82R7134 ALB-D
By: Kolkhorst H.B. No. 13
A BILL TO BE ENTITLED
AN ACT
relating to the Medicaid program and alternate methods of providing
health services to low-income persons in this state.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle I, Title 4, Government Code, is amended
by adding Chapter 536 to read as follows:
CHAPTER 536. GLOBAL MEDICAID DEMONSTRATION PROJECT WAIVER
Sec. 536.001. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services
Commission.
(2) "Demonstration project" means the global
demonstration project described by Section 536.003.
(3) "Executive commissioner" means the executive
commissioner of the Health and Human Services Commission.
(4) "High deductible health plan" has the meaning
assigned by Section 223, Internal Revenue Code of 1986.
Sec. 536.002. CONSTRUCTION OF CHAPTER. This chapter shall
be liberally construed and applied in relation to applicable
federal laws so that adequate and high quality health care may be
made available to all children and adults who need the care and are
not financially able to pay for it.
Sec. 536.003. FEDERAL AUTHORIZATION; DEVELOPMENT OF
DEMONSTRATION PROJECT. (a) The executive commissioner may seek a
waiver under Section 1115 of the federal Social Security Act (42
U.S.C. Section 1315) to the state Medicaid plan to operate a global
demonstration project that will allow the commission to more
efficiently and effectively use federal money paid to this state
under the Medicaid program to assist low-income residents of this
state with obtaining health benefits coverage by using that federal
money and appropriated state money to the extent necessary for
purposes consistent with this chapter.
(b) The commission may develop and administer the
demonstration project according to the provisions of this chapter,
except that any provision that would not achieve the goal stated in
Subsection (a) or a goal specified by Section 536.004 need not be
addressed in the project.
(c) The executive commissioner may adopt rules necessary
for the proper and efficient operation of the demonstration
project.
Sec. 536.004. DEMONSTRATION PROJECT GOALS. (a) The
demonstration project must employ strategies designed to achieve
the following goals:
(1) maintaining health benefits through the Medicaid
managed care program under Chapter 533 for a person whose net family
income is at or below 100 percent of the federal poverty level and
for a Medicaid recipient who is aged, blind, or disabled;
(2) providing a subsidy in accordance with Section
536.005 to a person whose net family income exceeds 100 percent of
the federal poverty level but does not exceed 175 percent of the
federal poverty level to cover a portion of the cost of a private
health benefits plan as an alternative to providing traditional
Medicaid services for the person;
(3) making a Lone Star Health electronic benefits card
available in accordance with Section 536.006 to any person eligible
to receive Medicaid benefits that is linked to an account
containing funds to assist the cardholder with paying for a high
deductible health plan; and
(4) accounting for changes in federal law resulting
from 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), that will take
effect during the period the demonstration project will operate.
(b) In developing the demonstration project, the commission
shall seek to achieve the goal of maximizing flexibility under the
project by negotiating with the Centers for Medicare and Medicaid
Services to obtain a waiver from the mandatory benchmark benefits
package and the mandatory duration and amount of Medicaid benefits
required by federal law as a condition for obtaining federal
matching funds for support of the Medicaid program.
Sec. 536.005. SUBSIDY TO ASSIST WITH MONTHLY PREMIUM;
MANAGED CARE ALTERNATIVE. (a) As part of the demonstration project
under this chapter, the commission may develop a subsidy program
under which a person whose net family income exceeds 100 percent of
the federal poverty level but does not exceed 175 percent of the
federal poverty level is eligible for a subsidy to assist with the
payment of a monthly premium for a private health benefits plan.
(b) Rules adopted by the executive commissioner must
require that:
(1) the amount of the subsidy described by Subsection
(a) be determined on a sliding scale based on a person's net family
income, where a person with the lowest net family income on the
scale receives a 100 percent subsidy and a person with the highest
net family income on the scale receives a 25 percent subsidy; and
(2) if the commission determines adequate funds exist,
the subsidy program may be expanded to include a person whose net
family income exceeds 175 percent of the federal poverty level but
does not exceed 200 percent of the federal poverty level.
(c) A recipient shall use a subsidy provided under this
section to pay all or a portion of a monthly premium charged for a
private health benefits plan.
(d) Notwithstanding Subsection (a), a person whose net
family income is at or below 100 percent of the federal poverty
level may choose to receive a subsidy under this section in lieu of
participating in the Medicaid managed care program.
(e) Notwithstanding Subsection (a), a person whose net
family income exceeds 100 percent of the federal poverty level but
does not exceed 175 percent of the federal poverty level is eligible
to receive benefits through the Medicaid managed care program if
the person is unable to obtain benefits through a private health
benefits plan and the person's Medicaid caseworker provides written
proof that the person was unable to obtain those benefits.
