By: Nelson S.B. No. 23
(In the Senate - Filed February 9, 2011; February 9, 2011,
read first time and referred to Committee on Finance;
April 20, 2011, reported adversely, with favorable Committee
Substitute by the following vote: Yeas 13, Nays 0; April 20, 2011,
sent to printer.)
COMMITTEE SUBSTITUTE FOR S.B. No. 23 By: Nelson
A BILL TO BE ENTITLED
AN ACT
relating to efficiency, cost-saving, fraud prevention, and funding
measures for certain health and human services and health benefits
programs, including the medical assistance and child health plan
programs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. SEXUAL ASSAULT PROGRAM FUND; FEE IMPOSED ON
CERTAIN SEXUALLY ORIENTED BUSINESSES. (a) Section 102.054,
Business & Commerce Code, is amended to read as follows:
Sec. 102.054. ALLOCATION OF [CERTAIN] REVENUE FOR SEXUAL
ASSAULT PROGRAMS. The comptroller shall deposit the amount [first
$25 million] received from the fee imposed under this subchapter
[in a state fiscal biennium] to the credit of the sexual assault
program fund.
(b) The comptroller of public accounts shall collect the fee
imposed under Section 102.052, Business & Commerce Code, until a
court, in a final judgment upheld on appeal or no longer subject to
appeal, finds Section 102.052, Business & Commerce Code, or its
predecessor statute, to be unconstitutional.
(c) Section 102.055, Business & Commerce Code, is repealed.
(d) This section prevails over any other Act of the 82nd
Legislature, Regular Session, 2011, regardless of the relative
dates of enactment, that purports to amend or repeal Subchapter B,
Chapter 102, Business & Commerce Code, or any provision of Chapter
1206 (H.B. No. 1751), Acts of the 80th Legislature, Regular
Session, 2007.
SECTION 2. ACCESS TO CERTAIN LONG-TERM CARE SERVICES AND
SUPPORTS UNDER MEDICAID PROGRAM. (a) Subchapter B, Chapter 531,
Government Code, is amended by adding Section 531.02181 to read as
follows:
Sec. 531.02181. PROVISION AND COORDINATION OF CERTAIN
ATTENDANT CARE SERVICES. (a) The commission shall ensure that
recipients who are eligible to receive attendant care services
under the community-based alternatives program are first provided
those services, if available, under a Medicaid state plan program,
including the primary home care and community attendant services
programs. The commission may allow a recipient to receive
attendant care services under the community-based alternatives
program only if:
(1) the recipient requires services beyond those that
are available under a Medicaid state plan program; or
(2) the services are not otherwise provided under a
Medicaid state plan program.
(b) The executive commissioner shall adopt rules and
procedures necessary to implement this section, including:
(1) rules and procedures for the coordination of
services between Medicaid state plan programs and the
community-based alternatives program to ensure that recipients'
needs are being met and to prevent duplication of services;
(2) rules and procedures for an automated
authorization system through which case managers authorize the
provision of attendant care services through the Medicaid state
plan program or the community-based alternatives program, as
appropriate, and register the number of hours authorized through
each program; and
(3) billing procedures for attendant care services
provided through the Medicaid state plan program or the
community-based alternatives program, as appropriate.
(b) Subchapter B, Chapter 531, Government Code, is amended
by adding Section 531.0515 to read as follows:
Sec. 531.0515. RISK MANAGEMENT CRITERIA FOR CERTAIN WAIVER
PROGRAMS. (a) In this section, "legally authorized
representative" has the meaning assigned by Section 531.051.
(b) The commission shall consider developing risk
management criteria under home and community-based services waiver
programs designed to allow individuals eligible to receive services
under the programs to assume greater choice and responsibility over
the services and supports the individuals receive.
(c) The commission shall ensure that any risk management
criteria developed under this section include:
(1) a requirement that if an individual to whom
services and supports are to be provided has a legally authorized
representative, the representative must be involved in determining
which services and supports the individual will receive; and
(2) a requirement that if services or supports are
declined, the decision to decline must be clearly documented.
