|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to the system redesign for delivery of Medicaid acute care |
|
services and long term services and supports to persons with an |
|
intellectual or developmental disability and a pilot for certain |
|
populations with similar functional needs receiving services in |
|
managed care. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Section 534.001, Subchapter A, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.001. DEFINITIONS. In this chapter: |
|
(3) ["Department" means the Department of Aging and
|
|
Disability Services.] "Commission" means the Health and Human |
|
Services Commission or an agency operating part of the state |
|
Medicaid managed care program, as appropriate. |
|
(4) "Comprehensive long term services and supports |
|
provider" is defined as a provider of long term services and |
|
supports specified under this chapter that ensures the coordinated, |
|
seamless provision of the full range of services as approved in |
|
participants' program plans as described under Section 534.1045 |
|
(b), (b-2),(c), and (d). A comprehensive service provider includes: |
|
(A) an ICF/IID program provider who is authorized |
|
to deliver services in the program defined under Section 534.001 |
|
(8), and |
|
(B) a Medicaid waiver program provider who is |
|
authorized to deliver services in the programs specified under |
|
Section 534.001 (12) and certified in accordance with 534.301 (b). |
|
[(4)] (5) "Functional need" means the measurement of |
|
an individual's services and supports needs, including the |
|
individual's intellectual, psychiatric, medical, and physical |
|
support needs. |
|
[(5)] (6) "Habilitation services" includes assistance |
|
provided to an individual with acquiring, retaining, or improving: |
|
(A) skills related to the activities of daily |
|
living; and |
|
(B) the social and adaptive skills necessary to |
|
enable the individual to live and fully participate in the |
|
community. |
|
[(6)] (7) "ICF-IID" means the program under Medicaid |
|
serving individuals with an intellectual or developmental |
|
disability who receive care in intermediate care facilities other |
|
than a state supported living center. |
|
[(7)] (8) "ICF-IID program" means a program under |
|
Medicaid serving individuals with an intellectual or developmental |
|
disability who reside in and receive care from: |
|
(A) intermediate care facilities licensed under |
|
Chapter 252, Health and Safety Code; or |
|
(B) community-based intermediate care facilities |
|
operated by local intellectual and developmental disability |
|
authorities. |
|
[(8)] (9) "Local intellectual and developmental |
|
disability authority" has the meaning assigned by Section 531.002, |
|
Health and Safety Code. |
|
[(9)] (11) "Managed care organization," "managed care |
|
plan," and "potentially preventable event" have the meanings |
|
assigned under Section 536.001. |
|
(10) Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, |
|
Sec. 2.287(17), eff. April 2, 2015. |
|
[(11)] (12) "Medicaid waiver program" means only the |
|
following programs that are authorized under Section 1915(c) of the |
|
federal Social Security Act (42 U.S.C. Section 1396n(c)) for the |
|
provision of services to persons with an intellectual or |
|
developmental disability: |
|
(A) the community living assistance and support |
|
services (CLASS) waiver program; |
|
(B) the home and community-based services (HCS) |
|
waiver program; |
|
(C) the deaf-blind with multiple disabilities |
|
(DBMD) waiver program; and |
|
(D) the Texas home living (TxHmL) waiver program. |
|
(13) "Residential Services" means services provided |
|
for an individual with intellectual or developmental disability in |
|
a community-based ICF/IID, a three or four persons home and host |
|
home/companion service offered through the 1915(c) home and |
|
community-based waiver services program, or a group home in the |
|
Deaf Blind Multiple Disabilities program. |
|
[(12)] (14) "State supported living center" has the |
|
meaning assigned by Section 531.002, Health and Safety Code. |
|
SECTION 2. Section 534.051, Subchapter B, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.051. ACUTE CARE SERVICES AND LONG-TERM SERVICES |
|
AND SUPPORTS SYSTEM FOR INDIVIDUALS WITH AN INTELLECTUAL OR |
|
DEVELOPMENTAL DISABILITY. In accordance with this chapter, the |
|
commission [and the department] shall [jointly] design and |
|
implement an acute care services and long-term services and |
|
supports system for individuals with an intellectual or |
|
developmental disability that supports the following goals: |
|
(1) provide Medicaid services to more individuals in a |
|
cost-efficient manner by providing the type and amount of services |
|
most appropriate to the individuals' needs and preferences in the |
|
most integrated and least restrictive setting; |
|
SECTION 3. Section 534.052, Subchapter B, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.052. IMPLEMENTATION OF SYSTEM REDESIGN. The |
|
commission [and department] shall, in consultation and |
|
collaboration with the advisory committee, [jointly] implement the |
|
acute care services and long-term services and supports system for |
|
individuals with an intellectual or developmental disability in the |
|
manner and in the stages described in this chapter. |
|
SECTION 4. Section 534.053, Subchapter B, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.053. INTELLECTUAL AND DEVELOPMENTAL DISABILITY |
|
SYSTEM REDESIGN ADVISORY COMMITTEE. (a) The Intellectual and |
|
Developmental Disability System Redesign Advisory Committee shall |
|
advise the commission [and the department] on the implementation of |
|
the acute care services and long-term services and supports system |
|
redesign under this chapter. Subject to Subsection (b), the |
|
executive commissioner [and the commissioner of aging and
|
|
disability services] shall [jointly] appoint members of the |
|
advisory committee who are stakeholders from the intellectual and |
|
developmental disabilities community, including: |
|
(b) To the greatest extent possible, the executive |
|
commissioner [and the commissioner of aging and disability
|
|
services] shall appoint members of the advisory committee who |
|
reflect the geographic diversity of the state and include members |
|
who represent rural Medicaid recipients. |
|
(e-1) The advisory committee may establish work groups that |
|
meet at other times for purposes of studying and making |
|
recommendations on issues the committee considers appropriate. |
|
[(g) On January 1, 2026:
|
|
(1) the advisory committee is abolished ; and
|
|
(2) this section expires]. |
|
(g) On the [one year] two-year anniversary of the date the |
|
commission completes implementation of the transition required |
|
under Section 534.202: |
|
(1) the advisory committee is abolished; and |
|
(2) this section expires. |
|
SECTION 5. Section 534.054, Subchapter B, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.054. ANNUAL REPORT ON IMPLEMENTATION. |
|
(b) On the two-year anniversary of the date the commission |
|
completes implementation of the transition required under Section |
|
534.202 this [This] section expires [January 1, 2026]. |
|
SECTION 6. Section 534.101, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.101. Pilot Program Workgroup [DEFINITIONS]. In |
|
accordance with Section 534.053 (e-1), for puposes of [In] this |
|
subchapter the advisory committee shall establish a h Workgroup |
|
that includes representatives from the advisory committee, |
|
stakeholders representing individuals with an intellectual and |
|
developmental disability, individuals with similar functional |
|
needs, and the STAR+PLUS managed care organizations. [:] |
|
[(1)
"Capitation" means a method of compensating a
|
|
