87R6749 KFF-D
 
  By: Shaheen H.B. No. 2603
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to a direct primary care model pilot program for Medicaid.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter B, Chapter 531, Government Code, is
  amended by adding Section 531.024151 to read as follows:
         Sec. 531.024151.  DIRECT PRIMARY CARE MODEL PILOT PROGRAM
  FOR MEDICAID.  (a)  In this section:
               (1)  "Direct fee" means a fee charged by a physician to
  a patient or a patient's designee for primary medical care services
  provided by, or to be provided by, the physician to the
  patient.  The term includes a fee in any form, including a:
                     (A)  retainer;
                     (B)  membership fee;
                     (C)  subscription fee; or
                     (D)  fee paid under a medical service agreement.
               (2)  "Direct primary care," "medical service
  agreement," "physician," and "primary medical care service" have
  the meanings assigned by Section 162.251, Occupations Code.
               (3)  "Participating physician" means a physician
  participating in the pilot program.
               (4)  "Participating recipient" means a Medicaid
  recipient participating in the pilot program.
               (5)  "Pilot program" means the direct primary care
  model pilot program established under this section.
         (b)  The commission shall develop a pilot program to
  implement a direct primary care model in Medicaid through which a
  Medicaid recipient enters into a medical service agreement with a
  physician for the provision of primary medical care services in
  exchange for a direct fee that is paid on a monthly basis.
         (c)  The commission shall implement the pilot program
  statewide.
         (d)  Under the pilot program, a participating physician:
               (1)  is not required to enroll as a Medicaid provider;
  and
               (2)  notwithstanding Subdivision (1), has the
  authority of ordering, referring, and prescribing Medicaid
  providers for purposes of the pilot program.
         (e)  To be eligible to participate in the pilot program, a
  physician must be practicing under a direct primary care model that
  does not accept payment or otherwise seek reimbursement for primary
  medical care services from a third-party insurer or managed care
  organization.
         (f)  A Medicaid recipient must be younger than 65 years of
  age to be eligible to participate in the pilot program.  The
  recipient or the recipient's parent or legally authorized
  representative on behalf of the recipient must enter into a medical
  service agreement with a physician eligible to participate in the
  pilot program.  After the commission verifies that the recipient or
  the recipient's parent or legally authorized representative has
  entered into the agreement, the commission shall pay the lesser of:
               (1)  the amount of the direct fee required under the
  agreement; or
               (2)  $40 per month for a recipient who is 18 years of
  age or younger, or $70 per month for a recipient who is at least 19
  years of age but younger than 65 years of age.
         (g)  A participating recipient shall pay the amount of the
  direct fee required under the medical service agreement that
  exceeds the maximum fee amount the commission pays under Subsection
  (f).
         (h)  The commission may pay the amount of the direct fee
  under a medical service agreement directly to the participating
  recipient, who is then responsible for paying the participating
  physician under the agreement, or may establish a system under
  which the commission pays the fee directly to the physician, either
  by depositing the fee into an account established for the physician
  for that purpose or by another means the commission determines most
  appropriate.  If cost-effective, the commission may issue an
  electronic benefits transfer card to a participating recipient who
  shall use the card to pay the amount of the direct fee under an
  agreement.
         (i)  To the extent permitted by the contract entered into
  between the commission and a Medicaid managed care organization,
  the commission shall fund the direct fee required under a medical
  service agreement by making an appropriate reduction in the
  capitation rate paid to the organization that issued the managed
  care plan in which the participating recipient is enrolled.
         (j)  A participating recipient shall immediately notify the
  commission when a medical service agreement terminates.
         (k)  Not later than December 31, 2024, the commission shall
  prepare and submit a report to the legislature that includes:
               (1)  a summary of the commission's evaluation of the
  effect of the pilot program on the provision of primary medical care
  services and Medicaid costs; and
               (2)  a recommendation as to whether the pilot program
  should be continued or terminated.
         (l)  The executive commissioner shall adopt rules as
  necessary to implement this section.
         (m)  The pilot program terminates and this section expires
  September 1, 2025.
         SECTION 2.  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 3.  This Act takes effect September 1, 2021.