(c) Section 533.0355, Health and Safety Code, is amended by
adding Subsection (h) to read as follows:
(h) The Department of Aging and Disability Services shall
ensure that local mental retardation authorities are informing and
counseling individuals and their legally authorized
representatives, if applicable, about all program and service
options for which the individuals are eligible in accordance with
Section 533.038(d), including options such as the availability and
types of ICF-MR placements for which an individual may be eligible
while the individual is on a department interest list or other
waiting list for other services.
(d) Subchapter D, Chapter 161, Human Resources Code, is
amended by adding Sections 161.084 and 161.085 to read as follows:
Sec. 161.084. MEDICAID SERVICE OPTIONS PUBLIC EDUCATION
INITIATIVE. (a) In this section, "Section 1915(c) waiver program"
has the meaning assigned by Section 531.001, Government Code.
(b) The department, in cooperation with the commission,
shall educate the public on:
(1) the availability of home and community-based
services under a Medicaid state plan program, including the primary
home care and community attendant services programs, and under a
Section 1915(c) waiver program; and
(2) the various service delivery options available
under the Medicaid program, including the consumer direction models
available to recipients under Section 531.051, Government Code.
(c) The department may coordinate the activities under this
section with any other related activity.
Sec. 161.085. INTEREST LIST REPORTING. The department
shall post on the department's Internet website historical data,
categorized by state fiscal year, on the percentages of individuals
who elect to receive services under a program for which the
department maintains an interest list once their names reach the
top of the list.
(e) As soon as practicable after the effective date of this
Act, the executive commissioner of the Health and Human Services
Commission shall apply for and actively pursue, from the federal
Centers for Medicare and Medicaid Services or any other appropriate
federal agency, amendments to the community living assistance and
support services waiver and the home and community-based services
program waiver granted under Section 1915(c) of the federal Social
Security Act (42 U.S.C. Section 1396n(c)) to authorize the
provision of personal attendant services through the programs
operated under those waivers.
SECTION 3. OBJECTIVE ASSESSMENT PROCESSES FOR CERTAIN
MEDICAID SERVICES. (a) Subchapter B, Chapter 531, Government
Code, is amended by adding Sections 531.02417, 531.024171, and
531.024172 to read as follows:
Sec. 531.02417. MEDICAID NURSING SERVICES ASSESSMENTS.
(a) In this section, "acute nursing services" means home health
skilled nursing services, home health aide services, and private
duty nursing services.
(b) The commission shall develop an objective assessment
process for use in assessing a Medicaid recipient's needs for acute
nursing services. The commission shall require that:
(1) the assessment be conducted:
(A) by a state employee or contractor who is not
the person who will deliver any necessary services to the recipient
and is not affiliated with the person who will deliver those
services; and
(B) in a timely manner so as to protect the health
and safety of the recipient by avoiding unnecessary delays in
service delivery; and
(2) the process include:
(A) an assessment of specified criteria and
documentation of the assessment results on a standard form;
(B) an assessment of whether the recipient should
be referred for additional assessments regarding the recipient's
needs for therapy services, as defined by Section 531.024171,
attendant care services, and durable medical equipment; and
(C) completion by the person conducting the
assessment of any documents related to obtaining prior
authorization for necessary nursing services.
(c) The commission shall:
(1) implement the objective assessment process
developed under Subsection (b) within the Medicaid fee-for-service
model and the primary care case management Medicaid managed care
model; and
(2) take necessary actions, including modifying
contracts with managed care organizations under Chapter 533 to the
extent allowed by law, to implement the process within the STAR and
STAR + PLUS Medicaid managed care programs.
(d) The executive commissioner shall adopt rules providing
for a process by which a provider of acute nursing services who
disagrees with the results of the assessment conducted under
Subsection (b) may request and obtain a review of those results.
Sec. 531.024171. THERAPY SERVICES ASSESSMENTS. (a) In
this section, "therapy services" includes occupational, physical,
and speech therapy services.
(b) After implementing the objective assessment process for
acute nursing services as required by Section 531.02417, the
commission shall consider whether implementing an objective
assessment process for assessing the needs of a Medicaid recipient
for therapy services that is comparable to the process required
under Section 531.02417 for acute nursing services would be
feasible and beneficial.