provider on a monthly basis for providing or coordinating the
|
|
provision of a defined set of services and supports that is based on
|
|
a predetermined payment per services recipient.] |
|
[(2)
"Provider" means a person with whom the
|
|
commission contracts for the provision of long-term services and
|
|
supports under Medicaid to a specific population based on
|
|
capitation.] |
|
SECTION 7. Section 534.102, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.102. PILOT PROGRAM [S] TO TEST PERSON-CENTERED |
|
MANAGED CARE STRATEGIES AND IMPROVEMENTS BASED ON CAPITATION. The |
|
commission [and the department may] ,in consultation and |
|
collaboration with the advisory committee and Pilot Program |
|
Workgroup, shall develop and implement a pilot program[s] in |
|
accordance with this subchapter to test, through the STAR+PLUS |
|
Medicaid managed care program, the delivery of [one or more service
|
|
delivery models involving] long term services and supports [a
|
|
managed care strategy based on capitation to deliver long-term
|
|
services and supports under Medicaid] to individuals [with an
|
|
intellectual or developmental disability]specified under Section |
|
534.1065. |
|
SECTION 8. Section 534.103, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.103. STAKEHOLDER INPUT. As part of developing and |
|
implementing a pilot program under this subchapter, the |
|
[department] commission, in consultation and collaboration with |
|
the advisory committee and Pilot Program Workgroup, shall develop a |
|
process to receive and evaluate input from statewide stakeholders |
|
and stakeholders from the STAR+PLUS service area [region] of the |
|
state in which the pilot program will be implemented and other |
|
evaluations and data. |
|
SECTION 9. Chaoter 534, Government Code is amended to add |
|
new Section 534.1035, SELECTION OF MANAGED CARE ORGANIZATION |
|
VENDORS, to read as follows: |
|
Sec.534.1035. SELECTON OF MANAGED CARE ORGANIZATION PILOT |
|
VENDORS. (a) The commission shall select and contract with no more |
|
than two managed care organizations contracted to provide services |
|
under the STAR+PLUS Medicaid managed care program to participate in |
|
the pilot. |
|
(b) The commission, in consultation and collaboration with |
|
the advisory committee and Pilot Program Workgroup, shall develop |
|
criteria regarding the selection of managed care organizations to |
|
conduct the pilot program. |
|
SECTION 10. Section 534.104, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.104. PILOT DESIGN [MANAGED CARE STRATEGY
|
|
PROPOSALS; PILOT PROGRAM SERVICE PROVIDERS]. |
|
[(a)
The department, in consultation and collaboration with
|
|
the advisory committee, shall identify private services providers
|
|
or managed care organizations that are good candidates to develop a
|
|
service delivery model involving a managed care strategy based on
|
|
capitation and to test the model in the provision of long-term
|
|
services and supports under Medicaid to individuals with an
|
|
intellectual or developmental disability through a pilot program
|
|
established under this subchapter]. |
|
[(b)
The department shall solicit managed care strategy
|
|
proposals from the private services providers and managed care
|
|
organizations identified under Subsection (a). In addition, the
|
|
department may accept and approve a managed care strategy proposal
|
|
from any qualified entity that is a private services provider or
|
|
managed care organization if the proposal provides for a
|
|
comprehensive array of long-term services and supports, including
|
|
case management and service coordination.] |
|
[(c)] (a) [A managed care strategy based on capitation
|
|
developed for implementation through a] The pilot program under |
|
this subchapter must be designed to: |
|
(1) increase access to long-term services and |
|
supports; |
|
(2) improve quality of acute care services and |
|
long-term services and supports; |
|
(3) promote informed choice and meaningful outcomes by |
|
using person-centered planning, flexible consumer directed |
|
services, individualized budgeting, and self-determination, and |
|
promote community inclusion and engagement; |
|
(4) promote integrated service coordination of acute |
|
care services and long-term services and supports; |
|
(5) promote efficiency and the best use of funding |
|
based on the individual's needs and preferences; |
|
(6) promote [the placement of an individual in] |
|
housing stability through housing supports and navigation services |
|
that is the most integrated and least restrictive setting |
|
appropriate to the individual's needs and preferences; |
|
(7) promote employment assistance and customized, |
|
integrated, and competitive employment; |
|
(8) provide fair hearing and appeals processes in |
|
accordance with applicable federal and state law; and |
|
(9) promote sufficient flexibility to achieve the |
|
goals listed in this section through the pilot program [.] ; |
|
(10) promote the use of innovative technology and |
|
benefits, including telemonitoring and testing of remote |
|
monitoring for individuals participating in the pilot. The remote |
|
monitoring and telemonitoring is voluntary and shall ensure an |
|
individual's privacy and health and welfare and allow access to |
|
housing in the most integrated and least restrictive environment. |
|
Innovations may include transportation and other innovations that |
|
support community integration. If a pilot participant voluntarily |
|
decides to use telemonitoring or remote monitoring or other |
|
innovative technologies, the managed care organization providing |
|
the pilot services shall deliver the telemonitoring, remote |
|
monitoring and/or innovative technology services in a way that: |
|
(A) assesses individual needs and preferences in |
|
a manner that promotes autonomy, self-determination, consumer |
|
directed services, privacy and increases personal independence; |
|
(B) determines the extent in which remote |
|
monitoring, telemedicine and other innovative technologies will be |
|
used, including but not limited to, times of day, where the |
|
equipment can be used, what types of telemonitoring and/or remote |
|
monitoring, for what tasks; |
|
(C) is identified and agreed to through the |
|
person centered planning process; |
|
(D) ensures the staff overseeing remote |
|
monitoring, telemedicine and other innovative technologies review |
|
person-centered plans and implementation plans of each individual |
|
they are monitoring prior to monitoring that individual and |
|
demonstrate competency regarding the support needs of each |
|
individual they are monitoring; and |
|
(E) ensures an individual can request to remove |
|
the remote monitoring and other innovative technology equipment at |
|
any point during the IDD pilot and the managed care organizations |
|
must remove the equipment immediately. |
|
(F) ensures individuals can choose not to use |
|
telemedicine at any point during participation in the pilot and |
|
that the pilot participating managed care organization must arrange |
|
for services that do not require the use of telemedicine. |
|
(11) ensure an adequate provider network that includes |
|
comprehensive long term services and supports providers as |
|
described in Section 534.001 (4) and Section 534.107 (a)(2) and |
|
choice from among these providers; |
|
(12) ensure timely initiation and consistent |
|
provision of long term services and supports in accordance with an |
|
individual's person centered care plan; |
|
(13) ensure individuals with complex behavioral, |
|
medical and physical needs receive services based on assessed needs |
|
and in the most integrated, least restrictive setting according to |
|
the each individual's needs and preferences; |
|
(14) increase, expand flexibility and promote use of |
|
