| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to a "Texas solution" to reforming and addressing issues |
|
|
related to the Medicaid program, including the creation of an |
|
|
alternative program designed to ensure health benefit plan coverage |
|
|
to certain low-income individuals through the private marketplace; |
|
|
authorizing a fee. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
ARTICLE 1. BLOCK GRANT FUNDING SYSTEM FOR STATE MEDICAID PROGRAM |
|
|
SECTION 1.01. Subtitle I, Title 4, Government Code, is |
|
|
amended by adding Chapter 539 to read as follows: |
|
|
CHAPTER 539. BLOCK GRANT FUNDING SYSTEM FOR STATE MEDICAID PROGRAM |
|
|
SUBCHAPTER A. GENERAL PROVISIONS |
|
|
Sec. 539.001. DEFINITIONS. In this chapter: |
|
|
(1) "Health benefit exchange" means an American Health |
|
|
Benefit Exchange administered by the federal government or an |
|
|
exchange created under Section 1311(b) of the Patient Protection |
|
|
and Affordable Care Act (42 U.S.C. Section 18031(b)). |
|
|
(2) "Medicaid program" means the medical assistance |
|
|
program established and operated under Title XIX, Social Security |
|
|
Act (42 U.S.C. Section 1396 et seq.). |
|
|
(3) "State Medicaid program" means the medical |
|
|
assistance program provided by this state under the Medicaid |
|
|
program. |
|
|
Sec. 539.002. FEDERAL AUTHORIZATION TO REFORM MEDICAID |
|
|
REQUIRED. If the federal government establishes, through |
|
|
conversion or otherwise, a block grant funding system for the |
|
|
Medicaid program or otherwise authorizes the state Medicaid program |
|
|
to operate under a block grant funding system, including under a |
|
|
Medicaid program waiver, the commission, in cooperation with |
|
|
applicable health and human services agencies, shall, subject to |
|
|
Section 539.003, administer and operate the state Medicaid program |
|
|
in accordance with this chapter. |
|
|
Sec. 539.003. CONFLICT WITH OTHER LAW. To the extent of a |
|
|
conflict between a provision of this chapter and: |
|
|
(1) another provision of state law, the provision of |
|
|
this chapter controls, subject to Section 540.002(b); and |
|
|
(2) a provision of federal law or any authorization |
|
|
described under Section 539.002, the federal law or authorization |
|
|
controls. |
|
|
Sec. 539.004. ESTABLISHMENT OF REFORMED STATE MEDICAID |
|
|
PROGRAM. The commission shall establish a state Medicaid program |
|
|
that provides benefits under a risk-based Medicaid managed care |
|
|
model. |
|
|
Sec. 539.005. RULES. The executive commissioner shall |
|
|
adopt rules necessary to implement this chapter. |
|
|
SUBCHAPTER B. ACUTE CARE |
|
|
Sec. 539.051. ELIGIBILITY FOR MEDICAID ACUTE CARE. (a) An |
|
|
individual is eligible to receive acute care benefits under the |
|
|
state Medicaid program if the individual: |
|
|
(1) has a household income at or below 100 percent of |
|
|
the federal poverty level; |
|
|
(2) is under 19 years of age and: |
|
|
(A) is receiving Supplemental Security Income |
|
|
(SSI) under 42 U.S.C. Section 1381 et seq.; or |
|
|
(B) is in foster care or resides in another |
|
|
residential care setting under the conservatorship of the |
|
|
Department of Family and Protective Services; or |
|
|
(3) meets the eligibility requirements that were in |
|
|
effect on September 1, 2013. |
|
|
(b) The commission shall provide acute care benefits under |
|
|
the state Medicaid program to each individual eligible under this |
|
|
section through the most cost-effective means, as determined by the |
|
|
commission. |
|
|
(c) If an individual is not eligible for the state Medicaid |
|
|
program under Subsection (a), the commission shall refer the |
|
|
individual to the program established under Chapter 540 that helps |
|
|
connect eligible residents with health benefit plan coverage |
|
|
through private market solutions, a health benefit exchange, or any |
|
|
other resource the commission determines appropriate. |
|
|
