89R11869 JG-F

By: Manuel H.B. No. 5244

A BILL TO BE ENTITLED

AN ACT

relating to the development and implementation of the Texas Plan demonstration program to fund the purchase by and provision to certain eligible individuals of health care services.

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

SECTION 1. Subtitle I, Title 4, Government Code, is amended by adding Chapter 532A to read as follows:

CHAPTER 532A. TEXAS PLAN DEMONSTRATION PROGRAM

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 532A.0001. DEFINITIONS. In this chapter:

(1) "Board" means the board of directors of the med-pool.

(2) "Eligible individual" means an individual who is eligible to participate in the program.

(3) "Health benefit account" means a health benefit account the comptroller establishes for a participant under Subchapter E.

(4) "Health care provider" means:

(A) a primary care provider;

(B) a specialty and major medical care provider; and

(C) an integrated health care organization.

(5) "Integrated health care organization" means a health care organization that provides all of a participant's health care needs, including primary care and specialty and major medical care services, using a capitated payment model.

(6) "Med-pool" means the risk pool established under Subchapter F to provide specialty and major medical care services to participants.

(7) "Nondiscriminatory price" means a fixed, transparent, nonnegotiable price for a health care service that a health care provider charges each individual for the service regardless of the payment model used to pay for the service.

(8) "Participant" means an individual who is enrolled in the program.

(9) "Primary care provider" means a provider of primary care services.

(10) "Primary care services" includes whole-person, integrated, and accessible health care provided by interprofessional teams that are engaged to address the majority of an individual's health and wellness needs across different health care settings through sustained relationships with patients, families, and communities in order to achieve better health outcomes, better care, and lower health care prices.

(11) "Program" means the Texas Plan demonstration program established under this chapter.

(12) "Specialty and major medical care provider" means a provider of specialty and major medical care services.

(13) "Specialty and major medical care services" means health care services other than primary care services. The term includes:

(A) emergency care;

(B) urgent care;

(C) hospital care;

(D) allergy and immunology;

(E) anesthesiology;

(F) cardiology;

(G) dermatology;

(H) diagnostic radiology;

(I) medical genetics;

(J) nephrology;

(K) neurology;

(L) nuclear medicine;

(M) obstetrics and gynecology;

(N) oncology;

(O) ophthalmology;

(P) orthopedics;

(Q) pathology;

(R) pediatrics;

(S) physical medicine and rehabilitation;

(T) psychiatry;

(U) radiation oncology;

(V) surgery; and

(W) urology.

Sec. 532A.0002. FEDERAL AUTHORIZATION FOR PROGRAM. (a) The executive commissioner shall develop and seek a waiver under Section 1115 of the Social Security Act (42 U.S.C. Section 1315) or, if available, a block grant or comparable funding system that may be used for this purpose to obtain any federal money available for implementing the Texas Plan demonstration program to assist eligible individuals in obtaining health care services.

(b) The terms of the waiver the executive commissioner seeks must:

(1) be designed to:

(A) make high value health care services more accessible to eligible individuals;

(B) provide money to cover the costs of a participant's primary care services, specialty and major medical care services, dental health services, prescription drugs, and other eligible out-of-pocket health care expenses;

(C) for the purpose of shifting costs from hospital care to prevention, emphasize the provision of capitated, whole-person, person-centered primary care, including case management, mental health services, and health system navigation, as a core component of the program's overall health goals;

(D) improve health outcomes of participants based on the value of care the program offers, including by:

(i) when diagnosing and treating a participant, considering nonmedical factors that impact the participant's health, including nutrition, transportation, housing, and employment; and

(ii) to the extent possible, coordinating with community health organizations and other local resources available to address the nonmedical factors;

(E) emphasize and encourage price and quality transparency by program health care providers to enable:

(i) a participant to make informed decisions regarding health care price and quality; and

(ii) the commission and board to collect accurate and current pricing information for each provider, including nondiscriminatory price information;

