By: Nelson, Patrick S.B. No. 7
(In the Senate - Filed January 16, 2013; January 28, 2013,
read first time and referred to Committee on Health and Human
Services; March 5, 2013, reported adversely, with favorable
Committee Substitute by the following vote: Yeas 8, Nays 0;
March 5, 2013, sent to printer.)
COMMITTEE SUBSTITUTE FOR S.B. No. 7 By: Nelson
A BILL TO BE ENTITLED
AN ACT
relating to improving the delivery and quality of certain health
and human services, including the delivery and quality of Medicaid
acute care services and long-term services and supports.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. DELIVERY SYSTEM REDESIGN FOR THE PROVISION OF ACUTE CARE
SERVICES AND LONG-TERM SERVICES AND SUPPORTS TO INDIVIDUALS WITH
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
SECTION 1.01. Subtitle I, Title 4, Government Code, is
amended by adding Chapter 534 to read as follows:
CHAPTER 534. SYSTEM REDESIGN FOR DELIVERY OF MEDICAID ACUTE CARE
SERVICES AND LONG-TERM SERVICES AND SUPPORTS TO PERSONS WITH
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 534.001. DEFINITIONS. In this chapter:
(1) "Advisory committee" means the Intellectual and
Developmental Disability System Redesign Advisory Committee
established under Section 534.053.
(2) "Basic attendant services" means assistance with
the activities of daily living, including instrumental activities
of daily living, provided to an individual because of a physical,
cognitive, or behavioral limitation related to the individual's
disability or chronic health condition.
(3) "Department" means the Department of Aging and
Disability Services.
(4) "Habilitation services" includes assistance
provided to an individual with acquiring, retaining, or improving:
(A) skills related to the activities of daily
living; and
(B) the social and adaptive skills necessary to
enable the individual to live and fully participate in the
community.
(5) "ICF-IID" means the Medicaid program serving
individuals with intellectual and developmental disabilities who
receive care in intermediate care facilities other than a state
supported living center.
(6) "ICF-IID program" means a program under the
Medicaid program serving individuals with intellectual and
developmental disabilities who reside in and receive care from:
(A) intermediate care facilities licensed under
Chapter 252, Health and Safety Code; or
(B) community-based intermediate care facilities
operated by local intellectual and developmental disability
authorities.
(7) "Local intellectual and developmental disability
authority" means a local mental retardation authority described by
Section 533.035, Health and Safety Code.
(8) "Managed care organization," "managed care plan,"
and "potentially preventable event" have the meanings assigned
under Section 536.001.
(9) "Medicaid program" means the medical assistance
program established under Chapter 32, Human Resources Code.
(10) "Medicaid waiver program" means only the
following programs that are authorized under Section 1915(c) of the
federal Social Security Act (42 U.S.C. Section 1396n(c)) for the
provision of services to persons with intellectual and
developmental disabilities:
(A) the community living assistance and support
services (CLASS) waiver program;
(B) the home and community-based services (HCS)
waiver program;
(C) the deaf-blind with multiple disabilities
(DBMD) waiver program; and
(D) the Texas home living (TxHmL) waiver program.
(11) "State supported living center" has the meaning
assigned by Section 531.002, Health and Safety Code.
Sec. 534.002. CONFLICT WITH OTHER LAW. To the extent of a
conflict between a provision of this chapter and another state law,
the provision of this chapter controls.
SUBCHAPTER B. ACUTE CARE SERVICES AND LONG-TERM SERVICES AND
SUPPORTS SYSTEM
Sec. 534.051. ACUTE CARE SERVICES AND LONG-TERM SERVICES
AND SUPPORTS SYSTEM FOR INDIVIDUALS WITH INTELLECTUAL AND
DEVELOPMENTAL DISABILITIES. In accordance with this chapter, the
commission and the department shall jointly design and implement an
acute care services and long-term services and supports system for
individuals with intellectual and developmental disabilities that
supports the following goals:
(1) provide Medicaid services to more individuals in a
cost-efficient manner by providing the type and amount of services
most appropriate to the individuals' needs;
(2) improve individuals' access to services and
supports by ensuring that the individuals receive information about
all available programs and services, including employment and least
restrictive housing assistance, and how to apply for the programs
and services;
(3) improve the assessment of individuals' needs and
available supports;
(4) promote person-centered planning, self-direction,
self-determination, community inclusion, and customized gainful
employment;
(5) promote individualized budgeting based on an
assessment of an individual's needs and person-centered planning;
(6) promote integrated service coordination of acute
care services and long-term services and supports;
(7) improve acute care and long-term services and
supports outcomes, including reducing unnecessary
institutionalization and potentially preventable events;
(8) promote high-quality care;
(9) provide fair hearing and appeals processes in
accordance with applicable federal law; and
(10) ensure the availability of a local safety net
provider and local safety net services.