(c) If the commission determines that implementing a
comparable process with respect to one or more types of therapy
services is feasible and would be beneficial, the commission may
implement the process within:
(1) the Medicaid fee-for-service model;
(2) the primary care case management Medicaid managed
care model; and
(3) the STAR and STAR + PLUS Medicaid managed care
programs.
(d) An objective assessment process implemented under this
section must include a process that allows a provider of therapy
services to request and obtain a review of the results of an
assessment conducted as provided by this section that is comparable
to the process implemented under rules adopted under Section
531.02417(d).
Sec. 531.024172. ELECTRONIC VISIT VERIFICATION SYSTEM.
(a) In this section, "acute nursing services" has the meaning
assigned by Section 531.02417.
(b) If it is cost-effective and feasible, the commission
shall implement an electronic visit verification system to
electronically verify and document, through a telephone or
computer-based system, basic information relating to the delivery
of Medicaid acute nursing services, including:
(1) the provider's name;
(2) the recipient's name; and
(3) the date and time the provider begins and ends each
service delivery visit.
(b) Not later than September 1, 2012, the Health and Human
Services Commission shall implement the electronic visit
verification system required by Section 531.024172, Government
Code, as added by this section, if the commission determines that
implementation of that system is cost-effective and feasible.
SECTION 4. ACCESS TO MEDICALLY NECESSARY PRESCRIPTION DRUGS
UNDER MEDICAID MANAGED CARE PROGRAM. (a) Subsection (a), Section
533.005, 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;
(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; and
(16) a requirement that the managed care organization
develop, implement, and maintain an outpatient pharmacy benefit
plan for its enrolled recipients that:
(A) exclusively employs the vendor drug program
formulary or a more cost-effective alternative approved by the
commissioner;
(B) complies with the preferred drug list prior
authorization policies and procedures adopted by the commission
under Chapter 531 or a more cost-effective alternative approved by
the commissioner;
(C) includes rebates negotiated by the managed
care organization with a manufacturer or labeler as defined by
Section 531.070, except that a managed care organization may not
negotiate or obtain a rebate with respect to a product for which the
commission has negotiated or obtained a supplemental rebate; and
(D) complies with Section 531.089.
(b) Chapter 533, Government Code, is amended by adding
Subchapter E to read as follows:
SUBCHAPTER E. MEDICAID MANAGED CARE PRESCRIPTION DRUG COVERAGE
Sec. 533.081. DEFINITIONS. In this subchapter, "step
therapy protocol" or "fail first protocol" means a prescription
drug protocol under which coverage will not be provided under a
managed care plan for a particular drug until requirements of the
plan's coverage policy are met.
Sec. 533.082. APPLICABILITY OF SUBCHAPTER. This subchapter
applies to a managed care organization that contracts with the
commission under this chapter to provide a managed care plan under
the Medicaid program, regardless of the Medicaid managed care model
or arrangement through which that plan is provided.
Sec. 533.083. ESTABLISHMENT OF CERTAIN DRUG PROTOCOLS. The
commission may allow a managed care organization to establish for
purposes of the managed care plan offered by the organization a step
therapy protocol or fail first protocol only under the following
conditions:
(1) for a prescription drug restricted by the
protocol, the organization must provide to the prescribing
physician a clear and convenient process for expeditiously
requesting from the organization an override of the restriction;
(2) the organization shall grant an override requested
using the process required by Subdivision (1) not later than 24
hours after the request is made if the requesting physician can
demonstrate that the treatment required under the protocol:
(A) has previously been ineffective in treating
the enrollee's condition;
(B) is expected to be ineffective based on the
known relevant physical or mental characteristics of the enrollee
and known characteristics of the drug regimen; or
(C) will cause or will likely cause an adverse
reaction or other physical harm to the enrollee; and
(3) the treatment provided in accordance with the
protocol is required to be provided for not more than 14 days if, on
the expiration of that period, the prescribing physician deems the
treatment under the protocol to be clinically ineffective for the
enrollee.
