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A BILL TO BE ENTITLED
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AN ACT
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relating to the consideration of strategies by the Health and Human |
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Services Commission to ensure the appropriate use of diagnostic |
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ancillary services in the Medicaid program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter B, Chapter 531, Government Code, is |
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amended by adding Section 531.024162 to read as follows: |
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Sec. 531.024162. STRATEGIES TO ENSURE APPROPRIATE USE OF |
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DIAGNOSTIC ANCILLARY SERVICES. (a) The commission shall: |
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(1) adopt new cost-effective strategies to ensure the |
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appropriate use of diagnostic ancillary services in the Medicaid |
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program; and |
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(2) strengthen existing methods to reduce the use of |
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unnecessary diagnostic ancillary services in the Medicaid program. |
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(b) When considering the adoption of new cost-effective |
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strategies to ensure the appropriate use of diagnostic ancillary |
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services in the Medicaid program, the commission shall examine |
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implementing within the Medicaid fee-for-service model and the STAR |
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and STAR + PLUS Medicaid managed care programs a prior notification |
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program in which: |
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(1) outlier health care providers' use of diagnostic |
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ancillary services are compared to evidence-based clinical |
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guidelines; and |
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(2) health care providers are educated about the |
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appropriate use of diagnostic ancillary services. |
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(c) When considering strengthening existing methods to |
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reduce the use of unnecessary diagnostic ancillary services in the |
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Medicaid program, the commission shall examine: |
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(1) requiring every STAR and STAR + PLUS Medicaid |
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managed care program to implement a prior authorization program; |
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and |
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(2) modifying the existing prior authorization |
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programs within the Medicaid fee-for-service model and the STAR and |
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STAR + PLUS Medicaid managed care programs so that: |
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(A) the programs target health care providers who |
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order significantly more diagnostic ancillary services than other |
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providers who treat similar patients; |
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(B) outlier providers who order diagnostic |
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ancillary services inappropriately are required to participate in |
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the programs; and |
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(C) the programs are expanded to include |
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additional types of diagnostic ancillary services that account for |
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a significant share of spending, have evidence-based standards for |
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appropriate use, and exhibit variations in use among providers and |
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geographic areas. |
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(d) The commission shall examine options within the |
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Medicaid fee-for-service model and the STAR and STAR + PLUS |
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Medicaid managed care programs to improve payment accuracy for |
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diagnostic ancillary services and to reduce the financial incentive |
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for a health care provider to order unnecessary diagnostic |
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ancillary services to be performed at a facility in which the |
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provider has a financial interest. Options the commission shall |
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examine under this subsection and may consider implementing |
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include: |
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(1) accounting for duplications in the work of a |
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provider and the expenses relating to that work that occur when two |
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or more diagnostic ancillary services are provided at the same time |
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by: |
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(A) combining into a single payment rate or |
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comprehensive code multiple discrete diagnostic ancillary services |
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that are often provided at the same time by the same provider; or |
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(B) reducing the payment rate for subsequent |
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diagnostic ancillary services that are provided to a patient at the |
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same time by the same provider; and |
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(2) reducing the payment rates for certain diagnostic |
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ancillary services that are ordered and provided by the same |
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provider. |
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(e) The commission shall review strategies recommended by |
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the federal Medicare Payment Advisory Commission during fiscal year |
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2011 to reduce the use of unnecessary diagnostic ancillary services |
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in the Medicare program and consider adopting those strategies for |
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the Medicaid program. |
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(f) The commission shall identify cost-effective strategies |
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used by STAR and STAR + PLUS Medicaid managed care programs to |
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reduce the use of unnecessary diagnostic ancillary services and |
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consider: |
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(1) implementing those strategies within the Medicaid |
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fee-for-service model; and |
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(2) requiring the use of those strategies in other |
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STAR and STAR + PLUS Medicaid managed care programs. |
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SECTION 2. 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 3. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2013. |