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A BILL TO BE ENTITLED
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AN ACT
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relating to the development and implementation of the Live Well |
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Texas program and the expansion of Medicaid eligibility to provide |
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health benefit coverage to certain individuals; imposing |
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penalties. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle I, Title 4, Government Code, is amended |
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by adding Chapters 537A and 537B to read as follows: |
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CHAPTER 537A. LIVE WELL TEXAS PROGRAM |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 537A.0001. DEFINITIONS. In this chapter: |
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(1) "Basic plan" means the program health benefit plan |
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described by Section 537A.0202. |
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(2) "Eligible individual" means an individual who is |
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eligible to participate in the program. |
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(3) "Participant" means an individual who is: |
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(A) enrolled in a program health benefit plan; or |
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(B) receiving health care financial assistance |
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under Subchapter H. |
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(4) "Plus plan" means the program health benefit plan |
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described by Section 537A.0203. |
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(5) "POWER account" means a personal wellness and |
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responsibility account the commission establishes for a |
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participant under Section 537A.0251. |
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(6) "Program" means the Live Well Texas program |
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established under this chapter. |
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(7) "Program health benefit plan" includes: |
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(A) the basic plan; and |
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(B) the plus plan. |
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(8) "Program health benefit plan provider" means a |
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health benefit plan provider that contracts with the commission |
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under Section 537A.0107 to arrange for the provision of health care |
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services through a program health benefit plan. |
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SUBCHAPTER B. FEDERAL WAIVER FOR LIVE WELL TEXAS PROGRAM |
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Sec. 537A.0051. FEDERAL AUTHORIZATION FOR PROGRAM. (a) |
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Notwithstanding any other law, the executive commissioner shall |
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develop and seek a waiver under Section 1115 of the Social Security |
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Act (42 U.S.C. Section 1315) to the state Medicaid plan to implement |
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the Live Well Texas program to assist individuals in obtaining |
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health benefit coverage through a program health benefit plan or |
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health care financial assistance. |
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(b) The terms of a waiver the executive commissioner seeks |
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under this section must: |
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(1) be designed to: |
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(A) provide health benefit coverage options for |
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eligible individuals; |
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(B) produce better health outcomes for |
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participants; |
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(C) create incentives for participants to |
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transition from receiving public assistance benefits to achieving |
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stable employment; |
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(D) promote personal responsibility and engage |
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participants in making decisions regarding health care based on |
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cost and quality; |
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(E) support participants' self-sufficiency by |
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requiring unemployed participants to be referred to work search and |
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job training programs; |
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(F) support participants who become ineligible |
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to participate in a program health benefit plan in transitioning to |
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private health benefit coverage; and |
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(G) leverage enhanced federal medical assistance |
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percentage funding to minimize or eliminate the need for a program |
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enrollment cap; and |
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(2) allow for the operation of the program consistent |
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with the requirements of this chapter, except to the extent |
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deviation from the requirements is necessary to obtain federal |
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authorization of the waiver. |
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Sec. 537A.0052. FUNDING. Subject to approval of the waiver |
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described by Section 537A.0051, the commission shall implement the |
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program using enhanced federal medical assistance percentage |
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funding available under the Patient Protection and Affordable Care |
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Act (Pub. L. No. 111-148) as amended by the Health Care and |
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Education Reconciliation Act of 2010 (Pub. L. No. 111-152). |
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Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM. |
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(a) This chapter does not establish an entitlement to health |
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benefit coverage or health care financial assistance under the |
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program for eligible individuals. |
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(b) The program terminates at the time the share of federal |
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funding for the program under the Patient Protection and Affordable |
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Care Act (Pub. L. No. 111-148) as amended by the Health Care and |
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Education Reconciliation Act of 2010 (Pub. L. No. 111-152) is |
