81R2256 ALB-D
By: Shapleigh S.B. No. 2383
A BILL TO BE ENTITLED
AN ACT
relating to universal health coverage for Texans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. HEALTH COVERAGE PROGRAM
SECTION 1.01. The Health and Safety Code is amended by
adding Title 13 to read as follows:
TITLE 13. UNIVERSAL HEALTH COVERAGE FOR TEXANS
SUBTITLE A. GOVERNANCE OF HEALTH COVERAGE PROGRAM
CHAPTER 2001. GENERAL PROVISIONS
Sec. 2001.001. DEFINITIONS. In this title:
(1) "Agency" means the Texas Health Coverage Agency.
(2) "Commissioner" means the commissioner of health
coverage.
(3) "Finance director" means the finance director of
the system.
(4) "Health care facility" means a public or private
hospital, skilled nursing facility, intermediate care facility,
ambulatory surgical facility, family planning clinic that performs
ambulatory surgical procedures, rural or urban health initiative
clinic, kidney disease treatment facility, inpatient
rehabilitation facility, and any other facility designated a health
care facility by federal law. The term does not include the offices
of physicians or health care providers practicing individually or
in groups.
(5) "Health care provider" means an individual who is
licensed, certified, or otherwise authorized to provide or render
health care in the ordinary course of business or practice of a
profession.
(6) "Integrated health care system" has the meaning
assigned by Section 281.0517.
(7) "Premium commission" means the health care premium
commission.
(8) "System" means the Texas Health Coverage System.
CHAPTER 2002. GOVERNANCE OF TEXAS HEALTH COVERAGE AGENCY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 2002.001. DUTIES OF AGENCY. The Texas Health Coverage
Agency administers the Texas Health Coverage System under this
title.
Sec. 2002.002. SUNSET PROVISION. The agency is subject to
Chapter 325, Government Code (Texas Sunset Act). Unless continued
in existence as provided by that chapter, the agency is abolished
September 1, 2019.
Sec. 2002.003. GRANTS; FEDERAL FUNDING. The agency may
accept gifts, grants, and donations, including grants from the
federal government, to administer this title and provide health
coverage through the system.
[Sections 2002.004-2002.050 reserved for expansion]
SUBCHAPTER B. COMMISSIONER
Sec. 2002.051. COMMISSIONER. (a) The commissioner of
health coverage is appointed by the governor with the advice and
consent of the senate.
(b) The commissioner shall be appointed without regard to
race, color, disability, sex, religion, age, or national origin.
Sec. 2002.052. TERM. The commissioner serves a two-year
term expiring on February 1 of each odd-numbered year.
Sec. 2002.053. ELIGIBILITY FOR SERVICE. (a) In this
section, "Texas trade association" means a cooperative and
voluntarily joined statewide association of business or
professional competitors in this state designed to assist its
members and its industry or profession in dealing with mutual
business or professional problems and in promoting their common
interest.
(b) A person is not eligible to serve as commissioner if, at
any time within two years before the date on which service as
commissioner begins:
(1) the person is an officer, employee, or paid
consultant of a business or Texas trade association in the field of
health insurance, pharmaceuticals, or medical equipment; or
(2) the person's spouse is an officer, employee, or
paid consultant of a business or Texas trade association in the
field of health insurance, pharmaceuticals, or medical equipment.
(c) A person may not serve as commissioner if the person is
required to register as a lobbyist under Chapter 305, Government
Code, because of the person's activities for compensation on behalf
of a profession related to the operation of the agency.
(d) A person appointed to serve as commissioner may not
serve as an officer, employee, or paid consultant of a business or
Texas trade association in the field of health insurance,
pharmaceuticals, or medical equipment for a period of two years
after the person's appointment as commissioner ends.
Sec. 2002.054. POWERS AND DUTIES OF COMMISSIONER. (a) The
commissioner is the executive officer of the agency and is
responsible for administering the agency and the system.
(b) The commissioner may:
(1) set rates for payments by and to the system,
including premium payments owed to the system, and establish the
budget for the system;
(2) establish system objectives, priorities, and
standards;
(3) employ agency personnel;
(4) allocate system resources in accordance with this
title; and
(5) oversee the establishment and administration of
the following:
(A) the health coverage policy board;
(B) the health coverage advisory committee;
(C) the office of patient advocacy;
(D) the office of health care planning;
(E) the office of health care quality;
(F) the health coverage fund;
(G) the payments board; and
(H) partnerships for health.
(c) The commissioner may adopt rules to administer the
system and implement this title in accordance with Subchapter B,
Chapter 2001, Government Code.
(d) The commissioner shall oversee the establishment of
locally based integrated service networks, including physicians in
fee-for-service, solo, and group practice and essential community
and ancillary care providers and facilities, in order to pool and
assign resources, form interdisciplinary teams that share
responsibility and accountability for patient care, and provide a
continuum of coordinated high-quality primary to tertiary care to
residents of this state while preserving patient choice.
Sec. 2002.055. SYSTEM OFFICERS. The commissioner shall
appoint the following system officers:
(1) the deputy commissioner;
(2) the finance director;
(3) the patient advocate for the office of patient
advocacy;
(4) the inspector general;
(5) the director of the office of health care
planning;
(6) the chief medical officer;
(7) the payments board director;
(8) the director for the partnerships for health;
(9) a regional director for each health care planning
region;
(10) a chief enforcement counsel; and
(11) legal counsel, as determined by the commissioner.
[Sections 2002.056-2002.100 reserved for expansion]
SUBCHAPTER C. HEALTH COVERAGE POLICY BOARD AND HEALTH COVERAGE
ADVISORY COMMITTEE
Sec. 2002.101. HEALTH COVERAGE POLICY BOARD. (a) The
health coverage policy board establishes policy for the system and
advises the commissioner concerning the operation of the system.
The board assists the commissioner to establish:
(1) system objectives, priorities, and standards,
including research and capital investment priorities;
(2) the scope of services provided by the system;
(3) guidelines for evaluating the performance of the
system; and
(4) guidelines for ensuring public input.
(b) The health coverage policy board is composed of the
following 11 members:
(1) the commissioner;
(2) the deputy commissioner;
(3) the finance director;
(4) the patient advocate;
(5) the chief medical officer;
(6) the director of the office of health care
planning;
(7) the director of partnerships for health;
(8) the director of the payments board;
(9) one member of the health coverage advisory
committee, to be determined by the health coverage advisory
committee; and
(10) two representatives from regional planning
boards.
(b) The commissioner serves as the presiding officer of the
board.
(c) The members of the health coverage policy board
designated under Subsections (a)(9) and (10) serve two-year terms.
Sec. 2002.102. HEALTH COVERAGE ADVISORY COMMITTEE. (a)
The health coverage advisory committee advises the commissioner and
the health coverage policy board concerning implementation of the
system.
(b) The commissioner shall appoint the following members to
the health coverage advisory committee:
(1) four physicians, at least one of whom must be a
psychiatrist;
(2) one registered nurse;
(3) one licensed vocational nurse;
(4) one licensed allied health practitioner;
(5) one mental health care provider;
(6) one dentist;
(7) one representative of private hospitals;
(8) one representative of public hospitals;
(9) one representative of an integrated health care
delivery system;
(10) four consumers of health care, at least one of
whom is disabled and at least one of whom is at least 65 years of
age;
(11) one representative of organized labor;
(12) one representative of a health care facility that
serves low-income residents;
(13) one union member;
(14) one representative of an employer who employs
more than 50 employees;
(15) one representative of an employer who employs
fewer than 50 employees; and
(16) one pharmacist.
(c) In making appointments, the commissioner shall attempt
to reflect the geographic and cultural diversity of this state.