Sec. 534.052. IMPLEMENTATION OF SYSTEM REDESIGN. The
commission and department shall, in consultation with the advisory
committee, jointly implement the acute care services and long-term
services and supports system for individuals with intellectual and
developmental disabilities in the manner and in the stages
described in this chapter.
Sec. 534.053. INTELLECTUAL AND DEVELOPMENTAL DISABILITY
SYSTEM REDESIGN ADVISORY COMMITTEE. (a) The Intellectual and
Developmental Disability System Redesign Advisory Committee is
established to advise the commission and the department on the
implementation of the acute care services and long-term services
and supports system redesign under this chapter. Subject to
Subsection (b), the executive commissioner and the commissioner of
the department shall jointly appoint members of the advisory
committee who are stakeholders from the intellectual and
developmental disabilities community, including:
(1) individuals with intellectual and developmental
disabilities who are recipients of Medicaid waiver program services
or individuals who are advocates of those recipients;
(2) representatives of health care providers
participating in a Medicaid managed care program, including:
(A) physicians who are primary care providers and
physicians who are specialty care providers;
(B) nonphysician mental health professionals;
and
(C) providers of long-term services and
supports, including direct service workers;
(3) representatives of entities with responsibilities
for the delivery of Medicaid long-term services and supports or
other Medicaid program service delivery, including:
(A) independent living centers;
(B) area agencies on aging;
(C) aging and disability resource centers
established under the Aging and Disability Resource Center
initiative funded in part by the federal Administration on Aging
and the Centers for Medicare and Medicaid Services;
(D) community mental health and intellectual
disability centers; and
(E) the NorthSTAR Behavioral Health Program
provided under Chapter 534, Health and Safety Code; and
(4) representatives of managed care organizations
contracting with the state to provide services to individuals with
intellectual and developmental disabilities.
(b) To the greatest extent possible, the executive
commissioner and the commissioner of the department shall appoint
members of the advisory committee who reflect the geographic
diversity of the state and include members who represent rural
Medicaid program recipients.
(c) The executive commissioner shall appoint the presiding
officer of the advisory committee.
(d) The advisory committee must meet at least quarterly or
more frequently if the presiding officer determines that it is
necessary to address planning and development needs related to
implementation of the acute care services and long-term services
and supports system.
(e) A member of the advisory committee serves without
compensation. A member of the advisory committee who is a Medicaid
program recipient or the relative of a Medicaid program recipient
is entitled to a per diem allowance and reimbursement at rates
established in the General Appropriations Act.
(f) The advisory committee is subject to the requirements of
Chapter 551.
(g) On January 1, 2024:
(1) the advisory committee is abolished; and
(2) this section expires.
Sec. 534.054. ANNUAL REPORT ON IMPLEMENTATION. (a) Not
later than December 1 of each year, the commission shall submit a
report to the legislature regarding:
(1) the implementation of the system required by this
chapter, including appropriate information regarding the provision
of acute care services and long-term services and supports to
individuals with intellectual and developmental disabilities under
the Medicaid program; and
(2) recommendations, including recommendations
regarding appropriate statutory changes to facilitate the
implementation.
(b) This section expires January 1, 2024.
SUBCHAPTER C. STAGE ONE: PROGRAMS TO IMPROVE SERVICE
DELIVERY MODELS
Sec. 534.101. DEFINITIONS. In this subchapter:
(1) "Capitation" means a method of compensating a
provider on a monthly basis for providing or coordinating the
provision of a defined set of services and supports that is based on
a predetermined payment per services recipient.
(2) "Provider" means a person with whom the commission
contracts for the provision of long-term services and supports
under the Medicaid program to a specific population based on
capitation.
Sec. 534.102. PILOT PROGRAMS TO TEST MANAGED CARE
STRATEGIES BASED ON CAPITATION. The commission and the department
may develop and implement pilot programs in accordance with this
subchapter to test one or more service delivery models involving a
managed care strategy based on capitation to deliver long-term
services and supports under the Medicaid program to individuals
with intellectual and developmental disabilities.
Sec. 534.103. STAKEHOLDER INPUT. As part of developing and
implementing a pilot program under this subchapter, the department
shall develop a process to receive and evaluate input from
statewide stakeholders and stakeholders from the region of the
state in which the pilot program will be implemented.
Sec. 534.104. MANAGED CARE STRATEGY PROPOSALS; PILOT
PROGRAM SERVICE PROVIDERS. (a) The department shall identify
private services providers that are good candidates to develop a
service delivery model involving a managed care strategy based on
capitation and to test the model in the provision of long-term
services and supports under the Medicaid program to individuals
with intellectual and developmental disabilities through a pilot
program established under this subchapter.
(b) The department shall solicit managed care strategy
proposals from the private services providers identified under
Subsection (a).