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reduced below 90 percent. |
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SUBCHAPTER C. PROGRAM ADMINISTRATION |
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Sec. 537A.0101. PROGRAM OBJECTIVE. The program's principal |
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objective is to provide primary and preventative health care |
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through high deductible program health benefit plans to eligible |
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individuals. |
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Sec. 537A.0102. PROGRAM PROMOTION. The commission shall |
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promote and provide information about the program to individuals |
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who: |
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(1) are potentially eligible to participate in the |
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program; and |
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(2) live in medically underserved areas of this state. |
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Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH |
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BENEFIT PLAN PROVIDER CONTRACTS. The commission may: |
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(1) enter into contracts with health benefit plan |
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providers under Section 537A.0107; |
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(2) monitor program health benefit plan providers |
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through reporting requirements and other means to ensure contract |
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performance and quality delivery of services; |
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(3) monitor the quality of services delivered to |
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participants through outcome measurements; and |
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(4) provide payment under the contracts to program |
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health benefit plan providers. |
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Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO |
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ELIGIBILITY AND MEDICAID COORDINATION. The commission may: |
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(1) accept applications for health benefit coverage |
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under the program and implement program eligibility screening and |
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enrollment procedures; |
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(2) resolve grievances related to eligibility |
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determinations; and |
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(3) to the extent possible, coordinate the program |
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with Medicaid. |
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Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR |
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PROGRAM IMPLEMENTATION. (a) In administering the program, the |
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commission may contract with a third-party administrator to provide |
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enrollment and related services. |
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(b) If the commission contracts with a third-party |
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administrator under this section, the commission may: |
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(1) monitor the third-party administrator through |
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reporting requirements and other means to ensure contract |
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performance and quality delivery of services; and |
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(2) provide payment under the contract to the |
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third-party administrator. |
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(c) The executive commissioner shall retain all |
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policymaking authority over the program. |
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(d) The commission shall procure each contract with a |
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third-party administrator, as applicable, through a competitive |
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procurement process that complies with all federal and state laws. |
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Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a) |
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At the commission's request, the Texas Department of Insurance |
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shall provide any necessary assistance with the program. The |
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department shall monitor the quality of the services provided by |
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program health benefit plan providers and resolve grievances |
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related to those providers. |
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(b) The commission and the Texas Department of Insurance may |
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adopt a memorandum of understanding that addresses the |
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responsibilities of each agency with respect to the program. |
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(c) The Texas Department of Insurance, in consultation with |
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the commission, shall adopt rules as necessary to implement this |
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section. |
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Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS. |
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The commission shall select through a competitive procurement |
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process that complies with all federal and state laws and contract |
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with health benefit plan providers to provide health care services |
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under the program. To be eligible for a contract under this section, |
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an entity must: |
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(1) be a Medicaid managed care organization; |
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(2) hold a certificate of authority issued by the |
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Texas Department of Insurance that authorizes the entity to provide |
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the types of health care services offered under the program; and |
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(3) satisfy, except as provided by this chapter, any |
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applicable requirement of the Insurance Code or another insurance |
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law of this state. |
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Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care |
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provider who provides health care services under the program must |
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meet certification and licensure requirements required by |
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commission rules and other law. |
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(b) In adopting rules governing the program, the executive |
