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 is 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 encounter data provided by managed care
organizations under Chapter 533 in a format that allows the data to
be queried across recipients, regardless of whether the recipients
are receiving services under the health maintenance organization
model, primary care case management model, or fee-for-service
system.
(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. MEDICAID 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:
(1) "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.
(2) "Physician" means an individual licensed to
practice medicine in this state or another state of the United
States.
(b) In order to prevent unnecessary emergency room visits
and ensure that Medicaid recipients seek medical treatment in the
most medically appropriate and cost-effective setting, the
commission shall develop 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.
(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 50 percent of 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,
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.
(h) The participation of a physician in a telephone hotline
that is part of a pilot program established under this section does
not constitute the practice of medicine in this state.
(b) Not later than January 1, 2006, the Health and Human
Services Commission shall select the counties in which the pilot
program will be implemented.
(c) 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.
(d) 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 required by Section 531.02131, Government Code,
as added by this section. 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 5. 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 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) developing and implementing a single
clearinghouse for submission of Medicaid claims;
(2) expanding the utilization of the electronic claims
payment system;
(3) developing an Internet portal system for prior
authorization requests;
(4) encouraging Medicaid providers to submit their
program participation applications electronically;
(5) ensuring that the Medicaid provider application is
easy to locate on the Internet so that providers may conveniently
apply to the program;
(6) working with federal partners to take advantage of
every opportunity to maximize additional federal funding for
technology in the Medicaid program; and
(7) encouraging the increased use of medical
technology by providers, including increasing their use of:
(A) electronic communications between patients
and their physicians;
(B) electronic prescribing tools that provide
up-to-date payer formulary information at the time a physician
writes a prescription and that support the electronic transmission
of a prescription;
(C) ambulatory computerized physician order
entry systems that facilitate physician orders at the point-of-care
for medications and laboratory and radiological tests;
(D) inpatient computerized physician 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. 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) 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 6. 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. (a) 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) making efforts to expand the provider-base for
consumer-directed services by 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;
(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; and
(4) identifying, in conjunction with the Department on
Aging and Disability Services, information with respect to a
recipient who resides in a nursing facility that would assist the
department in placing the recipient in the community and gathering
that information if doing so would improve the recipient's health
or quality of life outcome.
(b) The commission shall ensure that stakeholders are
educated on issues faced by caregivers providing long-term care for
recipients.
Sec. 531.084. MEDICAID LONG-TERM CARE COST CONTAINMENT
STRATEGIES. 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 incurred medical
expenses for dental services controlled in long-term care
facilities;
(2) implement a fee schedule for allowable 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 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 on 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 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.
SECTION 7. MEDICAID MANAGED CARE. (a) Section 533.005(a),
Government Code, is amended 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 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; and
(13) a requirement that the organization use advanced
practice nurses as primary care providers to increase the
availability of primary care providers in the organization's
provider network.
(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) 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 pre-authorization 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) This section does not apply to a
managed care organization operated by a political subdivision of
this state.
(b) 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. The record must be prepared
not later than the 30th day after the date the commission orders the
imposition of a sanction against the organization.
(c) 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.
(d) The commission shall post and maintain the records
required by this section on the commission's Internet website 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 monthly.
(e) 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.
(f) A record prepared under this section may not include
information that is excepted from disclosure under Chapter 552.
(g) The executive commissioner shall adopt rules as
necessary to implement this section.
(c) The Health and Human Services Commission and the Texas
Department of Insurance shall jointly develop policies for the
joint regulation of the exclusive provider organization model used
in the children's health insurance program and in the primary care
case management model. The policies must be developed to regulate
exclusive provider organizations in a manner similar to the manner
in which health maintenance organizations are regulated. In
addition, the commission shall evaluate the possibility that the
state is currently at risk of financial exposure to risks
associated with the exclusive provider organization model used in
the children's health insurance program and in the primary care
case management model and shall determine whether additional
regulation by the Texas Department of Insurance is necessary.
(d) The Health and Human Services Commission shall
re-evaluate 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.
(e) 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.
(f) 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 provide
immunizations to Medicaid clients;
(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 meaningful
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.
(g) 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.
(h) 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 8. ENHANCED UTILIZATION MANAGEMENT SYSTEMS. (a)
Subchapter B, Chapter 32, Human Resources Code, is amended by
adding Sections 32.0551, 32.0552, and 32.0553 to read as follows:
Sec. 32.0551. ENHANCED UTILIZATION MANAGEMENT SYSTEMS. (a)
The department shall develop the enhanced utilization management
systems required by Sections 32.0552 and 32.0553 to more
effectively coordinate medical and case management services
provided to recipients who do not receive services through a
managed care organization to:
(1) eliminate duplication of and barriers to receiving
services; and
(2) ensure the most appropriate use of services.
(b) The department shall require each managed care
organization with which the department contracts under Chapter 533,
Government Code, to:
(1) develop and implement enhanced utilization
management systems that are equivalent to those required under
Sections 32.0552 and 32.0553; or
(2) if the managed care organization already operates
enhanced utilization management systems equivalent to those
required under Sections 32.0552 and 32.0553, maintain those
systems.