the consumer directed services model ; and |
|
(15) promote independence, self-determination, |
|
consumer directed services and decision making by using |
|
alternatives to guardianship, including supported decision-making |
|
agreements under Chapter 1357, Estates Code. |
|
(b) The pilot program shall be designed to test innovations |
|
and payment models for the provision of long-term services and |
|
supports to achieve the goals outlined in subsection (a) utilizing |
|
methods such as: |
|
(1) payment of a bundled amount without downside risk |
|
to a long term services and supports provider for some or all |
|
services delivered as part of a comprehensive array of long term |
|
services and supports; |
|
(2) enhanced incentive payments to providers of long |
|
term services and supports based on meeting pre-determined outcome |
|
or quality metrics; and |
|
(3) any other payment models approved by the |
|
commission. |
|
(c) The alternative payment rates or methodologies tested |
|
under subsection (b) must be agreed to in writing by the managed |
|
care organization and participating long term services and supports |
|
provider. In developing the alternative payment rates or |
|
methodologies, the parties must utilize: |
|
(1) the historical costs of long term services and |
|
supports, including Medicaid fee-for-service rates; and |
|
(2) reasonable cost estimates for new pilot program |
|
services; and |
|
(3) whether alternative payment rates or |
|
methodologies are sufficient to ensure the provider's continued |
|
participation in the pilot program and promote quality outcomes. |
|
(d) For long term services and supports delivered under the |
|
pilot, the alternative payment models tested under subsection (b) |
|
shall not reduce the minimum payment to providers below the current |
|
fee for service reimbursement rates. |
|
(e) The pilot program must allow existing providers of |
|
long-term services and supports for persons with intellectual and |
|
developmental disabilities, as defined in Section 534.001 (4), and |
|
providers of long term services and supports for persons with |
|
similar functional needs to voluntarily participate in one or more |
|
pilot projects. Failure to participate in a pilot project does not |
|
affect the contracting status of any provider as a significant |
|
traditional provider. |
|
[(d)
The department, in consultation and collaboration with
|
|
the advisory committee, shall evaluate each submitted managed care
|
|
strategy proposal and determine whether:
|
|
(1)
the proposed strategy satisfies the requirements
|
|
of this section; and
|
|
(2)
the private services provider or managed care
|
|
organization that submitted the proposal has a demonstrated ability
|
|
to provide the long-term services and supports appropriate to the
|
|
individuals who will receive services through the pilot program
|
|
based on the proposed strategy, if implemented.]
|
|
[(e)
Based on the evaluation performed under Subsection
|
|
(d), the department may select as pilot program service providers
|
|
one or more private services providers or managed care
|
|
organizations with whom the commission will contract.]
|
|
(f) [For each pilot program service provider, the
|
|
department__shall develop and implement a pilot program.] Under a |
|
pilot program, the [pilot program service provider] the |
|
participating managed care organizations shall provide long-term |
|
services and supports under Medicaid to persons with an |
|
intellectual or developmental disability, and other individuals |
|
with disabilities with similar functional needs, to test its |
|
managed care strategy based on capitation. |
|
(g) The [department] commission, in consultation and |
|
collaboration with the advisory committee and Pilot Program |
|
Workgroup, shall analyze information provided by the [pilot program
|
|
service providers] participating managed care organizations and |
|
any information collected by the [department] commission during the |
|
operation of the pilot program[s] for purposes of making a |
|
recommendation about a system of programs and services for |
|
implementation through future state legislation or rules. |
|
(h) The analysis under Subsection (g) must include an |
|
assessment of the effect of the managed care strategies implemented |
|
in the pilot program[s] on the goals specified under Subsections |
|
(a), (b), (c) and (d). [:] |
|
[(1) access to long-term services and supports;
|
|
(2)
the quality of acute care services and long-term
|
|
services and supports;
|
|
(3)
meaningful outcomes using person-centered
|
|
planning, individualized budgeting, and self-determination,
|
|
including a person's inclusion in the community;
|
|
(4)
the integration of service coordination of acute
|
|
care services and long-term services and supports;
|
|
(5) the efficiency and use of funding;
|
|
(6)
the placement of individuals in housing that is
|
|
the least restrictive setting appropriate to an individual's needs;
|
|
(7)
employment assistance and customized, integrated,
|
|
competitive employment options; and
|
|
(8)
the number and types of fair hearing and appeals
|
|
processes in accordance with applicable federal law.]
|
|
(i) Prior to implementation of the pilot program, the |
|
commission, in consultation and collaboration with the advisory |
|
committee and Pilot Program Workgroup, shall develop a process to |
|
ensure 12 months continuous Medicaid eligibility for pilot |
|
participants. |
|
SECTION 11. Chapter 534, Government Code is amended to add |
|
new section 534.1045, PILOT BENEFITS AND PROVIDER QUALIFICATIONS as |
|
follows: |
|
Sec. 534.1045. PILOT BENEFITS AND PROVIDER QUALIFICATIONS. |
|
(a) The pilot program must ensure that participating managed care |
|
organizations provide: |
|
(1) all Medicaid state plan acute care benefits |
|
available under the STAR+PLUS program; |
|
(2) long term services and supports in the Medicaid |
|
state plan, including: |
|
(A) Community First Choice services; |
|
(B) Personal Assistant services; |
|
(C) Day Activity Health Services; |
|
(D) Habilitation services defined under Section |
|
534/001 (6); |
|
(3) long term services and supports in the STAR+PLUS |
|
home and community-based services waiver, including: |
|
(A) assisted living |
|
(B) personal assistance services; |
|
(C) employment assistance; |
|
(D) supported employment; |
|
(E) adult foster care; |
|
(F) dental care; |
|
(G) nursing care; |
|
(H) respite care; |
|
(I) home-delivered meals; |
|
(J) cogniticve rehabilitative therapy; |
|
(K) physical therapy; |
|
(L) occupational therapy; |
|
(M) speech-language pathology; |
|
(N) medical supplies; |
|
(O) minor home modifcations; |
|
(P) adaptive aids; |
|
(4) long term services and supports available in the |
|
Medicaid waiver programs defined in Section 534.001 (12), |
|
including: |
|
(A) enhanced behavioral health services; |
|
(B) behavioral supports; |
|
(C) day habilitation; |
|
(D) community support transporation; |
|
(5) additional long term services and supports, |
|
including: |
|
(A) housing supports; |
|
(B) behavioral health crisis intervention; |
|
(C) high medical needs services; and |
|
(6) Other non-residential long term services and |
|
supports the commission, in consultation and coordination with the |
|
advisory committee and Pilot Program Workgroup, determines |
|
appropriate and consistent with the regulations governing the 1915 |
|
(c) waiver programs defined in Section 534.001 (12), |
|
person-centered approaches, home and community-based settings |
|
requirements, and the most integrated and least restrictive setting |
|
according to an individual's needs and preferences. |
|
(b) A comprehensive long term services and supports |
|
provider is authorized to deliver services listed under under |
|
subsections (a)(2)(A), (a)(2)(D), (a)(3)(B), (a)(3)(C), (a)(3)(D), |