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commissioner shall ensure that a health care provider who provides |
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health care services under the program is reimbursed at a rate that |
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is at least equal to the rate paid under Medicare for the provision |
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of the same or substantially similar services. |
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Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTHCARE |
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PROVIDERS. The executive commissioner shall adopt rules that |
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prohibit a health care provider from providing program health care |
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services for a reasonable period, as determined by the executive |
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commissioner, if the health care provider: |
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(1) fails to repay program overpayments; or |
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(2) owns, controls, manages, or is otherwise |
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affiliated with and has financial, managerial, or administrative |
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influence over a health care provider who has been suspended or |
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prohibited from providing program health care services. |
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SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE |
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Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An |
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individual is eligible to enroll in a program health benefit plan |
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if: |
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(1) the individual is a resident of this state; |
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(2) the individual is 19 years of age or older but |
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younger than 65 years of age; |
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(3) applying the eligibility criteria in effect in |
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this state on December 31, 2022, the individual is not eligible for |
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Medicaid; and |
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(4) federal matching funds are available under the |
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Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as |
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amended by the Health Care and Education Reconciliation Act of 2010 |
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(Pub. L. No. 111-152) to provide benefits to the individual under |
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the federal medical assistance program established under Title XIX, |
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Social Security Act (42 U.S.C. Section 1396 et seq.). |
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(b) An individual who is a parent or caretaker relative to |
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whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a |
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program health benefit plan. |
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(c) In determining eligibility for the program, the |
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commission shall apply the same eligibility criteria regarding |
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residency and citizenship in effect for Medicaid in this state on |
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December 31, 2022. |
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Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall |
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ensure that an individual who is initially determined or |
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redetermined to be eligible to participate in the program and |
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enroll in a program health benefit plan will remain eligible for |
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coverage under the plan for a period of 12 months beginning on the |
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first day of the month following the date eligibility was |
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determined or redetermined, subject to Section 537A.0252(f). |
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Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The |
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executive commissioner shall adopt an application form and |
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application procedures for the program. The form and procedures |
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must be coordinated with forms and procedures under Medicaid to |
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ensure that there is a single consolidated application process to |
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seek health benefit coverage under the program or Medicaid. |
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(b) To the extent possible, the commission shall make the |
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application form available in languages other than English. |
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(c) The executive commissioner may permit an individual to |
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apply by mail, over the telephone, or through the Internet. |
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Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a) |
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The executive commissioner shall adopt eligibility screening and |
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enrollment procedures or use the Texas Integrated Enrollment |
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Services eligibility determination system or a compatible system to |
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screen individuals and enroll eligible individuals in the program. |
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(b) The eligibility screening and enrollment procedures |
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must ensure that an individual applying for the program who appears |
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eligible for Medicaid is identified and assisted with obtaining |
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Medicaid coverage. If the individual is denied Medicaid coverage |
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but is determined eligible to enroll in a program health benefit |
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plan, the commission shall enroll the individual in a program |
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health benefit plan of the individual's choosing and for which the |
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individual is eligible without further application or |
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qualification. |
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(c) Not later than the 30th day after the date an individual |
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submits a complete application form and unless the individual is |
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identified and assisted with obtaining Medicaid coverage under |
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Subsection (b), the commission shall ensure that the individual's |
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eligibility to participate in the program is determined and that |