(c) Subsection (a), Section 32.046, Human Resources Code,
is amended to read as follows:
(a) The department shall adopt rules governing sanctions
and penalties that apply to a provider in the vendor drug program or
enrolled as a network pharmacy provider of a managed care
organization or its subcontractor who submits an improper claim for
reimbursement under the program.
SECTION 5. ABOLISHING STATE KIDS INSURANCE PROGRAM.
(a) Section 62.101, Health and Safety Code, is amended by adding
Subsection (a-1) to read as follows:
(a-1) A child who is the dependent of an employee of an
agency of this state and who meets the requirements of Subsection
(a) may be eligible for health benefits coverage in accordance with
42 U.S.C. Section 1397jj(b)(6) and any other applicable law or
regulations.
(b) Sections 1551.159 and 1551.312, Insurance Code, are
repealed.
(c) The State Kids Insurance Program operated by the
Employees Retirement System of Texas is abolished on the effective
date of this Act. The board of trustees of the system may not
provide dependent child coverage under the program after the first
annual open enrollment period that begins under the employee group
benefits program after the effective date of this Act.
(d) The Health and Human Services Commission, in
cooperation with the Employees Retirement System of Texas, shall
establish a process to ensure the automatic enrollment of eligible
children in the child health plan program established under Chapter
62, Health and Safety Code, on or before the date those children are
scheduled to stop receiving dependent child coverage under the
State Kids Insurance Program, as provided by Subsection (c) of this
section. The commission shall modify any applicable administrative
procedures to ensure that children described by this subsection
maintain continuous health benefits coverage while transitioning
from enrollment in the State Kids Insurance Program to enrollment
in the child health plan program.
SECTION 6. PREVENTION OF CRIMINAL OR FRAUDULENT CONDUCT BY
CERTAIN FACILITIES, PROVIDERS, AND RECIPIENTS. (a) Section
31.0325, Human Resources Code, is amended to read as follows:
Sec. 31.0325. FRAUD PREVENTION [ELECTRONIC IMAGING]
PROGRAM. [(a)] In conjunction with other appropriate agencies,
the department [by rule] shall develop and implement a program to
prevent welfare fraud by using cost-effective technology to:
(1) confirm the identity [a type of electronic
fingerprint-imaging or photo-imaging] of adult and teen parent
applicants for and adult and teen parent recipients of financial
assistance under this chapter or supplemental nutrition assistance
[food stamp benefits] under Chapter 33; and
(2) prevent the provision of duplicate benefits to a
person under the financial assistance program or under the
Supplemental Nutrition Assistance Program, as applicable.
[(b) In adopting rules under this section, the department
shall:
[(1) provide for an exemption from the electronic
imaging requirements of Subsection (a) for a person who is elderly
or disabled if the department determines that compliance with those
requirements would cause an undue burden to the person;
[(2) establish criteria for an exemption under
Subdivision (1); and
[(3) ensure that any electronic imaging performed by
the department is strictly confidential and is used only to prevent
fraud by adult and teen parent recipients of financial assistance
or food stamp benefits.
[(c) The department shall:
[(1) establish the program in conjunction with an
electronic benefits transfer program;
[(2) use an imaging system; and
[(3) provide for gradual implementation of this
section by selecting specific counties or areas of the state as test
sites.
[(d) Each fiscal quarter, the department shall submit to the
governor and the legislature a report on the status and progress of
the programs in the test sites selected under Subsection (c)(3).]
(b) The Health and Human Services Commission shall make
reasonable efforts to ensure the prevention of criminal or
fraudulent conduct by health care facilities and providers,
including facilities and providers under the Medicaid program, and
recipients of benefits under programs administered by the
commission.
SECTION 7. STREAMLINING OF AND UTILIZATION MANAGEMENT IN
MEDICAID LONG-TERM CARE WAIVER PROGRAMS. (a) Section 161.077,
Human Resources Code, as added by Chapter 759 (S.B. 705), Acts of
the 81st Legislature, Regular Session, 2009, is redesignated as
Section 161.081, Human Resources Code, and amended to read as
follows:
Sec. 161.081 [161.077]. LONG-TERM CARE MEDICAID WAIVER
PROGRAMS: STREAMLINING AND UNIFORMITY. (a) In this section,
"Section 1915(c) waiver program" has the meaning assigned by
Section 531.001, Government Code.
