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A BILL TO BE ENTITLED
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AN ACT
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relating to a "Texas Way" to reforming and addressing issues |
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related to the Medicaid program, including the creation of an |
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alternative program designed to ensure health benefit plan coverage |
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to certain low-income individuals through the private marketplace. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. BLOCK GRANT FUNDING SYSTEM FOR STATE MEDICAID PROGRAM |
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SECTION 1.01. Subtitle I, Title 4, Government Code, is |
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amended by adding Chapter 540 to read as follows: |
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CHAPTER 540. BLOCK GRANT FUNDING SYSTEM FOR STATE MEDICAID PROGRAM |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 540.0001. DEFINITIONS. Notwithstanding Section |
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531.001, in this chapter: |
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(1) "Health benefit exchange" means an American Health |
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Benefit Exchange administered by the federal government or an |
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exchange created under Section 1311(b) of the Patient Protection |
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and Affordable Care Act (42 U.S.C. Section 18031(b)). |
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(2) "Medicaid program" means the medical assistance |
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program established and operated under Title XIX, Social Security |
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Act (42 U.S.C. Section 1396 et seq.). |
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(3) "State Medicaid program" means the medical |
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assistance program provided by this state under the Medicaid |
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program. |
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Sec. 540.0002. FEDERAL AUTHORIZATION TO REFORM MEDICAID |
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REQUIRED. If the federal government establishes, through |
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conversion or otherwise, a block grant funding system for the |
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Medicaid program or otherwise authorizes the state Medicaid program |
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to operate under a block grant funding system, including under a |
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Medicaid program waiver, the commission, in cooperation with |
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applicable health and human services agencies, shall, subject to |
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Section 540.0003, administer and operate the state Medicaid program |
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in accordance with this chapter. |
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Sec. 540.0003. CONFLICT WITH OTHER LAW. To the extent of a |
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conflict between a provision of this chapter and: |
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(1) another provision of state law, the provision of |
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this chapter controls, subject to Section 540A.0002(b); and |
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(2) a provision of federal law or any authorization |
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described under Section 540.0002, the federal law or authorization |
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controls. |
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Sec. 540.0004. ESTABLISHMENT OF REFORMED STATE MEDICAID |
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PROGRAM. The commission shall establish a state Medicaid program |
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that provides benefits under a risk-based Medicaid managed care |
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model. |
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Sec. 540.0005. RULES. The executive commissioner shall |
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adopt rules necessary to implement this chapter. |
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SUBCHAPTER B. ACUTE CARE |
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Sec. 540.0051. ELIGIBILITY FOR MEDICAID ACUTE CARE. (a) An |
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individual is eligible to receive acute care benefits under the |
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state Medicaid program if the individual: |
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(1) has a household income at or below 100 percent of |
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the federal poverty level; |
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(2) is under 19 years of age and: |
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(A) is receiving Supplemental Security Income |
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(SSI) under 42 U.S.C. Section 1381 et seq.; or |
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(B) is in foster care or resides in another |
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residential care setting under the conservatorship of the |
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Department of Family and Protective Services; or |
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(3) meets the eligibility requirements that were in |
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effect in this state on August 31, 2023. |
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(b) The commission shall provide acute care benefits under |
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the state Medicaid program to each individual eligible under this |
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section through the most cost-effective means, as determined by the |
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commission. |
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(c) If an individual is not eligible for the state Medicaid |
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program under Subsection (a), the commission shall refer the |
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individual to the program established under Chapter 540A that helps |
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connect eligible residents with health benefit plan coverage |
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through private market solutions, a health benefit exchange, or any |
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other resource the commission determines appropriate. |
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Sec. 540.0052. MEDICAID SLIDING SCALE SUBSIDIES. (a) An |
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individual who is eligible for the state Medicaid program under |
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Section 540.0051 may receive a Medicaid sliding scale subsidy to |
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purchase a health benefit plan from an authorized health benefit |
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plan issuer. |
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(b) A sliding scale subsidy provided to an individual under |
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this section must: |
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(1) be based on: |
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(A) the average premium in the market; and |
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(B) a realistic assessment of the individual's |
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ability to pay a portion of the premium; and |
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(2) include an enhancement for individuals who choose |
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a high deductible health plan with a health savings account. |
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(c) The commission shall ensure that counselors are made |
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available to individuals receiving a subsidy to advise the |
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individuals on selecting a health benefit plan that meets the |
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individuals' needs. |
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(d) An individual receiving a subsidy under this section is |
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responsible for paying: |
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(1) any difference between the premium costs |
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associated with the purchase of a health benefit plan and the amount |
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of the individual's subsidy under this section; and |
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(2) any copayments associated with the health benefit |
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plan, except to the extent the individual receives an additional |
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subsidy under Section 540.0053 to pay the copayments. |
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(e) If the amount of a subsidy received by an individual |
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under this section exceeds the premium costs associated with the |
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individual's purchase of a health benefit plan, the individual may |
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deposit the excess amount in a health savings account that may be |