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the individual, if eligible, is provided with information on |
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program health benefit plans and program health benefit plan |
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providers. The commission shall enroll the individual in the |
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program health benefit plan and with the program health benefit |
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plan provider of the individual's choosing in a timely manner, as |
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determined by the commission. |
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(d) The executive commissioner may establish enrollment |
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periods for the program. |
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Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS; |
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DISENROLLMENT. (a) Not later than the 90th day before a |
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participant's coverage period expires, the commission shall notify |
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the participant regarding the eligibility redetermination process |
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and request documentation necessary to redetermine the |
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participant's eligibility. |
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(b) The commission shall provide written notice of |
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termination of eligibility to a participant not later than the 30th |
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day before the date the participant's eligibility will terminate. |
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The commission shall disenroll the participant from the program if: |
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(1) the participant does not submit the requested |
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eligibility redetermination documentation before the last day of |
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the participant's coverage period; or |
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(2) the commission, based on the submitted |
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documentation, determines the participant is no longer eligible for |
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the program, subject to Subchapter H. |
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(c) An individual may submit the requested eligibility |
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redetermination documentation not later than the 90th day after the |
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date the commission disenrolls the individual from the program. If |
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the commission determines that the individual continues to meet |
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program eligibility requirements, the commission shall reenroll |
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the individual in the program without any additional application |
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requirements. |
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(d) An individual who does not complete the eligibility |
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redetermination process in accordance with this section and who the |
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commission disenrolls from the program may not participate in the |
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program for a period of 180 days beginning on the date of |
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disenrollment. This subsection does not apply to an individual: |
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(1) described by Section 537A.0206 or 537A.0208; or |
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(2) who is: |
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(A) pregnant; or |
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(B) younger than 21 years of age. |
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(e) At the time the commission disenrolls a participant from |
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the program, the commission shall provide to the participant: |
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(1) notice that the participant may be eligible to |
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receive health care financial assistance under Subchapter H in |
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transitioning to private health benefit coverage; and |
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(2) information on and the eligibility requirements |
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for that financial assistance. |
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SUBCHAPTER E. BASIC AND PLUS PLANS |
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Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY. |
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(a) The basic and plus plans offered under the program must: |
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(1) comply with this subchapter and coverage |
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requirements prescribed by other law; and |
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(2) at a minimum, provide coverage for essential |
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health benefits required under 42 U.S.C. Section 18022(b). |
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(b) In modifying covered health benefits under the basic and |
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plus plans, the executive commissioner shall consider the health |
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care needs of healthy individuals and individuals with special |
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health care needs. |
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(c) The basic and plus plans must allow a participant with a |
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chronic, disabling, or life-threatening illness to select an |
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appropriate specialist as the participant's primary care |
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physician. |
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Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME |
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ELIGIBILITY. (a) The program must include a basic plan that is |
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sufficient to meet the basic health care needs of individuals who |
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enroll in the plan. |
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(b) The covered health benefits under the basic plan must |
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include: |
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(1) primary care physician services; |
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(2) prenatal and postpartum care; |
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(3) specialty care physician visits; |
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(4) home health services, not to exceed 100 visits per |
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year; |
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(5) outpatient surgery; |
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(6) allergy testing; |
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(7) chemotherapy; |
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(8) intravenous infusion services; |
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(9) radiation therapy; |
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(10) dialysis; |