(c) A managed care strategy based on capitation developed
for implementation through a pilot program under this subchapter
must be designed to:
(1) increase access to long-term services and
supports;
(2) improve quality of acute care services and
long-term services and supports;
(3) promote meaningful outcomes by using
person-centered planning, individualized budgeting, and
self-determination, and promote community inclusion and customized
gainful employment;
(4) promote integrated service coordination of acute
care services and long-term services and supports;
(5) promote efficiency and the best use of funding;
(6) promote the placement of an individual in housing
that is the least restrictive setting appropriate to the
individual's needs;
(7) promote employment assistance and supported
employment;
(8) provide fair hearing and appeals processes in
accordance with applicable federal law; and
(9) promote sufficient flexibility to achieve the
goals listed in this section through the pilot program.
(d) The department, in consultation with the advisory
committee, shall evaluate each submitted managed care strategy
proposal and determine whether:
(1) the proposed strategy satisfies the requirements
of this section; and
(2) the private services provider that submitted the
proposal has a demonstrated ability to provide the long-term
services and supports appropriate to the individuals who will
receive services through the pilot program based on the proposed
strategy, if implemented.
(e) Based on the evaluation performed under Subsection (d),
the department may select as pilot program service providers one or
more private services providers.
(f) For each pilot program service provider, the department
shall develop and implement a pilot program. Under a pilot program,
the pilot program service provider shall provide long-term services
and supports under the Medicaid program to persons with
intellectual and developmental disabilities to test its managed
care strategy based on capitation.
(g) The department shall analyze information provided by
the pilot program service providers and any information collected
by the department during the operation of the pilot programs for
purposes of making a recommendation about a system of programs and
services for implementation through future state legislation or
rules.
Sec. 534.105. PILOT PROGRAM: MEASURABLE GOALS. (a) The
department, in consultation with the advisory committee, shall
identify measurable goals to be achieved by each pilot program
implemented under this subchapter. The identified goals must:
(1) align with information that will be collected
under Section 534.108(a); and
(2) be designed to improve the quality of outcomes for
individuals receiving services through the pilot program.
(b) The department, in consultation with the advisory
committee, shall propose specific strategies for achieving the
identified goals. A proposed strategy may be evidence-based if
there is an evidence-based strategy available for meeting the pilot
program's goals.
Sec. 534.106. IMPLEMENTATION, LOCATION, AND DURATION.
(a) The commission and the department shall implement any pilot
programs established under this subchapter not later than September
1, 2016.
(b) A pilot program established under this subchapter must
operate for not less than 24 months, except that a pilot program may
cease operation before the expiration of 24 months if the pilot
program service provider terminates the contract with the
commission before the agreed-to termination date.
(c) A pilot program established under this subchapter shall
be conducted in one or more regions selected by the department.
Sec. 534.107. COORDINATING SERVICES. In providing
long-term services and supports under the Medicaid program to an
individual with intellectual or developmental disabilities, a
pilot program service provider shall:
(1) coordinate through the pilot program
institutional and community-based services available to the
individual, including services provided through:
(A) a facility licensed under Chapter 252, Health
and Safety Code;
(B) a Medicaid waiver program; or
(C) a community-based ICF-IID operated by local
authorities;
(2) collaborate with managed care organizations to
provide integrated coordination of acute care services and
long-term services and supports, including discharge planning from
acute care services to community-based long-term services and
supports;
(3) have a process for preventing inappropriate
institutionalizations of individuals; and
(4) accept the risk of inappropriate
institutionalizations of individuals previously residing in
community settings.
Sec. 534.108. PILOT PROGRAM INFORMATION. (a) The
commission and the department shall collect and compute the
following information with respect to each pilot program
implemented under this subchapter to the extent it is available:
(1) the difference between the average monthly cost
per person for all acute care services and long-term services and
supports received by individuals participating in the pilot program
while the program is operating, including services provided through
the pilot program and other services with which pilot program
services are coordinated as described by Section 534.107, and the
average cost per person for all services received by the
individuals before the operation of the pilot program;
(2) the percentage of individuals receiving services
through the pilot program who begin receiving services in a
nonresidential setting instead of from a facility licensed under
Chapter 252, Health and Safety Code, or any other residential
setting;
(3) the difference between the percentage of
individuals receiving services through the pilot program who live
in non-provider-owned housing during the operation of the pilot
program and the percentage of individuals receiving services
through the pilot program who lived in non-provider-owned housing
before the operation of the pilot program;
(4) the difference between the average total Medicaid
cost, by level of need, for individuals in various residential
settings receiving services through the pilot program during the
operation of the program and the average total Medicaid cost, by
level of need, for those individuals before the operation of the
program;
(5) the difference between the percentage of
individuals receiving services through the pilot program who obtain
and maintain employment in meaningful, integrated settings during
the operation of the program and the percentage of individuals
receiving services through the program who obtained and maintained
employment in meaningful, integrated settings before the operation
of the program;
(6) the difference between the percentage of
individuals receiving services through the pilot program whose
behavioral, medical, life-activity, and other personal outcomes
have improved since the beginning of the program and the percentage
of individuals receiving services through the program whose
behavioral, medical, life-activity, and other personal outcomes
improved before the operation of the program, as measured over a
comparable period; and
(7) a comparison of the overall client satisfaction
with services received through the pilot program, including for
individuals who leave the program after a determination is made in
the individuals' cases at hearings or on appeal, and the overall
client satisfaction with services received before the individuals
entered the pilot program.
