By: Zaffirini, et al. S.B. No. 1756
A BILL TO BE ENTITLED
AN ACT
relating to the managed care delivery system known as integrated
care management.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Section 533.001,
Government Code, is amended by adding new Subsections (6), (7) and
(8) to read as follows:
Sec. 533.001. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services
Commission or an agency operating part of the state Medicaid
managed care program, as appropriate.
(2) "Commissioner" means the commissioner of health
and human services.
(3) "Health and human services agencies" has the
meaning assigned by Section 531.001.
(4) "Managed care organization" means a person who is
authorized or otherwise permitted by law to arrange for or provide a
managed care plan.
(5) "Managed care plan" means a plan under which a
person undertakes to provide, arrange for, pay for, or reimburse
any part of the cost of any health care services. A part of the plan
must consist of arranging for or providing health care services as
distinguished from indemnification against the cost of those
services on a prepaid basis through insurance or otherwise. The
term includes a primary care case management provider network. The
term does not include a plan that indemnifies a person for the cost
of health care services through insurance.
(6) "Medical home", for the purposes of this
subchapter, means a primary care physician or health care provide
with whom the patient has a continuous, ongoing professional
relationship and who manages and coordinates all aspects of a
patient's health care. Children or adults with special health care
needs or disabilities may select a subspecialist to act as their
medical home if the specialist agrees to serve in that role.
(7) "Case Management", for purposes of this
subchapter, means the method of identifying, assessing, and
monitoring recipients with complex, chronic or high cost health
care needs and developing a plan of care to coordinate the medical
and social support services needed to achieve optimum patient
outcomes in a cost-effective manner.
(8) "Care Coordination", for purposes of this
subchapter, means a process to link recipients with special health
care needs to medical, functional and social support services and
resources in a coordinated effort to maximize the potential of the
recipient to achieve optimal health care, independence, and
functionality.
(9) (6) "Recipient" means a recipient of medical
assistance under Chapter 32, Human Resources Code.
(10) (7) "Health care service region" or "region"
means a Medicaid managed care service area as delineated by the
commission.
SECTION 2. Subchapter A, Chapter 533, Section 533.002,
Government Code is amended to read as follows:
Sec. 533.002. PURPOSE. The commission shall implement the
Medicaid managed care program as part of the health care delivery
system developed under Chapter 532 by contracting with managed care
organizations in a manner that, to the extent possible:
(1) improves the health of Texans by:
(A) emphasizing prevention;
(B) promoting continuity of care; and
(C) providing a medical home for recipients;
(2) ensures that each recipient receives high quality,
comprehensive health care services in the recipient's local
community;
(3) encourages the training of and access to primary
care physicians and providers;
(4) maximizes cooperation with existing public health
entities, including local departments of health;
(5) provides incentives to managed care organizations
to improve the quality of health care services for recipients by
providing value-added services; [and]
(6) reduces administrative and other nonfinancial
barriers for recipients in obtaining health care services;[.]
(7) reduces administrative, financial and
nonfinancial barriers for physicians and providers who participate
in the medical assistance program; and
(8) minimizes non-direct care expenditures, except
those non-direct care expenditures which assure better care
outcomes.
SECTION 3. Subchapter A, Chapter 533, Section 533.025,
Government Code, is amended to read as follows:
Sec. 533.0025. DELIVERY OF SERVICES. (a) In this section,
"medical assistance" has the meaning assigned by Section 32.003,
Human Resources Code.
(b) Except as otherwise provided by this section and
notwithstanding any other law, the commission shall provide medical
assistance for health [acute] care through the most cost-effective
model of Medicaid managed care as determined by the commission. In
any geographic area that may be affected by a Medicaid managed care
model, the commission shall seek local input and shall hold a public
hearing in the affected area prior to making a determination as to
any Medicaid managed care model to be implemented. If the
commission determines that it is more cost-effective, the
commission may provide medical assistance for health [acute] care
in a certain part of this state or to a certain population of
recipients using:
(1) a health maintenance organization model,
including the acute care portion of Medicaid Star + Plus pilot
programs;
(2) a primary care case management model;
(3) a prepaid health plan model;
(4) an exclusive provider organization model; or
(5) another Medicaid managed care model or
arrangement.