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(11) emergency care hospital services; |
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(12) emergency transportation, including ambulance |
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and air ambulance; |
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(13) urgent care clinic services; |
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(14) hospitalization, including for: |
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(A) general inpatient hospital care; |
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(B) inpatient physician services; |
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(C) inpatient surgical services; |
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(D) non-cosmetic reconstructive surgery; |
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(E) a transplant; |
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(F) treatment for a congenital abnormality; |
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(G) anesthesia; |
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(H) hospice care; and |
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(I) care in a skilled nursing facility for a |
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period not to exceed 100 days per occurrence; |
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(15) inpatient and outpatient behavioral health |
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services; |
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(16) inpatient, outpatient, and residential substance |
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use treatment; |
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(17) prescription drugs, including tobacco cessation |
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drugs; |
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(18) inpatient and outpatient rehabilitative and |
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habilitative care, including physical, occupational, and speech |
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therapy, not to exceed 60 combined visits per year; |
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(19) medical equipment, appliances, and assistive |
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technology, including prosthetics and hearing aids, and the repair, |
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technical support, and customization needed for individual use; |
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(20) laboratory and pathology tests and services; |
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(21) diagnostic imaging, including x-rays, magnetic |
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resonance imaging, computed tomography, and positron emission |
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tomography; |
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(22) preventative care services as described by |
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Section 537A.0204; and |
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(23) services under the early and periodic screening, |
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diagnostic, and treatment program for participants who are younger |
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than 21 years of age. |
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(c) To be eligible for health care benefits under the basic |
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plan, an individual who is eligible for the program must have an |
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annual household income that is equal to or less than 100 percent of |
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the federal poverty level. |
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Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY. |
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(a) The program must include a plus plan that includes the covered |
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health benefits listed in Section 537A.0202 and the following |
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additional enhanced health benefits: |
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(1) services related to the treatment of conditions |
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affecting the temporomandibular joint; |
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(2) dental care; |
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(3) vision care; |
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(4) notwithstanding Section 537A.0202(b)(18), |
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inpatient and outpatient rehabilitative and habilitative care, |
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including physical, occupational, and speech therapy, not to exceed |
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75 combined visits per year; |
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(5) bariatric surgery; and |
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(6) other services the commission considers |
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appropriate. |
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(b) An individual who is eligible for the program and whose |
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annual household income exceeds 100 percent of the federal poverty |
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level will automatically be enrolled in and receive health benefits |
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under the plus plan. An individual who is eligible for the program |
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and whose annual household income is equal to or less than 100 |
|
percent of the federal poverty level may choose to enroll in the |
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plus plan. |
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(c) A participant enrolled in the plus plan is required to |
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make POWER account contributions in accordance with Section |
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537A.0252. |
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Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The |
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commission shall provide to each participant a list of health care |
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services that qualify as preventative care services based on the |
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participant's age, gender, and preexisting conditions. In |
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developing the list, the commission shall consult with the federal |
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Centers for Disease Control and Prevention. |
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(b) A program health benefit plan shall, at no cost to the |
|
participant, provide coverage for: |
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(1) preventative care services described by 42 U.S.C. |
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Section 300gg-13; and |
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(2) a maximum of $500 per year of preventative care |
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services other than those described by Subdivision (1). |
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(c) A participant who receives preventative care services |
|
not described by Subsection (b) that are covered under the |
|
participant's program health benefit plan is subject to deductible |
|
and copayment requirements for the services in accordance with the |
|
terms of the plan. |
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Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in |
|
the basic plan shall pay a copayment for each covered health benefit |
