86R3614 KFF-F

By: Klick H.B. No. 2409

A BILL TO BE ENTITLED

AN ACT

relating to establishing supplemental payment programs for the reimbursement of certain ambulance providers under Medicaid.

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

SECTION 1. Chapter 32, Human Resources Code, is amended by adding Subchapter H to read as follows:

SUBCHAPTER H. SUPPLEMENTAL PAYMENT PROGRAM FOR CERTAIN AMBULANCE

PROVIDERS

Sec. 32.351. DEFINITIONS. In this subchapter:

(1) "Participating provider" means an ambulance provider that participates in a supplemental payment program.

(2) "Supplemental payment program" means a supplemental payment program implemented under Section 32.352.

Sec. 32.352. AMBULANCE PROVIDER SUPPLEMENTAL PAYMENT PROGRAMS. The commission shall:

(1) develop and implement two programs, one under the Medicaid fee-for-service delivery model and one under the Medicaid managed care delivery model, designed to provide supplemental payments to eligible ambulance providers; and

(2) apply for and actively pursue from the federal Centers for Medicare and Medicaid Services or other appropriate federal agency any waiver or other authorization necessary to implement the programs required by this section.

Sec. 32.353. PROVIDER ELIGIBILITY. (a) An ambulance provider is eligible to participate in a supplemental payment program if the provider:

(1) provides ground emergency medical transportation services to Medicaid recipients;

(2) is enrolled as a Medicaid provider at the time services are provided; and

(3) meets one of the following conditions:

(A) is a state or local governmental entity, including a state or local governmental entity that employs or contracts with persons who are licensed to provide emergency medical services in this state; or

(B) contracts, under an interlocal agreement, with a local governmental entity, including a local fire protection district, to provide emergency medical services in this state.

(b) Participation by a governmental entity in a supplemental payment program is voluntary.

Sec. 32.354. MEDICAID FEE-FOR-SERVICE SUPPLEMENTAL PAYMENT PROGRAM: REIMBURSEMENT REQUIREMENTS AND METHODOLOGY. (a) This section applies only to a supplemental payment program implemented under the Medicaid fee-for-service delivery model.

(b) A governmental entity that is a participating provider or contracts with a participating provider as described by Section 32.353(a)(3)(B) shall:

(1) certify that the expenditures claimed for the provision of ground emergency medical transportation services to Medicaid recipients are public funds eligible for federal financial participation in accordance with the requirements of 42 C.F.R. Section 433.51;

(2) provide evidence supporting the certification of public funds in the manner determined by the commission;

(3) submit data required by the commission for purposes of determining the amounts the commission may claim as expenditures qualifying for federal financial participation; and

(4) maintain and have readily available for the commission any records related to the expenditure.

(c) Under the supplemental payment program, the commission shall claim federal financial participation for expenditures described by Subsection (b)(1) that are allowable costs under the authorization to implement the supplemental payment program obtained under Section 32.352(2).

(d) A provider participating in the supplemental payment program shall receive, in addition to the rate of payment that the provider would otherwise receive for the provision of ground emergency medical transportation services to a Medicaid recipient, a supplemental reimbursement payment. The payment must:

(1) except as provided by Subsection (e), be equal to the amount of federal financial participation received by the commission for the service provided and claimed; and

(2) be paid on a per-transport basis or other federally permissible basis.

(e) The amount certified under Subsection (b)(1), when combined with the amount received by a participating provider from all sources of reimbursement under Medicaid, may not exceed 100 percent of the provider's actual costs for the provision of services. The commission shall reduce a payment to a participating provider to ensure compliance with this subsection.

Sec. 32.355. MEDICAID MANAGED CARE SUPPLEMENTAL PAYMENT PROGRAM: REIMBURSEMENT REQUIREMENTS AND METHODOLOGY. (a) In this section:

(1) "Managed care organization" has the meaning assigned by Section 533.001, Government Code.

(2) "Medicaid managed care organization" means a managed care organization that contracts with the commission under Chapter 533, Government Code, to provide health care services to Medicaid recipients.