(b) The pilot program service provider shall collect any
information described by Subsection (a) that is available to the
provider and provide the information to the department and the
commission not later than the 30th day before the date the program's
operation concludes.
(c) In addition to the information described by Subsection
(a), the pilot program service provider shall collect any
information specified by the department for use by the department
in making an evaluation under Section 534.104(g).
(d) On or before December 1, 2016, and December 1, 2017, the
commission and the department, in consultation with the advisory
committee, shall review and evaluate the progress and outcomes of
each pilot program implemented under this subchapter and submit a
report to the legislature during the operation of the pilot
programs. Each report must include recommendations for program
improvement and continued implementation.
Sec. 534.109. PERSON-CENTERED PLANNING. The commission, in
cooperation with the department, shall ensure that each individual
with intellectual or developmental disabilities who receives
services and supports under the Medicaid program through a pilot
program established under this subchapter, or the individual's
legally authorized representative, has access to a facilitated,
person-centered plan that identifies outcomes for the individual
and drives the development of the individualized budget. The
consumer direction model, as defined by Section 531.051, may be an
outcome of the plan.
Sec. 534.110. TRANSITION BETWEEN PROGRAMS. The commission
shall ensure that there is a comprehensive plan for transitioning
the provision of Medicaid program benefits between a Medicaid
waiver program and a pilot program under this subchapter to protect
continuity of care.
Sec. 534.111. CONCLUSION OF PILOT PROGRAMS; EXPIRATION. On
September 1, 2018:
(1) each pilot program established under this
subchapter that is still in operation must conclude; and
(2) this subchapter expires.
SUBCHAPTER D. STAGE ONE: PROVISION OF ACUTE CARE AND
CERTAIN OTHER SERVICES
Sec. 534.151. DELIVERY OF ACUTE CARE SERVICES FOR
INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES. The
commission shall provide acute care Medicaid program benefits to
individuals with intellectual and developmental disabilities
through the STAR + PLUS Medicaid managed care program or the most
appropriate integrated capitated managed care program delivery
model.
Sec. 534.152. DELIVERY OF CERTAIN OTHER SERVICES UNDER STAR
+ PLUS AND STAR KIDS MEDICAID MANAGED CARE PROGRAMS. The commission
shall implement the most cost-effective option for the delivery of
basic attendant and habilitation services for individuals with
intellectual and developmental disabilities under the STAR + PLUS
and STAR Kids Medicaid managed care programs that maximizes federal
funding for the delivery of services across those and other similar
programs.
SUBCHAPTER E. STAGE TWO: TRANSITION OF LONG-TERM CARE MEDICAID
WAIVER PROGRAM RECIPIENTS TO INTEGRATED MANAGED CARE SYSTEM
Sec. 534.201. TRANSITION OF RECIPIENTS UNDER TEXAS HOME
LIVING (TxHmL) WAIVER PROGRAM TO MANAGED CARE PROGRAM. (a) This
section applies to individuals with intellectual and developmental
disabilities who are receiving long-term services and supports
under the Texas home living (TxHmL) waiver program on the date the
commission implements the transition described by Subsection (b).
(b) Not later than September 1, 2017, the commission shall
transition the provision of Medicaid program benefits to
individuals to whom this section applies to the STAR + PLUS Medicaid
managed care program delivery model or the most appropriate
integrated capitated managed care program delivery model, as
determined by the commission based on cost-effectiveness and the
experience of the STAR + PLUS Medicaid managed care program in
providing basic attendant and habilitation services and of the
pilot programs established under Subchapter C, subject to
Subsection (c)(1).
(c) At the time of the transition described by Subsection
(b), the commission shall determine whether to:
(1) continue operation of the Texas home living
(TxHmL) waiver program for purposes of providing supplemental
long-term services and supports not available under the managed
care program delivery model selected by the commission; or
(2) provide all or a portion of the long-term services
and supports previously available under the Texas home living
(TxHmL) waiver program through the managed care program delivery
model selected by the commission.
(d) In implementing the transition described by Subsection
(b), the commission shall develop a process to receive and evaluate
input from interested statewide stakeholders that is in addition to
the input provided by the advisory committee.
(e) The commission shall ensure that there is a
comprehensive plan for transitioning the provision of Medicaid
program benefits under this section that protects the continuity of
care provided to individuals to whom this section applies.