(d) Members of the health coverage advisory committee serve
two-year terms.
Sec. 2002.103. DISCRIMINATION PROHIBITED. The members of
the health coverage policy board and health coverage advisory
committee shall be appointed without regard to race, color,
disability, sex, religion, age, or national origin.
Sec. 2002.104. ELIGIBILITY. (a) It is a ground for removal
from the health coverage policy board or health coverage advisory
committee that a member:
(1) is ineligible for membership under this
subchapter;
(2) cannot, because of illness or disability,
discharge the member's duties for a substantial part of the member's
term; or
(3) is absent from more than half of the regularly
scheduled board or committee meetings that the member is eligible
to attend during a calendar year without an excuse approved by a
majority vote of the board or committee, as applicable.
(b) A person may not serve as a member of the health coverage
policy board or health coverage advisory committee if the person is
required to register as a lobbyist under Chapter 305, Government
Code, because of the person's activities for compensation on behalf
of a profession related to the operation of the agency.
(c) If the commissioner has knowledge that a potential
ground for removal exists, the commissioner shall notify the
presiding officer of the board or committee, as applicable, of the
potential ground. The presiding officer shall then notify the
governor and the attorney general that a potential ground for
removal exists. If the potential ground for removal involves the
presiding officer, the commissioner shall notify the next highest
ranking officer of the board or committee, as applicable, who shall
then notify the governor and the attorney general that a potential
ground for removal exists.
Sec. 2002.105. TRAINING. (a) A person who is appointed to
and qualifies for office as a member of the health coverage policy
board or health coverage advisory committee may not vote,
deliberate, or be counted as a member in attendance at a meeting of
the board or committee until the person completes a training
program that complies with this section.
(b) The training program must provide the person with
information regarding:
(1) this title;
(2) the programs, functions, rules, and budget of the
agency;
(3) the results of the most recent formal audit of the
agency;
(4) the requirements of laws relating to open
meetings, public information, administrative procedure, and
conflicts of interest; and
(5) any applicable ethics policies adopted by the
agency or the Texas Ethics Commission.
(c) A person appointed to the health coverage policy board
or health coverage advisory committee is entitled to reimbursement,
as provided by the General Appropriations Act, for the travel
expenses incurred in attending the training program regardless of
whether the attendance at the program occurs before or after the
person qualifies for office.
Sec. 2002.106. COMPENSATION; REIMBURSEMENT. A person
appointed to the health coverage policy board or health coverage
advisory committee is not entitled to compensation for service on
the board or committee but is entitled to reimbursement, as
provided by the General Appropriations Act, for the expenses
incurred in attending board or committee meetings or performing
other official functions of the board or committee.
Sec. 2002.107. APPLICABILITY OF OTHER LAW. Chapter 2110,
Government Code, does not apply to the health coverage advisory
committee.
[Sections 2002.108-2002.150 reserved for expansion]
SUBCHAPTER D. OFFICE OF PATIENT ADVOCACY
Sec. 2002.151. OFFICE ESTABLISHED. The office of patient
advocacy is within the agency and is operated under the direction of
the patient advocate.
Sec. 2002.152. DUTIES OF OFFICE. The office:
(1) represents the interests of the public and
consumers of health care;
(2) assists patients in obtaining health care services
and benefits through the system;
(3) acts as an advocate for patients receiving
services and benefits through the system; and
(4) responds to complaints made to the agency.
Sec. 2002.153. PATIENT ADVOCATE. (a) The commissioner
shall appoint a patient advocate to administer the office.
(b) The patient advocate shall:
(1) oversee the establishment and maintenance of a
grievance process;
(2) participate in the grievance process under
Subdivision (1) and an independent medical review system on behalf
of consumers;
(3) receive, evaluate, and respond to consumer
complaints;
(4) receive recommendations from the public regarding
methods to improve the system and hold public hearings at least
annually;
(5) develop educational and informational guidelines
for consumers describing consumer rights and responsibilities and
informing consumers about effective ways to exercise the right to
secure health care services and participate in the system;
(6) establish a toll-free telephone number to receive
complaints;
(7) report annually to the public, the commissioner,
and the legislature regarding consumer perspective on system
performance, including recommendations for needed improvements;
and
(8) establish an independent medical review system to
provide timely examination of disputed health care services and
coverage decisions to ensure the system provides efficient,
appropriate services and responds to enrollee disputes.
[Sections 2002.154-2002.200 reserved for expansion]
SUBCHAPTER E. INSPECTOR GENERAL FOR HEALTH COVERAGE
Sec. 2002.201. INSPECTOR GENERAL APPOINTED. The inspector
general for health coverage is appointed by the commissioner.
Sec. 2002.202. DUTIES OF INSPECTOR GENERAL. (a) The
inspector general for health coverage shall:
(1) investigate, audit, and review the financial and
business records of entities that provide services or products to
the system;
(2) investigate allegations of misconduct by an agency
employee or appointee or by a provider of health care services
reimbursed by the system and report any findings of misconduct to
the attorney general;
(3) investigate patterns of medical practice that may
indicate fraud or abuse of power related to inappropriate
utilization of medical products and services;
(4) arrange for the collection and analysis of data
needed to investigate inappropriate utilization of products and
services under the system;
(5) conduct additional reviews or investigations when
requested by the governor or a member of the legislature and report
findings of the review to the governor, lieutenant governor, and
legislature; and
(6) establish a telephone hotline for anonymous
reporting of allegations of failure to make health insurance
premium payments established by the commission.
(b) The inspector general may refer any matter to the
attorney general, an appropriate prosecuting attorney, or a
regulatory agency of this state for criminal prosecution or
disciplinary action in accordance with law.
[Sections 2002.203-2002.250 reserved for expansion]
SUBCHAPTER F. OFFICE OF HEALTH CARE PLANNING
Sec. 2002.251. OFFICE. The office of health care planning
is within the agency and operates under the direction of the
director of the office.
Sec. 2002.252. DUTIES OF OFFICE. (a) The office of health
care planning shall assist the commissioner in planning for the
short-term and long-term health care needs of eligible residents of
this state in accordance with this title and the policies
established by the commissioner.
(b) The office of health care planning shall evaluate the
health care workforce and facility needs of this state, identify
medically underserved areas of this state, and develop plans to
provide services within those areas.
(c) The office of health care planning shall assist the
commissioner in developing performance criteria applicable to
health care goals.
Sec. 2002.253. DIRECTOR. The director of the office of
health care planning shall:
(1) establish performance criteria for health care
goals;
(2) evaluate the effectiveness of performance
criteria in measuring quality of care, administration, and
planning;
(3) assist the health care planning regions in
developing operating and capital requests;
(4) estimate the health care workforce needed to meet
the needs of the population and the cost to the state of that
workforce;
(5) estimate the number, types, and costs of
facilities required to meet the health care needs of this state; and
(6) appoint a technology advisory group to advise the
office regarding technological advances that streamline costs and
improve efficiency of the system.
[Sections 2002.254-2002.300 reserved for expansion]
SUBCHAPTER G. OFFICE OF HEALTH CARE QUALITY
Sec. 2002.301. ADMINISTRATION. The office of health care
quality is within the agency and operates under the direction of the
chief medical officer.
Sec. 2002.302. DUTIES OF OFFICE. The office of health care
quality shall assist the commissioner in supporting the delivery of
high-quality, efficient health care, monitoring the quality of care
delivered through the system, and promoting patient satisfaction
and shall assist the regional directors in the development and
evaluation of regional operating and capital budget requests.