|
(a)(3)(G), (a)(3)(H), (a)(3)(J), (a)(3)(K), (a)(3)(L), (a)(3)(M), |
|
and (a)(3)(4),if they also deliver the service in a Medicaid waiver |
|
defined under Section 534.001 (12). |
|
(b-2) A comprehensive long term services and supports |
|
provider may deliver services under subsections (a)(5) and (a)(6) |
|
if agreed to under contract with the pilot participating managed |
|
care organization. |
|
(c) Day habilitation services under (a)(4)(c) may be |
|
delivered by a provider who is contracted or subcontracted under a |
|
1915 (c) Medicaid waiver as defined under Section 534.001 (12) or an |
|
ICF/IID program as defined under Section 534.001 (8). |
|
(d) A comprehensive long term services and supports |
|
provider works in consultation with the pilot participating managed |
|
care organization's care coordinators to ensure the seamless |
|
delivery of acute care and long term services and supports on a |
|
day-to-day basis in accordance with an individual's plan of care |
|
and may be reimbursed by the managed care organization for this |
|
coordination. |
|
(e) Prior to implementation of the pilot program, the |
|
commission, in consultation and collaboration with the advisory |
|
committee and Pilot Program Workgroup, shall: |
|
(1) develop recommendations to modify, for the pilot |
|
program only, the Adult Foster Care, Supported Employment and |
|
Employment Assistance benefits to ensure increased access to and |
|
availability of this service, and |
|
(2) as needed, definitions for services described |
|
under subsection (a)(4) and (5), and any services added under |
|
subsection (6). |
|
SECTION 12. Section 534.105, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.105. PILOT PROGRAM: MEASURABLE GOALS. (a) The |
|
[department] commission, in consultation and collaboration with |
|
the advisory committee and Pilot Program Workgroup, shall identify |
|
measurable goals using National Core Indicators, National Quality |
|
Forum LTSS measures and other appropriate CAHPS measures to be |
|
achieved by [each] the pilot program implemented under this |
|
subchapter. [The identified goals must:
|
|
(1)
align with information that will be collected
|
|
under Section 534.108(a); and
|
|
(2)
be designed to improve the quality of outcomes for
|
|
individuals receiving services through the pilot program.] |
|
(b) The [department] commission, in consultation and |
|
collaboration with the advisory committee and Pilot Program |
|
Workgroup, shall [propose] develop specific strategies and |
|
performance measures for achieving the identified goals. A proposed |
|
strategy may be evidence-based if there is an evidence-based |
|
strategy available for meeting the pilot program's goals. |
|
(c) The commission, in consultation and collaboration with |
|
the advisory committee and Pilot Program Workgroup, shall ensure |
|
that the mechanisms to report, track and assess the specific |
|
strategies and performance measures for achieving the identified |
|
goals are established prior to implementation of the pilot program. |
|
SECTION 13. Section 534.106, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.106. IMPLEMENTATION, LOCATION, AND DURATION. (a) |
|
The commission [and the department] shall implement [any] the pilot |
|
program[s] established under this subchapter [not later than] on |
|
September 1, [2017] 2023. |
|
(b) A pilot program established under this subchapter [may] |
|
shall operate for at least [up to] 24 months. [A pilot program may
|
|
cease operation if the pilot program service provider terminates
|
|
the contract with the commission before the agreed-to termination
|
|
date.] |
|
(c) A pilot program established under this subchapter shall |
|
be conducted in [one or more] the STAR+PLUS service area [regions] |
|
selected by the [department] commission. |
|
SECTION 14. Section 534.1065, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.1065. RECIPIENT ENROLLMENT, PARTICIPATION AND |
|
ELIGIBILITY [IN PROGRAM VOLUNTARY]. (a) Enrollment |
|
[Participation]in a pilot program established under this |
|
subchapter by an individual [with an intellectual or developmental
|
|
disability] shall occur using an opt-out process [is voluntary,
|
|
and] with the decision whether to participate in a program and |
|
receive long-term services and supports from a provider through |
|
that program [may] to be made only by the individual or the |
|
individual's legally authorized representative. |
|
(1) The commission, in consultation and collaboration |
|
with the advisory committee and Pilot Program Workgroup, shall |
|
develop a timeline and process for and informational materials |
|
related to educating pilot participants about the pilot including |
|
its benefits, impact on current services and other related |
|
information to ensure prospective pilot participants are able to |
|
make an informed decision regarding participation. The process must |
|
ensure: |
|
(A) the timeline for development and |
|
distribution of the pilot informational materials allows for |
|
sufficient advance notification to and education of individuals |
|
eligible for pilot participation, their families and other |
|
individuals actively involved in their lives; |
|
(B) individuals eligible for pilot |
|
participation, including new and current STAR+PLUS enrollees and |
|
other individuals specified in subsection (a) (1) (A), receive oral |
|
and written information about the pilot prior to participation, |
|
(C) the information provided is written in clear, |
|
simple language and presented in a manner individuals are able to |
|
understand and, at a minimum, explains that: |
|
(i) upon conclusion of the pilot, |
|
individuals will be requested to provide input on their pilot |
|
participation experience, including whether the pilot was able to |
|
meet their unique support needs; |
|
(ii) participation in the pilot does not |
|
remove individuals from any Interest List or, in accordance with |
|
Section 534.1065 (c), the right to select an enrollment, transition |
|
or diversion offer; and |
|
(iii) individuals have choice among acute |
|
care and long term services providers, including the consumer |
|
directed services model and the comprehensive services model. |
|
(b) The commission, in consultation and coordination with |
|
the advisory committee and Pilot Program Workgroup, shall develop |
|
pilot program participant eligibility criteria. The criteria must |
|
ensure pilot participants include: |
|
(1) individuals with an intellectual and |
|
developmental disability including autism and individuals with |
|
significant complex behavioral, medical and physical needs |
|
receiving home and community-based services through STAR+PLUS or a |
|
STAR+PLUS member who is also on a Medicaid Waiver Interest List or |
|
is a STAR+PLUS member meeting criteria for intellectual |
|
disabilities. It does not include individuals who are receiving |
|
only acute care services under STAR+PLUS and enrolled in the |
|
community-based ICF/IID program or one of the Medicaid waiver |
|
programs defined under Section 534.001 (12). |
|
(2) individuals receiving services under the |
|
STAR+PLUS Medicaid managed care program who have a traumatic brain |
|
injury that occurred after the age of 22; and |
|
(3) other individuals with disabilities who have |
|
similar functional needs independent of age of onset or diagnosis. |
|
(c) Individuals participating in the pilot who, during the |
|
pilot's implementation, are offered enrollment in one of the 1915 |
|
(c) Medicaid waiver programs defined under Section 534.001 (12) |
|
shall be eligible to accept the enrollment, transition or diversion |
|
offer. |
|
SECTION 15. Section 534.107, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.107. [COORDINATING SERVICES] COMMISSION |
|