Sec. 539.052. MEDICAID SLIDING SCALE SUBSIDIES. (a) An |
|
|
individual who is eligible for the state Medicaid program under |
|
|
Section 539.051 may receive a Medicaid sliding scale subsidy to |
|
|
purchase a health benefit plan from an authorized health benefit |
|
|
plan issuer. |
|
|
(b) A sliding scale subsidy provided to an individual under |
|
|
this section must: |
|
|
(1) be based on: |
|
|
(A) the average premium in the market; and |
|
|
(B) a realistic assessment of the individual's |
|
|
ability to pay a portion of the premium; and |
|
|
(2) include an enhancement for individuals who choose |
|
|
a high deductible health plan with a health savings account. |
|
|
(c) The commission shall ensure that counselors are made |
|
|
available to individuals receiving a subsidy to advise the |
|
|
individuals on selecting a health benefit plan that meets the |
|
|
individuals' needs. |
|
|
(d) An individual receiving a subsidy under this section is |
|
|
responsible for paying: |
|
|
(1) any difference between the premium costs |
|
|
associated with the purchase of a health benefit plan and the amount |
|
|
of the individual's subsidy under this section; and |
|
|
(2) any copayments associated with the health benefit |
|
|
plan. |
|
|
(e) If the amount of a subsidy received by an individual |
|
|
under this section exceeds the premium costs associated with the |
|
|
individual's purchase of a health benefit plan, the individual may |
|
|
deposit the excess amount in a health savings account that may be |
|
|
used only in the manner described by Section 539.054(b). |
|
|
Sec. 539.053. ADDITIONAL COST-SHARING SUBSIDIES. In |
|
|
addition to providing a subsidy to an individual under Section |
|
|
539.052, the commission shall provide additional subsidies for |
|
|
coinsurance payments, copayments, deductibles, and other |
|
|
cost-sharing requirements associated with the individual's health |
|
|
benefit plan. The commission shall provide the additional |
|
|
subsidies on a sliding scale based on income. |
|
|
Sec. 539.054. DELIVERY OF SUBSIDIES; HEALTH SAVINGS |
|
|
ACCOUNTS. (a) The commission shall determine the most appropriate |
|
|
manner for delivering and administering subsidies provided under |
|
|
Sections 539.052 and 539.053. In determining the most appropriate |
|
|
manner, the commission shall consider depositing subsidy amounts |
|
|
for an individual in a health savings account established for that |
|
|
individual. |
|
|
(b) A health savings account established under this section |
|
|
may be used only to: |
|
|
(1) pay health benefit plan premiums and cost-sharing |
|
|
amounts; and |
|
|
(2) if appropriate, purchase health care-related |
|
|
goods and services. |
|
|
Sec. 539.055. MEDICAID HEALTH BENEFIT PLAN ISSUERS AND |
|
|
MINIMUM COVERAGE. The commission shall allow any health benefit |
|
|
plan issuer authorized to write health benefit plans in this state |
|
|
to participate in the state Medicaid program. The commission in |
|
|
consultation with the commissioner of insurance shall establish |
|
|
minimum coverage requirements for a health benefit plan to be |
|
|
eligible for purchase under the state Medicaid program, subject to |
|
|
the requirements specified by this chapter. |
|
|
Sec. 539.056. REINSURANCE FOR PARTICIPATING HEALTH BENEFIT |
|
|
PLAN ISSUERS. (a) The commission in consultation with the |
|
|
commissioner of insurance shall study a reinsurance program to |
|
|
reinsure participating health benefit plan issuers. |
|
|
(b) In examining options for a reinsurance program, the |
|
|
commission and commissioner of insurance shall consider a plan |
|
|
design under which: |
|
|
(1) a participating health benefit plan is not charged |
|
|
a premium for the reinsurance; and |
|
|
(2) the health benefit plan issuer retains risk on a |
|
|
sliding scale. |
|
|
SUBCHAPTER C. LONG-TERM SERVICES AND SUPPORTS |
|
|
Sec. 539.101. PLAN TO REFORM DELIVERY OF LONG-TERM SERVICES |