(b) This section applies only to a supplemental payment program implemented under the Medicaid managed care delivery model.

(c) The commission shall develop the supplemental payment program under the Medicaid managed care delivery model in consultation with providers eligible to participate in the supplemental payment program. The supplemental payment program must use intergovernmental transfers to finance increased capitation payments for the purpose of supplementing the reimbursement amount paid to participating providers.

(d) To the extent intergovernmental transfers are voluntarily made by, and accepted from, a governmental entity that is a participating provider or contracts with a participating provider as described by Section 32.353(a)(3)(B), and the participating provider is a provider under a Medicaid managed care delivery model, the commission shall make increased capitation payments to the requisite Medicaid managed care organizations to be used to pay the participating provider in accordance with an enhanced fee schedule that establishes a minimum reimbursement rate.

(e) The executive commissioner by rule shall adopt the enhanced fee schedule described by Subsection (d). The commission shall include a provision in each contract with a Medicaid managed care organization that requires the organization to pay reimbursement rates to participating providers in accordance with that schedule.

(f) The increased capitation payments made under the supplemental payment program and the enhanced fee schedule adopted under Subsection (e) must allow for a supplemental payment to a participating provider that is at least comparable in amount to the supplemental payment the provider would receive if providing the same service under the supplemental payment program implemented under the Medicaid fee-for-service delivery model under Section 32.354.

(g) A managed care organization that receives an increased capitation payment under the supplemental payment program shall pay 100 percent of the increase to the participating provider in accordance with the enhanced fee schedule adopted under Subsection (e).

(h) All federal matching money obtained as a result of an intergovernmental transfer under the supplemental payment program must be used to pay increased capitation payments and provide supplemental payments to participating providers.

(i) To the extent that the commission determines that an intergovernmental transfer does not comply with the authorization obtained by the commission under Section 32.352(2), the commission may return the transfer, refuse to accept the transfer, or adjust the amount of the transfer as necessary to comply with the authorization.

(j) A participating provider and governmental entity that contracts with a participating provider must agree to comply with any requests for information or data requirements imposed by the commission for purposes of obtaining supporting documentation necessary to claim federal financial participation or obtain federal approval for implementation of the supplemental payment program.

(k) The commission shall ensure a Medicaid managed care organization complies with any request for information or similar requirements necessary to implement the supplemental payment program.

Sec. 32.356. FUNDING; USE OF GENERAL REVENUE PROHIBITED. (a) The commission may not use general revenue to:

(1) administer a supplemental payment program; or

(2) provide reimbursements under a supplemental payment program.

(b) A governmental entity that is a participating provider or contracts with a participating provider as described by Section 32.353(a)(3)(B), as a condition of participating providers receiving supplemental payments under Section 32.354, must enter into and maintain an agreement with the commission to provide:

(1) the nonfederal share of the supplemental payments by certifying expenditures to the commission in accordance with Section 32.354(b); and

(2) funding necessary to pay the cost of administering the supplemental payment program under Section 32.354.

(c) A governmental entity that is a participating provider or contracts with a participating provider as described by Section 32.353(a)(3)(B), as a condition of participating providers receiving supplemental payments under Section 32.355, must enter into and maintain an agreement with the commission to provide:

(1) the nonfederal share of the increased capitation payments by making intergovernmental transfers as provided by Section 32.355; and

(2) funding necessary to pay the cost of administering the supplemental payment program under Section 32.355.

SECTION 2. (a) As soon as possible after the effective date of this Act, the Health and Human Services Commission shall seek any waiver or other authorization necessary to implement the supplemental payment programs required by Subchapter H, Chapter 32, Human Resources Code, as added by this Act.

(b) To the extent permitted by the waiver or other authorization necessary to implement the supplemental payment programs required by Subchapter H, Chapter 32, Human Resources Code, as added by this Act, the Health and Human Services Commission shall implement the supplemental payment program implemented under the Medicaid managed care program on a retroactive basis.

SECTION 3. This Act takes effect September 1, 2019.