Sec. 2002.303. CHIEF MEDICAL OFFICER. The chief medical
officer shall:
(1) collaborate with regional medical officers,
regional directors, and other necessary personnel to develop
community-based networks of providers to offer comprehensive,
multidisciplinary, coordinated services to patients;
(2) establish standards of care, based on best
practices, to serve as guidelines for providers;
(3) measure and monitor the quality of care throughout
the system;
(4) support health care providers in correcting
quality of care problems;
(5) identify medical errors and their causes and
develop plans to prevent errors; and
(6) provide information and assistance to the
commissioner regarding all aspects of quality of health care
delivered through the system.
[Sections 2002.304-2002.350 reserved for expansion]
SUBCHAPTER H. PARTNERSHIPS FOR HEALTH
Sec. 2002.351. PARTNERSHIPS FOR HEALTH. Partnerships for
health is a program within the agency that improves health through
community health initiatives, supports innovative methods to
improve health care quality, promotes efficient delivery of health
care, and educates the public.
Sec. 2002.352. DIRECTOR. The director of partnerships for
health is responsible for administration of the program.
Sec. 2002.353. ROLE OF PATIENT ADVOCATE. The patient
advocate shall work with community and health care providers to
propose partnerships for health projects.
[Sections 2002.354-2002.400 reserved for expansion]
SUBCHAPTER I. HEALTH CARE PLANNING REGIONS
Sec. 2002.401. HEALTH CARE PLANNING REGIONS ESTABLISHED.
(a) The commissioner, in consultation with the director of the
office of health care planning, shall establish geographically
contiguous health care planning regions for the state on the basis
of:
(1) patterns of usage of health care services;
(2) health care resources, including health care
workforce resources;
(3) health care needs, including public health needs;
(4) geography;
(5) population and demographic characteristics; and
(6) other considerations as determined by the
commissioner.
(b) To the extent consistent with Subsection (a), the
commissioner may designate as health care planning regions the
public health regions established by the Department of State Health
Services under Chapter 121.
Sec. 2002.402. REGIONAL DIRECTOR. (a) The commissioner
shall appoint a regional director for each health care planning
region. The regional director directs the health care planning
region and establishes health policy for the region.
(b) A regional director serves at the pleasure of the
commissioner and may serve not more than eight two-year terms.
Sec. 2002.403. DUTIES OF REGIONAL DIRECTOR. The regional
director shall:
(1) direct the region;
(2) reside in the region in which the director serves;
(3) establish and administer a regional office of the
commission, including an office of patient advocacy, an office of
health care planning, an office of health care quality, and an
office of partnerships for health;
(4) appoint a regional planning board and serve as the
executive director of the board;
(5) identify and prioritize regional health care needs
and goals, in collaboration with the regional medical officer,
regional health care providers, regional planning board, and
regional director of partnerships for health;
(6) assess projected revenue and expenditures to
ensure fiscal solvency of the regional planning system and advise
the commissioner regarding potential revenue shortfalls and the
possible need for cost containment measures;
(7) assure that regional administrative costs meet
standards established by the agency and seek innovative ways to
lower administrative costs;
(8) plan for the delivery of, and equal access to,
high-quality and culturally and linguistically sensitive health
care, including care to disabled persons;
(9) seek innovative and systemic methods to improve
health care quality and efficiency and to achieve system access for
all state residents;
(10) make needed revenue sharing arrangements so that
regionalization does not limit a patient's choice of provider;
(11) implement dispute resolution procedures;
(12) implement methods for public comment;
(13) report at regular intervals to the public and the
commissioner regarding the status of the regional planning system,
including evaluating access to care, quality of care, provider
performance, and other issues related to regional health care
needs;
(14) establish guidelines for providers to identify,
maintain, and provide to the regional director inventories of
regional health care assets;
(15) establish and maintain regional health care
databases that are coordinated with other regional and statewide
databases;
(16) in collaboration with the regional medical
officer, enforce reporting requirements established by the system;
(17) establish and implement a regional capital
management plan under the capital management plan established by
the commissioner for the system;
(18) implement standards and formats established by
the commissioner for the development and submission of operating
and capital budget requests and make recommendations to the
commissioner and the director of the office of health planning for
needed changes;
(19) support regional providers in developing
operating and capital budget requests;
(20) receive, evaluate, and prioritize provider
operating and capital budget requests under standards and criteria
established by the commissioner;
(21) prepare a three-year regional operating and
capital budget request that meets the health care needs of the
region under this division for submission to the commissioner; and
(22) establish a comprehensive three-year regional
planning budget using funds allocated to the region by the
commissioner.
Sec. 2002.404. REGIONAL MEDICAL OFFICER. (a) Each
regional director shall appoint a regional medical officer for each
health care planning region.
(b) A regional medical officer shall:
(1) administer all aspects of the regional office of
health care quality;
(2) serve as a member of the regional planning board;
(3) oversee the establishment of integrated service
networks that:
(A) include physicians in fee-for-service, solo,
and group practice, essential community and ancillary care
providers, and facilities;
(B) pool and align resources and form
interdisciplinary teams to share responsibility and accountability
for patient care; and
(C) provide a continuum of coordinated
high-quality primary to tertiary care to all residents of the
region;
(4) assure the evaluation and measurement of the
quality of health care delivered in the region, including
assessment of the performance of individual providers under
standards established by the chief medical officer, to ensure a
single standard of high-quality care is delivered to all state
residents;
(5) in collaboration with the chief medical officer
and regional providers, evaluate standards of care in use at the
time the system becomes operative;
(6) ensure a smooth transition toward use of standards
based on clinical efficacy that guide clinical decision-making;
(7) support the development and distribution of
user-friendly software for use by providers in order to support the
delivery of high-quality health care;
(8) provide feedback to, and support and supervision
of, health care providers to ensure the delivery of high-quality
care under standards established by the system;
(9) collaborate with the regional partnerships for
health to develop patient education to assist consumers in
evaluating and appropriately utilizing health care providers and
facilities;
(10) collaborate with regional public health officers
to establish regional health policies that support the public
health;
(11) establish a regional program to monitor and
decrease medical errors and their causes using standards and
methods established by the chief medical officer;
(12) support the development and implementation of
innovative means to provide high-quality care and assist providers
in securing funds for innovative demonstration projects that seek
to improve care quality;
(13) establish means to assess the impact of the
system's policies intended to assure the delivery of high-quality
care;
(14) collaborate with the chief medical officer, the
director of the office of health care planning, the regional
director, and health care providers in the development and
maintenance of regional health care databases;
(15) ensure the enforcement of, and recommend needed
changes to, the system's reporting requirements;
(16) support providers in developing regional budget
requests; and
(17) annually report to the commissioner, the public,
the regional planning board, and the chief medical officer on the
status of regional health care programs, needed improvements, and
plans to implement and evaluate delivery of care improvements.
Sec. 2002.405. REGIONAL PLANNING BOARD. The commissioner
shall appoint a regional planning board for each health care
planning region. The regional planning board shall advise the
regional director concerning health policy for the region.
Sec. 2002.406. COMPOSITION OF REGIONAL PLANNING BOARD. (a)
A regional director shall appoint 13 members to a regional planning
board.
(b) Members serve two-year terms that coincide with the term
of the regional director and may be reappointed for not more than
eight terms.
(c) Regional planning board members must have resided for at
least two years in the region in which they serve before appointment
to the board.
(d) Regional planning board members shall reside in the
region they serve while on the board.
(e) The board consists of the following members:
(1) the regional director;
(2) the regional medical officer;
(3) the regional director of partnerships for health;
(4) a public health officer from one of the counties in
the region, rotating among the county public health officers on a
timetable to be established by each regional planning board;
(5) a representative from the office of patient
advocacy;
(6) one expert in health care financing;
(7) one expert in health care planning;
(8) two members who are direct care providers in the
region, one of whom is a registered nurse;
(9) one member who represents ancillary health care
workers in the region;
(10) one member who represents hospitals in the
region;
(11) one member who represents essential community
providers in the region; and
(12) one member representing the public.