Sec. 32.0552. ACUTE CARE ENHANCED UTILIZATION MANAGEMENT
SYSTEM. (a) The department shall develop an acute care enhanced
utilization management system to improve the medical outcomes for
recipients receiving acute care services who do not receive those
services through a managed care organization and to maximize the
cost-effectiveness of the Medicaid acute care system.
(b) The department shall develop the acute care enhanced
utilization management system in a manner that prioritizes
recipient populations that are identified through data analysis as
needing additional assistance and with respect to which the
department has evidence indicating that providing focused
interventions or case management may be successful in:
(1) improving the health outcomes of recipients
included in those populations; and
(2) controlling costs.
(c) In developing the system, the department must
appropriately acknowledge variations among the different kinds of
applicable service delivery modalities while concurrently
providing a consistent platform to leverage development efforts.
The care coordination system for each applicable service delivery
modality must be designed to ensure that care is managed for
high-cost recipients, regardless of the recipients' diagnoses.
(d) The acute care enhanced utilization management system
must include:
(1) a mechanism to identify those recipients who reach
a specified level of expense to the program and identify specific,
medically appropriate interventions for those recipients;
(2) care coordination, case management, disease
management, support services, utilization management, and other
services in a single, complete system;
(3) predictive modeling applications that use health
risk assessments and claims data to identify recipients with
utilization patterns or complex health conditions that are likely
to generate disproportionately large health care costs in the
future;
(4) targeted case management programs to serve
recipients who have complex conditions that are not addressed
through existing treatment protocols and standardized care plans;
and
(5) incentives for providers who are especially
effective at managing complex or costly cases and a
provider-profiling tool to monitor, measure, and report
performance results at individual provider and health plan levels.
(e) The department shall consider including in the
incentives for providers required under Subsection (d)(5)
financial incentives in the form of increased case management fees
or enhancements to the fee schedule that could be funded through
cost savings achieved by the acute care enhanced utilization
management system.
(f) The department may collaborate with managed care
organizations under Chapter 533, Government Code, to avoid
duplication of effort and to integrate the acute care enhanced
utilization management system with the disease management, care
coordination, and utilization management systems used by managed
care organizations under that chapter.
Sec. 32.0553. LONG-TERM CARE ENHANCED UTILIZATION
MANAGEMENT SYSTEM. The department shall develop a long-term care
enhanced utilization management system to provide intensive case
management and care coordination for recipients receiving
long-term care services who do not receive those services through a
managed care organization.
(b) In developing the acute care and long-term care enhanced
utilization management systems required by Sections 32.0552 and
32.0553, Human Resources Code, as added by this section, 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 conduct a
study regarding the cost-effectiveness of including within
Medicaid disease management programs in existence on the effective
date of this section end-stage renal disease, home health services
for children with chronic conditions that are not included in the
existing disease management programs, the use of schools and school
nurses to manage chronic conditions of children, and the inclusion
of other diseases, conditions, and strategies. In studying the
cost-effectiveness of including other diseases, conditions, and
strategies, the commission shall review existing research and
examine the experiences of other states, insurance companies, and
managed care organizations.
(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. 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. TEXAS HEALTH STEPS PROGRAM. (a) Section 32.056,
Human Resources Code, is amended to read as follows:
Sec. 32.056. COMPLIANCE WITH TEXAS HEALTH STEPS. (a) The
executive commissioner of the Health and Human Services Commission
by rule shall develop procedures to ensure that recipients of
medical assistance who are eligible for Texas Health Steps comply
with the regimen of care prescribed by the Texas Health Steps
program.
(b) The department, in conjunction with the Department of
State Health Services, shall develop mechanisms to increase
compliance with the checkup and immunization schedules of the Texas
Health Steps program.
(b) Subchapter B, Chapter 32, Human Resources Code, is
amended by adding Section 32.0561 to read as follows:
Sec. 32.0561. TEXAS HEALTH STEPS PROGRAM MULTIAGENCY
ENHANCEMENTS. (a) The Health and Human Services Commission, in
conjunction with the health and human services agencies, as defined
by Section 531.001, Government Code, shall develop a quality
assurance system for the Texas Health Steps program.
(b) The Health and Human Services Commission and the
Department of State Health Services shall encourage enhanced
coordination and communication between providers of checkups under
the Texas Health Steps program and primary care providers under the
Medicaid program with regard to children involved in both programs.
(c) The Health and Human Services Commission shall
facilitate the integration of Texas Health Steps program services
and Medicaid primary care physicians for children involved in both
programs.
(c) The Health and Human Services Commission and the
Department of State Health Services shall continue to coordinate
efforts to obtain approval from the Centers for Medicare and
Medicaid Services to include prenatal and family planning exams as
components of Texas Health Steps program medical exams.
SECTION 10. 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 physicians or nonemergency 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 11. 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 12. 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 13. EFFECTIVE DATE. This Act takes effect
September 1, 2005.