(F) provide a framework for the commission and board to use existing data sources or develop new data sources to obtain and publish information on high-value care that:

(i) identifies health care providers who provide low health care prices and high quality of care, including health care centers of excellence; and

(ii) facilitates a participant's ability to navigate between health care providers to obtain high-value care; and

(G) subject to Section 532A.0104, provide continuous coverage for participants for the duration of the program;

(2) because some participants may have limited primary care options, recognize a broad range of primary care arrangements and providers under the program, including:

(A) direct primary care, advanced primary care, and similar primary care service arrangements provided virtually or on-site;

(B) federally qualified health centers, as defined by 42 U.S.C. Section 1396d(l)(2)(B); and

(C) commercial retailers that provide primary care services at a published, nondiscriminatory price for each offered service;

(3) allow health care services to be provided remotely as telehealth services or telemedicine medical services; and

(4) allow for the operation of the program consistent with the requirements of this chapter for a period of five years, except to the extent deviation from the requirements is necessary to obtain the waiver.

Sec. 532A.0003. FUNDING. (a) Subject to approval of the waiver described by Section 532A.0002, the commission shall implement the program using federal money obtained and state money available for that purpose.

(b) The commission shall implement the program in accordance with the following spending requirements:

(1) except as provided by Subdivision (2), the commission shall use state money appropriated for the program to cover:

(A) the administrative costs of implementing and operating the program; and

(B) the costs of med-pool health care claims and excess loss coverage to protect the med-pool against financial losses that may place the med-pool's solvency in financial jeopardy; and

(2) except as provided by Subsection (c), the commission shall use federal money received for the program and an amount of state money appropriated for the program that the commission determines necessary to cover the costs of providing health care services to program participants by distributing the money among each participant on a per capita basis in the following proportions and manner:

(A) 25 percent of allocated money must be:

(i) used to cover the costs of providing a participant's primary care services, including dental health and prescription drug costs related to those services; and

(ii) deposited into the participant's health benefit account in accordance with Subchapter E; and

(B) 75 percent of allocated money must be:

(i) used to cover the costs of providing a participant's specialty and major medical care services, including prescription drug costs related to those services; and

(ii) disbursed to the med-pool.

(c) For a participant who receives all of the participant's health care needs from an integrated health care organization, the commission shall:

(1) disburse 96 percent of the per capita amount described by Subsection (b)(2) to the organization to cover the costs of providing the participant's health care services; and

(2) deposit the remaining four percent into the participant's health benefit account in accordance with Subchapter E to cover the costs of eligible out-of-pocket health care expenses.

Sec. 532A.0004. EXPIRATION. The program concludes and this chapter expires September 1, 2031.

SUBCHAPTER B. PROGRAM ADMINISTRATION

Sec. 532A.0051. PROGRAM OBJECTIVE. The program's objective is to enable eligible individuals to obtain, and to provide money to participants to cover the costs of, health care services, including dental health services, and prescription drugs in a manner that:

(1) offers convenient access to high-value care;

(2) prioritizes whole-person, person-centered, coordinated primary care services; and

(3) lowers the overall costs for providing health care services to participants over the course of the program.

Sec. 532A.0052. PROGRAM PROMOTION. The commission shall promote and provide information on the program to individuals who are potentially eligible to participate in the program. The commission shall ensure the program's promotion is designed in a manner to reach as many eligible individuals as possible.

Sec. 532A.0053. COMMISSION'S AUTHORITY RELATED TO ELIGIBILITY AND MEDICAID COORDINATION. The commission may:

(1) accept applications for program participation and implement program eligibility screening and enrollment procedures;

(2) resolve grievances related to eligibility determinations; and

(3) to the extent possible, coordinate the program with Medicaid and any exchange offering a health benefit plan under the Patient Protection and Affordable Care Act (Pub. L. No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152).