(b) The department, in consultation with the commission,
shall streamline the administration of and delivery of services
through Section 1915(c) waiver programs. In implementing this
subsection, the department, subject to Subsection (c), may consider
implementing the following streamlining initiatives:
(1) reducing the number of forms used in administering
the programs;
(2) revising program provider manuals and training
curricula;
(3) consolidating service authorization systems;
(4) eliminating any physician signature requirements
the department considers unnecessary;
(5) standardizing individual service plan processes
across the programs; [and]
(6) if feasible:
(A) concurrently conducting program
certification and billing audit and review processes and other
related audit and review processes;
(B) streamlining other billing and auditing
requirements;
(C) eliminating duplicative responsibilities
with respect to the coordination and oversight of individual care
plans for persons receiving waiver services; and
(D) streamlining cost reports and other cost
reporting processes; and
(7) any other initiatives that will increase
efficiencies in the programs.
(c) The department shall ensure that actions taken under
Subsection (b) [this section] do not conflict with any requirements
of the commission under Section 531.0218, Government Code.
(d) The department and the commission shall jointly explore
the development of uniform licensing and contracting standards that
would:
(1) apply to all contracts for the delivery of Section
1915(c) waiver program services;
(2) promote competition among providers of those
program services; and
(3) integrate with other department and commission
efforts to streamline and unify the administration and delivery of
the program services, including those required by this section or
Section 531.0218, Government Code.
(b) Subchapter D, Chapter 161, Human Resources Code, is
amended by adding Section 161.082 to read as follows:
Sec. 161.082. LONG-TERM CARE MEDICAID WAIVER PROGRAMS:
UTILIZATION REVIEW. (a) In this section, "Section 1915(c) waiver
program" has the meaning assigned by Section 531.001, Government
Code.
(b) The department shall perform a utilization review of
services in all Section 1915(c) waiver programs. The utilization
review must include reviewing program recipients' levels of care
and any plans of care for those recipients that exceed service level
thresholds established in the applicable waiver program
guidelines.
SECTION 8. ELECTRONIC VISIT VERIFICATION SYSTEM FOR
MEDICAID PROGRAM. Subchapter D, Chapter 161, Human Resources Code,
is amended by adding Section 161.086 to read as follows:
Sec. 161.086. ELECTRONIC VISIT VERIFICATION SYSTEM. If it
is cost-effective, the department shall implement an electronic
visit verification system under appropriate programs administered
by the department under the Medicaid program that allows providers
to electronically verify and document basic information relating to
the delivery of services, including:
(1) the provider's name;
(2) the recipient's name;
(3) the date and time the provider begins and ends the
delivery of services; and
(4) the location of service delivery.
SECTION 9. REPORT ON LONG-TERM CARE SERVICES. (a) In this
section:
(1) "Long-term care services" has the meaning assigned
by Section 22.0011, Human Resources Code.
(2) "Medical assistance program" means the medical
assistance program administered under Chapter 32, Human Resources
Code.
(3) "Nursing facility" means a convalescent or nursing
home or related institution licensed under Chapter 242, Health and
Safety Code.
(b) The Health and Human Services Commission, in
cooperation with the Department of Aging and Disability Services,
shall prepare a written report regarding individuals who receive
long-term care services in nursing facilities under the medical
assistance program. The report shall use existing data and
information to identify:
(1) the reasons medical assistance recipients of
long-term care services are placed in nursing facilities as opposed
to being provided long-term care services in home or
community-based settings;
(2) the types of medical assistance services
recipients residing in nursing facilities typically receive and
where and from whom those services are typically provided;
(3) the community-based services and supports
available under a Medicaid state plan program, including the
primary home care and community attendant services programs, or
under a medical assistance waiver granted in accordance with
Section 1915(c) of the federal Social Security Act (42 U.S.C.
Section 1396n(c)) for which recipients residing in nursing
facilities may be eligible; and
(4) ways to expedite recipients' access to
community-based services and supports identified under Subdivision
(3) of this subsection for which interest lists or other waiting
lists exist.
