82R7521 KFF-F
By: Parker H.B. No. 2368
A BILL TO BE ENTITLED
AN ACT
relating to copayments under the medical assistance program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Sections 32.064(a) and (b), Human Resources
Code, are amended to read as follows:
(a) To the extent permitted under Title XIX, Social Security
Act (42 U.S.C. Section 1396 et seq.), as amended, and any other
applicable law or regulations, the executive commissioner of the
Health and Human Services Commission shall adopt provisions
requiring recipients of medical assistance to share the cost of
medical assistance, including provisions requiring recipients to
pay:
(1) an enrollment fee;
(2) a deductible; [or]
(3) coinsurance or a portion of the plan premium, if
the recipients receive medical assistance under the Medicaid
managed care program under Chapter 533, Government Code, or a
Medicaid managed care demonstration project under Section 32.041;
or
(4) a copayment in accordance with Section 32.0642.
(b) Subject to Subsection (d) and except as provided by
Section 32.0642, cost-sharing provisions adopted under this
section shall ensure that families with higher levels of income are
required to pay progressively higher percentages of the cost of the
medical assistance.
SECTION 2. Sections 32.0641(a) and (c), Human Resources
Code, are amended to read as follows:
(a) If the department determines that it is feasible and
cost-effective, and to the extent permitted under Title XIX, Social
Security Act (42 U.S.C. Section 1396 et seq.) and any other
applicable law or regulation or under a federal waiver or other
authorization, the executive commissioner of the Health and Human
Services Commission shall adopt cost-sharing provisions that
require a recipient who chooses a high-cost medical service
provided through a hospital emergency room to pay a [copayment,]
premium payment[,] or other cost-sharing payment other than a
copayment for the high-cost medical service if:
(1) the hospital from which the recipient seeks
service:
(A) performs an appropriate medical screening
and determines that the recipient does not have a condition
requiring emergency medical services;
(B) informs the recipient:
(i) that the recipient does not have a
condition requiring emergency medical services;
(ii) that, if the hospital provides the
nonemergency service, the hospital may require payment of a
[copayment,] premium payment[,] or other cost-sharing payment by
the recipient in advance; and
(iii) of the name and address of a
nonemergency Medicaid provider who can provide the appropriate
medical service without imposing a cost-sharing payment; and
(C) offers to provide the recipient with a
referral to the nonemergency provider to facilitate scheduling of
the service; and
(2) after receiving the information and assistance
described by Subdivision (1) from the hospital, the recipient
chooses to obtain emergency medical services despite having access
to medically acceptable, lower-cost medical services.
(c) If the executive commissioner of the Health and Human
Services Commission adopts a [copayment or other] cost-sharing
payment under Subsection (a), the commission may not reduce
hospital payments to reflect the potential receipt of a
cost-sharing [copayment or other] payment from a recipient
receiving medical services provided through a hospital emergency
room.
SECTION 3. Subchapter B, Chapter 32, Human Resources Code,
is amended by adding Section 32.0642 to read as follows:
Sec. 32.0642. COPAYMENTS. (a) The department shall
require a recipient to pay nominal copayments as follows:
(1) not more than $5 for each hospital outpatient
visit at the time of the visit;
(2) not more than $5 for each medical visit with a
physician at the time of the visit;
(3) up to five percent of the first $300 of the medical
assistance reimbursement rate for an emergency room service at the
time the service is provided; and
(4) 2.5 percent of the medical assistance
reimbursement rate for a prescription drug at the time of receipt,
not to exceed $7.50 per prescription drug.
(b) The department shall, subject to applicable federal
law, require copayments for the following other services under the
medical assistance program:
(1) hospital inpatient services;
(2) laboratory and x-ray services;
(3) transportation services;
(4) home health care services;
(5) community mental health services;
(6) rural health services;
(7) federally qualified health clinic services; and
(8) nurse practitioner services.
(c) The department may establish copayments for a medical
assistance service not specified in this section only if the
copayment is specifically provided for in other law.
(d) Notwithstanding Subsections (a) and (b) and in
accordance with applicable federal law, the department may not
require copayments from the following recipients:
(1) a child who is under 21 years of age;
(2) a pregnant woman if the services relate to the
pregnancy or any other medical condition that may complicate the
pregnancy, including postpartum services provided up to six weeks
after the delivery date;
(3) any person who is an inpatient in a hospital,
long-term care facility, or other medical institution if the person
is required, as a condition of receiving services in the
institution, to spend all of the person's income for medical care
costs, other than a minimal amount for personal needs;
(4) any person who requires emergency services after
the sudden onset of a medical condition that, if left untreated,
would place the person's health in serious jeopardy;
(5) any person when the services or supplies relate to
family planning; and
(6) any person who is enrolled in a Medicaid managed
care plan under Chapter 533, Government Code.
(e) A provider may not impose more than one copayment under
this section for a single encounter with a recipient.
(f) The department shall develop a mechanism by which
medical assistance providers are able to identify recipients under
Subsection (d) from whom a copayment may not be required.
(g) This section does not require a medical assistance
provider to bill or collect from a recipient a copayment required or
authorized under this section. If the provider chooses not to bill
or collect a copayment from a recipient, the department shall
deduct the applicable copayment amount from the reimbursement
payment made to the provider.
SECTION 4. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 5. This Act takes effect September 1, 2011.