Sec. 534.202. TRANSITION OF ICF-IID PROGRAM RECIPIENTS AND
CERTAIN OTHER MEDICAID WAIVER PROGRAM RECIPIENTS TO MANAGED CARE
PROGRAM. (a) This section applies to individuals with
intellectual and developmental disabilities who, on the date the
commission implements the transition described by Subsection (b),
are receiving long-term services and supports under:
(1) a Medicaid waiver program other than the Texas
home living (TxHmL) waiver program; or
(2) an ICF-IID program.
(b) After implementing the transition required by Section
534.201 but not later than September 1, 2020, the commission shall
transition the provision of Medicaid program benefits to
individuals to whom this section applies to the STAR + PLUS Medicaid
managed care program delivery model or the most appropriate
integrated capitated managed care program delivery model, as
determined by the commission based on cost-effectiveness and the
experience of the transition of Texas home living (TxHmL) waiver
program recipients to a managed care program delivery model under
Section 534.201, subject to Subsection (c)(1).
(c) At the time of the transition described by Subsection
(b), the commission shall determine whether to:
(1) continue operation of the Medicaid waiver programs
or Medicaid ICF-IID program for purposes of providing supplemental
long-term services and supports not available under the managed
care program delivery model selected by the commission; or
(2) provide all or a portion of the long-term services
and supports previously available under the Medicaid waiver
programs or Medicaid ICF-IID program through the managed care
program delivery model selected by the commission.
(d) In implementing the transition described by Subsection
(b), the commission shall develop a process to receive and evaluate
input from interested statewide stakeholders that is in addition to
the input provided by the advisory committee.
(e) The commission shall ensure that there is a
comprehensive plan for transitioning the provision of Medicaid
program benefits under this section that protects the continuity of
care provided to individuals to whom this section applies.
(f) Before transitioning the provision of Medicaid program
benefits for children under this section, a managed care
organization providing services under the managed care program
delivery model selected by the commission must demonstrate to the
satisfaction of the commission that the organization's network of
providers has experience and expertise in the provision of services
to children with intellectual and developmental disabilities.
SECTION 1.02. Not later than October 1, 2013, the executive
commissioner of the Health and Human Services Commission and the
commissioner of the Department of Aging and Disability Services
shall appoint the members of the Intellectual and Developmental
Disability System Redesign Advisory Committee as required by
Section 534.053, Government Code, as added by this article.
SECTION 1.03. The Health and Human Services Commission
shall submit:
(1) the initial report on the implementation of the
acute care services and long-term services and supports system for
individuals with intellectual and developmental disabilities as
required by Section 534.054, Government Code, as added by this
article, not later than December 1, 2014; and
(2) the final report under that section not later than
December 1, 2023.
SECTION 1.04. Not later than June 1, 2016, the Health and
Human Services Commission shall submit a report to the legislature
regarding the commission's experience in, including the
cost-effectiveness of, delivering basic attendant and habilitation
services for individuals with intellectual and developmental
disabilities under the STAR + PLUS and STAR Kids Medicaid managed
care programs under Section 534.152, Government Code, as added by
this article.
SECTION 1.05. The Health and Human Services Commission and
the Department of Aging and Disability Services shall implement any
pilot program to be established under Subchapter C, Chapter 534,
Government Code, as added by this article, as soon as practicable
after the effective date of this Act.
SECTION 1.06. (a) The Health and Human Services Commission
and the Department of Aging and Disability Services shall:
(1) in consultation with the Intellectual and
Developmental Disability System Redesign Advisory Committee
established under Section 534.053, Government Code, as added by
this article, review and evaluate the outcomes of:
(A) the transition of the provision of benefits
to individuals under the Texas home living (TxHmL) waiver program
to a managed care program delivery model under Section 534.201,
Government Code, as added by this article; and
(B) the transition of the provision of benefits
to individuals under the Medicaid waiver programs, other than the
Texas home living (TxHmL) waiver program, and the ICF-IID program
to a managed care program delivery model under Section 534.202,
Government Code, as added by this article; and
(2) submit as part of an annual report required by
Section 534.054, Government Code, as added by this article, due on
or before December 1 of 2018, 2019, and 2020, a report on the review
and evaluation conducted under Paragraphs (A) and (B), Subdivision
(1), of this subsection that includes recommendations for continued
implementation of and improvements to the acute care and long-term
services and supports system under Chapter 534, Government Code, as
added by this article.
(b) This section expires September 1, 2024.
ARTICLE 2. MEDICAID MANAGED CARE EXPANSION
SECTION 2.01. Section 533.0025, Government Code, is amended
by amending Subsections (a) and (b) and adding Subsections (f),
(g), and (h) to read as follows:
(a) In this section and Sections 533.00251, 533.00252, and
533.00253, "medical assistance" has the meaning assigned by Section
32.003, Human Resources Code.