SUBCHAPTER C. PROGRAM ELIGIBILITY

Sec. 532A.0101. ELIGIBILITY REQUIREMENTS. An individual is eligible to participate in the program if:

(1) the individual is a:

(A) citizen or permanent resident of the United States; and

(B) resident of this state;

(2) the individual is 19 years of age or older but younger than 65 years of age;

(3) applying the eligibility criteria in effect in this state on December 31, 2024, the individual is not eligible for Medicaid; and

(4) federal money is available to provide benefits to the individual under the program.

Sec. 532A.0102. APPLICATION FORM AND PROCEDURES. (a) The executive commissioner shall adopt an application form and application procedures for the program. The form and procedures may be coordinated with Medicaid forms and procedures to ensure there is a single consolidated application process to seek health care services under the program or Medicaid.

(b) To the extent possible, the commission shall make the application form available in languages other than English.

(c) The executive commissioner may permit an individual to apply by mail, over the telephone, or through the Internet.

Sec. 532A.0103. ELIGIBILITY SCREENING AND ENROLLMENT. (a) The executive commissioner shall adopt eligibility screening and enrollment procedures or use the Texas Integrated Enrollment Services eligibility determination system or a compatible or successor system to screen individuals and enroll eligible individuals in the program.

(b) The eligibility screening and enrollment procedures must ensure that an individual applying for the program who appears eligible for Medicaid is identified and assisted with obtaining Medicaid coverage. If the individual is denied Medicaid coverage but is otherwise determined eligible to participate in the program, the commission shall enroll the individual in the program without additional application or qualification.

(c) Not later than the 30th day after the date an individual submits a complete application form and unless the individual is identified and assisted with obtaining Medicaid coverage under Subsection (b), the commission shall ensure that the individual's eligibility to participate in the program is determined and that the individual is enrolled in the program.

(d) At the time an eligible individual is enrolled in the program and using the database the commission establishes under Section 532A.0152, the commission shall assist the individual in selecting an accessible, high-value primary care provider under the program. A participant may:

(1) change the participant's primary care provider at any time; and

(2) contact the commission for assistance in selecting a new primary care provider.

Sec. 532A.0104. CONTINUOUS COVERAGE; ELIGIBILITY REDETERMINATION AND DISENROLLMENT. (a) If authorized by the terms of the waiver the executive commissioner seeks under Section 532A.0002, the commission shall ensure that an individual who is initially determined to be eligible to participate in the program remains enrolled in the program until the program concludes.

(b) If the terms of the waiver the executive commissioner seeks under Section 532A.0002 do not authorize continuous coverage described by Subsection (a), the commission shall:

(1) redetermine a participant's eligibility to participate in the program during the later of the 12th month following the date the participant is initially enrolled in the program or was most recently redetermined eligible for the program;

(2) to the extent possible, conduct an eligibility redetermination automatically without requiring information from the participant using information from verifiable electronic data sources or that is otherwise available to the commission;

(3) not later than the 60th day before the expiration of a participant's coverage period, take all reasonable steps to notify the participant regarding the eligibility redetermination process and request documentation necessary to redetermine the participant's eligibility;

(4) disenroll a participant from the program if:

(A) the participant does not submit the requested eligibility redetermination documentation on or before the last day of the participant's coverage period; or

(B) the commission, based on the submitted documentation, determines the participant is no longer eligible to participate in the program; and

(5) ensure the eligibility redetermination process is as seamless and contains as little administrative burden for the participant as possible to facilitate the participant's successful eligibility redetermination.

SUBCHAPTER D. HEALTH CARE PROVIDERS AND PROVISION OF HEALTH CARE

UNDER PROGRAM

Sec. 532A.0151. HEALTH CARE PROVIDER REGISTRATION AND PRICING INFORMATION. (a) The commission shall establish a streamlined registration process through which a health care provider may register to participate in the program.