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except for a preventative care or family planning service. The |
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executive commissioner by rule shall adopt a copayment schedule for |
|
basic plan services, subject to Subsection (c). |
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(b) Except as provided by Subsection (c), a participant |
|
enrolled in the plus plan may not be required to pay a copayment for |
|
a covered service. |
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(c) A participant enrolled in the basic or plus plan shall |
|
pay a copayment in an amount set by commission rule not to exceed |
|
$25 for nonemergency use of hospital emergency department services |
|
unless: |
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(1) the participant has met the cost-sharing maximum |
|
for the calendar quarter, as prescribed by commission rule; |
|
(2) the participant is referred to the hospital |
|
emergency department by a health care provider; |
|
(3) the visit is a true emergency, as defined by |
|
commission rule; or |
|
(4) the participant is pregnant. |
|
Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE |
|
MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R. |
|
Section 440.315 who is enrolled in the basic or plus plan is |
|
entitled to receive under the program all health benefits that |
|
would be available under the state Medicaid plan. |
|
(b) A participant to which this section applies is subject |
|
to the cost-sharing requirements, including copayment and POWER |
|
account contribution requirements, of the program health benefit |
|
plan in which the participant is enrolled. |
|
(c) The commission shall develop screening measures to |
|
identify participants to which this section applies. |
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Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant |
|
who becomes pregnant while enrolled in the program and who meets the |
|
eligibility requirements for Medicaid may choose to remain in the |
|
program or enroll in Medicaid. |
|
(b) A pregnant participant described by Subsection (a) who |
|
is enrolled in the basic or plus plan and who remains in the program |
|
is: |
|
(1) notwithstanding Section 537A.0205, not subject to |
|
any cost-sharing requirements, including copayment and POWER |
|
account contribution requirements, of the program health benefit |
|
plan in which the participant is enrolled until the expiration of |
|
the second month following the month in which the pregnancy ends; |
|
(2) entitled to receive as a Medicaid wrap-around |
|
benefit all Medicaid services a pregnant woman enrolled in Medicaid |
|
is entitled to receive, including a pharmacy benefit, when the |
|
participant exceeds coverage limits under the participant's |
|
program health benefit plan or if a service is not covered by the |
|
plan; and |
|
(3) eligible for additional vision and dental care |
|
benefits. |
|
Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A |
|
parent or caretaker relative to whom 42 C.F.R. Section 435.110 |
|
applies is entitled to receive as a Medicaid wrap-around benefit |
|
all Medicaid services to which the individual would be entitled |
|
under the state Medicaid plan that are not covered under the |
|
individual's program health benefit plan or exceed the plan's |
|
coverage limits. |
|
(b) An individual described by Subsection (a) who chooses to |
|
participate in the program is subject to the cost-sharing |
|
requirements, including copayment and POWER account contribution |
|
requirements, of the program health benefit plan in which the |
|
individual is enrolled. |
|
SUBCHAPTER F. PERSONAL WELLNESS AND RESPONSIBILITY (POWER) |
|
ACCOUNTS |
|
Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF POWER |
|
ACCOUNTS. (a) The commission shall establish a personal wellness |
|
and responsibility (POWER) account for each participant who is |
|
enrolled in a program health benefit plan that is funded with money |
|
contributed in accordance with this subchapter. |
|
(b) The commission shall enable each participant to access |
|
and manage money in and information regarding the participant's |
|
POWER account through an electronic system. The commission may |
|
contract with an entity that has appropriate experience and |
|
expertise to establish, implement, or administer the electronic |
|
system. |
|
(c) Except as otherwise provided by Section 537A.0252, the |
|
commission shall require each participant to contribute to the |
|
participant's POWER account in amounts described by that section. |
|
Sec. 537A.0252. POWER ACCOUNT CONTRIBUTIONS; DEDUCTIBLE. |
|
(a) The executive commissioner by rule shall establish an annual |
|
universal deductible for each participant enrolled in the basic or |
|
plus plan. |
|
(b) To ensure each participant's POWER account contains a |
|
sufficient amount of money at the beginning of a coverage period, |
|
the commission shall, before the beginning of that period, fund |
|
each account with the following amounts: |
|
(1) for a participant enrolled in the basic plan, the |
|
annual universal deductible amount; and |
|
(2) for a participant enrolled in the plus plan, the |
|
difference between the annual universal deductible amount and the |
|
participant's required annual contribution as determined by the |
|
schedule established under Subsection (c). |
|
(c) The executive commissioner by rule shall establish a |
|
graduated annual POWER account contribution schedule for |
|
participants enrolled in the plus plan that: |
|
(1) is based on a participant's annual household |
|
income, with participants whose annual household incomes are less |
|
than the federal poverty level paying progressively less and |
|
participants whose annual household incomes are equal to or greater |
|
than the federal poverty level paying progressively more; and |
|
(2) may not require a participant to contribute more |
|
than a total of five percent of the participant's annual household |
|
income to the participant's POWER account. |
|
(d) A participant's employer may contribute on behalf of the |
|
participant any amount of the participant's annual POWER account |
|
contribution. A nonprofit organization may contribute on behalf of |
|
a participant any amount of the participant's annual POWER account |
|
contribution. |
|
(e) Subject to the contribution cap described by Subsection |
|
(c)(2) and not before the expiration of the participant's first |
|
coverage period, the commission shall require a participant who |
|
uses one or more tobacco products to contribute to the |
|
participant's POWER account an annual POWER account contribution |
|
amount that is one percent more than the participant would |
|
otherwise be required to contribute under the schedule established |
|
under Subsection (c). |
|
(f) An annual POWER account contribution must be paid by or |
|
on behalf of a participant monthly in installments that are at least |
|
equal to one-twelfth of the total required contribution. The |
|
coverage period for a participant whose annual household income |
|
exceeds 100 percent of the federal poverty level may not begin until |
|
the first day of the first month following the month in which the |
|
first monthly installment is received. |
|
Sec. 537A.0253. USE OF POWER ACCOUNT MONEY. A participant |
|
may use money in the participant's POWER account to pay copayments |
|
and deductible costs the participant's program health benefit plan |
|
requires. The commission shall issue to each participant an |
|
electronic payment card that allows the participant to use the card |
|
to pay the program health benefit plan costs. |
|
Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER |
|
REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS; |
|
SMOKING CESSATION INITIATIVE. (a) A program health benefit plan |
|
provider shall establish a rewards program through which a |
|
participant receiving health care through a program health benefit |
|
plan the program health benefit plan provider offers may earn money |
|
to be contributed to the participant's POWER account. |
|