(f) The regional director serves as chair of the board.
(g) The regional planning board shall advise and make
recommendations to the regional director on all aspects of regional
health policy.
[Sections 2002.407-2002.450 reserved for expansion]
SUBCHAPTER J. OFFICE OF TRANSITION ASSISTANCE
Sec. 2002.451. TRANSITION ASSISTANCE. The office of
transition assistance is within the agency and operates under the
direction of the commissioner.
Sec. 2002.452. TRANSITION ADVISORY COMMITTEE. The
commissioner shall appoint a transition advisory group composed of
the following members:
(1) the commissioner;
(2) the patient advocate;
(3) the chief medical officer;
(4) the director of the office of health care
planning;
(5) the finance director;
(6) experts in health care financing and health care
administration;
(7) direct care providers;
(8) representatives of retirement boards;
(9) employer and employee representatives;
(10) representatives of hospitals, integrated health
care delivery systems, and other health care facilities;
(11) representatives of state health and human
services agencies;
(12) representatives of counties; and
(13) health care consumers.
Sec. 2002.453. DUTIES OF OFFICE. The office of transition
assistance shall:
(1) provide assistance to individuals who lose
employment, directly or indirectly, as a result of the
implementation of the system, including job training and job
placement;
(2) advise the commission regarding the
implementation of the system;
(3) make recommendations to the commissioner
regarding the integration of health care delivery; and
(4) make recommendations to the governor, lieutenant
governor, and legislature regarding research needed to support
transition to the system.
Sec. 2002.454. EXPIRATION. This subchapter expires
December 31, 2014.
CHAPTER 2003. FISCAL MANAGEMENT
SUBCHAPTER A. HEALTH COVERAGE FUND
Sec. 2003.001. FUND. The health coverage fund is a fund in
the state treasury. The fund is composed of:
(1) all funds collected from health care;
(2) federal funds allocated to the fund; and
(3) other money allocated to the fund under law.
Sec. 2003.002. ADMINISTRATION OF FUND. (a) The finance
director administers the fund under the supervision and direction
of the commissioner.
(b) The finance director may employ actuaries, accountants,
and other experts as necessary to perform the finance director's
duties under law.
Sec. 2003.003. ACCOUNTS IN FUND. The finance director
shall establish the following accounts in the fund:
(1) a system account to provide for all annual state
expenditures for health care; and
(2) a reserve account.
Sec. 2003.004. PREMIUMS SUFFICIENT TO COVER COSTS.
Premiums collected each year under this title shall be sufficient
to cover that year's projected costs.
Sec. 2003.005. USE OF FUND. (a) Money in the fund may be
used in accordance with the General Appropriations Act to pay
claims for health care services provided through the system and the
administrative costs of the system.
(b) Not more than five percent of the money in the fund may
be used for administrative costs of the system.
(c) Notwithstanding Subsection (b), not more than 10
percent of the money in the fund may be used for administrative
costs of the system. This subsection expires August 31, 2022.
Sec. 2003.006. LEGISLATIVE APPROPRIATION REQUEST. (a) Not
later than November 1 of each even-numbered year, the commissioner,
in consultation with the finance director, shall submit to the
Legislative Budget Board:
(1) an estimate of projected system revenues under
this title;
(2) an estimate of projected system liabilities for
the succeeding fiscal biennium; and
(3) a legislative appropriation request for the
succeeding fiscal biennium.
(b) The legislative appropriation request shall specify
amounts to be allocated to the health care planning regions for
health care services in those regions.
(c) The legislative appropriation request must include
amounts necessary to provide transition assistance to individuals
who lose employment, directly or indirectly, as a result of the
implementation of the system. This subsection expires December 31,
2014.
Sec. 2003.007. RESERVES FOR FUTURE SYSTEM LIABILITY. (a)
The comptroller, at the direction of the finance director, shall
establish one or more separate accounts for system reserves against
future liability.
(b) The commissioner shall work with the Department of
Insurance, the Health and Human Services Commission, and other
experts to determine an appropriate level of reserves for the
system for the first year and future years of the system's
operation.
(c) Funds held in reserve by state health programs and
federal money for health care shall be transferred to the reserve
account at the time the state assumes financial responsibility for
health care.
Sec. 2003.008. SELF-INSURED SYSTEM. The commissioner may
implement a program to self-insure the system against unforeseen
expenditures or revenue shortfalls not covered by reserves or may
borrow funds to cover temporary revenue shortfalls not covered by
system reserves, including the issuance of revenue bonds payable
from the premiums received by the system for this purpose,
whichever is more cost effective.
Sec. 2003.009. DUTY TO MONITOR SYSTEM SOLVENCY; NOTICE TO
LEGISLATURE. The finance director shall monitor the solvency of
the system. If the finance director determines that system
liabilities may exceed system revenue in any year, the finance
director shall notify the commissioner, the health coverage policy
board, the governor, the lieutenant governor, and the speaker of
the house of representatives.
Sec. 2003.010. COST CONTAINMENT. (a) After receiving
notice under Section 2003.009, the commissioner, in consultation
with the finance director and the health coverage policy board, may
implement cost containment measures and may require each regional
planning board to impose cost containment measures within the
region subject to the board's jurisdiction.
(b) Cost containment measures may include:
(1) changes in the system or health facility
administration that improve efficiency;
(2) changes in the delivery of health care services
that improve efficiency and quality of care;
(3) postponement of introduction of new benefits or
benefit improvements;
(4) the seeking of statutory authority for a temporary
decrease in benefits;
(5) postponement of planned capital expenditures;
(6) adjustments of health care provider payments to
correct for deficiencies in quality of care and failure to meet
compensation contract performance goals;
(7) adjustments to compensation of managerial
employees and upper-level managers under contract with the system
to correct for deficiencies in management and failure to meet
contract performance goals;
(8) limitations on reimbursement budgets of the
system's providers and upper-level managers whose compensation is
determined by the payments board;
(9) limitations on aggregate reimbursements to
manufacturers of pharmaceutical and durable and nondurable medical
equipment;
(10) deferred funding of the reserve account;
(11) imposition of copayments or deductible payments
except where prohibited by federal law and as determined by federal
law for persons with low income; and
(12) imposition of an eligibility waiting period and
other means if the commissioner determines that many individuals
are emigrating to the state for the purpose of obtaining health care
through the system.
(c) Nothing in this section shall be construed to diminish
the benefits that an individual has under a collective bargaining
agreement.
(d) Nothing in this section shall preclude an employee from
receiving benefits available to the employee under a collective
bargaining agreement or other employee-employer agreement or a
statute that are superior to benefits under this section.
(e) Cost containment measures implemented under this
section must remain in place until the commissioner and the health
coverage policy board determine that the cause of a revenue
shortfall has been corrected.
(f) If the health coverage policy board determines that cost
containment measures implemented under this section are not
sufficient to meet a revenue shortfall, the commissioner shall
report to the legislature and the public on the causes of the
shortfall and the reasons for the failure of cost containment
measures and shall recommend measures to correct the shortfall,
including an increase in premium payments to the system.
Sec. 2003.011. REGIONAL COST CONTAINMENT. (a) If the
commissioner or a regional director determines that regional
revenue and expenditure trends indicate a need for regional cost
containment measures, the regional director shall convene the
regional planning board to discuss the possible need for cost
containment measures and make a recommendation about appropriate
measures to control costs.