|
|
AND SUPPORTS. The commission shall develop a comprehensive plan to |
|
|
reform the delivery of long-term services and supports that is |
|
|
designed to achieve the following objectives under the state |
|
|
Medicaid program or any other program created as an alternative to |
|
|
the state Medicaid program: |
|
|
(1) encourage consumer direction; |
|
|
(2) simplify and streamline the provision of services; |
|
|
(3) provide flexibility to design benefits packages |
|
|
that meet the needs of individuals receiving long-term services and |
|
|
supports under the program; |
|
|
(4) improve the cost-effectiveness and sustainability |
|
|
of the provision of long-term services and supports; |
|
|
(5) reduce reliance on institutional settings; and |
|
|
(6) encourage cost sharing by family members when |
|
|
appropriate. |
|
|
ARTICLE 2. IMMEDIATE REFORM: PROGRAM TO ENSURE HEALTH BENEFIT |
|
|
COVERAGE FOR CERTAIN INDIVIDUALS THROUGH PRIVATE MARKETPLACE |
|
|
SECTION 2.01. Subtitle I, Title 4, Government Code, is |
|
|
amended by adding Chapter 540 to read as follows: |
|
|
CHAPTER 540. PROGRAM TO ENSURE HEALTH BENEFIT PLAN COVERAGE FOR |
|
|
CERTAIN INDIVIDUALS THROUGH PRIVATE MARKET SOLUTIONS |
|
|
SUBCHAPTER A. GENERAL PROVISIONS |
|
|
Sec. 540.001. DEFINITION. In this chapter, "medical |
|
|
assistance program" means the program established under Chapter 32, |
|
|
Human Resources Code. |
|
|
Sec. 540.002. CONFLICT WITH OTHER LAW. (a) Except as |
|
|
provided by Subsection (b), to the extent of a conflict between a |
|
|
provision of this chapter and: |
|
|
(1) another provision of state law, the provision of |
|
|
this chapter controls; and |
|
|
(2) a provision of federal law or any authorization |
|
|
described under Subchapter B, the federal law or authorization |
|
|
controls. |
|
|
(b) The program operated under this chapter is in addition |
|
|
to any medical assistance program operated under a block grant |
|
|
funding system under Chapter 539. |
|
|
Sec. 540.003. PROGRAM FOR HEALTH BENEFIT PLAN COVERAGE |
|
|
THROUGH PRIVATE MARKET SOLUTIONS. Subject to the requirements of |
|
|
this chapter, the commission in consultation with the Texas |
|
|
Department of Insurance shall develop and implement a program that |
|
|
helps connect certain low-income residents of this state with |
|
|
health benefit plan coverage through private market solutions. |
|
|
Sec. 540.004. NOT AN ENTITLEMENT. This chapter does not |
|
|
establish an entitlement to assistance in obtaining health benefit |
|
|
plan coverage. |
|
|
Sec. 540.005. RULES. The executive commissioner shall |
|
|
adopt rules necessary to implement this chapter. |
|
|
SUBCHAPTER B. FEDERAL AUTHORIZATION |
|
|
Sec. 540.051. FEDERAL AUTHORIZATION FOR FLEXIBILITY TO |
|
|
ESTABLISH PROGRAM. (a) The commission in consultation with the |
|
|
Texas Department of Insurance shall negotiate with the United |
|
|
States secretary of health and human services, the federal Centers |
|
|
for Medicare and Medicaid Services, and other appropriate persons |
|
|
for purposes of seeking a waiver or other authorization necessary |
|
|
to obtain the flexibility to use federal matching funds to help |
|
|
provide, in accordance with Subchapter C, health benefit plan |
|
|
coverage to certain low-income individuals through private market |
|
|
solutions. |
|
|
(b) Any agreement reached under this section must: |
|
|
(1) create a program that is made cost neutral to this |
|
|
state by: |
|
|
(A) leveraging premium tax revenues; and |
|
|
(B) achieving cost savings through offsets to |
|
|
general revenue health care costs or the implementation of other |
|
|
cost savings mechanisms; |
|
|
(2) create more efficient health benefit plan coverage |
|
|
options for eligible individuals through: |
|
|
(A) program changes that may be made without the |
|
|
need for additional federal approval; and |
|
|
(B) program changes that require additional |
|
|
federal approval; |
|
|