(b) Under a rewards program, a program health benefit plan |
|
provider shall contribute money to a participant's POWER account if |
|
the participant engages in certain healthy behaviors. The executive |
|
commissioner by rule shall determine: |
|
(1) the behaviors in which a participant must engage |
|
to receive a contribution, which must include behaviors related to: |
|
(A) completion of a health risk assessment; |
|
(B) smoking cessation; and |
|
(C) as applicable, chronic disease management; |
|
and |
|
(2) the amount of money a program health benefit plan |
|
provider shall contribute for each behavior described by |
|
Subdivision (1). |
|
(c) Subsection (b) does not prevent a program health benefit |
|
plan provider from contributing money to a participant's POWER |
|
account if the participant engages in a behavior not specified by |
|
that subsection or a rule the executive commissioner adopts in |
|
accordance with that subsection. If a program health benefit plan |
|
provider chooses to contribute money under this subsection, the |
|
program health benefit plan provider shall determine the amount of |
|
money to be contributed for the behavior. |
|
(d) A participant may use contributions a program health |
|
benefit plan provider makes under a rewards program to offset a |
|
maximum of 50 percent of the participant's required annual POWER |
|
account contribution the executive commissioner establishes under |
|
Section 537A.0252. |
|
(e) Contributions a program health benefit plan provider |
|
makes under a rewards program that result in a participant's POWER |
|
account balance exceeding the participant's required annual POWER |
|
account contribution may be rolled over into the next coverage |
|
period in accordance with Section 537A.0256. |
|
(f) During the first coverage period of a participant who |
|
uses one or more tobacco products, a program health benefit plan |
|
provider shall actively attempt to engage the participant in and |
|
provide educational materials to the participant on: |
|
(1) smoking cessation activities for which the |
|
participant may receive a monetary contribution under this section; |
|
and |
|
(2) other smoking cessation programs or resources |
|
available to the participant. |
|
Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall |
|
distribute to each participant with a POWER account a monthly |
|
statement that includes information on: |
|
(1) the participant's POWER account activity during |
|
the preceding month, including information on the cost of health |
|
care services delivered to the participant during that month; |
|
(2) the balance of money available in the POWER |
|
account at the time the statement is issued; and |
|
(3) the amount of any contributions due from the |
|
participant. |
|
Sec. 537A.0256. POWER ACCOUNT ROLL OVER. (a) The executive |
|
commissioner by rule shall establish a process in accordance with |
|
this section to roll over money in a participant's POWER account to |
|
the succeeding coverage period. The commission shall calculate the |
|
amount to be rolled over at the time the participant's program |
|
eligibility is redetermined. |
|
(b) For a participant enrolled in the basic plan, the |
|
commission shall calculate the amount to be rolled over to a |
|
subsequent coverage period POWER account from the participant's |
|
current coverage period POWER account based on: |
|
(1) the amount of money remaining in the participant's |
|
POWER account from the current coverage period; and |
|
(2) whether the participant received recommended |
|
preventative care services during the current coverage period. |
|
(c) For a participant enrolled in the plus plan who, as |
|
determined by the commission, timely makes POWER account |
|
contributions in accordance with this subchapter, the commission |
|
shall calculate the amount to be rolled over to a subsequent |
|
coverage period POWER account from the participant's current |
|
coverage period POWER account based on: |
|
(1) the amount of money remaining in the participant's |
|
POWER account from the current coverage period; |
|
(2) the total amount of money the participant |
|
contributed to the participant's POWER account during the current |
|
coverage period; and |
|
(3) whether the participant received recommended |
|
preventative care services during the current coverage period. |
|
(d) Except as provided by Subsection (e), a participant may |
|
use money rolled over into the participant's POWER account for the |
|
succeeding coverage period to offset required annual POWER account |
|
contributions, as applicable, during that coverage period. |
|
(e) A participant enrolled in the basic plan who rolls over |
|
money into the participant's POWER account for the succeeding |
|
coverage period and who chooses to enroll in the plus plan for that |
|
coverage period may use the money rolled over to offset a maximum of |
|
50 percent of the required annual POWER account contributions for |
|
that coverage period. |
|
Sec. 537A.0257. REFUND. If at the end of a participant's |
|
coverage period the participant chooses to cease participating in a |
|
program health benefit plan or is no longer eligible to participate |
|
in a program health benefit plan, or if the commission disenrolls a |
|
participant from the program health benefit plan under Section |
|
537A.0258 for failure to pay required contributions, the commission |
|
shall refund to the participant any money the participant |
|
contributed that remains in the participant's POWER account at the |
|
end of the coverage period or on the disenrollment date. |
|
Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE POWER ACCOUNT |
|
CONTRIBUTIONS. (a) For a participant whose annual household |
|
income exceeds 100 percent of the federal poverty level and who |
|
fails to make a contribution in accordance with Section 537A.0252, |
|
the commission shall provide a 60-day grace period during which the |
|
participant may make the contribution without penalty. If the |
|
participant fails to make the contribution during the grace period, |
|
the commission shall disenroll the participant from the program |
|
health benefit plan in which the participant is enrolled and the |
|
participant may not reenroll in a program health benefit plan |
|
until: |
|
(1) the 181st day after the disenrollment date; and |
|
(2) the participant pays any debt accrued due to the |
|
participant's failure to make the contribution. |
|
(b) For a participant enrolled in the plus plan whose annual |
|
household income is equal to or less than 100 percent of the federal |
|
poverty level and who fails to make a contribution in accordance |
|
with Section 537A.0252, the commission shall disenroll the |
|
participant from the plus plan and enroll the participant in the |
|
basic plan. A participant enrolled in the basic plan under this |
|
subsection may not change enrollment to the plus plan until the |
|
participant's program eligibility is redetermined. |
|
SUBCHAPTER G. EMPLOYMENT INITIATIVE |
|
Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The |
|
commission shall develop and implement a gateway to work program |
|
to: |
|
(1) integrate existing job training and job search |
|
programs available in this state through the Texas Workforce |
|
Commission or other appropriate state agencies with the Live Well |
|
Texas program; and |
|
(2) provide each participant with general information |
|
on the job training and job search programs. |
|
(b) Under the gateway to work program, the commission shall |
|
refer each participant who is unemployed or working less than 20 |
|
hours a week to available job search and job training programs. |
|
SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN |
|
PARTICIPANTS |
|
Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR |
|
CONTINUITY OF CARE. (a) The commission shall ensure continuity of |
|
care by providing health care financial assistance in accordance |
|
with and in the manner described by this subchapter for a |
|
participant who: |
|
(1) the commission disenrolls from a program health |
|