(b) Notwithstanding [Except as otherwise provided by this
section and notwithstanding] any other law, the commission shall
provide medical assistance for acute care services through the most
cost-effective model of Medicaid capitated managed care as
determined by the commission. The [If the] commission shall
require mandatory participation in a Medicaid capitated managed
care program for all persons eligible for acute care [determines
that it is more cost-effective, the commission may provide] medical
assistance benefits [for acute care in a certain part of this state
or to a certain population of recipients using:
[(1) a health maintenance organization model,
including the acute care portion of Medicaid Star + Plus pilot
programs;
[(2) a primary care case management model;
[(3) a prepaid health plan model;
[(4) an exclusive provider organization model; or
[(5) another Medicaid managed care model or
arrangement].
(f) The commission shall:
(1) conduct a study to evaluate the feasibility of
automatically enrolling applicants determined eligible for
benefits under the medical assistance program in a Medicaid managed
care plan; and
(2) report the results of the study to the legislature
not later than December 1, 2014.
(g) Subsection (f) and this subsection expire September 1,
2015.
(h) If the commission determines that it is feasible, the
commission may, notwithstanding any other law, implement an
automatic enrollment process under which applicants determined
eligible for medical assistance benefits are automatically
enrolled in a Medicaid managed care plan. The commission may elect
to implement the automatic enrollment process as to certain
populations of recipients under the medical assistance program.
SECTION 2.02. Subchapter A, Chapter 533, Government Code,
is amended by adding Sections 533.00251, 533.00252, and 533.00253
to read as follows:
Sec. 533.00251. DELIVERY OF NURSING FACILITY BENEFITS
THROUGH STAR + PLUS MEDICAID MANAGED CARE PROGRAM. (a) In this
section and Section 533.00252:
(1) "Advisory committee" means the STAR + PLUS Nursing
Facility Advisory Committee established under Section 533.00252.
(2) "Nursing facility" means a convalescent or nursing
home or related institution licensed under Chapter 242, Health and
Safety Code, that provides long-term services and supports to
Medicaid recipients.
(3) "Potentially preventable event" has the meaning
assigned by Section 536.001.
(b) The commission shall expand the STAR + PLUS Medicaid
managed care program to all areas of this state to serve individuals
eligible for acute care services and long-term services and
supports under the medical assistance program.
(c) Notwithstanding any other law, the commission, in
consultation with the advisory committee, shall provide benefits
under the medical assistance program to recipients who reside in
nursing facilities through the STAR + PLUS Medicaid managed care
program. In implementing this subsection, the commission shall
ensure:
(1) that the commission is responsible for setting the
minimum reimbursement rate paid to a nursing facility under the
managed care program, including the staff rate enhancement paid to
a nursing facility that qualifies for the enhancement;
(2) that a nursing facility is paid not later than the
10th day after the date the facility submits a clean claim;
(3) the appropriate utilization of services;
(4) a reduction in the incidence of potentially
preventable events and unnecessary institutionalizations;
(5) that a managed care organization providing
services under the managed care program provides discharge
planning, transitional care, and other education programs to
physicians and hospitals regarding all available long-term care
settings;
(6) that a managed care organization providing
services under the managed care program provides payment incentives
to nursing facility providers that reward reductions in preventable
acute care costs and encourage transformative efforts in the
delivery of nursing facility services, including efforts to promote
a resident-centered care culture through facility design and
services provided; and
(7) the establishment of a single portal through which
nursing facility providers participating in the STAR + PLUS
Medicaid managed care program may submit claims to any
participating managed care organization.
(d) Subject to Subsection (e), the commission shall ensure
that a nursing facility provider authorized to provide services
under the medical assistance program on September 1, 2013, is
allowed to participate in the STAR + PLUS Medicaid managed care
program through August 31, 2016. This subsection expires September
1, 2017.
(e) The commission shall establish credentialing and
minimum performance standards for nursing facility providers
seeking to participate in the STAR + PLUS Medicaid managed care
program. A managed care organization may refuse to contract with a
nursing facility provider if the nursing facility does not meet the
minimum performance standards established by the commission under
this section.
Sec. 533.00252. STAR + PLUS NURSING FACILITY ADVISORY
COMMITTEE. (a) The STAR + PLUS Nursing Facility Advisory
Committee is established to advise the commission on the
implementation of and other activities related to the provision of
medical assistance benefits to recipients who reside in nursing
facilities through the STAR + PLUS Medicaid managed care program
under Section 533.00251, including advising the commission
regarding its duties with respect to:
(1) developing quality-based outcomes and process
measures for long-term services and supports provided in nursing
facilities;
(2) developing quality-based long-term care payment
systems and quality initiatives for nursing facilities;
(3) transparency of information received from managed
care organizations;
(4) the reporting of outcome and process measures;
(5) the sharing of data among health and human
services agencies; and
(6) patient care coordination, quality of care
improvement, and cost savings.