(b) Cost containment measures under this section may
include any of the following:
(1) changes in the administration of the system or in
health facility administration that improve efficiency;
(2) changes in the delivery of health care services
and health system management that improve efficiency or quality of
care;
(3) postponement of planned regional capital
expenditures;
(4) adjustment of payments to health care providers to
reflect deficiencies in quality of care and failure to meet
compensation contract performance goals and payments to
upper-level managers to reflect deficiencies in management and
failure to meet compensation contract performance goals;
(5) adjustment of payments to health care providers
and upper-level managers above a specified amount of aggregate
billing; and
(6) adjustment of payments to pharmaceutical and
medical equipment manufacturers and others selling goods and
services to the system above a specified amount of aggregate
billing.
(c) Cost containment measures shall remain in place in a
region until the regional director and the commissioner determine
that the cause of a revenue shortfall has been corrected.
[Sections 2003.012-2003.050 reserved for expansion]
SUBCHAPTER B. FEDERAL FUNDING
Sec. 2003.051. APPLICATION FOR FEDERAL FUNDING. The
commissioner, through applications for appropriate waivers from
the Centers for Medicare and Medicaid Services or another
appropriate funding source, shall seek federal funding for the
operation of the system.
[Sections 2003.052-2003.100 reserved for expansion]
SUBCHAPTER C. BUDGET
Sec. 2003.101. SYSTEM BUDGET. The budget for the system
shall include each of the following:
(1) a transition budget;
(2) a providers and managers budget;
(3) a capitated operating budget;
(4) a noncapitated operating budget;
(5) a capital investment budget;
(6) a purchasing budget, including prescription drugs
and durable and nondurable medical equipment;
(7) a research and innovation budget;
(8) a workforce training and development budget;
(9) a system administration budget; and
(10) regional budgets.
Sec. 2003.102. BUDGET CONSIDERATIONS. In establishing a
budget under this section, the commissioner shall consider the
following:
(1) the costs of transition to the new system;
(2) projections regarding the health care services
anticipated to be used by residents of this state;
(3) differences in the costs of living between
regions, including the overhead costs of maintaining medical
practices;
(4) the health risk of enrollees;
(5) the scope of services provided;
(6) innovative programs that improve health care
quality, administrative efficiency, and workplace safety;
(7) the unrecovered costs of providing care to persons
who are not enrolled in the system;
(8) the costs of workforce training and development;
(9) the costs of corrective health outcome disparities
and the unmet needs of previously uninsured and underinsured
enrollees;
(10) relative usage of different health care
providers;
(11) needed improvements in access to care;
(12) projected savings in administrative costs;
(13) projected savings due to provision of primary and
preventive care to the population, including savings from decreases
in preventable emergency room visits and hospitalizations;
(14) projected savings from improvements in quality of
care;
(15) projected savings from decreases in medical
errors;
(16) projected savings from system-wide management of
capital expenditures;
(17) the cost of incentives and bonuses to support the
delivery of high-quality health care, including incentives and
bonuses needed to recruit and retain an adequate number of needed
providers and managers and to attract health care providers to
medically underserved areas;
(18) the costs of treating complex illnesses,
including disease management programs;
(19) the cost of implementing standards of health care
coordination;
(20) the cost of electronic medical records and other
electronic initiatives; and
(21) the costs of new technology, including research
and development costs.
[Sections 2003.103-2003.150 reserved for expansion]
SUBCHAPTER D. PAYMENTS BOARD
Sec. 2003.151. PAYMENTS BOARD. (a) The commissioner shall
establish the payments board and shall appoint a director and
members of the board.
(b) The payments board is composed of:
(1) experts in health care finance and insurance
systems;
(2) a designated representative of the commissioner;
(3) a designated representative of the health coverage
fund; and
(4) a representative of the regional directors.
(c) The position of regional representative shall rotate
among the directors of the regional planning boards every two
years.
Sec. 2003.152. COMPENSATION PLAN. (a) The payments board
shall establish and supervise a uniform payments system for health
care providers and managers and shall maintain a compensation plan
for each of the following health care providers and managers under
the providers and managers budget established by the commissioner:
(1) upper-level managers employed by, or under
contract with, private health care facilities;
(2) managers and officers of the system; and
(3) health care providers, including physicians,
osteopathic physicians, dentists, podiatrists, optometrists, nurse
practitioners, physician assistants, chiropractors,
acupuncturists, psychologists, social workers, marriage, family,
and child counselors, and other professional health care providers
who are licensed to practice in this state and who provide services
under the system.
(b) Health care providers licensed and accredited to
provide services in this state may choose to be compensated for
their services either by the system or by a person to whom they
provide services.
(c) Health care providers who elect to receive compensation
from the system shall enter into a contract with the system.
(d) Health care providers who elect to receive compensation
by individuals to whom they provide services instead of by the
system may establish charges for their services.
(e) A health care provider who accepts payment from the
system under this section may not bill a patient for any covered
service, except as authorized by the commissioner.
(f) A health care provider who receives compensation from
the system may choose to be compensated as a fee-for-service
provider or a provider employed by, or under contract with, a health
care system that provides comprehensive, coordinated services.
(g) Nothing in this section restricts the right of a
supervising health care provider to enter into a contractual
arrangement that provides for salaried compensation for employees
who must be supervised by a physician.
(h) The compensation plan must include the following:
(1) actuarially sound payments that include a just and
fair return for health care providers in the fee-for-service sector
and for health care providers working in health systems where
comprehensive and coordinated services are provided, including the
actuarial basis for the payment;
(2) payment schedules that are in effect for three
years; and
(3) bonus and incentive payments.
(i) A health care provider shall be paid for each service
provided, including care provided to an individual subsequently
determined to be ineligible for the system.
(j) A health care provider who delivers services that are
not covered under the system may establish rates and charge
patients for those services.
(k) Reimbursement to health care providers and compensation
to managers may not exceed the amount allocated by the commissioner
to provider and manager annual budgets.
Sec. 2003.153. REIMBURSEMENT FOR FEE-FOR-SERVICE
PROVIDERS. (a) Fee-for-service health care providers shall choose
representatives of their specialties to negotiate reimbursement
rates with the payments board on their behalf.
(b) The payments board shall establish a uniform system of
payments for all services provided.
(c) Payment schedules must be available to health care
providers in printed and electronic format.
(d) Payment schedules are in effect for three years. Payment
adjustments may be made at the discretion of the payments board to
meet the goals of the system.
(e) In establishing a uniform system of payments, the
payments board shall collaborate with regional directors and health
care providers and consider regional differences in the cost of
living and the need to recruit and retain skilled health care
providers in the region.
(f) Fee-for-service health care providers shall submit
claims electronically to the health coverage fund and shall be paid
not later than the 30th business day after the date the claim is
received.
[Sections 2003.154-2003.200 reserved for expansion]
SUBCHAPTER E. CAPITAL MANAGEMENT
Sec. 2003.201. CAPITAL MANAGEMENT PLAN. (a) The
commissioner shall develop a capital management plan that governs
all capital investments and acquisitions.
(b) The commissioner shall develop and maintain a capital
inventory for each region and establish a process for each region to
prepare a business plan that includes proposed investments and
acquisitions.
Sec. 2003.202. COMPETITIVE BIDDING PROCESS. (a) The
commissioner shall establish a competitive bidding process for the
development of capital management plans.
(b) The system may fund all or part of capital projects.
Sec. 2003.203. NO INVESTMENTS FROM OPERATING BUDGETS. A
capital investment may not be funded by money set aside in a
regional or system-wide operating budget.
Sec. 2003.204. REGIONAL CAPITAL INVESTMENT PLANS. Each
regional director shall submit to the commissioner a regional
capital management plan that is based on the capital management
plan developed by the commissioner under Section 2003.201.