benefit plan in accordance with Section 537A.0155 because the |
|
participant's annual household income exceeds the income |
|
eligibility requirements for enrollment in a program health benefit |
|
plan; and |
|
(2) seeks and obtains private health benefit coverage |
|
within 12 months following the date of disenrollment. |
|
(b) To receive health care financial assistance under this |
|
subchapter, a participant must provide to the commission, in the |
|
form and manner the commission requires, documentation showing the |
|
participant has obtained or is actively seeking private health |
|
benefit coverage. |
|
(c) The commission may not impose an upper income |
|
eligibility limit on a participant to receive health care financial |
|
assistance under this subchapter. |
|
Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE |
|
FINANCIAL ASSISTANCE. (a) A participant described by Section |
|
537A.0351 may receive health care financial assistance under this |
|
subchapter until the first anniversary of the date the commission |
|
disenrolled the participant from a program health benefit plan. |
|
(b) Health care financial assistance the commission makes |
|
available to a participant under this subchapter: |
|
(1) may not exceed the amount described by Section |
|
537A.0353; and |
|
(2) may be used only to pay for eligible services |
|
described by Section 537A.0354. |
|
Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The |
|
commission shall establish a bridge account for each participant |
|
eligible to receive health care financial assistance under Section |
|
537A.0351. The account is funded with money the commission |
|
contributes in accordance with this section. |
|
(b) The commission shall enable each participant for whom |
|
the commission establishes a bridge account to access and manage |
|
money in and information regarding the participant's account |
|
through an electronic system. The commission may contract with the |
|
same entity described by Section 537A.0251(b) or another entity |
|
with appropriate experience and expertise to establish, implement, |
|
or administer the electronic system. |
|
(c) The commission shall fund each bridge account in an |
|
amount equal to $1,000 using money the commission retains or |
|
recoups: |
|
(1) during the roll over process described by Section |
|
537A.0256; |
|
(2) following the issuance of a refund as described by |
|
Section 537A.0257; or |
|
(3) under Subsection (e). |
|
(d) The commission may not require a participant to |
|
contribute money to the participant's bridge account. |
|
(e) The commission shall retain or recoup any unexpended |
|
money in a participant's bridge account at the end of the period for |
|
which the participant is eligible to receive health care financial |
|
assistance under this subchapter for the purpose of funding another |
|
participant's POWER account under Subchapter F or bridge account |
|
under this subchapter. |
|
Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The |
|
commission shall issue to each participant for whom the commission |
|
establishes a bridge account an electronic payment card that allows |
|
the participant to use the card to pay costs for eligible services |
|
described by Subsection (b). |
|
(b) A participant may use money in the participant's bridge |
|
account to pay: |
|
(1) premium costs incurred during the private health |
|
benefit coverage enrollment process and coverage period; and |
|
(2) copayments, deductible costs, and coinsurance |
|
associated with the private health benefit coverage the participant |
|
obtains for health care services that would otherwise be |
|
reimbursable under Medicaid. |
|
(c) Costs described by Subsection (b)(2) associated with |
|
eligible services delivered to a participant may be paid by: |
|
(1) a participant using the electronic payment card |
|
issued under Subsection (a); or |
|
(2) a health care provider directly charging and |
|
receiving payment from the participant's bridge account. |
|
Sec. 537A.0355. ENROLLMENT COUNSELING. The commission |
|
shall provide enrollment counseling to an individual who is seeking |
|
private health benefit coverage and who is otherwise eligible to |
|
receive health care financial assistance under this subchapter. |
|
CHAPTER 537B. EXPANDED MEDICAID ELIGIBILITY FOR CERTAIN |
|
INDIVIDUALS |
|
Sec. 537B.0001. APPLICABILITY. This chapter applies only |
|
to an individual who would be eligible to participate in the Live |
|
Well Texas program under Chapter 537A based on the eligibility |
|
requirements described by Section 537A.0151, if the commission were |
|
to establish the program. |
|
Sec. 537B.0002. EXPANDED MEDICAID ELIGIBILITY UNDER |
|
PATIENT PROTECTION AND AFFORDABLE CARE ACT. (a) Except as provided |
|
by Subsection (b) and notwithstanding any other law, the commission |
|
shall provide Medicaid benefits to all individuals who apply for |
|
those benefits and to whom this chapter applies. |
|
(b) After the waiver described by Section 537A.0051 is |
|
approved and the commission implements the Live Well Texas program |
|
under Chapter 537A, the commission shall: |
|
(1) provide health benefit coverage through that |
|
program in accordance with Chapter 537A to individuals to whom this |
|
chapter applies; and |
|
(2) cease providing Medicaid benefits to those |
|
individuals, except as provided by Chapter 537A. |
|
(c) The commission shall: |
|
(1) continue to provide Medicaid benefits to |
|
individuals described by Subsection (a) if the waiver described by |
|
Section 537A.0051 is not approved; and |
|
(2) resume providing Medicaid benefits to individuals |
|
described by Subsection (a) if the Live Well Texas program |
|
implemented under Chapter 537A terminates in accordance with |
|
Section 537A.0053(b). |
|
(d) The executive commissioner shall adopt rules regarding |
|
the provision of Medicaid benefits as required by this section, |
|
including, as applicable, rules on transitioning individuals from |
|
receiving Medicaid benefits under this section to receiving health |
|
benefit coverage under the Live Well Texas program implemented |
|
under Chapter 537A. |
|
SECTION 2. As soon as practicable after the effective date |
|
of this Act, the executive commissioner of the Health and Human |
|
Services Commission shall apply for and actively pursue from the |
|
federal Centers for Medicare and Medicaid Services or another |
|
appropriate federal agency the waiver as required by Section |
|
537A.0051, Government Code, as added by this Act. The commission |
|
may delay implementing other provisions of Chapter 537A, Government |
|
Code, as added by this Act, until the waiver applied for under that |
|
section is granted. |
|
SECTION 3. (a) Chapter 537B, Government Code, as added by |
|
this Act, applies only to an initial determination or |
|
recertification of an individual's Medicaid eligibility under |
|
Chapter 32, Human Resources Code, made on or after the |
|
implementation of Chapter 537B, regardless of the date the |
|
individual applied for Medicaid. |
|
(b) As soon as practicable after the effective date of this |
|
Act, the executive commissioner of the Health and Human Services |
|
Commission shall take all necessary actions to expand Medicaid |
|
eligibility in accordance with Chapter 537B, Government Code, as |
|
added by this Act, including notifying appropriate federal agencies |
|
of that expanded eligibility. If before implementing Chapter 537B a |
|
state agency determines that any other waiver or authorization from |
|
a federal agency is necessary for implementation of that chapter, |
|
the agency affected by the chapter shall request the waiver or |
|
authorization and may delay implementing that chapter until the |
|
waiver or authorization is granted. |
|
SECTION 4. This Act takes effect immediately if it receives |
|
a vote of two-thirds of all the members elected to each house, as |
|
provided by Section 39, Article III, Texas Constitution. If this |
|
Act does not receive the vote necessary for immediate effect, this |
|
Act takes effect on the 91st day after the last day of the |
|
legislative session. |