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used only in the manner described by Section 540.0054(b). |
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Sec. 540.0053. ADDITIONAL COST-SHARING SUBSIDIES. In |
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addition to providing a subsidy to an individual under Section |
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540.0052, the commission shall provide additional subsidies for |
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coinsurance payments, copayments, deductibles, and other |
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cost-sharing requirements associated with the individual's health |
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benefit plan. The commission shall provide the additional |
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subsidies on a sliding scale based on income. |
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Sec. 540.0054. DELIVERY OF SUBSIDIES; HEALTH SAVINGS |
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ACCOUNTS. (a) The commission shall determine the most appropriate |
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manner for delivering and administering subsidies provided under |
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Sections 540.0052 and 540.0053. In determining the most |
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appropriate manner, the commission shall consider depositing |
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subsidy amounts for an individual in a health savings account |
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established for that individual. |
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(b) A health savings account established under this section |
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may be used only to: |
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(1) pay health benefit plan premiums and cost-sharing |
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amounts; and |
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(2) if appropriate, purchase health care-related |
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goods and services. |
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Sec. 540.0055. MEDICAID HEALTH BENEFIT PLAN ISSUERS AND |
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MINIMUM COVERAGE. The commission shall allow any health benefit |
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plan issuer authorized to write health benefit plans in this state |
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to participate in the state Medicaid program. The commission in |
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consultation with the commissioner of insurance shall establish |
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minimum coverage requirements for a health benefit plan to be |
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eligible for purchase under the state Medicaid program, subject to |
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the requirements specified by this chapter. |
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Sec. 540.0056. REINSURANCE FOR PARTICIPATING HEALTH |
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BENEFIT PLAN ISSUERS. (a) The commission in consultation with the |
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commissioner of insurance shall study a reinsurance program to |
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reinsure participating health benefit plan issuers. |
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(b) In examining options for a reinsurance program, the |
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commission and the commissioner of insurance shall consider a plan |
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design under which: |
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(1) a participating health benefit plan is not charged |
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a premium for the reinsurance; and |
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(2) the health benefit plan issuer retains risk on a |
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sliding scale. |
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SUBCHAPTER C. LONG-TERM SERVICES AND SUPPORTS |
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Sec. 540.0101. PLAN TO REFORM DELIVERY OF LONG-TERM |
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SERVICES AND SUPPORTS. The commission shall develop a |
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comprehensive plan to reform the delivery of long-term services and |
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supports that is designed to achieve the following objectives under |
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the state Medicaid program or any other program created as an |
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alternative to the state Medicaid program: |
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(1) encourage consumer direction; |
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(2) simplify and streamline the provision of services; |
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(3) provide flexibility to design benefits packages |
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that meet the needs of individuals receiving long-term services and |
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supports under the program; |
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(4) improve the cost-effectiveness and sustainability |
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of the provision of long-term services and supports; |
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(5) reduce reliance on institutional settings; and |
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(6) encourage cost-sharing by family members when |
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appropriate. |
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ARTICLE 2. PROGRAM TO ENSURE HEALTH BENEFIT COVERAGE FOR CERTAIN |
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INDIVIDUALS THROUGH PRIVATE MARKETPLACE |
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SECTION 2.01. Subtitle I, Title 4, Government Code, is |
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amended by adding Chapter 540A to read as follows: |
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CHAPTER 540A. PROGRAM TO ENSURE HEALTH BENEFIT PLAN COVERAGE FOR |
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CERTAIN INDIVIDUALS THROUGH PRIVATE MARKET SOLUTIONS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 540A.0001. DEFINITION. In this chapter, "state |
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Medicaid program" has the meaning assigned by Section 540.0001. |
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Sec. 540A.0002. CONFLICT WITH OTHER LAW. (a) Except as |
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provided by Subsection (b), to the extent of a conflict between a |
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provision of this chapter and: |
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(1) another provision of state law, the provision of |
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this chapter controls; and |
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(2) a provision of federal law or any authorization |
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described under Subchapter B, the federal law or authorization |
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controls. |
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(b) The program operated under this chapter is in addition |
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to the state Medicaid program operated under Chapter 32, Human |
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Resources Code, or under a block grant funding system under Chapter |
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540. |
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Sec. 540A.0003. PROGRAM FOR HEALTH BENEFIT PLAN COVERAGE |
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THROUGH PRIVATE MARKET SOLUTIONS. Subject to the requirements of |
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this chapter, the commission in consultation with the commissioner |
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of insurance shall develop and implement a program that helps |
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connect certain low-income residents of this state with health |
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benefit plan coverage through private market solutions. |
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Sec. 540A.0004. NOT AN ENTITLEMENT. This chapter does not |
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establish an entitlement to assistance in obtaining health benefit |
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plan coverage. |
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Sec. 540A.0005. RULES. The executive commissioner shall |
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adopt rules necessary to implement this chapter. |
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SUBCHAPTER B. FEDERAL AUTHORIZATION |
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Sec. 540A.0051. FEDERAL AUTHORIZATION FOR FLEXIBILITY TO |
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ESTABLISH PROGRAM. (a) The commission in consultation with the |
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commissioner of insurance shall negotiate with the United States |
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secretary of health and human services, the Centers for Medicare |
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and Medicaid Services, and other appropriate persons for purposes |
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of seeking a waiver or other authorization necessary to obtain the |
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flexibility to use federal matching funds to help provide, in |