[Sections 2003.205-2003.250 reserved for expansion]
SUBCHAPTER F. PREMIUM COMMISSION
Sec. 2003.251. HEALTH CARE PREMIUM COMMISSION. (a) The
health care premium commission is composed of 14 members, appointed
as follows:
(1) three health economists with experience relevant
to the duties of the commission, one of whom is appointed by the
governor, one of whom is appointed by the lieutenant governor, and
one of whom is appointed by the governor from a list submitted by
the speaker of the house of representatives;
(2) a representative of the business community, other
than the small business community, appointed by the governor;
(3) a representative of the small business community,
appointed by the lieutenant governor;
(4) two representatives of employees in this state,
one of whom is appointed by the lieutenant governor and one of whom
is appointed by the governor from a list submitted by the speaker of
the house of representatives;
(5) two representatives of nonprofit organizations
interested in the establishment of a system of universal health
care in this state, one of whom is appointed by the lieutenant
governor and one of whom is appointed by the governor from a list
submitted by the speaker of the house of representatives;
(6) one representative of a nonprofit advocacy
organization concerned with taxation policy and sustainable
funding for public infrastructure, appointed by the governor from a
list submitted by the speaker of the house of representatives;
(7) the comptroller, or the comptroller's designee;
(8) the director of the division of workforce
development of the Texas Workforce Commission;
(9) the executive commissioner of the Health and Human
Services Commission, or the executive commissioner's designee; and
(10) the lieutenant governor.
(b) The lieutenant governor and the speaker of the house of
representatives shall designate a member of the senate and the
house of representatives, respectively, to advise the premium
commission.
(c) The appointed members of the premium commission serve
for staggered terms of six years, with as near as possible to
one-third of the members' terms expiring every February 1 of each
odd-numbered year.
Sec. 2003.252. PREMIUM COMMISSION FUNCTIONS. The premium
commission shall perform the following functions:
(1) determine the aggregate costs of providing health
care coverage to residents of this state; and
(2) develop an equitable and affordable premium
structure that will generate adequate revenue for the health
coverage fund established under Subchapter A and ensure stable and
actuarially sound funding for the system.
Sec. 2003.253. PREMIUM STRUCTURE. (a) The premium
structure developed by the premium commission shall satisfy the
following criteria:
(1) be means-based and generate adequate revenue to
implement the system;
(2) to the greatest extent possible, ensure that all
income earners and all employers contribute a premium amount that
is affordable and consistent with existing funding sources for
health care in this state;
(3) maintain the current ratio for aggregate health
care contributions among the traditional health care funding
sources, including employers, individuals, government, and other
sources;
(4) provide a fair distribution of monetary savings
achieved from the establishment of a universal health coverage
system;
(5) coordinate with existing, ongoing funding sources
from federal and state programs;
(6) be consistent with state and federal requirements
governing financial contributions for persons eligible for
existing public programs;
(7) comply with federal requirements; and
(8) include an exemption for employers and employees
who are subject to a collective bargaining agreement.
(b) The premium commission shall seek expert and legal
advice regarding the best method to structure premium payments
consistent with existing employer-employee health care financing
structures.
Sec. 2003.254. POWERS AND DUTIES. The premium commission
may:
(1) obtain grants from and contract with individuals
and private, local, state, and federal agencies, organizations, and
institutions;
(2) receive gifts, grants, and donations; and
(3) seek structured input from representatives of
stakeholder organizations, policy institutes, and other persons
with expertise in health care, health care financing, or universal
health care models.
Sec. 2003.255. REPORT TO LEGISLATURE. On or before
November 1 of each even-numbered year, the premium commission shall
submit to the governor, the lieutenant governor, and both houses of
the legislature a detailed recommendation for a premium structure.
[Sections 2003.256-2003.300 reserved for expansion]
SUBCHAPTER G. GOVERNMENTAL PAYMENTS
Sec. 2003.301. PAYMENTS FROM FEDERAL GOVERNMENT. (a) The
commission shall seek any waivers, exemptions, agreements, or
legislation necessary to ensure that all federal payments to the
state for health care services are paid directly to the system. The
system shall assume responsibility for all benefits and services
previously paid by the federal government with those funds.
(b) In obtaining the waivers, exemptions, agreements, or
legislation under Subsection (a), the commissioner shall seek from
the federal government a contribution for health care services that
does not decrease in relation to the contribution to other states as
a result of the waivers, exemptions, agreements, or legislation.
Sec. 2003.302. PAYMENTS FROM STATE GOVERNMENTS. (a) The
commission shall seek any waivers, exemptions, agreements, or
legislation necessary to ensure that all state payments for health
care services are paid directly to the system. The system shall
assume responsibility for all benefits and services previously paid
by this state.
(b) The commissioner shall establish formulas for equitable
contributions to the system from each county in this state and other
local governmental entities.
Sec. 2003.303. AGREEMENT WITH ENTITIES CONTRIBUTING TO
FUND. In order to minimize the administrative burden of
maintaining eligibility records for programs transferred to the
system, the commissioner shall attempt to reach an agreement with
federal, state, and local governments in which contributions to the
health coverage fund are fixed to the rate of change of the state
gross domestic product, the size and age of population, and the
number of residents living below the federal poverty level.
Sec. 2003.304. PAYMENTS THROUGH THE MEDICAL ASSISTANCE
PROGRAM. To the extent that federal law allows the transfer of
funding for the medical assistance program under Chapter 31, Human
Resources Code, to the system, the commissioner shall pay from the
health coverage fund all premiums, deductible payments, and
coinsurance for eligible recipients of health benefits under the
medical assistance program under Chapter 31, Human Resources Code.
Sec. 2003.305. MEDICARE PAYMENTS. To the extent that the
commissioner obtains authorization to incorporate Medicare
revenues into the health coverage fund, Medicare Part B payments
that previously were made by individuals or the state shall be paid
by the system for all individuals eligible for both the system and
the Medicare program.
[Sections 2003.306-2003.350 reserved for expansion]
SUBCHAPTER H. FEDERAL PREEMPTION
Sec. 2003.351. WAIVER FOR FEDERAL PREEMPTION. The
commissioner shall pursue all reasonable means to secure a repeal
or a waiver of any provision of federal law that preempts any
provision of this title.
Sec. 2003.352. EMPLOYMENT CONTRACT. (a) To the extent
permitted by federal law, an employee entitled to health or related
benefits under a contract or plan that, under federal law, preempts
provisions of this title, shall first seek benefits under that
contract or plan before receiving benefits from the system.
(b) A benefit may not be denied under the system unless the
employee has failed to take reasonable steps to secure similar
benefits from the contract or plan, if those benefits are
available.
(c) Nothing in this section precludes a person from
receiving benefits from the system that are superior to benefits
available to the person under an existing contract or plan.
(d) This title may not be construed to discourage recourse
to contracts or plans that are protected by federal law.
(e) To the extent permitted by federal law, a health care
provider shall first seek payment from the contract or plan before
submitting a bill to the system.
[Sections 2003.353-2003.400 reserved for expansion]
SUBCHAPTER I. SUBROGATION
Sec. 2003.401. PURPOSE. (a) In this subchapter,
"collateral source" means:
(1) an insurance policy written by an insurer,
including the medical components of automobile, homeowners, and
other forms of insurance;
(2) health care service plans and pension plans;
(3) employers;
(4) employee benefit contracts;
(5) government benefit programs;
(6) a judgment for damages for personal injury; or
(7) a third party who is or may be liable to an
individual for health care services or costs.
(b) Until the role of all other payers for health care
services has been terminated, costs for health care services may be
collected from collateral sources whenever health care services
provided to an individual are covered services under a policy of
insurance, health care service plan, or other collateral source
available to that individual, or for which the individual has a
right of action for compensation to the extent permitted by law.
