BILL ANALYSIS

Senate Research Center                                                                                                 C.S.S.B. 569

                                                                                                                                           By: Deuell

Health & Human Services

4/4/2007

Committee Report (Substituted)

AUTHOR'S / SPONSOR'S STATEMENT OF INTENT

Under current law, the Medicaid Primary Care Case Management program (program), operating exclusively in Texas' rural areas, is exempted by interpretation from the requirement that managed care organizations reimburse a federally-qualified health center (health center) or a rural health clinic for service provided outside of regular business hours if the patient's primary care provider does not provide the patient with a referral.  Often, during after-hours clinics, health centers, rural health clinics, and physician offices or clinics see patients not assigned to them and who come without referrals.  If the patient's assigned primary care provider is not readily available to refer the patient, the claims of the health centers, rural health clinics, and physician offices or clinics may be rejected.

C.S.S.B. 569 requires the Health and Human Services Commission to reimburse health centers, rural health clinics, and physician offices or clinics for care provided outside regular business hours to Medicaid recipients participating in the program without a referral from the patient's primary care provider.  This bill provides that health centers and clinics that remain open outside of regular business hours are eligible for certain incentives. 

RULEMAKING AUTHORITY

Rulemaking authority is expressly granted to the executive commissioner of the Health and Human Services Commission in SECTION 1 (Section 533.01315, Government Code) of this bill.

SECTION BY SECTION ANALYSIS

SECTION 1.  Amends Subchapter A, Chapter 533, Government Code, by adding Section 533.01315, as follows:

Sec. 533.01315.  REIMBURSEMENT FOR SERVICES PROVIDED OUTSIDE OF REGULAR BUSINESS HOURS.  (a)  Provides that this section applies only to a recipient receiving medical assistance though any Medicaid managed care model or arrangement (recipient). 

(b)  Requires the Health and Human Services Commission (HHSC) to ensure that a federally qualified health center, rural health clinic, or physician office or clinic is reimbursed for health care services (services) provided to a recipient outside of regular business hours, including a weekend or holiday, equal to the rate allowed for those services by Section 32.028 (Fees, Charges, and Rates), Human Resources Code, regardless of whether the recipient has a referral from the recipient's primary care physician.

(c)  Requires the executive commissioner of HHSC to adopt rules regarding the days, times of days, and holidays that are considered to be outside of regular business hours for the purposes of Subsection (b).

SECTION 2.  Authorizes a state agency to delay implementing a provision of this Act until a requested federal waiver or authorization necessary to implement that provision is obtained.

SECTION 3.  Effective date: September 1, 2007.