RESPONSIBILTIES. (a) [In providing long-term services and supports
|
|
under Medicaid to individuals with an intellectual or developmental
|
|
disability,] The commission [a pilot program service provider] |
|
shall require managed care organizations participating in the pilot |
|
program to: |
|
(1) ensure individuals participating in the pilot have |
|
choice among acute care and comprehensive long term services and |
|
supports providers and service delivery options including the |
|
consumer directed services model as specified under Section |
|
534.109. [coordinate through the pilot program institutional and
|
|
community-based services available to the individuals, including
|
|
services provided through:
|
|
(A)
a facility licensed under Chapter 252, Health
|
|
and Safety Code;
|
|
(B) a Medicaid waiver program; or
|
|
(C)
a community-based ICF-IID operated by local
|
|
authorities] ; |
|
(2) demonstrate to the satisfaction of the commission |
|
that their network of acute care, long term services and supports |
|
and comprehensive service providers have experience and expertise |
|
providing services for individuals with an intellectual or |
|
developmental disability and individuals with similar functional |
|
needs; |
|
[collaborate with managed care organizations to provide
|
|
integrated coordination of acute care services and long-term
|
|
services and supports, including discharge planning from acute care
|
|
services to community-based long-term services and supports];
|
|
(3) have a process for preventing inappropriate |
|
institutionalizations of individuals; and |
|
(4) ensure timely initiation and consistent provision |
|
of services in accordance with an individual's person-centered plan |
|
[accept the risk of inappropriate institutionalizations of
|
|
individuals previously residing in community settings]. |
|
(b) For the duration of the pilot the commission must ensure |
|
that comprehensive long term services and supports providers as |
|
defined under Section 534.001(4) are deemed significant |
|
traditional providers and included in the provider network of the |
|
managed care organizations participating in the pilot. |
|
SECTION 16. Section 534.108, Subchapter C., Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Section 534.108. Pilot Program Information. (a) The |
|
commission [and the department, in consultation and coordination |
|
with the advisory committee and Pilot Program Workgroup, shall |
|
determine the information to be collected from each managed care |
|
organization participating in the pilot for use in the evaluation |
|
and reports required under Section 534.121. [collect and compute
|
|
the following information with respect to each pilot program
|
|
implemented under this subchapter to the extent it is available:]
|
|
(b) For the duration of the pilot each managed care |
|
organization participating in the pilot shall submit to the |
|
commission and the advisory committee a quarterly report on the |
|
services provided to each pilot participant that includes the |
|
following information: |
|
(A) the level of services requested, and the |
|
authorization and utilization rates of services for each pilot |
|
service; |
|
(B) timeliness of services requested, |
|
authorized, initiated, and number and duration of unplanned service |
|
breaks; |
|
(C) number of pilot participants using |
|
employment assistance and supported employment services; |
|
(D) number of service denials and fair hearings, |
|
and disposition of fair hearings; |
|
(E) number of complaints and inquiries received |
|
by the commission and managed care organizations participating in |
|
the pilot and the outcome of the complaints; and |
|
(F) number of participants who select the |
|
consumer directed services model and reasons participants did not |
|
select the service model. |
|
(c) The commission shall ensure that the mechanisms to |
|
report and track the information and data required in subsections |
|
(a) and (b) are established prior to implementation of the pilot |
|
program. |
|
[(1)
the difference between the average monthly cost
|
|
per person for all acute care services and long-term services and
|
|
supports received by individuals participating in the pilot program
|
|
while the program is operating, including services provided through
|
|
the pilot program and other services with which pilot program
|
|
services are coordinated as described by Section 534.107, and the
|
|
average monthly cost per person for all services received by the
|
|
individuals before the operation of the pilot program;
|
|
(2)
the percentage of individuals receiving services
|
|
through the pilot program who begin receiving services in a
|
|
nonresidential setting instead of from a facility licensed under
|
|
Chapter 252, Health and Safety Code, or any other residential
|
|
setting;
|
|
(3)
the difference between the percentage of
|
|
individuals receiving services through the pilot program who live
|
|
in non-provider-owned housing during the operation of the pilot
|
|
program and the percentage of individuals receiving services
|
|
through the pilot program who lived in non-provider-owned housing
|
|
before the operation of the pilot program;
|
|
(4)
the difference between the average total Medicaid
|
|
cost, by level of need, for individuals in various residential
|
|
settings receiving services through the pilot program during the
|
|
operation of the program and the average total Medicaid cost, by
|
|
level of need, for those individuals before the operation of the
|
|
program;
|
|
(5)
the difference between the percentage of
|
|
individuals receiving services through the pilot program who obtain
|
|
and maintain employment in meaningful, integrated settings during
|
|
the operation of the program and the percentage of individuals
|
|
receiving services through the program who obtained and maintained
|
|
employment in meaningful, integrated settings before the operation
|
|
of the program;
|
|
(6)
the difference between the percentage of
|
|
individuals receiving services through the pilot program whose
|
|
behavioral, medical, life-activity, and other personal outcomes
|
|
have improved since the beginning of the program and the percentage
|
|
of individuals receiving services through the program whose
|
|
behavioral, medical, life-activity, and other personal outcomes
|
|
improved before the operation of the program, as measured over a
|
|
comparable period; and
|
|
(7)
a comparison of the overall client satisfaction
|
|
with services received through the pilot program, including for
|
|
individuals who leave the program after a determination is made in
|
|
the individuals' cases at hearings or on appeal, and the overall
|
|
client satisfaction with services received before the individuals
|
|
entered the pilot program.
|
|
(b)
The pilot program service provider shall collect any
|
|
information described by Subsection (a) that is available to the
|
|
provider and provide the information to the department and the
|
|
commission not later than the 30th day before the date the program's
|
|
operation concludes.
|
|
(c)
In addition to the information described by Subsection
|
|
(a), the pilot program service provider shall collect any
|
|
information specified by the department for use by the department
|
|
in making an evaluation under Section 534.104(g).
|
|
(d)
The commission and the department, in consultation and
|
|
collaboration with the advisory committee, shall review and
|
|
evaluate the progress and outcomes of each pilot program
|
|
implemented under this subchapter and submit, as part of the annual
|
|
report to the legislature required by Section 534.054, a report to
|
|
the legislature during the operation of the pilot programs. Each
|
|
report must include recommendations for program improvement and
|
|
continued implementation.]