(c) Not later than September 1, 2012, the Health and Human
Services Commission shall submit the report described by Subsection
(b) of this section, together with the commission's
recommendations, to the governor, the Legislative Budget Board, the
Senate Committee on Finance, the Senate Committee on Health and
Human Services, the House Appropriations Committee, and the House
Human Services Committee. The recommendations must address options
for expediting access to community-based services and supports by
recipients described by Subdivision (3), Subsection (b) of this
section.
SECTION 10. REGULATION AND OVERSIGHT OF CERTAIN FACILITIES
AND CARE PROVIDERS. (a) In this section, "executive commissioner"
means the executive commissioner of the Health and Human Services
Commission.
(b) The executive commissioner may adopt rules designed to:
(1) enhance the quality of services provided by
certain community-based services agencies through:
(A) the adoption of minimum standards,
additional training requirements, and other similar means; and
(B) the imposition of additional oversight
requirements and limitations on those agencies and home and
community support services agency administrators, and the
prescribing of the duties and responsibilities of those
administrators.
(c) The executive commissioner may adopt rules relating to
nursing institutions regarding application requirements for an
initial or renewal license under Chapter 242, Health and Safety
Code, that are designed to evaluate the applicant's compliance with
applicable laws.
(d) The executive commissioner may adopt rules designed to
prevent criminal or fraudulent conduct by facilities and providers
engaged in the provision of health and human services in this state,
including rules providing for reviewing criminal history
information.
(e) The Department of Aging and Disability Services,
through rules adopted by the executive commissioner, may implement
strategies designed to enhance adult day-care facilities'
compliance with applicable laws and regulations.
SECTION 11. ACCOUNTABILITY AND STANDARDS UNDER MEDICAID
MANAGED CARE PROGRAM. (a) Section 533.002, Government Code, is
amended to read as follows:
Sec. 533.002. PURPOSE. The commission shall implement the
Medicaid managed care program as part of the health care delivery
system developed under former Chapter 532 as it existed on August
31, 2001, by contracting with managed care organizations in a
manner that, to the extent possible:
(1) improves the health of Texans by:
(A) emphasizing prevention;
(B) promoting continuity of care; and
(C) providing a medical home for recipients;
(2) ensures that each recipient receives high quality,
comprehensive health care services in the recipient's local
community;
(3) encourages the training of and access to primary
care physicians and providers;
(4) maximizes cooperation with existing public health
entities, including local departments of health;
(5) provides incentives to managed care organizations
to improve the quality of health care services for recipients by
providing value-added services; and
(6) reduces administrative and other nonfinancial
barriers for recipients in obtaining health care services.
(b) Section 533.0025, Government Code, is amended by
amending Subsection (e) and adding Subsection (f) to read as
follows:
(e) In the expansion of the health maintenance organization
model of Medicaid managed care into South Texas, the executive
commissioner shall determine the most effective alignment of
managed care service delivery areas for each model of managed care
in Duval, Hidalgo, Jim Hogg, Cameron, Maverick, McMullen, Starr,
Webb, Willacy, and Zapata Counties. In developing the service
delivery areas for each managed care model, the executive
commissioner shall consider the number of lives impacted, the usual
source of health care services for residents of these counties, and
other factors that impact the delivery of health care services in
this 10-county area [Notwithstanding Subsection (b)(1), the
commission may not provide medical assistance using a health
maintenance organization in Cameron County, Hidalgo County, or
Maverick County].
(f) Managed care organizations that operate within the
10-county South Texas service delivery area must maintain a medical
director within the service delivery area. The medical director
may be a managed care organization employee or under contract with
the managed care organization. The duties of the medical director
in the service delivery area must include oversight and management
of the managed care organization medical necessity determination
process. The managed care organization medical director must be
available for peer-to-peer discussions about managed care
organization medical necessity determinations and other managed
care organization clinical policies. The managed care organization
medical director may not be affiliated with any hospital, clinic,
or other health care related institution or business that operates
within the service delivery area.