(c) A collateral source under this section does not include
a contract or plan subject to federal preemption or a governmental
unit, agency, or service. A contract or relationship with a
governmental unit, agency, or service does not exclude an entity
from the obligations of this section.
(d) The commissioner shall attempt to negotiate waivers,
seek federal legislation, or make other arrangements to incorporate
collateral sources in this state into the system.
Sec. 2003.402. NOTIFICATION OF COVERAGE BY COLLATERAL
SOURCE. (a) If an individual receives health care services under
the system and is entitled to coverage, reimbursement, indemnity,
or other compensation from a collateral source, the individual
shall notify the health care provider and provide information
identifying the collateral source, the nature and extent of
coverage or entitlement, and other relevant information.
(b) The health care provider shall forward the information
provided in Subsection (a) to the commissioner. The individual who
receives services under Subsection (a) and who is entitled to
coverage, reimbursement, indemnity, or other compensation from a
collateral source shall provide additional information as
requested by the commissioner.
Sec. 2003.403. SYSTEM REIMBURSEMENT. The system shall seek
reimbursement from the collateral source for services provided to
the individual under Section 2003.402(a) and may institute
appropriate action, including filing suit, to recover the
reimbursement. Upon demand, the collateral source shall pay to the
health coverage fund the sums the collateral source would have paid
or expended on behalf of the individual for the health care services
provided by the system.
Sec. 2003.404. EXEMPT FROM SUBROGATION. If a collateral
source is exempt from subrogation or the obligation to reimburse
the system as provided by this subchapter, the commissioner may
require that an individual who is entitled to health care services
from the source first seek those services from that source before
seeking those services from the system.
SUBTITLE B. TEXAS HEALTH COVERAGE SYSTEM
CHAPTER 2101. ELIGIBILITY
SUBCHAPTER A. GENERAL ELIGIBILITY REQUIREMENTS
Sec. 2101.001. RESIDENTS AND CERTAIN EMPLOYEES ELIGIBLE.
Except as otherwise provided by this chapter, each resident of this
state is eligible for health coverage provided through the system.
Residency is based on physical presence in the state with the intent
to reside.
Sec. 2101.002. UNAUTHORIZED ALIEN INELIGIBLE. (a) A
person who is not lawfully admitted for residence in the United
States is not eligible for health coverage provided through the
system.
(b) To the extent required by federal law, the system shall
provide emergency services to a person otherwise ineligible for
health coverage through the system under this section.
Sec. 2101.003. MILITARY PERSONNEL. United States military
personnel are not eligible for health coverage provided through the
system.
Sec. 2101.004. CERTAIN INMATES. A person covered by a
managed health care plan for persons confined under the
jurisdiction of the Texas Department of Criminal Justice is not
eligible for health coverage provided through the system.
Sec. 2101.005. WORKERS' COMPENSATION. Coverage is not
provided through the system for services covered under a program of
workers' compensation insurance.
[Sections 2101.006-2101.050 reserved for expansion]
SUBCHAPTER B. ELIGIBILITY DETERMINATIONS
Sec. 2101.051. VERIFICATION OF ELIGIBILITY. The
commissioner by rule shall adopt procedures for verifying residence
as necessary to establish eligibility for health coverage provided
through the system.
Sec. 2101.052. RESIDENCE OF MINOR. For purposes of this
chapter, and except as provided by rules of the commissioner, an
unmarried, unemancipated minor has the same residency status as the
minor's parent or managing conservator.
Sec. 2101.053. EVIDENCE OF COVERAGE. The system may issue
an identification card or other evidence of coverage to be used by
an eligible resident to show proof that the resident is eligible for
health coverage provided through the system.
Sec. 2101.054. PRESUMPTION APPLICABLE TO CERTAIN
INDIVIDUALS. A health care facility is entitled to presume that a
person who arrives at the facility and who is unable to provide
proof of eligibility because the person is unconscious, is in need
of emergency services, or is in need of acute psychiatric care is an
eligible resident.
[Sections 2101.055-2101.100 reserved for expansion]
SUBCHAPTER C. SERVICES PROVIDED TO NONRESIDENTS
Sec. 2101.101. PAYMENT OF CLAIMS AUTHORIZED. The system
may, in accordance with rules adopted by the commissioner, pay a
claim for health care services provided to a nonresident who is
temporarily in this state. The nonresident remains liable for the
cost of all services provided to the nonresident through the
system.
CHAPTER 2102. HEALTH CARE SERVICES
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 2102.001. COVERAGE FOR HEALTH CARE SERVICES. The
system must provide coverage for medically necessary health care
services for an eligible resident at at least the level at which
those services were provided under the state acute care Medicaid
program, as that program existed on January 1, 2009.
Sec. 2102.002. LONG-TERM CARE. Notwithstanding Section
2102.001, the system may not provide coverage for long-term care
services.
[Sections 2102.003-2102.050 reserved for expansion]
SUBCHAPTER B. OUT-OF-STATE BENEFITS
Sec. 2102.051. TEMPORARY BENEFITS. The system must provide
health coverage for medically necessary health care services
provided to an eligible resident who is out of this state for a
temporary period not to exceed 90 days.
Sec. 2102.052. ELIGIBILITY. The commissioner by rule shall
establish procedures for verifying eligibility for health coverage
provided through the system under this subchapter.
Sec. 2102.053. EMERGENCY SERVICES. The system shall pay a
claim for emergency services under this subchapter at the usual and
customary rate for those services at the place at which the services
are provided.
Sec. 2102.054. CLAIMS FOR SERVICES OTHER THAN EMERGENCY
SERVICES. The system shall pay a claim for services not under this
subchapter, other than emergency services, at a rate established by
the commissioner.
CHAPTER 2103. BENEFITS
Sec. 2103.001. MEDICAID. A resident who is eligible for
medical assistance program benefits under Chapter 31, Human
Resources Code, is entitled to all benefits available under that
chapter.
Sec. 2103.002. COVERED BENEFITS. (a) Covered benefits
under this chapter include all medical care determined appropriate
by an individual's health care provider, except as provided in
Subsection (c).
(b) Covered benefits under this section include:
(1) inpatient and outpatient health facility
services;
(2) inpatient and outpatient professional health care
provider services by licensed health care professionals;
(3) diagnostic imaging, laboratory services, and
other diagnostic and evaluative services;
(4) durable medical equipment, appliances, and
assistive technology, including prosthetics, eyeglasses, hearing
aids, and repair;
(5) rehabilitative care;
(6) emergency transportation and necessary
transportation for health care services for disabled and indigent
persons;
(7) language interpretation and translation for
health care services, including sign language for those unable to
speak or hear, or who are language impaired, and Braille
translation or other services for those with no or low vision;
(8) child and adult immunizations and preventive care;
(9) health education;
(10) hospice care;
(11) home health care;
(12) prescription drugs listed on the system's
preferred drug list;
(13) nonformulary prescription drugs if standards and
criteria established by the commissioner are met;
(14) mental and behavioral health care;
(15) dental care;
(16) podiatric care;
(17) chiropractic care;
(18) acupuncture;
(19) blood and blood products;
(20) emergency care services;
(21) vision care;
(22) adult day care;
(23) case management and coordination to ensure
services necessary to enable a person to remain safely in the least
restrictive setting;
(24) substance abuse treatment;
(25) care of not more than 100 days in a skilled
nursing facility following hospitalization;
(26) dialysis;
(27) benefits offered by a bona fide church, sect,
denomination, or organization whose principles include healing
entirely by prayer or spiritual means provided by a duly authorized
and accredited practitioner or nurse of that bona fide church,
sect, denomination, or organization;
(28) chronic disease management;
(29) family planning services and supplies, except
services related to an abortion; and
(30) early and periodic screening, diagnosis, and
treatment services, as defined in 42 U.S.C. Section 1396d(r), for
patients younger than 21 years of age, regardless of whether those
services are covered benefits for persons who are at least 21 years
of age.