|
|
SECTION 17. Section 534.109, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.109. PERSON-CENTERED PLANNING. The commission, in |
|
consultation and collaboration [cooperation] with the [department] |
|
advisory committee and Pilot Program Workgroup, shall ensure that |
|
each individual[with an intellectual or developmental disability] |
|
who receives services and supports under Medicaid through a pilot |
|
program established under this subchapter, or the individual's |
|
legally authorized representative, has access to a comprehensive |
|
facilitated, person-centered plan that identifies outcomes for the |
|
individual and drives the development of the individualized budget. |
|
The consumer directed services[direction] model, as defined by |
|
Section 531.051, [may be an outcome of the plan] must be an |
|
available option for individuals to achieve self-determination, |
|
choice and control. |
|
SECTION 18. Section 534.110, Subchapter C., Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.110. TRANSITION BETWEEN PROGRAMS; CONTINUITY OF |
|
SERVICES. (a) During the evaluation of the pilot required under |
|
Section 534.121,[The] the commission may continue the pilot to |
|
protect continuity of care. If the commission determines not to |
|
continue the pilot during the evaluation, the commission, in |
|
consultation and collaboration with the advisory committee and |
|
Pilot Program Workgroup, shall ensure that there is a comprehensive |
|
plan for transitioning the provision of Medicaid benefits provided |
|
to pilot participants to the services provided before the pilot. |
|
[between a Medicaid waiver program or an ICF-IID program and a pilot
|
|
program under this subchapter to protect continuity of care.]
|
|
(b) The transition plan shall be developed in consultation |
|
and collaboration with the advisory committee and with stakeholder |
|
input as described by Section 534.103. |
|
SECTION 19. Section 534.111, Subchapter C, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.111. CONCLUSION OF PILOT PROGRAM[S]; EXPIRATION. |
|
Contingent on the decision made under Section 534.110, [On] on |
|
September 1, [2019] 2025: |
|
(1) [each] the pilot program established under this |
|
subchapter [that is still in operation] either continues or must |
|
conclude. [; and
|
|
(2) this subchapter expires.] |
|
SECTION 21. Chapter 534, Government Code,is amended to add |
|
new Subchapter C-1 to read as follows: SUBCHAPTER C-1. PILOT |
|
EVALUATION AND REPORT |
|
Section 534.121. EVALUATION OF AND REPORT ON PILOT PROGRAM. |
|
(a) The commission, in consultation and collaboration with the |
|
advisory committee and Pilot Program Workgroup, shall review and |
|
evaluate the progress and outcomes of the pilot program implemented |
|
under Subchapter C of this Chapter and submit, as part of the annual |
|
report required by Section 534.054, a report on the status of the |
|
pilot program. The report must include recommendations for program |
|
improvement. |
|
(b) Upon conclusion of the pilot program required under |
|
Subchapter C, the commission, in consultation and collaboration |
|
with the advisory committee and Pilot Program Workgroup, shall |
|
evaluate the pilot program and prepare and submit a report to the |
|
legislature based on a comprehensive analysis of the pilot. |
|
(c) The comprehensive analysis must: |
|
(1) include an assessment of the effect of the pilot |
|
on: |
|
(A) access to and improved quality of long-term |
|
services and supports; |
|
(B) informed choice and meaningful outcomes |
|
using person-centered planning, flexible consumer directed |
|
services, individualized budgeting, and self-determination, |
|
including a person's inclusion in the community; |
|
(C) the integration of service coordination of |
|
acute care services and long-term services and supports; |
|
(D) employment assistance and customized, |
|
integrated, competitive employment options; |
|
(E) the number, types and dispositions of fair |
|
hearing and appeals processes in accordance with applicable federal |
|
and state law; |
|
(F) increasing use and flexibility of the |
|
consumer directed service model; |
|
(G) increasing use of alternatives to |
|
guardianship, including supported decision-making agreements under |
|
Chapter 1357, Estates Code; |
|
(H) achieving cost effectiveness and best use of |
|
funding based on individuals' needs and preferences; and |
|
(I) attendant recruitment and retention; |
|
(2) provide an analysis of the experience and outcome |
|
of the following systems changes: |
|
(A) the IDD assessment tool required under |
|
Chapter 533, Subchapter B, Section 533.0335, Health and Safety |
|
Code; |
|
(B) the 21st Century Cures Act; |
|
(C) implementation of the federal HCBS Settings |
|
regulations; and |
|
(D) the provision of basic attendant and |
|
habilitation services required under Section 534.152 of this |
|
Chapter, and |
|
(E) the benefits of providing STAR+PLUS services |
|
to persons based on functional needs; |
|
(3) include input from the individuals with |
|
intellectual and developmental disabilities and participants of |
|
similar functional needs, families and other individuals actively |
|
involved in the lives of the individuals; and providers of long term |
|
services and supports programs defined under Section 534.001 (8) |
|
and (12) who participated in the pilot about their experiences; |
|
(4) be incorporated into the annual report to the |
|
legislature required under Section 534.054; and |
|
(5) include recommendations about a system of programs |
|
and services for consideration by the legislature, including |
|
recommendations for needed statutory changes and whether to |
|
transition the pilot to a statewide program under the STAR+PLUS |
|
program for individuals who meet the eligibility criteria specified |
|
in Section 534.1065. |
|
SECTION 22. The heading to Subchapter E, Chapter 534, |
|
Government Code, is amended to read as follows: SUBCHAPTER E. STAGE |
|
TWO: TRANSITION OF ICF-IID PROGRAM RECIPIENTS AND LONG-TERM CARE |
|
MEDICAID WAIVER PROGRAM RECIPIENTS TO INTEGRATED MANAGED CARE |
|
SYSTEM |
|
SECTION 23. Section 534.201, Subchapter E, Chapter 534, |
|
Government Code, is repealed: |
|
[Sec. 534.201. TRANSITION OF RECIPIENTS UNDER TEXAS HOME
|
|
LIVING (TxHmL) WAIVER PROGRAM TO MANAGED CARE PROGRAM.] [(a)[This
|
|
section applies to individuals with an intellectual or
|
|
developmental disability who are receiving long-term services and
|
|
supports under the Texas home living (TxHmL) waiver program on the
|
|
date the commission implements the transition described by
|
|
Subsection (b).]
|
|
[(b)
On September 1, 2020, the commission shall transition
|
|
the provision of Medicaid benefits to individuals to whom this
|
|
section applies to the STAR + PLUS Medicaid managed care program
|
|
delivery model or the most appropriate integrated capitated managed
|
|
care program delivery model, as determined by the commission based
|
|
on cost-effectiveness and the experience of the STAR + PLUS
|
|
Medicaid managed care program in providing basic attendant and
|
|
habilitation services and of the pilot programs established under
|
|
Subchapter C, subject to Subsection (c)(1).]