The commissioner may not utilize a capitated risk model for health
care services for aged, blind and disabled populations.
(c) In determining whether a model or arrangement described
by Subsection (b) is more cost-effective, the commissioner must
consider:
(1) the scope, duration, and types of health benefits
or services to be provided in a certain part of this state or to a
certain population of recipients;
(2) administrative costs necessary to meet federal and
state statutory and regulatory requirements;
(3) the anticipated effect of market competition
associated with the configuration of Medicaid service delivery
models determined by the commission; [and]
(4) the gain or loss to this state of a tax collected
under Article 4.11, Insurance Code [.];
(5) the impact, including fiscal impact, to the
medical delivery infrastructure of municipalities, counties,
hospital districts or other taxing entities that provide health
care or health care service for indigent or Medicaid populations;
and
(6) the long term impact to the medical assistance
provider network, including participation in the network by
privately practicing physicians, home and community support
services providers, mental health providers, and assisted living
and adult daycare providers.
(d) The commissioner shall issue a public report providing
his findings, determinations, evaluations and weight given to each
required provision of this section and such report shall be
provided to the Governor, Lt. Governor and the Speaker of the House
of Representatives.
(e) If the commission determines that it is not more
cost-effective to use a Medicaid managed care model to provide
certain types of medical assistance in a certain area or to certain
medical assistance recipients as prescribed by this section, the
commission shall provide medical assistance through a traditional
fee-for-service arrangement.
(f)(1) Notwithstanding Subsection (b)(1), the commission
may not provide medical assistance using a health maintenance
organization in Cameron County, Hidalgo County, or Maverick
County[.], and
(2) shall maintain and enhance any primary care case
management program in existence on January 1, 2005.
(g) In any Medicaid managed care program established after
January 1, 2005, the commission shall establish a primary care case
management model as one option.
SECTION 4. Subchapter A, Chapter 533, Government Code, is
amended to add a new Section 533.026, to read as follows:
Section 533.026. ESTABLISHMENT OF AN INTEGRATED CARE
MANAGEMENT MODEL. (a) The commission by rule shall establish an
integrated care management model throughout the state.
(b) For purposes of this section, Integrated Care
Management shall be established as "Integrated Care Management I"
and "Integrated Care Management II".
(c) Populations to be include within "Integrated Care
Management I" include:
(1) Temporary Assistance and Needy Families and
Temporary and Needy Family related populations;
(2) pregnant women; and
(3) children.
(d) Populations to be included within "Integrated Care
Management II" include:
(1) recipients eligible for Supplemental Security
Income payments;
(2) recipients who are determined eligible for 1915(c)
community based alternatives waiver services; and
(3) recipients who are dually eligible for medical
assistance and Medicare.
(e) For purposes of this section, Integrated Care
Management I includes:
(1) assignment of integrated care management patients
to a medical home;
(2) at least quarterly patient level reporting to
physicians or appropriate health care providers of the utilization
and costs of health care services, including prescription drug
utilization and costs, of the integrated care management
populations;
(3) health risk assessment screenings for patients
upon enrollment in the integrated care management program to
identify patients with chronic illnesses or diseases or who are at
risk of developing such illnesses or diseases and reports of the
results of assessment screenings are made to the patient's medical
home.
(4) coordination by the patient's medical home of
support services, including home health or durable medical
equipment;
(5) a mechanism for increased levels of payment for
physicians or providers who establish and maintain clinics to treat
patients after normal business hours as established by commission
rule;
(7) case management for patients identified with
chronic conditions;
(8) a mechanism to provide for increased levels of
payment to providers who adhere to physician developed, evidence
based, peer reviewed, clinical guidelines and performance
measures;
(9) coordination of disease management, case
management, and pharmacy management;
(10) a comprehensive quality management program;
(11) a mechanism to provide increased levels of
payment for integrated care providers who incorporate EPSDT
services into the medical home;
(12) outreach initiatives to recruit physicians and
health care providers to participate; and
(13) mechanisms to assist recipients to easily
identify participating physicians and health care providers, such
as a list of participating providers on the Internet.
