82R22116 KFF-F

By: Parker H.B. No. 2368

Substitute the following for H.B. No. 2368:

By: Truitt C.S.H.B. No. 2368

A BILL TO BE ENTITLED

AN ACT

relating to copayments and other cost-sharing payments under the medical assistance program.

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

SECTION 1. Sections 32.064(a) and (b), Human Resources Code, are amended to read as follows:

(a) To the extent permitted under Title XIX, Social Security Act (42 U.S.C. Section 1396 et seq.), as amended, and any other applicable law or regulations, the executive commissioner of the Health and Human Services Commission shall adopt provisions requiring recipients of medical assistance to share the cost of medical assistance, including provisions requiring recipients to pay:

(1) an enrollment fee;

(2) a deductible; [or]

(3) coinsurance or a portion of the plan premium, if the recipients receive medical assistance under the Medicaid managed care program under Chapter 533, Government Code, or a Medicaid managed care demonstration project under Section 32.041; or

(4) a copayment in accordance with Section 32.0641(c).

(b) Subject to Subsection (d) and except as provided by Section 32.0641(c), cost-sharing provisions adopted under this section shall ensure that families with higher levels of income are required to pay progressively higher percentages of the cost of the medical assistance.

SECTION 2. The heading to Section 32.0641, Human Resources Code, is amended to read as follows:

Sec. 32.0641. COST SHARING FOR CERTAIN HEALTH CARE [HIGH-COST MEDICAL] SERVICES.

SECTION 3. Section 32.0641, Human Resources Code, is amended by amending Subsections (a) and (c) and adding Subsections (a-1) and (d) to read as follows:

(a) To [If the department determines that it is feasible and cost-effective, and to] the extent permitted under Title XIX, Social Security Act (42 U.S.C. Section 1396 et seq.) and any other applicable law or regulation or under a federal waiver or other authorization, and subject to Subsection (c), the executive commissioner of the Health and Human Services Commission shall adopt cost-sharing provisions that encourage personal accountability and appropriate utilization of health care services.

(a-1) The executive commissioner of the Health and Human Services Commission shall adopt a cost-sharing provision under Subsection (a) that requires [require] a recipient who chooses to receive a nonemergency [a high-cost] medical service [provided] through a hospital emergency room to pay a copayment[, premium payment,] or other cost-sharing payment for the nonemergency [high-cost] medical service if:

(1) the hospital from which the recipient seeks service:

(A) performs an appropriate medical screening and determines that the recipient does not have a condition requiring emergency medical services;

(B) informs the recipient:

(i) that the recipient does not have a condition requiring emergency medical services;

(ii) that, if the hospital provides the nonemergency medical service, the hospital may require payment of a copayment[, premium payment,] or other cost-sharing payment by the recipient in advance; and

(iii) of the name and address of a nonemergency Medicaid provider who can provide the appropriate medical service without imposing a cost-sharing payment; and

(C) offers to provide the recipient with a referral to the nonemergency provider to facilitate scheduling of the service; and

(2) after receiving the information and assistance described by Subdivision (1) from the hospital, the recipient chooses to obtain [emergency] medical services through the hospital emergency room despite having access to appropriate and medically acceptable[, lower-cost] medical services.

(c) If the executive commissioner of the Health and Human Services Commission adopts copayments [a copayment or other cost-sharing payment] under Subsection (a) for the following health care services, the executive commissioner shall require that a recipient pay copayments in the following amounts:

(1) not more than $5 for each hospital outpatient visit at the time of the visit, other than a visit for a nonemergency medical service provided through a hospital emergency room;

(2) not more than $5 for each medical visit with a physician at the time of the visit; and

(3) not more than $7.50 per prescription drug [commission may not reduce hospital payments to reflect the potential receipt of a copayment or other payment from a recipient receiving medical services provided through a hospital emergency room].

(d) Subsection (c) does not require a medical assistance provider to bill or collect from a recipient a copayment required or authorized under this section.

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, 2011.