(3) require the commission to achieve efficiency and |
|
|
reduce unnecessary utilization, including duplication, of health |
|
|
care services; |
|
|
(4) be designed with the goals of: |
|
|
(A) relieving local tax burdens; |
|
|
(B) reducing general revenue reliance so as to |
|
|
make general revenue available for other state priorities; and |
|
|
(C) minimizing the impact of any federal health |
|
|
care laws on Texas-based businesses; and |
|
|
(5) afford this state the opportunity to develop a |
|
|
state-specific solution with benefits that specifically meet the |
|
|
unique needs of this state's population. |
|
|
(c) An agreement reached under this section may be: |
|
|
(1) limited in duration; and |
|
|
(2) contingent on continued funding by the federal |
|
|
government. |
|
|
SUBCHAPTER C. PROGRAM REQUIREMENTS |
|
|
Sec. 540.101. ENROLLMENT ELIGIBILITY. (a) Subject to |
|
|
Subsection (b), an individual may be eligible to enroll in a program |
|
|
designed and established under this chapter if the person: |
|
|
(1) is younger than 65; |
|
|
(2) has a household income at or below 133 percent of |
|
|
the federal poverty level; and |
|
|
(3) is not otherwise eligible to receive benefits |
|
|
under the medical assistance program, including through a program |
|
|
operated under Chapter 539 through a block grant funding system or a |
|
|
waiver, other than one granted under this chapter, to the program. |
|
|
(b) The executive commissioner may amend or further define |
|
|
the eligibility requirements of this section if the commission |
|
|
determines it necessary to reach an agreement under Subchapter B. |
|
|
Sec. 540.102. MINIMUM PROGRAM REQUIREMENTS. A program |
|
|
designed and established under this chapter must: |
|
|
(1) if cost-effective for this state, provide premium |
|
|
assistance to purchase health benefit plan coverage in the private |
|
|
market, including health benefit plan coverage offered through a |
|
|
managed care delivery model; |
|
|
(2) provide enrollees with access to health benefits, |
|
|
including benefits provided through a managed care delivery model, |
|
|
that: |
|
|
(A) are tailored to the enrollees; |
|
|
(B) provide levels of coverage that are |
|
|
customized to meet health care needs of individuals within defined |
|
|
categories of the enrolled population; and |
|
|
(C) emphasize personal responsibility and |
|
|
accountability through flexible and meaningful cost sharing |
|
|
requirements and wellness initiatives, including through |
|
|
incentives for compliance with health, wellness, and treatment |
|
|
strategies and disincentives for noncompliance; |
|
|
(3) include pay-for-performance initiatives for |
|
|
private health benefit plan issuers that participate in the |
|
|
program; |
|
|
(4) use technology to maximize the efficiency with |
|
|
which the commission and any health benefit plan issuer, health |
|
|
care provider, or managed care organization participating in the |
|
|
program manages enrollee participation; |
|
|
(5) allow recipients under the medical assistance |
|
|
program to enroll in the program to receive premium assistance as an |
|
|
alternative to the medical assistance program; |
|
|
(6) encourage eligible individuals to enroll in other |
|
|
private or employer-sponsored health benefit plan coverage, if |
|
|
available and appropriate; |
|
|
(7) encourage the utilization of health care services |
|
|
in the most appropriate low-cost settings; and |
|
|
(8) establish health savings accounts for enrollees, |
|
|
as appropriate. |
|
|
SECTION 2.02. The Health and Human Services Commission in |
|
|
consultation with the Texas Department of Insurance and the |
|
|
Medicaid Reform Task Force shall actively develop a proposal for |
|
|
the authorization from the appropriate federal entity as required |
|
|
by Subchapter B, Chapter 540, Government Code, as added by this |
|
|
article. As soon as possible after the effective date of this Act, |