(f) For purposes this section, Integrated Care Management
II includes:
(1) the services outlined in Section (d) (1)-(13);
(2) a functional needs assessment, performed in the
most cost effective manner, to determine community and social
support services needed by recipients;
(3) aggressive efforts to prevent or delay
institutionalization of recipients through the effective
utilization of home and community based support services; and
(4) promotion of the Promoting Independence
Initiative to identify persons wishing to leave a nursing facility
and reside in the community.
(g) In developing the long term care provisions of the
integrated care management model, policy development shall
continue to reside within the Department of Aging and Disability
Services. (THIS IS IN RESPONSE TO CONSUMER CONCERNS ABOUT
FRAGMENTATION BETWEEN HHSC AND DADS).
(h) In establishing Integrated Care Management II, the
commission shall limit its implementation to nine urban service
delivery areas of the state. (NOT SURE HOW TO DEFINE THE AREAS THAT
WOULD HAVE BEEN INCLUDED IN STAR+PLUS HMO EXPANSION-Houston,
Galveston, Nueces, Travis, Bexar, Lubbock, El Paso, Dallas,
Tarrant)
(i) The commissioner shall contract for technological
support and care coordination necessary to assure proper
utilization of services and cost effective outcomes. The
contracted tools of care management should enhance the ability of
the integrated care management provider to be effective and
responsive in making treatment decisions. The commissioner may
amend contracts or enter into new contracts with existing
contractors to perform the services required by this subsection.
In contracting, the commissioner shall take into account the effect
on the physicians and health care providers who will utilize the
system and make every reasonable attempt to minimize any
administrative burden on the physicians and health care providers
within the program.
(j) The commissioner shall establish an advisory committee
to assist in the development of the integrated care management
model. The commission shall consult with the advisory committee
during the development of the model and before and during any rule
making relating to the model. The members shall serve without
compensation. The committee is not subject to Chapter 551,
Government Code. The advisory committee shall establish one
subcommittee to address the specific medical and community support
services of children with complex or special health care needs and
one subcommittee to address the medical and community support
services of adults with complex or special health care needs. The
advisory committee may establish other subcommittees, as
necessary, to address operational and design issues relating to
Integrated Care Management implementation. Any subcommittee
members shall serve without compensation. Members of the advisory
committee shall include:
(1) six practicing primary care physicians drawn from
geographically different areas of the state, including at least two
with experience practicing under a primary care management program;
(2) three specialty care physicians;
(3) one representative of a Federally Qualified Health
Center;
(4) one representative of a Rural Health Clinic;
(5) one hospital representative;
(6) two home care providers; and
(7) two consumer representatives.
(k) The commissioner shall establish a regional advisory
committee to assist in the development and implementation of the
model in each geographic area encompassed by the model. Members of
the regional advisory committee shall be drawn from the geographic
area covered by the model and shall include the same categories or
representatives as specified in Subsection (f) of this section.
The committee is not subject to Chapter 551, Government Code.
(l) Not later than January 5th, 2007, the commission shall
submit to the Legislative Budget Board, the Lt. Governor and the
Speaker of the House of Representatives a preliminary report
containing the findings of the implementation of the integrated
care management program and the commission's recommendations for
further improvements of the model. The report shall include
patient and provider satisfaction, patient access to primary and
specialty care services, patient outcomes and health status
improvement, cost savings and cost impact to local funding
entities.
SECTION 5. Subchapter A, Chapter 533, Government Code, is
amended to add a new Section 533.027, to read as follows:
Section 533.027. EFFECTIVENESS OF AN INTEGRATED CARE
MANAGEMENT MODEL. (a) In determining whether integrated care
management achieves cost savings, the commission shall consider the
following:
(1) savings achieved through the continuation of
disease management; and
(2) increased utilization of home and community based
services instead of more expensive institutional care.
(b) The comptroller of public accounts shall verify the
findings of the commission in evaluating the cost savings of the
integrated care management model.
SECTION 6. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2005.