(c) Subchapter A, Chapter 533, Government Code, is amended
by adding Sections 533.0027, 533.0028, and 533.0029 to read as
follows:
Sec. 533.0027. PROCEDURES TO ALLOW CERTAIN CHILDREN TO
CHANGE MANAGED CARE PLANS. The commission shall ensure that all
children who reside in the same household may, at the family's
election, be enrolled in the same health plan.
Sec. 533.0028. EVALUATION OF CERTAIN MEDICAID STAR + PLUS
MANAGED CARE PROGRAM SERVICES. The external quality review
organization shall periodically conduct studies and surveys to
assess the quality of care and satisfaction with health care
services provided to enrollees in the Medicaid Star + Plus managed
care program who are eligible to receive health care benefits under
both the Medicaid and Medicare programs.
Sec. 533.0029. PROMOTION AND PRINCIPLES OF
PATIENT-CENTERED MEDICAL HOMES FOR RECIPIENTS. (a) For purposes
of this section, a "patient-centered medical home" means a medical
relationship:
(1) between a primary care physician and a child or
adult patient in which the physician:
(A) provides comprehensive primary care to the
patient; and
(B) facilitates partnerships between the
physician, the patient, acute care and other care providers, and,
when appropriate, the patient's family; and
(2) that encompasses the following primary
principles:
(A) the patient has an ongoing relationship with
the physician, who is trained to be the first contact for the
patient and to provide continuous and comprehensive care to the
patient;
(B) the physician leads a team of individuals at
the practice level who are collectively responsible for the ongoing
care of the patient;
(C) the physician is responsible for providing
all of the care the patient needs or for coordinating with other
qualified providers to provide care to the patient throughout the
patient's life, including preventive care, acute care, chronic
care, and end-of-life care;
(D) the patient's care is coordinated across
health care facilities and the patient's community and is
facilitated by registries, information technology, and health
information exchange systems to ensure that the patient receives
care when and where the patient wants and needs the care and in a
culturally and linguistically appropriate manner; and
(E) quality and safe care is provided.
(b) The commission shall, to the extent possible, work to
ensure that managed care organizations:
(1) promote the development of patient-centered
medical homes for recipients; and
(2) provide payment incentives for providers that meet
the requirements of a patient-centered medical home.
(d) Section 533.003, Government Code, is amended to read as
follows:
Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS.
(a) In awarding contracts to managed care organizations, the
commission shall:
(1) give preference to organizations that have
significant participation in the organization's provider network
from each health care provider in the region who has traditionally
provided care to Medicaid and charity care patients;
(2) give extra consideration to organizations that
agree to assure continuity of care for at least three months beyond
the period of Medicaid eligibility for recipients;
(3) consider the need to use different managed care
plans to meet the needs of different populations; [and]
(4) consider the ability of organizations to process
Medicaid claims electronically; and
(5) give extra consideration in each service delivery
area to an organization that:
(A) is locally owned, managed, and operated, if
one exists; and
(B) notwithstanding Section 533.004 or any other
law, is not owned or operated by and does not have a contract,
agreement, or other arrangement with a hospital district in the
region.
(b) For purposes of this section, a managed care
organization is considered to be locally owned if the organization
is formed under the laws of this state and is headquartered in and
operates in, and the majority of whose staff resides in, the region
where the organization provides health care services.