(b) As part of the registration process, a health care provider may submit to the commission:

(1) information on:

(A) the provider's office location; and

(B) specific pricing information the provider charges for a health care service, including pricing information on, as applicable:

(i) capitated arrangements;

(ii) bundled services;

(iii) fee-for-service prices; and

(iv) health care services for which the provider charges a nondiscriminatory price; and

(2) other information or data the provider determines relevant to allow the commission and board to assess the provider's value of care based on metrics that include:

(A) patient-reported health outcomes for patients the provider serves; and

(B) the provider's quality of care provided based on objective clinical metrics.

(c) The commission shall ensure a health care provider is able to easily and timely update any information the provider submits.

(d) A primary care provider charging a monthly or annual capitated rate may not charge a participant for a health care service, regardless of the payment model used to pay for the service, in an amount that is greater than the amount specified for that service in the pricing information submitted under this section but may charge participants different amounts in accordance with price categories the provider establishes based on age or gender only if the provider charges the same price for all participants in those price categories.

(e) The commission, in collaboration with the board, may develop processes to ensure information on a health care provider's pricing and quality of care is accurate and up-to-date to enable the commission and board to adequately and meaningfully measure and assess the provider's value of services for the purpose of compiling and processing data under Section 532A.0152.

Sec. 532A.0152. VALUE OF CARE METRICS AND DATA; PROVIDER DATABASE. (a) The commission may develop and use metrics to measure and assess the value of care provided by program health care providers who submit to the commission the information described by Section 532A.0151. The metrics may:

(1) include measurements that demonstrate improvements in an individual's objective and subjective health outcomes relative to the cost of achieving those improvements; and

(2) be designed to measure as broad a range of health care services as is practicable, including:

(A) primary care services; and

(B) specialty and major medical care services.

(b) The commission may compile and process data on a health care provider's value of care based on the measurements and assessments submitted to the commission by the provider or based on information independently obtained by the commission or board. The commission shall ensure the data is sufficient to enable a participant to make informed decisions in selecting, including at the time the participant is initially enrolled in the program, health care providers that:

(1) are accessible to the participant; and

(2) provide high-value care.

(c) The commission may develop and maintain a public machine-readable database of high-value program health care providers as the commission and board determine in accordance with this section.

(d) The commission shall collaborate with the board in implementing this section.

Sec. 532A.0153. SPECIALTY AND MAJOR MEDICAL CARE. (a) The med-pool or integrated health care organization with which a participant enrolls shall pay the costs for providing the participant's specialty and major medical care services, including prescription drug costs related to those services.

(b) The board and commission shall develop and implement procedures for a participant to seek and obtain payment for specialty and major medical care costs the participant incurs.

Sec. 532A.0154. EMERGENCY CARE PRICING. Unless the board determines otherwise or contracts for a lesser rate, emergency care services provided to a participant through the med-pool or an integrated health care organization will be reimbursed at the same rate at which those services are reimbursed under the Medicare program.

SUBCHAPTER E. HEALTH BENEFIT ACCOUNTS

Sec. 532A.0201. ESTABLISHMENT OF HEALTH BENEFIT ACCOUNTS. (a) The comptroller, in collaboration with the commission and board, shall establish and maintain for each participant a health benefit account that is funded in accordance with this subchapter. The comptroller may contract with a qualified entity to perform the comptroller's duties under this subchapter.

(b) The comptroller shall establish an electronic portal or similar system through which a participant may electronically access and manage money in and information regarding the participant's health benefit account.

Sec. 532A.0202. HEALTH BENEFIT ACCOUNT FUNDING. Subject to Section 532A.0003, the comptroller shall fund each participant's health benefit account with federal and state money in accordance with Section 532A.0003(b). The amount deposited must be:

(1) equal for each participant based on the program's total funding and the spending requirements prescribed in Section 532A.0003; and

(2) in excess of money remaining in a participant's health benefit account from a preceding coverage period, as applicable.