|
|
[(c)
At the time of the transition described by Subsection
|
|
(b), the commission shall determine whether to:
|
|
(1)
continue operation of the Texas home living
|
|
(TxHmL) waiver program for purposes of providing supplemental
|
|
long-term services and supports not available under the managed
|
|
care program delivery model selected by the commission; or
|
|
(2)
provide all or a portion of the long-term services
|
|
and supports previously available under the Texas home living
|
|
(TxHmL) waiver program through the managed care program delivery
|
|
model selected by the commission.]
|
|
[(d)
In implementing the transition described by Subsection
|
|
(b), the commission, in consultation and collaboration with the
|
|
advisory committee, shall develop a process to receive and evaluate
|
|
input from interested statewide stakeholders.]
|
|
[(e)
The commission, in consultation and collaboration with
|
|
the advisory committee, shall ensure that there is a comprehensive
|
|
plan for transitioning the provision of Medicaid benefits under
|
|
this section that protects the continuity of care provided to
|
|
individuals to whom this section applies.]
|
|
[(f)
In addition to the requirements of Section 533.005, a
|
|
contract between a managed care organization and the commission for
|
|
the organization to provide Medicaid benefits under this section
|
|
must contain a requirement that the organization implement a
|
|
process for individuals with an intellectual or developmental
|
|
disability that:
|
|
(1)
ensures that the individuals have a choice of
|
|
providers;
|
|
(2)
to the greatest extent possible, protects those
|
|
individuals' continuity of care with respect to access to primary
|
|
care providers, including the use of single-case agreements with
|
|
out-of-network providers; and
|
|
(3)
provides access to a member services phone line
|
|
for individuals or their legally authorized representatives to
|
|
obtain information on and assistance with accessing services
|
|
through network providers, including providers of primary,
|
|
specialty, and other long-term services and supports]. |
|
[(g)]
[The commission, in consultation and collaboration
|
|
with the advisory committee, shall analyze the outcomes of the
|
|
transition of the long-term services and supports under the Texas
|
|
home living (TxHmL) Medicaid waiver program to a managed care
|
|
program delivery model.] [The analysis must:]
|
|
[(1)
include an assessment of the effect of the
|
|
transition on:]
|
|
[(A) access to long-term services and supports;] |
|
[(B)
meaningful outcomes using person-centered
|
|
planning, individualized budgeting, and self-determination,
|
|
including a person's inclusion in the community;
|
|
[(C)
the integration of service coordination of
|
|
acute care services and long-term services and supports;]
|
|
[(D)
employment assistance and customized,
|
|
integrated, competitive employment options; and] |
|
[(E)
the number and types of fair hearing and
|
|
appeals processes in accordance with applicable federal law;] |
|
[(2)
be incorporated into the annual report to the
|
|
legislature required under Section 534.054; and] |
|
(3)
include recommendations for improvements to the
|
|
transition implementation for consideration by the legislature,
|
|
including recommendations for needed statutory changes.] |
|
SECTION 24. Section 534.202, Subchapter E, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.202. DETERMINATION TO TRANSITION [OF] ICF-IID |
|
PROGRAM RECIPIENTS AND CERTAIN [OTHER] MEDICAID WAIVER PROGRAM |
|
RECIPIENTS TO MANAGED CARE PROGRAM. (a) This section applies to |
|
individuals with an intellectual or developmental disability who |
|
[ , on the date the commission implements the transition
|
|
described by Subsection (b), ] are receiving long-term services and |
|
supports under: |
|
(1) a Medicaid waiver program as defined under Section |
|
534.001 (12) [other than the Texas home living (TxHmL) waiver
|
|
program]; or |
|
(2) an ICF-IID program. |
|
(b) After implementing the pilot [transition] required by |
|
Subchapter C of this Chapter, completing the evaluation required |
|
under Section 534.121, and subject to subsection (g)[on September
|
|
1, 2021], the commission, in consultation and collaboration with |
|
the advisory committee, shall develop a plan for the transition of |
|
all or a portion of the services provided through the programs |
|
defined in Sections 534.001 (8) and (12) which were not included in |
|
the pilot under Subchapter C. The plan must include: |
|
(1) The process for transitioning the services in the |
|
programs defined in Sections 534.001 (8) and (12) in a phased-in |
|
manner as follows: |
|
(A) Texas Home Living; |
|
(B) CLASS; |
|
(C) non-residential services provided through |
|
the 1915 (c) Home and Community-based Services and DBMD waivers; |
|
and |
|
(D) subject to subsection (b) (3), the |
|
residential services offered through the ICF/IID program and the |
|
HCS and DBMD waiver programs. |
|
(2) With the exception of the residential services |
|
provided through the programs specified in subsection (b) (1)(D), |
|
the schedule for transitioning the services and individuals into |
|
managed care must occur in the order specified under subsection |
|
(b)(1)beginning with TxHmL on September 1, 2027; CLASS on September |
|
1, 2029,; and the non-residential services provided through the |
|
Home and Community-based services and DBMD waivers on September 1, |
|
2031. |
|
(3) The process for evaluating the feasibility and |
|
cost efficiency of transitioning the residential services offered |
|
through the ICF/IID program and the HCS and DBMD waiver programs, |
|
and, as appropriate, transitioning to the managed care program. |
|
(A) The process for determining the transition of |
|
the residential services must be based on an evaluation of a two |
|
year pilot. |
|
[transition the provision of Medicaid benefits to individuals to
|
|
whom this section applies to the STAR + PLUS Medicaid managed care
|
|
program delivery model or the most appropriate integrated capitated
|
|
managed care program delivery model, as determined by the
|
|
commission based on cost-effectiveness and the experience of the
|
|
transition of Texas home living (TxHmL) waiver program recipients
|
|
to a managed care program delivery model under Section 534.201
|
|
subject to Subsections (c)(1) and (g).]