Sec. 536.006. LONE STAR HEALTH CARD. (a) As part of the
demonstration project under this chapter, the commission may
develop an electronic benefits card, to be known as a Lone Star
Health card. The card must be:
(1) available to any person eligible to receive
benefits through the demonstration project; and
(2) linked to an account containing funds determined
by the commission on a sliding scale based on the cardholder's net
family income to assist the cardholder with paying for a high
deductible health plan.
(b) The cardholder's account must be funded annually in an
amount determined in accordance with a sliding scale adopted by the
executive commissioner by rule. Any balance remaining in the
account at the end of each year carries over into subsequent years
and may be used by the cardholder for purposes described by this
section.
(c) If the cardholder loses eligibility for benefits under
this chapter, the card remains active, and the cardholder may
continue to use any funds remaining in the account to pay for
health-related services.
Sec. 536.007. CONSUMER ASSISTANCE; INTERNET PORTAL. The
commission and the Texas Department of Insurance shall establish a
consumer assistance program to be used by a person eligible for a
subsidy under Section 536.005 or the electronic benefits card under
Section 536.006. As part of that program, the commission and the
department shall establish and maintain an insurance purchasing
portal on the department's Internet website to assist a person
eligible for benefits through the demonstration project with
finding and obtaining health benefits coverage through a private
health benefits plan.
Sec. 536.008. REINSURANCE; WRAP AROUND BENEFITS. The
executive commissioner may adopt rules providing for:
(1) a program developed in conjunction with the Texas
Department of Insurance for the provision of reinsurance to health
benefits plan providers that participate in the demonstration
project; and
(2) wraparound benefits and supplemental benefits to
ensure adequate coverage for persons receiving benefits through the
demonstration project.
Sec. 536.009. OFFICE OF INDIVIDUAL EMPOWERMENT AND
EMPLOYMENT OPPORTUNITIES. (a) If the commission establishes the
demonstration project, the commission shall establish the Office of
Individual Empowerment and Employment Opportunities to increase
the employment rate of Medicaid recipients and those recipients'
access to private health benefits coverage by providing job
training and education opportunities to:
(1) female Medicaid recipients; and
(2) other Medicaid recipients who are at least 18
years of age but younger than 22 years of age.
(b) The commission may use not more than five percent of
federal money paid to this state under the Medicaid program for job
training and education programs described by Subsection (a) and
shall ensure that program services are particularly focused on
areas of this state with high unemployment.
(c) The office may coordinate with the Texas Workforce
Commission to administer this section.
(d) The commission shall annually prepare and publish on the
commission's Internet website a report summarizing the number of
persons assisted through the office, the funds spent, and
recommendations for modifications to the program.
Sec. 536.010. DEMONSTRATION PROJECT MODIFICATIONS. (a)
The commission may modify any process or methodology specified in
this chapter to the extent necessary to comply with federal law or
the terms of the waiver authorizing the demonstration project. The
commission may modify a process or methodology for any other reason
only if the commission determines that the modification is
consistent with federal law and the terms of the waiver.
(b) Except as otherwise provided by this section and subject
to the terms of the waiver authorized by this section, the
commission has broad discretion to develop the demonstration
project.
SECTION 2. Section 533.005(a), Government Code, is amended
to read as follows:
(a) A contract between a managed care organization and the
commission for the organization to provide health care services to
recipients must contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation rates that ensure the cost-effective
provision of quality health care;
(2-a) average efficiency standards adopted by the
executive commissioner by rule that encourage quality of care while
containing costs;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than the
45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to exceed
60 days, specified by a written agreement between the physician or
provider and the managed care organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the managed
care organization, inform the organization of the recipient's
Medicaid certification date;
(9) a requirement that the managed care organization
comply with Section 533.006 as a condition of contract retention
and renewal;
(10) a requirement that the managed care organization
provide the information required by Section 533.012 and otherwise
comply and cooperate with the commission's office of inspector
general;
(11) a requirement that the managed care
organization's usages of out-of-network providers or groups of
out-of-network providers may not exceed limits for those usages
relating to total inpatient admissions, total outpatient services,
and emergency room admissions determined by the commission;
(12) if the commission finds that a managed care
organization has violated Subdivision (11), a requirement that the
managed care organization reimburse an out-of-network provider for
health care services at a rate that is equal to the allowable rate
for those services, as determined under Sections 32.028 and
32.0281, Human Resources Code;
(13) a requirement that the organization use advanced
practice nurses in addition to physicians as primary care providers
to increase the availability of primary care providers in the
organization's provider network;
(14) a requirement that the managed care organization
reimburse a federally qualified health center or rural health
clinic for health care services provided to a recipient outside of
regular business hours, including on a weekend day or holiday, at a
rate that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician; and
(15) a requirement that the managed care organization
develop, implement, and maintain a system for tracking and
resolving all provider appeals related to claims payment, including
a process that will require:
(A) a tracking mechanism to document the status
and final disposition of each provider's claims payment appeal;
(B) the contracting with physicians who are not
network providers and who are of the same or related specialty as
the appealing physician to resolve claims disputes related to
denial on the basis of medical necessity that remain unresolved
subsequent to a provider appeal; and
(C) the determination of the physician resolving
the dispute to be binding on the managed care organization and
provider.
