81R11564 ALB-D

By: Rose H.B. No. 4156

A BILL TO BE ENTITLED

AN ACT

relating to the medical assistance program.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 32.021(b), Human Resources Code, is amended to read as follows:

(b) The department shall enter into agreements with any federal agency designated by federal law to administer medical assistance when the department determines the agreements to be compatible with the state's participation in the medical assistance program and within the limits of appropriated funds. The department shall cooperate with federal agencies designated by federal law to administer medical assistance in any reasonable manner necessary to qualify for federal funds, including funds available under the American Recovery and Reinvestment Act of 2009 (Pub. L. No. 111-5).

SECTION 2. Section 32.024, Human Resources Code, is amended by amending Subsections (f), (l), (t), and (w) and adding Subsections (z-2) and (ee) to read as follows:

(f) The department shall set the income eligibility cap for persons qualifying for nursing home care at an amount that is not less than $1,102 [$1,104] and that does not exceed the highest income for which federal matching funds are payable. The department shall set the cap at a higher amount than the minimum provided by this subsection if appropriations made by the legislature for a fiscal year will finance benefits at the higher cap for at least the same number of recipients of the benefits during that year as were served during the preceding fiscal year, as estimated by the department. In setting an income eligibility cap under this subsection, the department shall consider the cost of the adjustment required by Subsection (g) of this section.

(l) The department shall set the income eligibility cap for medical assistance for pregnant women and infants up to age one at not less than 135 [130] percent of the federal poverty guidelines.

(t) The department by rule shall require a physician, nursing facility, health care provider, or other responsible party to obtain authorization from the department or a person authorized to act on behalf of the department before an ambulance is used to transport a recipient of medical assistance under this chapter in circumstances not involving an emergency. The rules must provide that:

(1) except as provided by Subdivision (3), a request for authorization must be evaluated based on the recipient's medical needs and may be granted for a length of time appropriate to the recipient's medical condition;

(2) except as provided by Subdivision (3), a response to a request for authorization must be made not later than 48 hours after receipt of the request;

(3) a request for authorization must be immediately granted and must be effective for a period of not more than 180 days from the date of issuance if the request includes a written statement from a physician that:

(A) states that alternative means of transporting the recipient are contraindicated; and

(B) is dated not earlier than the 60th day before the date on which the request for authorization is made;

(4) a person denied payment for ambulance services rendered is entitled to payment from the nursing facility, health care provider, or other responsible party that requested the services if:

(A) payment under the medical assistance program is denied because of lack of prior authorization; and

(B) the person provides the nursing facility, health care provider, or other responsible party with a copy of the bill for which payment was denied; and

(5) a person denied payment for services rendered because of failure to obtain prior authorization or because a request for prior authorization was denied is entitled to appeal the denial of payment to the department.

(w) The department shall set a personal needs allowance of not less than $70 [$60] a month for a resident of a convalescent or nursing home or related institution licensed under Chapter 242, Health and Safety Code, personal care facility, ICF-MR facility, or other similar long-term care facility who receives medical assistance. The department may send the personal needs allowance directly to a resident who receives Supplemental Security Income (SSI) (42 U.S.C. Section 1381 et seq.). This subsection does not apply to a resident who is participating in a medical assistance waiver program administered by the department.

(z-2) Notwithstanding any other law, the department, in its rules and standards governing the vendor drug program, may not limit to less than four the number of medications prescribed each month to a recipient of prescription drug benefits under the medical assistance program if one of those medications is prescribed for 30 days or less and may not be refilled.

(ee) In its rules and standards governing the vendor drug program, the department, to the maximum extent allowed by federal law and subject to Subsection (z), shall provide medical assistance to a recipient, including a recipient of medical assistance under the Medicaid managed care program under Chapter 533, Government Code, for the off-label use of a prescription medication if the off-label use appears in one or more drug reference compendia and is approved by the recipient's physician.

SECTION 3. Section 32.025, Human Resources Code, is amended by adding Subsection (d-1) to read as follows:

(d-1) The procedures under Subsection (d) shall ensure that children are screened simultaneously for eligibility under this chapter and for eligibility under the child health plan program under Chapter 62, Health and Safety Code, and the eligibility of a child for the appropriate program is determined without further eligibility application or qualification. This subsection applies to an initial application and any subsequent recertification review. The department shall ensure continuous coverage for an eligible child who is transferred to a different program as a result of the recertification review with no gap in coverage between the two programs.

SECTION 4. 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 5. This Act takes effect September 1, 2009.