|
|
the Health and Human Services Commission shall request and actively |
|
|
pursue obtaining the authorization from the appropriate federal |
|
|
entity. |
|
|
ARTICLE 3. MEDICAID: INCREMENTAL REFORM |
|
|
SECTION 3.01. Subchapter B, Chapter 531, Government Code, |
|
|
is amended by adding Section 531.0974 to read as follows: |
|
|
Sec. 531.0974. CUSTOMIZED BENEFITS PACKAGE. The commission |
|
|
shall, for individuals receiving home and community-based services |
|
|
and supports instead of institutional long-term services and |
|
|
supports, develop and implement customized benefits packages that |
|
|
are designed to prevent the overutilization of services. |
|
|
Customized benefits packages under this section must be based on an |
|
|
individualized needs assessment administered at a single point of |
|
|
entry. |
|
|
SECTION 3.02. Subchapter B, Chapter 32, Human Resources |
|
|
Code, is amended by adding Sections 32.0501, 32.0642, and 32.077 to |
|
|
read as follows: |
|
|
Sec. 32.0501. DUAL ELIGIBLE INTEGRATED CARE DEMONSTRATION |
|
|
PROJECT. (a) In this section: |
|
|
(1) "ICF-IDD" has the meaning assigned to "ICF-MR" by |
|
|
Section 531.002, Health and Safety Code. |
|
|
(2) "Nursing facility" has the meaning assigned by |
|
|
Section 531.912, Government Code. |
|
|
(3) "State supported living center" has the meaning |
|
|
assigned by Section 531.002, Health and Safety Code. |
|
|
(b) Subject to Subsection (c), the department shall |
|
|
establish a dual eligible integrated care demonstration project |
|
|
that would allow appropriate individuals described by Section |
|
|
32.050(a), as determined by the department, to receive long-term |
|
|
services and supports under both the medical assistance program and |
|
|
the Medicare program through a single managed care plan. |
|
|
(c) An individual who is a resident of a nursing facility, |
|
|
ICF-IDD, or state supported living center is exempt from |
|
|
participation in the demonstration project. |
|
|
Sec. 32.0642. PARENTAL FEE PROGRAM. (a) To the extent |
|
|
allowed by federal law, the department shall establish a parental |
|
|
fee program that requires the parent or legal guardian of a child |
|
|
receiving institutional long-term services and supports or home and |
|
|
community-based services and supports under the medical assistance |
|
|
program established under this chapter to pay a fee that: |
|
|
(1) correlates with the services and supports |
|
|
provided; and |
|
|
(2) takes into consideration the child's household |
|
|
income. |
|
|
(b) Failure to pay a fee under this section may not affect a |
|
|
child's eligibility for benefits under the medical assistance |
|
|
program. |
|
|
(c) The executive commissioner of the Health and Human |
|
|
Services Commission shall adopt rules necessary to implement this |
|
|
section. |
|
|
Sec. 32.077. HOUSING BENEFITS FOR CERTAIN RECIPIENTS. To |
|
|
the extent allowed by federal law, the department shall provide |
|
|
housing payment assistance for recipients receiving home and |
|
|
community-based services and supports under the medical assistance |
|
|
program established under this chapter. |
|
|
SECTION 3.03. (a) The Health and Human Services Commission |
|
|
shall conduct a study to examine the estate recovery program |
|
|
implemented by this state under 42 U.S.C. Section 1396p(b)(1) and |
|
|
determine options the state has to improve recovery under and |
|
|
increase the efficacy of the program. |
|
|
(b) Not later than December 1, 2014, the commission shall |
|
|
submit a written report containing the findings of the study |
|
|
conducted under this section together with the commission's |
|
|
recommendations to the governor, the lieutenant governor, and the |
|
|
standing committees of the senate and house of representatives |
|
|
having primary jurisdiction over the Medicaid program. |
|
|
SECTION 3.04. (a) The Health and Human Services Commission |
|
|
