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A BILL TO BE ENTITLED
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AN ACT
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relating to a direct primary care model pilot program for Medicaid. |
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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 531.024151 to read as follows: |
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Sec. 531.024151. DIRECT PRIMARY CARE MODEL PILOT PROGRAM |
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FOR MEDICAID. (a) In this section: |
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(1) "Direct fee" means a fee charged by a physician to |
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a patient or a patient's designee for primary medical care services |
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provided by, or to be provided by, the physician to the |
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patient. The term includes a fee in any form, including a: |
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(A) retainer; |
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(B) membership fee; |
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(C) subscription fee; or |
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(D) fee paid under a medical service agreement. |
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(2) "Direct primary care," "medical service |
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agreement," "physician," and "primary medical care service" have |
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the meanings assigned by Section 162.251, Occupations Code. |
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(3) "Participating physician" means a physician |
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participating in the pilot program. |
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(4) "Participating recipient" means a Medicaid |
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recipient participating in the pilot program. |
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(5) "Pilot program" means the direct primary care |
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model pilot program established under this section. |
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(b) The commission shall develop a pilot program to |
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implement a direct primary care model in Medicaid through which a |
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Medicaid recipient enters into a medical service agreement with a |
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physician for the provision of primary medical care services in |
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exchange for a direct fee that is paid on a monthly basis. |
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(c) The commission shall implement the pilot program |
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statewide. |
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(d) Under the pilot program, a participating physician: |
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(1) is not required to enroll as a Medicaid provider; |
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and |
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(2) notwithstanding Subdivision (1), has the |
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authority of ordering, referring, and prescribing Medicaid |
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providers for purposes of the pilot program. |
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(e) To be eligible to participate in the pilot program, a |
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physician must be practicing under a direct primary care model that |
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does not accept payment or otherwise seek reimbursement for primary |
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medical care services from a third-party insurer or managed care |
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organization. |
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(f) A Medicaid recipient must be younger than 65 years of |
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age to be eligible to participate in the pilot program. The |
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recipient or the recipient's parent or legally authorized |
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representative on behalf of the recipient must enter into a medical |
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service agreement with a physician eligible to participate in the |
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pilot program. After the commission verifies that the recipient or |
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the recipient's parent or legally authorized representative has |
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entered into the agreement, the commission shall pay the lesser of: |
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(1) the amount of the direct fee required under the |
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agreement; or |
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(2) $40 per month for a recipient who is 18 years of |
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age or younger, or $70 per month for a recipient who is at least 19 |
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years of age but younger than 65 years of age. |
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(g) A participating recipient shall pay the amount of the |
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direct fee required under the medical service agreement that |
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exceeds the maximum fee amount the commission pays under Subsection |
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(f). |
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(h) The commission may pay the amount of the direct fee |
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under a medical service agreement directly to the participating |
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recipient, who is then responsible for paying the participating |
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physician under the agreement, or may establish a system under |
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which the commission pays the fee directly to the physician, either |
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by depositing the fee into an account established for the physician |
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for that purpose or by another means the commission determines most |
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appropriate. If cost-effective, the commission may issue an |
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electronic benefits transfer card to a participating recipient who |
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shall use the card to pay the amount of the direct fee under an |
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agreement. |
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(i) To the extent permitted by the contract entered into |
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between the commission and a Medicaid managed care organization, |
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the commission shall fund the direct fee required under a medical |
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service agreement by making an appropriate reduction in the |
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capitation rate paid to the organization that issued the managed |
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care plan in which the participating recipient is enrolled. |
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(j) A participating recipient shall immediately notify the |
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commission when a medical service agreement terminates. |
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(k) Not later than December 31, 2024, the commission shall |
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prepare and submit a report to the legislature that includes: |
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(1) a summary of the commission's evaluation of the |
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effect of the pilot program on the provision of primary medical care |
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services and Medicaid costs; and |
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(2) a recommendation as to whether the pilot program |
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should be continued or terminated. |
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(l) The executive commissioner shall adopt rules as |
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necessary to implement this section. |
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(m) The pilot program terminates and this section expires |
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September 1, 2025. |
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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 September 1, 2021. |