82R9349 KLA-D

By: Perry H.B. No. 2478

A BILL TO BE ENTITLED

AN ACT

relating to the provision of nonemergency medical services to Medicaid recipients and reimbursement for those services.

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

SECTION 1. Subchapter B, Chapter 531, Government Code, is amended by adding Section 531.02193 to read as follows:

Sec. 531.02193. ACCESS TO COMMUNITY HEALTH CLINICS. The executive commissioner shall adopt policies designed to improve Medicaid recipient access to nonemergency medical services by encouraging federally qualified health centers, as defined by Section 531.02192, and other community health clinics that provide services to Medicaid recipients to maintain hours of operation that include evening hours until at least 10 p.m.

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

Sec. 32.0641. REIMBURSEMENT [COST SHARING] FOR CERTAIN NONEMERGENCY [HIGH-COST] MEDICAL SERVICES. (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 except as provided by Subsection (c), the department [executive commissioner of the Health and Human Services Commission] shall deny medical assistance reimbursement for the provision of a nonemergency [adopt cost-sharing provisions that require a recipient who chooses a high-cost] medical service to a medical assistance recipient [provided] through a hospital emergency room unless, at the time the recipient is seeking care, there is no nonemergency medical services provider available within 50 miles of the hospital emergency room that could provide the service to the recipient [to pay a copayment, premium payment, or other cost-sharing payment for the 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 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 despite having access to medically acceptable, lower-cost medical services].

(a-1) The executive commissioner of the Health and Human Services Commission shall adopt rules prescribing a process under which a hospital emergency room that receives reimbursements under the medical assistance program provides information to a medical assistance recipient seeking nonemergency medical services at the hospital emergency room regarding the availability of nonemergency medical services providers. The rules must require the hospital emergency room to:

(1) inform the recipient that the recipient's condition is not an emergency medical condition;

(2) provide to the recipient a list of the names, addresses, and hours of operation of nonemergency medical services providers, including federally qualified health centers and other community health centers, that are located within 50 miles of the hospital emergency room and that could provide the services to the recipient; and

(3) offer to provide the recipient with a referral to the nonemergency medical services provider to facilitate scheduling of the service.

(b) The department may not deny reimbursement [seek a federal waiver or other authorization] under Subsection (a) if the denial [that] would:

(1) prevent a Medicaid recipient who has a condition requiring emergency medical services from receiving care through a hospital emergency room; or

(2) waive any provision under Section 1867, Social Security Act (42 U.S.C. Section 1395dd).

(c) The department may not deny reimbursement under the medical assistance program for the provision of nonemergency medical services provided in a hospital emergency room to a medical assistance recipient who is younger than six years of age. [If the executive commissioner of the Health and Human Services Commission adopts a copayment or other cost-sharing payment under Subsection (a), the 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.]

SECTION 3. 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 4. This Act takes effect September 1, 2011.