shall conduct a study on imposing alternative income and asset |
|
|
limits for purposes of determining eligibility for long-term |
|
|
services and supports under the medical assistance program under |
|
|
Chapter 32, Human Resources Code. The commission shall consider: |
|
|
(1) imposing greater restrictions on exempt assets; |
|
|
(2) limiting the amount of income that an individual |
|
|
may transfer into a qualified trust under 42 U.S.C. Section |
|
|
1396p(d)(4)(B) to an amount equal to the average cost of nursing |
|
|
home care; and |
|
|
(3) reducing the income eligibility limit to qualify |
|
|
for Medicaid institutional long-term services and supports or home |
|
|
and community-based waiver services under the medical assistance |
|
|
program under Chapter 32, Human Resources Code. |
|
|
(b) Not later than December 1, 2014, the commission shall |
|
|
submit a written report containing the findings of the study |
|
|
conducted under this section together with the commission's |
|
|
recommendations to the governor, the lieutenant governor, and the |
|
|
standing committees of the senate and house of representatives |
|
|
having primary jurisdiction over the Medicaid program. |
|
|
ARTICLE 4. MEDICAID REFORM TASK FORCE |
|
|
SECTION 4.01. (a) In this section: |
|
|
(1) "Commission" means the Health and Human Services |
|
|
Commission. |
|
|
(2) "Medicaid program" and "state Medicaid program" |
|
|
have the meanings assigned by Section 539.001, Government Code, as |
|
|
added by this Act. |
|
|
(3) "Task force" means the Medicaid Reform Task Force |
|
|
established under this section. |
|
|
(b) The Medicaid Reform Task Force is established for |
|
|
purposes of advising the commission in designing a state Medicaid |
|
|
plan and program and a program for ensuring health benefit plan |
|
|
coverage for low-income individuals that are: |
|
|
(1) consistent with Articles 2 and 3 of this Act; and |
|
|
(2) if the federal government establishes a block |
|
|
grant funding system in accordance with Section 539.002, Government |
|
|
Code, as added by this Act, consistent with Article 1 of this Act. |
|
|
(c) The task force consists of 12 members appointed as |
|
|
follows: |
|
|
(1) one member appointed by the governor; |
|
|
(2) two members of the senate appointed by the |
|
|
lieutenant governor; |
|
|
(3) two members of the house of representatives |
|
|
appointed by the speaker of the house of representatives; |
|
|
(4) one member from the Senate Committee on Finance, |
|
|
appointed by the presiding officer; |
|
|
(5) one member from the House Appropriations |
|
|
Committee, appointed by the presiding officer; |
|
|
(6) one member of the Senate Committee on Health and |
|
|
Human Services, appointed by the presiding officer; |
|
|
(7) one member of the House Public Health Committee, |
|
|
appointed by the presiding officer; |
|
|
(8) the executive commissioner of the commission or |
|
|
the executive commissioner's designee; |
|
|
(9) the commissioner of insurance or the |
|
|
commissioner's designee to represent the Texas Department of |
|
|
Insurance; and |
|
|
(10) the director of the Legislative Budget Board or |
|
|
the director's designee. |
|
|
(d) The lieutenant governor and the speaker of the house of |
|
|
representatives shall each appoint a member of the task force to act |
|
|
as co-presiding officers. |
|
|
(e) A member of the task force serves without compensation. |
|
|
(f) Not later than January 1, 2014, the appropriate |
|
|
appointing officers shall appoint the members of the task force. |
|
|
(g) Not later than December 1, 2014, the task force shall |
|
|
submit a report to the legislature regarding its activities under |
|
|
this section. |
|
|
(h) This section expires September 1, 2015. |
|
|
ARTICLE 5. FEDERAL AUTHORIZATION AND EFFECTIVE DATE |
|
|
SECTION 5.01. Subject to Section 2.02 of this Act, 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 5.02. This Act takes effect September 1, 2013. |