(b) The executive commissioner shall appoint the members of
the advisory committee. The committee must consist of nursing
facility providers, representatives of managed care organizations,
and other stakeholders interested in nursing facility services
provided in this state, including:
(1) at least one member who is a nursing facility
provider with experience providing the long-term continuum of care,
including home care and hospice;
(2) at least one member who is a nonprofit nursing
facility provider;
(3) at least one member who is a for-profit nursing
facility provider;
(4) at least one member who is a consumer
representative; and
(5) at least one member who is from a managed care
organization providing services as provided by Section 533.00251.
(c) The executive commissioner shall appoint the presiding
officer of the advisory committee.
(d) A member of the advisory committee serves without
compensation.
(e) The advisory committee is subject to the requirements of
Chapter 551.
(f) On September 1, 2016:
(1) the advisory committee is abolished; and
(2) this section expires.
Sec. 533.00253. STAR KIDS MEDICAID MANAGED CARE PROGRAM.
(a) In this section:
(1) "Health home" means a primary care provider
practice, or, if appropriate, a specialty care provider practice,
incorporating several features, including comprehensive care
coordination, family-centered care, and data management, that are
focused on improving outcome-based quality of care and increasing
patient and provider satisfaction under the medical assistance
program.
(2) "Potentially preventable event" has the meaning
assigned by Section 536.001.
(b) The commission shall establish a mandatory STAR Kids
capitated managed care program tailored to provide medical
assistance benefits to children with disabilities. The managed
care program developed under this section must:
(1) provide medical assistance benefits that are
customized to meet the health care needs of recipients under the
program through a defined system of care, including benefits
described under Section 534.152;
(2) better coordinate care of recipients under the
program;
(3) improve the health outcomes of recipients;
(4) improve recipients' access to health care
services;
(5) achieve cost containment and cost efficiency;
(6) reduce the administrative complexity of
delivering medical assistance benefits;
(7) reduce the incidence of unnecessary
institutionalizations and potentially preventable events by
ensuring the availability of appropriate services and care
management;
(8) require a health home;
(9) coordinate and collaborate with long-term care
service providers and long-term care management providers, if
recipients are receiving long-term services and supports outside of
the managed care organization; and
(10) coordinate services provided to children also
receiving services under Section 534.152.
(c) The commission shall provide medical assistance
benefits through the STAR Kids managed care program established
under this section to children who are receiving benefits under the
medically dependent children (MDCP) waiver program. The commission
shall ensure that the STAR Kids managed care program provides all or
a portion of the benefits provided under the medically dependent
children (MDCP) waiver program to the extent necessary to implement
this subsection.
(d) The commission shall ensure that there is a plan for
transitioning the provision of Medicaid program benefits to
recipients 21 years of age or older from under the STAR Kids program
to under the STAR + PLUS Medicaid managed care program that protects
continuity of care. The plan must ensure that coordination between
the programs begins when a recipient reaches 18 years of age.
SECTION 2.03. Section 32.0212, Human Resources Code, is
amended to read as follows:
Sec. 32.0212. DELIVERY OF MEDICAL ASSISTANCE.
Notwithstanding any other law [and subject to Section 533.0025,
Government Code], the department shall provide medical assistance
for acute care services through the Medicaid managed care system
implemented under Chapter 533, Government Code, or another Medicaid
capitated managed care program.
SECTION 2.04. Subsections (c) and (d), Section 533.0025,
Government Code, and Subchapter D, Chapter 533, Government Code,
are repealed.
SECTION 2.05. (a) The Health and Human Services Commission
and the Department of Aging and Disability Services shall:
(1) review and evaluate the outcomes of the transition
of the provision of benefits to recipients under the medically
dependent children (MDCP) waiver program to the STAR Kids managed
care program delivery model established under Section 533.00253,
Government Code, as added by this article;
(2) not later than December 1, 2016, submit an initial
report to the legislature on the review and evaluation conducted
under Subdivision (1) of this subsection, including
recommendations for continued implementation and improvement of
the program; and
(3) not later than December 1 of each year after 2016
and until December 1, 2020, submit additional reports that include
the information described by Subdivision (1) of this subsection.
(b) This section expires September 1, 2021.
SECTION 2.06. As soon as practicable after the effective
date of this Act, the Health and Human Services Commission shall
provide a single portal through which nursing facility providers
participating in the STAR + PLUS Medicaid managed care program may
submit claims in accordance with Subdivision (7), Subsection (c),
Section 533.00251, Government Code, as added by this article.
SECTION 2.07. The changes in law made by this article are
not intended to negatively affect Medicaid recipients' access to
quality health care. The Health and Human Services Commission, as
the state agency designated to supervise the administration and
operation of the Medicaid program and to plan and direct the
Medicaid program in each state agency that operates a portion of the
Medicaid program, including directing the Medicaid managed care
system, shall continue to timely enforce all laws applicable to the
Medicaid program and the Medicaid managed care system, including
laws relating to provider network adequacy, the prompt payment of
claims, and the resolution of patient and provider complaints.
