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A BILL TO BE ENTITLED
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AN ACT
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relating to copayments and other cost-sharing payments under the |
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medical assistance program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Sections 32.064(a) and (b), Human Resources |
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Code, are amended to read as follows: |
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(a) To the extent permitted under Title XIX, Social Security |
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Act (42 U.S.C. Section 1396 et seq.), as amended, and any other |
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applicable law or regulations, the executive commissioner of the |
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Health and Human Services Commission shall adopt provisions |
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requiring recipients of medical assistance to share the cost of |
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medical assistance, including provisions requiring recipients to |
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pay: |
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(1) an enrollment fee; |
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(2) a deductible; [or] |
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(3) coinsurance or a portion of the plan premium, if |
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the recipients receive medical assistance under the Medicaid |
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managed care program under Chapter 533, Government Code, or a |
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Medicaid managed care demonstration project under Section 32.041; |
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or |
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(4) a copayment in accordance with Section 32.0641(c). |
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(b) Subject to Subsection (d) and except as provided by |
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Section 32.0641(c), cost-sharing provisions adopted under this |
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section shall ensure that families with higher levels of income are |
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required to pay progressively higher percentages of the cost of the |
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medical assistance. |
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SECTION 2. The heading to Section 32.0641, Human Resources |
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Code, is amended to read as follows: |
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Sec. 32.0641. COST SHARING FOR CERTAIN HEALTH CARE |
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[HIGH-COST MEDICAL] SERVICES. |
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SECTION 3. Section 32.0641, Human Resources Code, is |
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amended by amending Subsections (a) and (c) and adding Subsections |
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(a-1) and (d) to read as follows: |
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(a) To [If the department determines that it is feasible and
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cost-effective, and to] the extent permitted under Title XIX, |
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Social Security Act (42 U.S.C. Section 1396 et seq.) and any other |
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applicable law or regulation or under a federal waiver or other |
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authorization, and subject to Subsection (c), the executive |
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commissioner of the Health and Human Services Commission shall |
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adopt cost-sharing provisions that encourage personal |
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accountability and appropriate utilization of health care |
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services. |
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(a-1) The executive commissioner of the Health and Human |
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Services Commission shall adopt a cost-sharing provision under |
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Subsection (a) that requires [require] a recipient who chooses to |
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receive a nonemergency [a high-cost] medical service [provided] |
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through a hospital emergency room to pay a copayment[, premium
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payment,] or other cost-sharing payment for the nonemergency |
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[high-cost] medical service if: |
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(1) the hospital from which the recipient seeks |
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service: |
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(A) performs an appropriate medical screening |
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and determines that the recipient does not have a condition |
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requiring emergency medical services; |
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(B) informs the recipient: |
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(i) that the recipient does not have a |
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condition requiring emergency medical services; |
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(ii) that, if the hospital provides the |
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nonemergency medical service, the hospital may require payment of a |
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copayment[, premium payment,] or other cost-sharing payment by the |
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recipient in advance; and |
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(iii) of the name and address of a |
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nonemergency Medicaid provider who can provide the appropriate |
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medical service without imposing a cost-sharing payment; and |
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(C) offers to provide the recipient with a |
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referral to the nonemergency provider to facilitate scheduling of |
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the service; and |
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(2) after receiving the information and assistance |
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described by Subdivision (1) from the hospital, the recipient |
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chooses to obtain [emergency] medical services through the hospital |
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emergency room despite having access to appropriate and medically |
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acceptable[, lower-cost] medical services. |
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(c) If the executive commissioner of the Health and Human |
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Services Commission adopts copayments [a copayment or other
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cost-sharing payment] under Subsection (a) for the following health |
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care services, the executive commissioner shall require that a |
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recipient pay copayments in the following amounts: |
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(1) not more than $5 for each hospital outpatient |
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visit at the time of the visit, other than a visit for a |
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nonemergency medical service provided through a hospital emergency |
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room; |
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(2) not more than $5 for each medical visit with a |
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physician at the time of the visit; and |
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(3) not more than $7.50 per prescription drug |
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[commission may not reduce hospital payments to reflect the
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potential receipt of a copayment or other payment from a recipient
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receiving medical services provided through a hospital emergency
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room]. |
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(d) Subsection (c) does not require a medical assistance |
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provider to bill or collect from a recipient a copayment required or |
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authorized under this section. |
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SECTION 4. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 5. This Act takes effect September 1, 2011. |