89R17043 AB-D

By: Thompson, Bucy H.B. No. 2677

Substitute the following for H.B. No. 2677:

By: VanDeaver C.S.H.B. No. 2677

A BILL TO BE ENTITLED

AN ACT

relating to Medicaid coverage and reimbursement for the treatment of obesity and certain diabetes prevention program services.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subchapter B, Chapter 32, Human Resources Code, is amended by adding Sections 32.02461 and 32.02462 to read as follows:

Sec. 32.02461. REIMBURSEMENT FOR TREATING OBESITY. (a) In this section:

(1) "Anti-obesity medication" means a prescription medication approved by the United States Food and Drug Administration that is indicated for chronic weight management in an individual who is diagnosed with obesity.

(2) "Intensive behavioral therapy" means an evidence-based, multi-component behavioral or lifestyle modification intervention that:

(A) is designed to support healthy weight management as recommended by current clinical standards of care; and

(B) is provided by a variety of qualified providers, including licensed dietitians.

(3) "Metabolic and bariatric surgery" means a surgical procedure that:

(A) alters the stomach, the intestines, or both to cause weight loss in an individual diagnosed with obesity or an obesity-related metabolic disorder; and

(B) is endorsed by the American Society for Metabolic and Bariatric Surgery.

(4) "Obesity" means a chronic disease diagnosed as having a body mass index (BMI) of 30 or greater.

(5) "Recipient" means a recipient of medical assistance.

(6) "Telehealth service" and "telemedicine medical service" have the meanings assigned by Section 111.001, Occupations Code.

(b) The commission shall ensure that medical assistance reimbursement is provided for health care services provided to a recipient for the treatment of obesity, including:

(1) intensive behavioral therapy;

(2) metabolic and bariatric surgery; and

(3) subject to the medication's inclusion in or provisional availability under the vendor drug program, anti-obesity medication.

(c) Intensive behavioral therapy provided under the medical assistance program may include interventions certified or recognized by the Centers for Disease Control and Prevention or recommended by current clinical standards of care. The services may be provided in person, including in office or in a community-based setting, or remotely as a telehealth service or telemedicine medical service.

(d) The executive commissioner by rule shall establish medical necessity criteria for anti-obesity medications provided under the medical assistance program. The criteria:

(1) may not be more restrictive than the indications for the medications that are approved by the United States Food and Drug Administration; and

(2) must be based on the classes of obesity established by the Centers for Disease Control and Prevention.

(e) The commission or a Medicaid managed care organization may apply utilization management to determine medical necessity for a health care service authorized under this section only if the determinations of appropriateness and medical necessity are made in the same manner as those determinations are made for other health care services provided under the medical assistance program.

(f) The executive commissioner shall adopt rules necessary to implement this section.

Sec. 32.02462. REIMBURSEMENT FOR DIABETES PREVENTION PROGRAM SERVICES. (a) In this section:

(1) "Diabetes prevention program" means a program designed to prevent or delay the onset of Type 2 diabetes by providing a person enrolled in the program a series of structured behavioral health change sessions based on a curriculum approved by the Centers for Disease Control and Prevention.

(2) "Diabetes prevention program supplier" means an entity included in the National Registry of Recognized Diabetes Prevention Programs maintained by the Centers for Disease Control and Prevention.

(3) "Recipient" means a recipient of medical assistance.

(b) The commission shall ensure that medical assistance reimbursement is provided to a diabetes prevention program supplier for services provided to a recipient enrolled in a diabetes prevention program if the recipient:

(1) meets the program's eligibility requirements; and

(2) has not previously participated in the program while a recipient.

(c) The commission or a Medicaid managed care organization may use utilization management to determine medical necessity for services provided by a diabetes prevention program supplier under this section only if the determination of medical necessity, including a determination of the appropriateness of the services, is made in the same manner as the determination is made for other health care services provided under the medical assistance program.

SECTION 2. If before implementing any provision of this Act a state agency determines that a waiver or authorization from a federal agency is necessary for implementation of that provision, the agency affected by the provision shall request the waiver or authorization and may delay implementing that provision until the waiver or authorization is granted.

SECTION 3. As soon as practicable after the date Section 32.02461, Human Resources Code, as added by this Act, is implemented, the Health and Human Services Commission shall provide written notice to recipients of medical assistance under Chapter 32, Human Resources Code, regarding the availability of obesity treatment options under the medical assistance program.

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 September 1, 2025.