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accordance with Subchapter C, health benefit plan coverage to |
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certain low-income individuals through private market solutions. |
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(b) Any agreement reached under this section must: |
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(1) create a program that is made cost neutral to this |
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state by: |
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(A) leveraging premium tax revenues; and |
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(B) achieving cost savings through offsets to |
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general revenue health care costs or the implementation of other |
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cost savings mechanisms; |
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(2) create more efficient health benefit plan coverage |
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options for eligible individuals through: |
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(A) program changes that may be made without the |
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need for additional federal approval; and |
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(B) program changes that require additional |
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federal approval; |
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(3) require the commission to achieve efficiency and |
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reduce unnecessary utilization, including duplication, of health |
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care services; |
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(4) be designed with the goals of: |
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(A) relieving local tax burdens; |
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(B) reducing general revenue reliance so as to |
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make general revenue available for other state priorities; and |
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(C) minimizing the impact of any federal health |
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care laws on Texas-based businesses; and |
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(5) afford this state the opportunity to develop a |
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state-specific way with benefits that specifically meet the unique |
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needs of this state's population. |
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(c) An agreement reached under this section may be: |
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(1) limited in duration; and |
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(2) contingent on continued funding by the federal |
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government. |
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SUBCHAPTER C. PROGRAM REQUIREMENTS |
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Sec. 540A.0101. ENROLLMENT ELIGIBILITY. (a) Subject to |
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Subsection (b), an individual may be eligible to enroll in a program |
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designed and established under this chapter if the person: |
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(1) is younger than 65; |
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(2) has a household income at or below 133 percent of |
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the federal poverty level; and |
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(3) is not otherwise eligible to receive benefits |
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under the state Medicaid program, including through a program |
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operated under Chapter 32, Human Resources Code, or under Chapter |
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540 through a block grant funding system or a waiver, other than a |
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waiver granted under this chapter, to the program. |
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(b) The executive commissioner may modify or further define |
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the eligibility requirements of this section if the commission |
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determines it necessary to reach an agreement under Subchapter B. |
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Sec. 540A.0102. MINIMUM PROGRAM REQUIREMENTS. A program |
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designed and established under this chapter must: |
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(1) if cost-effective for this state, provide premium |
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assistance to purchase health benefit plan coverage in the private |
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market, including health benefit plan coverage offered through a |
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managed care delivery model; |
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(2) provide enrollees with access to health benefits, |
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including benefits provided through a managed care delivery model, |
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that: |
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(A) are tailored to the enrollees; |
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(B) provide levels of coverage that are |
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customized to meet health care needs of individuals within defined |
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categories of the enrolled population; and |
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(C) emphasize personal responsibility and |
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accountability through flexible and meaningful cost-sharing |
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requirements and wellness initiatives, including through |
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incentives for compliance with health, wellness, and treatment |
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strategies and disincentives for noncompliance; |
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(3) include pay-for-performance initiatives for |
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private health benefit plan issuers that participate in the |
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program; |
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(4) use technology to maximize the efficiency with |
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which the commission and any health benefit plan issuer, health |
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care provider, or managed care organization participating in the |
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program manage enrollee participation; |
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(5) allow recipients under the state Medicaid program |
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to enroll in the program to receive premium assistance as an |
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alternative to the state Medicaid program; |
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(6) encourage eligible individuals to enroll in other |
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private or employer-sponsored health benefit plan coverage, if |
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available and appropriate; |
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(7) encourage the utilization of health care services |
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in the most appropriate low-cost settings; and |
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(8) establish health savings accounts for enrollees, |
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as appropriate. |
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SECTION 2.02. The Health and Human Services Commission in |
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consultation with the commissioner of insurance shall actively |
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develop a proposal for the authorization from the appropriate |
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federal entity as required by Subchapter B, Chapter 540A, |
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Government Code, as added by this article. As soon as possible |
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after the effective date of this Act, the Health and Human Services |
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Commission shall request and actively pursue obtaining the |
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authorization from the appropriate federal entity. |
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ARTICLE 3. FEDERAL AUTHORIZATION AND EFFECTIVE DATE |
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SECTION 3.01. Subject to Section 2.02 of this Act, if before |
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implementing any provision of this Act a state agency determines |
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that a waiver or authorization from a federal agency is necessary |
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for implementation of that provision, the agency affected by the |
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provision shall request the waiver or authorization and may delay |
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implementing that provision until the waiver or authorization is |
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granted. |
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SECTION 3.02. This Act takes effect September 1, 2023. |