(e) Subsection (a), Section 533.005, 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;
(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) subject to Subdivision (17), 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) subject to Subdivision (17), 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;
(16) a requirement that the managed care organization
ensure that employees of the organization who hold management
positions, including patient-care coordinators and provider and
recipient support services personnel, are located in the region
where the organization provides health care services;
(17) a requirement that a medical director who is
authorized to make medical necessity determinations is available in
the region where the organization provides health care services;
(18) a requirement that the managed care organization
develop and establish a process for responding to provider appeals
in the region where the organization provides health care services;
(19) a requirement that the managed care organization
provide special programs and materials for recipients with limited
English proficiency or low literacy skills;
(20) a requirement that the managed care organization
develop and submit to the commission, before the organization
begins to provide health care services to recipients, a
comprehensive plan that describes how the organization's provider
network will provide recipients sufficient access to:
(A) preventive care;
(B) primary care;
(C) specialty care;
(D) after-hours urgent care; and
(E) chronic care;
(21) a requirement that the managed care organization
demonstrate to the commission, before the organization begins to
provide health care services to recipients, that:
(A) the organization's provider network has the
capacity to serve the number of recipients expected to enroll in a
managed care plan offered by the organization;
(B) the organization's provider network
includes:
(i) a sufficient number of primary care
providers;
(ii) a sufficient variety of provider
types; and
(iii) providers located throughout the
region where the organization will provide health care services;
and
(C) health care services will be accessible to
recipients through the organization's provider network to the same
extent that health care services would be available to recipients
under a fee-for-service or primary care case management model of
Medicaid managed care; and
(22) a requirement that the managed care organization
develop a monitoring program for measuring the quality of the
health care services provided by the organization's provider
network that:
(A) incorporates the National Committee for
Quality Assurance's Healthcare Effectiveness Data and Information
Set (HEDIS) measures;
(B) focuses on measuring outcomes; and
(C) includes the collection and analysis of
clinical data relating to prenatal care, preventive care, mental
health care, and the treatment of acute and chronic health
conditions and substance abuse.
(f) Subchapter A, Chapter 533, Government Code, is amended
by adding Section 533.0066 to read as follows:
Sec. 533.0066. PROVIDER INCENTIVES. The commission shall,
to the extent possible, work to ensure that managed care
organizations provide payment incentives to health care providers
in the organizations' networks whose performance in promoting
recipients' use of preventive services exceeds minimum established
standards.
(g) Section 533.0071, Government Code, is amended to read as
follows:
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission
shall make every effort to improve the administration of contracts
with managed care organizations. To improve the administration of
these contracts, the commission shall:
(1) ensure that the commission has appropriate
expertise and qualified staff to effectively manage contracts with
managed care organizations under the Medicaid managed care program;
(2) evaluate options for Medicaid payment recovery
from managed care organizations if the enrollee dies or is
incarcerated or if an enrollee is enrolled in more than one state
program or is covered by another liable third party insurer;
(3) maximize Medicaid payment recovery options by
contracting with private vendors to assist in the recovery of
capitation payments, payments from other liable third parties, and
other payments made to managed care organizations with respect to
enrollees who leave the managed care program;
(4) decrease the administrative burdens of managed
care for the state, the managed care organizations, and the
providers under managed care networks to the extent that those
changes are compatible with state law and existing Medicaid managed
care contracts, including decreasing those burdens by:
(A) where possible, decreasing the duplication
of administrative reporting requirements for the managed care
organizations, such as requirements for the submission of encounter
data, quality reports, historically underutilized business
reports, and claims payment summary reports;
(B) allowing managed care organizations to
provide updated address information directly to the commission for
correction in the state system;
(C) promoting consistency and uniformity among
managed care organization policies, including policies relating to
the preauthorization process, lengths of hospital stays, filing
deadlines, levels of care, and case management services; [and]
(D) reviewing the appropriateness of primary
care case management requirements in the admission and clinical
criteria process, such as requirements relating to including a
separate cover sheet for all communications, submitting
handwritten communications instead of electronic or typed review
processes, and admitting patients listed on separate
notifications; and
(E) providing a single portal through which
providers in any managed care organization's provider network may
submit claims and prior authorization requests and obtain
information; and
(5) reserve the right to amend the managed care
organization's process for resolving provider appeals of denials
based on medical necessity to include an independent review process
established by the commission for final determination of these
disputes.
SECTION 12. FEDERAL AUTHORIZATION. Subject to the
requirements of Subsection (e), Section 2 of this Act, 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 13. REPORT TO LEGISLATURE. Not later than December
1, 2013, the Health and Human Services Commission shall submit a
report to the legislature regarding the commission's work to ensure
that Medicaid managed care organizations promote the development of
patient-centered medical homes for recipients of medical
assistance as required under Section 533.0029, Government Code, as
added by this Act.
SECTION 14. CONTRACTING REQUIREMENTS. The Health and Human
Services Commission shall, 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 the effective date of
this Act, include the provisions required by Subsection (a),
Section 533.005, Government Code, as amended by this Act.
SECTION 15. EFFECTIVE DATE. This Act takes effect
September 1, 2011.
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