(c) The following health care services are not covered
benefits under the system:
(1) health care services determined to have no medical
indication by the commissioner and the chief medical officer;
(2) surgery, dermatology, orthodontia, prescription
drugs, or other procedures intended primarily for cosmetic
purposes, unless required to correct a congenital defect, restore
or correct a part of the body altered because of injury, disease, or
surgery, or determined by a health care provider to be medically
necessary;
(3) a private room in an inpatient facility if a
non-private room is available, unless determined to be medically
necessary; and
(4) services of a health care provider or facility
that is not licensed by this state, except for services provided to
a resident who is temporarily out of the state under Section
2102.051.
CHAPTER 2104. COST SHARING
Sec. 2104.001. COPAYMENTS REQUIRED. The finance director,
with the approval of the commissioner, shall establish copayment
amounts to be paid at the point of service by an eligible resident
receiving health care services for which coverage is provided
through the system.
Sec. 2104.002. DEDUCTIBLE AMOUNTS. The finance director,
with the approval of the commissioner, shall establish deductible
amounts that an eligible resident receiving health care services is
responsible to pay before coverage is provided through the system.
Sec. 2104.003. LIMITS ON COPAYMENTS AND DEDUCTIBLES. The
total amount payable for services provided through the system with
respect to an eligible resident, including copayment and deductible
amounts paid under this chapter, may not exceed five percent of the
eligible resident's family income, as determined under rules of the
commissioner.
CHAPTER 2105. HEALTH CARE PROVIDERS
Sec. 2105.001. ANY WILLING PROVIDER. (a) An eligible
resident may select any physician, health care practitioner, or
health care facility to provide medically necessary services within
the scope of the license or other authorization of the physician,
practitioner, or facility if the physician, practitioner, or
facility agrees to accept payment for claims from the system
subject to the terms imposed in accordance with this title.
(b) A physician, health care practitioner, or health care
facility is subject to credentialing under the system in the same
manner as the physician, practitioner, or facility is subject to
the credentialing requirements applicable under the state Medicaid
program as that program existed on January 1, 2009.
Sec. 2105.002. PRIMARY CARE PROVIDER; REQUIRED REFERRAL.
The commissioner by rule shall establish requirements under which
an eligible resident must designate a primary care provider and
must obtain a referral from that provider to obtain coverage for
specialty care services. The system shall use the same methodology
for primary care case management and referral as applicable under
the state Medicaid program as that program existed on January 1,
2009.
ARTICLE 2. CONFORMING AMENDMENTS
SECTION 2.01. Subchapter A, Chapter 531, Government Code,
is amended by adding Section 531.0001 to read as follows:
Sec. 531.0001. COORDINATION WITH TEXAS HEALTH COVERAGE
SYSTEM. (a) Notwithstanding any provision of this chapter or any
other law of this state, on and after January 1, 2012, the Texas
Health Coverage System is responsible for administering the system
for providing health coverage and health care services in this
state.
(b) The Health and Human Services Commission and each health
and human services agency remain responsible for safety and
licensing functions within the jurisdiction of the commission or
the agency before January 1, 2012, but except as provided by
Subsection (c), functions of the commission or agency relating to
the provision of health coverage or health care services are
transferred to the Texas Health Coverage Agency in accordance with
Title 13, Health and Safety Code.
(c) The Health and Human Services Commission and each health
and human services agency remain responsible for long-term care
services provided under the state Medicaid program.
SECTION 2.02. Chapter 30, Insurance Code, is amended by
adding Section 30.005 to read as follows:
Sec. 30.005. COORDINATION WITH TEXAS HEALTH COVERAGE
SYSTEM. Notwithstanding any provision of this code or any other law
of this state, on and after January 1, 2012, an insurer, health
maintenance organization, or other entity may not offer a health
benefits plan in this state to the extent that plan duplicates
coverage provided under the Texas Health Coverage System.
ARTICLE 3. TRANSITION PLAN
SECTION 3.01. Not later than October 1, 2009, the governor
shall appoint the commissioner of health coverage in accordance
with Chapter 2002, Health and Safety Code, as added by this Act.
SECTION 3.02. (a) Not later than January 1, 2010, the
commissioner of health coverage shall appoint a transition advisory
group. The transition advisory group must include representatives
of the public, the health care industry, and issuers of health
benefit plans and other experts identified by the commissioner.
(b) In consultation with the transition advisory group, the
commissioner of health coverage shall develop a plan for the
orderly implementation of Title 13, Health and Safety Code, as
added by this Act. The plan must include provisions to assist
individuals who lose employment, directly or indirectly, as a
result of the implementation of the system.
SECTION 3.03. The Texas Health Coverage System shall become
effective to provide coverage in accordance with Title 13, Health
and Safety Code, as added by this Act, not later than January 1,
2012.
SECTION 3.04. (a) In this section, "affected state agency"
means:
(1) the Health and Human Services Commission;
(2) the Texas Department of Insurance;
(3) the Department of State Health Services;
(4) the Department of Assistive and Rehabilitative
Services;
(5) the Department of Aging and Disability Services;
(6) the Department of Family and Protective Services;
(7) the Employees Retirement System of Texas;
(8) the Teacher Retirement System of Texas;
(9) The Texas A&M University System; and
(10) The University of Texas System.
(b) Effective January 1, 2012, or on an earlier date
specified by the commissioner of health coverage:
(1) the property and records of each affected state
agency related to the administration of health coverage, health
benefits, or health care services within the jurisdiction of the
Texas Health Coverage Agency are transferred to the Texas Health
Coverage Agency to assist that agency in beginning to administer
Title 13, Health and Safety Code, as added by this Act, as
efficiently as practicable;
(2) all powers, duties, functions, activities,
obligations, rights, contracts, records, property, and
appropriations or other money of the affected state agency related
to the administration of health coverage, health benefits, or
health care services within the jurisdiction of the Texas Health
Coverage Agency are transferred to the Texas Health Coverage
Agency;
(3) a rule or form adopted by each affected state
agency related to the administration of health coverage, health
benefits, or health care services within the jurisdiction of the
Texas Health Coverage Agency is a rule or form of the Texas Health
Coverage Agency and remains in effect until altered by that agency;
and
(4) a reference in law or an administrative rule to an
affected state agency that relates to the administration of health
coverage, health benefits, or health care services within the
jurisdiction of the Texas Health Coverage Agency means the Texas
Health Coverage Agency.
(c) An employee of an affected state agency employed on the
effective date of this Act who performs a function that relates to
the administration of health coverage, health benefits, or health
care services within the jurisdiction of the Texas Health Coverage
Agency does not automatically become an employee of the Texas
Health Coverage Agency. To become an employee of the Texas Health
Coverage Agency, a person must apply for a position at the Texas
Health Coverage Agency. In establishing the Texas Health Coverage
Agency in accordance with the transition plan developed under
Section 3.02 of this Act, the Texas Health Coverage Agency shall
give preference in employment to employees described by this
subsection who have the necessary qualifications for employment
with the Texas Health Coverage Agency.
(d) Until the date of the transfer specified by Subsection
(b) of this section, and subject to the transition plan developed
under Section 3.02 of this Act, each affected state agency shall
continue to exercise the powers and perform the duties assigned to
the state agency under the law as it existed immediately before the
effective date of this Act or as modified by another Act of the 81st
Legislature, Regular Session, 2009, that becomes law, and the
former law is continued in effect for that purpose.
ARTICLE 4. EFFECTIVE DATE
SECTION 4.01. 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, 2009.