SECTION 3. Sections 32.0248(a), (g), and (i), Human
Resources Code, are amended to read as follows:
(a) The department shall operate [establish] a [five-year]
demonstration project through the medical assistance program to
expand access to preventive health and family planning services for
women. A woman eligible under Subsection (b) to participate in the
demonstration project may receive appropriate preventive health
and family planning services, including:
(1) medical history recording and evaluation;
(2) physical examinations;
(3) health screenings, including screening for:
(A) diabetes;
(B) cervical cancer;
(C) breast cancer;
(D) sexually transmitted diseases;
(E) hypertension;
(F) cholesterol; and
(G) tuberculosis;
(4) counseling and education on contraceptive methods
emphasizing the health benefits of abstinence from sexual activity
to recipients who are not married, except for counseling and
education regarding emergency contraception;
(5) provision of contraceptives, except for the
provision of emergency contraception;
(6) risk assessment; and
(7) referral of medical problems to appropriate
providers that are entities or organizations that do not perform or
promote elective abortions or contract or affiliate with entities
that perform or promote elective abortions.
(g) Not later than December 1 of each even-numbered year,
the department shall submit a report to the legislature regarding
the department's progress in [establishing and] operating the
demonstration project.
(i) This section expires September 1, 2019 [2011].
SECTION 4. (a) The Health and Human Services Commission may
create and establish an indigent care program for eligible
residents of this state whose net family incomes are at or below 300
percent of the federal poverty level and who do not have private
health benefits coverage or receive benefits through the medical
assistance program under Chapter 32, Human Resources Code.
(b) The Health and Human Services Commission shall develop
the program described by Subsection (a) of this section to achieve
the following goals:
(1) providing financial assistance to an eligible
person for health care services, including access to a primary care
physician who serves as a medical home, through a monthly payment
plan based on total household income and family size;
(2) promoting patient responsibility and program
viability;
(3) paying providers on a fee-for-service basis; and
(4) developing community partnerships.
(c) The Health and Human Services Commission shall develop
the program under this section as soon as practicable after the
effective date of this Act.
SECTION 5. (a) In this section:
(1) "Commission" means the Health and Human Services
Commission.
(2) "FMAP" means the federal medical assistance
percentage by which state expenditures under the Medicaid program
are matched with federal funds.
(3) "Medicaid program" means the medical assistance
program under Chapter 32, Human Resources Code.
(b) The commission shall actively pursue a modification to
the formula prescribed by federal law for determining this state's
FMAP to achieve a formula that would produce an FMAP that accounts
for and is periodically adjusted to reflect changes in the
following factors in this state:
(1) the total population;
(2) the population growth rate; and
(3) the percentage of the population with household
incomes below the federal poverty level.
(c) The commission shall pursue the modification as
required by Subsection (b) of this section by providing to the Texas
delegation to the United States Congress and the federal Centers
for Medicare and Medicaid Services and other appropriate federal
agencies data regarding the factors listed in that subsection and
information indicating the effects of those factors on the Medicaid
program that are unique to this state.
(d) In addition to the modification to the FMAP described by
Subsection (b) of this section, the commission shall make efforts
to obtain additional federal Medicaid funding for Medicaid services
required to be provided to persons in this state who are not legally
present in the United States. As part of that effort, the
commission shall provide to the Texas delegation to the United
States Congress and the federal Centers for Medicare and Medicaid
Services and other appropriate federal agencies data regarding the
costs to this state of providing those services.
(e) This section expires September 1, 2013.
SECTION 6. (a) The executive commissioner of the Health and
Human Services Commission shall adopt the average efficiency
standards for purposes of Section 533.005(a)(2-a), Government
Code, as added by this Act, not later than January 1, 2012.
(b) The Health and Human Services Commission, in a contract
between the commission and a managed care organization under
Chapter 533, Government Code, that is entered into or renewed on or
after January 1, 2012, shall include the average efficiency
standards required by Section 533.005(a)(2-a), Government Code, as
added by this Act.
(c) The Health and Human Services Commission shall seek to
amend contracts entered into with managed care organizations under
Chapter 533, Government Code, before January 1, 2012, to include
the average efficiency standards required by Section
533.005(a)(2-a), Government Code, as added by this Act.
SECTION 7. (a) The Health and Human Services Commission
shall actively develop a proposal for a waiver or other
authorization from the appropriate federal agency that is necessary
to implement Chapter 536, Government Code, as added by this Act.
(b) As soon as possible after the effective date of this
Act, the Health and Human Services Commission shall request and
actively pursue approval from the appropriate federal agency of the
waiver or other authorization developed under Chapter 536,
Government Code, as added by this Act.
SECTION 8. 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, 2011.