|
|
(c) [At the time of] Prior to the transition [described by] |
|
dates specified under Subsection (b) (2) and subject to subsection |
|
(g), the commission shall determine whether to: |
|
(1) continue operation of the Medicaid waiver programs |
|
only for purposes of providing, if applicable: |
|
(A) supplemental long-term services and supports |
|
not available under the managed care program delivery model |
|
selected by the commission; or |
|
(B) long term services and supports to Medicaid |
|
waiver program recipients who choose to continue receiving benefits |
|
under the waiver programs who choose to continue receiving benefits |
|
under the waiver program as provided by Subsection (g); or |
|
(2) subject to Subsection (g), provide all or a |
|
portion of the long-term services and supports previously available |
|
under the Medicaid waiver programs through the managed care program |
|
delivery model selected by the commission. |
|
(d) In implementing the transition described by Subsection |
|
(b)(2), the commission shall develop a process to receive and |
|
evaluate input from interested statewide stakeholders that is in |
|
addition to the input provided by the advisory committee. |
|
(e) The commission shall ensure that there is a |
|
comprehensive plan for transitioning the provision of Medicaid |
|
benefits under this section that protects the continuity of care |
|
provided to individuals to whom this section applies and ensures |
|
individuals have a choice among acute care and comprehensive long |
|
term services and supports providers and service delivery options |
|
including the consumer directed services model as specified under |
|
Subsection (i). |
|
(f) Before transitioning the provision of Medicaid benefits |
|
for children under this section, a managed care organization |
|
providing services under the managed care program delivery model |
|
selected by the commission must demonstrate to the satisfaction of |
|
the commission that the organization's network of providers has |
|
experience and expertise in the provision of services to children |
|
with an intellectual or developmental disability. Before |
|
transitioning the provision of Medicaid benefits for adults with an |
|
intellectual or developmental disability under this section, a |
|
managed care organization providing services under the managed care |
|
program delivery model selected by the commission must demonstrate |
|
to the satisfaction of the commission that the organization's |
|
network of providers has experience and expertise in the provision |
|
of services to adults with an intellectual or developmental |
|
disability. |
|
(g) If the commission determines that all or a portion of |
|
the long-term services and supports previously available under the |
|
Medicaid waiver programs should be provided through a managed care |
|
program delivery model under Subsection (c)(1), the commission |
|
shall, at the time of the transition, allow each recipient |
|
receiving long-term services and supports under a Medicaid waiver |
|
program the option of: |
|
(1) continuing to receive the services and supports |
|
under the Medicaid waiver program; or |
|
(2) receiving the services and supports through the |
|
managed care program delivery model selected by the commission. |
|
(h) A recipient who chooses to receive long-term services |
|
and supports through a managed care program delivery model under |
|
Subsection (g) may not, at a later time, choose to receive the |
|
services and supports under a Medicaid waiver program. |
|
(i) In addition to the requirements of Section 533.005, a |
|
contract between a managed care organization and the commission for |
|
the organization to provide Medicaid benefits under this section |
|
must contain a requirement that the organization implement a |
|
process for individuals with an intellectual or developmental |
|
disability that: |
|
(1) ensures that the individuals have a choice among |
|
acute care and comprehensive long term services and supports |
|
providers and service delivery options including the consumer |
|
directed services model; |
|
(2) to the greatest extent possible, protects those |
|
individuals' continuity of care with respect to access to primary |
|
care providers, including the use of single-case agreements with |
|
out-of-network providers; and |
|
(3) provides access to a member services phone line |
|
for individuals or their legally authorized representatives to |
|
obtain information on and assistance with accessing services |
|
through network providers, including providers of primary, |
|
specialty, and other long-term services and supports. |
|
SECTION 25. Section 534.203, Subchapter E, Chapter 534, |
|
Government Code, is amended to read as follows: |
|
Sec. 534.203. RESPONSIBILITIES OF COMMISSION UNDER |
|
SUBCHAPTER. In administering this subchapter, the commission shall |
|
ensure that upon a determination to transition services in the |
|
programs defined under Sections 534.001 (8) and (12): |
|
(1) that the commission is responsible for setting the |
|
minimum reimbursement rate paid to a provider of ICF-IID services |
|
or a group home provider under the integrated managed care system, |
|
including the staff rate enhancement paid to a provider of ICF-IID |
|
services or a group home provider; |
|
(2) that an ICF-IID service provider or a group home |
|
provider is paid not later than the 10th day after the date the |
|
provider submits a clean claim in accordance with the criteria used |
|
by the department for the reimbursement of ICF-IID service |
|
providers or a group home provider, as applicable; and |
|
(3) the establishment of an electronic portal through |
|
which a provider of ICF-IID services or a group home provider |
|
participating in the STAR + PLUS Medicaid managed care program |
|
delivery model or the most appropriate integrated capitated managed |
|
care program delivery model, as appropriate, may submit long-term |
|
services and supports claims to any participating managed care |
|
organization [. ] ; and |
|
(4) that each individual with an intellectual or |
|
developmental disability and the individual's legally authorized |
|
representative has access to a comprehensive facilitated, |
|
person-centered plan that identifies outcomes for the individual. |
|
The consumer directed services model must be promoted as an |
|
available option for individuals to achieve self-determination, |
|
choice and control. |
|
SECTION 26. Chapter 534, Government Code, is amended to add |
|
Subchapter F. to read as follows: |
|
SUBCHAPTER F. OTHER IMPLEMENTATION REQUIREMENTS AND |
|
RESPONSIBILITIES UNDER THIS CHAPTER |
|
Sec. 534.301. IMPLEMENTATION AND RESPONSIBILITIES UNDER |
|
THIS CHAPTER. (a) The commission is authorized to delay |
|
implementation of this Chapter or its subchapters without further |
|
investigation or adjustments or legislative intervention, if it |
|
determines any provision under the Chapter or other related mandate |
|
or initiative integral to implementation adversely affects the |
|
system of services and supports to persons and programs to which the |
|
Chapter applies. |
|
(b) For purpose of the pilot under Subchpater C. of this |
|
Chapter and any subsequent transition of recipients receiving |
|
services under certain Medicaid waiver programs defined under |
|
Section 534.001 (12) to a managed care program as specified under |
|
Section 534.202 (c), the commission must: |
|
(1) maintain a certification process and regulatory |
|
oversight of Texas Home Living and Home and Community-based |
|
Services providers; and |
|
(2) require managed care organizations include in |
|
their network of qualified long term services and supports |
|
providers certified Texas Home Living and Home and Community-based |
|
Services providers that specialize in services for persons with |
|
intellectual disabilities. |
|
(c) Subject to Section 534.202 (b) and (c), upon a decision |
|
to transition the long term services and supports under a Medicaid |
|
waiver program defined under Section 534.001 (12), the commission |
|
shall ensure individuals do not lose the benefits they are |
|
receiving through these Medicaid waiver programs. |
|
(d) For purposes of the pilot under Subchapter C. and any |
|
future transition of services specified under Section 534.202 into |
|
the STAR+PLUS program, the comprehensive long term services and |
|
supports provider defined in Section 534.001 (4): |
|
(1) must report encounters of any directly contracted |
|
services to the managed care organization; provide quarterly |
|
reporting of coordinated services and timeframes to the managed |
|
care organization, and provide quarterly progress on goals and |
|
objectives set by an individual's person centered plan; and |
|
(2) will not be held accountable for the provision of |
|
services on an individual's service plan for which a managed care |
|
organization denies or does not authorize access to in a timely |
|
manner. |
|
SECTION 27. 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 28. If the Health and Human Services Commission |
|
determines that it is cost effective, the commission shall apply |
|
for and actively seek a waiver or authorization from the |
|
appropriate federal agency to allow the state to provide medical |
|
assistance under the waiver or authorization to medically fragile |
|
individuals; |
|
(1) Who are at least 21 years of age; and |
|
(2) Whose costs to receive care exceed cost limits |
|
under existing Medicaid waiver programs. |
|
SECTION 29. This act takes effect September 1, 2019. |