81R31630 ALB-F

By: Naishtat H.B. No. 4552

Substitute the following for H.B. No. 4552:

By: Rose C.S.H.B. No. 4552

A BILL TO BE ENTITLED

AN ACT

relating to certain Medicaid waiver programs.

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

SECTION 1. Subchapter B, Chapter 32, Human Resources Code, is amended by adding Section 32.0521 to read as follows:

Sec. 32.0521. HOSPITAL LEVEL OF CARE WAIVER PROGRAM FOR MEDICALLY FRAGILE INDIVIDUALS. (a) The department shall apply for a waiver under Section 1915(c) of the federal Social Security Act (42 U.S.C. Section 1396n(c)) to provide the state with the flexibility to provide medical assistance services outside the scope, amount, or duration of nonwaiver services available to medically fragile individuals who are at least 21 years of age and who require a hospital level of care under the medical assistance program.

(b) The waiver program under this section may include coverage for case management services, adaptive aids and medical supplies, nursing services, attendant services, in-home support services, specialized therapies, respite services, adult foster care, companion care, and consumer-directed service options.

(c) A medically fragile individual is eligible for the waiver program under this section only if:

(1) the individual meets the medical and functional criteria specified in the waiver;

(2) the projected cost of providing services to the individual over a 12-month period exceeds the individual cost limit specified in another medical assistance waiver program; and

(3) the individual would otherwise be eligible for services funded by general revenue under Section 32.058(c) or (c-1).

SECTION 2. The heading to Section 32.058, Human Resources Code, is amended to read as follows:

Sec. 32.058. LIMITATION ON CERTAIN MEDICAL ASSISTANCE WAIVER PROGRAMS [IN CERTAIN ALTERNATIVE COMMUNITY-BASED CARE SETTINGS].

SECTION 3. Section 32.058, Human Resources Code, is amended by amending Subsections (a), (b), (c), and (g) and adding Subsections (c-1), (c-2), (c-3), and (c-4) to read as follows:

(a) In this section, "medical assistance waiver program" means a program [administered by the Department of Aging and Disability Services], other than the Texas home living program, that provides services under a waiver granted in accordance with 42 U.S.C. Section 1396n(c).

(b) Except as provided by Subsection (c) or (c-1), [(d), (e), or (f),] the department may not provide services under a medical assistance waiver program to a person if the projected cost of providing those services over a 12-month period exceeds the individual cost limit specified in the medical assistance waiver program.

(c) Regardless of whether federal matching funds are available for the medical assistance waiver program and notwithstanding Section 32.024(e), the [The] department shall use general revenue funds appropriated to the department to continue to provide services [under a medical assistance waiver program] to a person who was receiving medical assistance waiver program [those] services on September 1, 2005, at a cost that exceeded the individual cost limit specified in the medical assistance waiver program [, if continuation of those services:

[(1) is necessary for the person to live in the most integrated setting appropriate to the needs of the person; and

[(2) does not affect the department's compliance with the federal average per capita expenditure requirement of the medical assistance waiver program under 42 U.S.C. Section 1396n(c)(2)(D)].

(c-1) Regardless of whether federal matching funds are available for the medical assistance waiver program and notwithstanding Section 32.024(e), the department, in addition to services provided under Subsection (c), may use general revenue funds appropriated to the department to provide services under a medical assistance waiver program to a person if:

(1) the projected cost of providing services to the person over a 12-month period exceeds the individual cost limit specified in the medical assistance waiver program;

(2) federal matching funds are not available to pay for the services; and

(3) the department determines that:

(A) the person's health and safety cannot be protected by the services provided within the cost limit established for the program;

(B) there is no other available medical assistance waiver program that can protect the person's health and safety within the cost limit of that program; and

(C) there is no available living arrangement in which the person's health and safety can be protected, as evidenced by:

(i) an assessment conducted by clinical staff of the Health and Human Services Commission or the Department of Aging and Disability Services; and

(ii) supporting documentation, including the person's medical and service records.

(c-2) The department may not expend any funds under Subsection (c) or (c-1) if the expenditure would affect the department's compliance with federal cost-effectiveness requirements applicable to medical assistance waiver programs, including 42 U.S.C. Section 1396n(c)(2)(D).

(c-3) The department shall employ utilization management and utilization review practices as necessary to ensure that the appropriate scope and level of services are provided to individuals receiving medical assistance waiver program services and to ensure compliance with federal cost-effectiveness requirements.

(c-4) This section does not establish an entitlement to services or to funding for services from general revenue funds.

(g) The executive commissioner of the Health and Human Services Commission may adopt rules to implement this section [Subsections (d), (e), and (f)].

SECTION 4. Sections 32.058(d), (e), and (f), Human Resources Code, are repealed.

SECTION 5. 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, 2009.