Sec. 532A.0203. USE OF HEALTH BENEFIT ACCOUNT MONEY. (a) A participant may use money in the participant's health benefit account to pay primary care costs, including dental health costs, prescription drug costs related to primary care services, and other eligible out-of-pocket health care expenses. The comptroller shall issue to the participant an electronic payment card that allows the participant to use the card to pay costs described by this section.

(b) For purposes of this section, "eligible out-of-pocket health care expense" means a health care-related expense not covered by the primary care capitation rate, including copayments for blood draws and other primary care services, over-the-counter medications, vision care, and copayments that may be required for specialty and major medical care services.

Sec. 532A.0204. CLOSING OF HEALTH BENEFIT ACCOUNT. If at the end of a participant's coverage period the participant chooses to cease participating in the program or is no longer eligible to participate in the program, the comptroller shall close the participant's health benefit account and the commission shall:

(1) recoup any money remaining in the account at the time it is closed; and

(2) use the recouped money to continue to fund the program in accordance with the spending requirements prescribed by Section 532A.0003.

SUBCHAPTER F. MED-POOL

Sec. 532A.0251. ESTABLISHMENT. The med-pool is established to provide specialty and major medical care services to participants.

Sec. 532A.0252. BOARD OF DIRECTORS. (a) The med-pool is governed by a board of directors. The board is composed of the following seven members appointed by the executive commissioner:

(1) two members with appropriate expertise in health insurance, risk pools, and the evaluation of risk within risk pools;

(2) one member who is a licensed physician;

(3) one member with appropriate expertise in health care technology;

(4) one member who is a representative of a federally qualified health center;

(5) one member who is a representative of a community health organization; and

(6) one public member.

(b) In making appointments under Subsection (a), the executive commissioner shall make an effort to select board members who reflect the ethnic and geographic diversity of this state.

(c) The board shall select from among the board members a presiding officer.

Sec. 532A.0253. EXCESS LOSS COVERAGE AUTHORIZED. The board may purchase excess loss coverage for the med-pool to the extent available state money is insufficient to protect the med-pool against actuarially projected financial losses the board determines may place the med-pool's solvency in financial jeopardy.

Sec. 532A.0254. INVESTMENTS. (a) The board shall invest med-pool money in accordance with Subchapter A, Chapter 2256, Government Code, to the extent that law can be made applicable.

(b) In addition to investments authorized under Subchapter A, Chapter 2256, Government Code, the board may invest med-pool money in any investment authorized under Subtitle B, Title 9, Property Code.

Sec. 532A.0255. AUDITS. (a) The board shall have the med-pool's fiscal accounts and records audited annually by an independent auditor. The audit must cover the med-pool's fiscal year.

(b) The independent auditor must be a certified public accountant or public accountant licensed by the Texas State Board of Public Accountancy.

(c) The board shall file annually with the commission a copy of the audit report. The commission shall make copies of the audit reports available to the public on the commission's Internet website.

Sec. 532A.0256. APPLICATION OF CERTAIN LAWS. The med-pool is not:

(1) insurance or an insurer under the Insurance Code and other laws of this state; or

(2) subject to regulation by the commissioner of insurance or the Texas Department of Insurance.

Sec. 532A.0257. LOW-VALUE PROVIDER COPAYMENT. The med-pool may require that a participant pay a copayment for services received from a provider that the commission has designated as a low-value provider unless a high-value provider is not available to the participant. The participant may use money in the participant's health benefit account to pay this expense.

SECTION 2. (a) The executive commissioner of the Health and Human Services Commission shall:

(1) apply for and actively pursue from the Centers for Medicare and Medicaid Services or another appropriate federal agency the waiver as required by Section 532A.0002, Government Code, as added by this Act, as soon as practicable after the effective date of this Act; and

(2) begin operating the Texas Plan demonstration program under Chapter 532A, Government Code, as added by this Act, not later than September 1, 2026.

(b) The Health and Human Services Commission may delay implementing this Act until the waiver described by Subsection (a)(1) of this section is granted.

SECTION 3. 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.