ARTICLE 3. OTHER PROVISIONS RELATING TO INDIVIDUALS WITH
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
SECTION 3.01. Subchapter B, Chapter 533, Health and Safety
Code, is amended by adding Section 533.0335 to read as follows:
Sec. 533.0335. COMPREHENSIVE ASSESSMENT AND RESOURCE
ALLOCATION PROCESS. (a) In this section:
(1) "Advisory committee" means the Intellectual and
Developmental Disability System Redesign Advisory Committee
established under Section 534.053, Government Code.
(2) "Department" means the Department of Aging and
Disability Services.
(3) "Functional need" means the measurement of an
individual's services and support needs, including the individual's
intellectual, psychiatric, medical, and physical support needs.
(4) "Medicaid waiver program" has the meaning assigned
by Section 534.001, Government Code.
(b) Subject to the availability of federal funding, the
department shall develop and implement a comprehensive assessment
instrument and a resource allocation process. The assessment
instrument and resource allocation process must be designed to
recommend for each individual with intellectual and developmental
disabilities enrolled in a Medicaid waiver program the type,
intensity, and range of services that are both appropriate and
available, based on the functional needs of that individual.
(c) The department, in consultation with the advisory
committee, shall establish a prior authorization process for
requests for supervised living or residential support services
available in the home and community-based services (HCS) Medicaid
waiver program. The process must ensure that supervised living or
residential support services available in the home and
community-based services (HCS) Medicaid waiver program are
available only to individuals for whom a more independent setting
is not appropriate or available.
(d) The department shall cooperate with the advisory
committee to establish the prior authorization process required by
Subsection (c). This subsection expires January 1, 2024.
SECTION 3.02. Subchapter B, Chapter 533, Health and Safety
Code, is amended by adding Sections 533.03551 and 533.03552 to read
as follows:
Sec. 533.03551. FLEXIBLE, LOW-COST HOUSING OPTIONS.
(a) To the extent permitted under federal law and regulations, the
executive commissioner shall adopt or amend rules as necessary to
allow for the development of additional housing supports for
individuals with intellectual and developmental disabilities in
urban and rural areas, including:
(1) a selection of community-based housing options
that comprise a continuum of integration, varying from most to
least restrictive, that permits individuals to select the most
integrated and least restrictive setting appropriate to the
individual's needs and preferences;
(2) non-provider-owned residential settings;
(3) assistance with living more independently; and
(4) rental properties with on-site supports.
(b) The Department of Aging and Disability Services, in
cooperation with the Texas Department of Housing and Community
Affairs, the Department of Agriculture, the Texas State Affordable
Housing Corporation, and the Intellectual and Developmental
Disability System Redesign Advisory Committee, shall coordinate
with federal, state, and local public housing entities as necessary
to expand opportunities for accessible, affordable, and integrated
housing to meet the complex needs of individuals with intellectual
and developmental disabilities.
(c) The Department of Aging and Disability Services shall
develop a process to receive input from statewide stakeholders to
ensure the most comprehensive review of opportunities and options
for housing services described by this section.
Sec. 533.03552. BEHAVIORAL SUPPORTS FOR INDIVIDUALS WITH
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AT RISK OF
INSTITUTIONALIZATION; INTERVENTION TEAMS. (a) In this section,
"department" means the Department of Aging and Disability Services.
(b) Subject to the availability of federal funding, the
department shall develop and implement specialized training for
providers, family members, caregivers, and first responders
providing direct services and supports to individuals with
intellectual and developmental disabilities and behavioral health
needs who are at risk of institutionalization.
(c) Subject to the availability of federal funding, the
department shall establish one or more behavioral health
intervention teams to provide services and supports to individuals
with intellectual and developmental disabilities and behavioral
health needs who are at risk of institutionalization. An
intervention team may include a:
(1) psychiatrist or psychologist;
(2) physician;
(3) registered nurse;
(4) pharmacist or representative of a pharmacy;
(5) behavior analyst;
(6) social worker;
(7) crisis coordinator;
(8) peer specialist; and
(9) family partner.
(d) In providing services and supports, a behavioral health
intervention team established by the department shall:
(1) use the team's best efforts to ensure that an
individual remains in the community and avoids
institutionalization;
(2) focus on stabilizing the individual and assessing
the individual for intellectual, medical, psychiatric,
psychological, and other needs;
(3) provide support to the individual's family members
and other caregivers;
(4) provide intensive behavioral assessment and
training to assist the individual in establishing positive
behaviors and continuing to live in the community; and
(5) provide clinical and other referrals.
(e) The department shall ensure that members of a behavioral
health intervention team established under this section receive
training on trauma-informed care, which is an approach to providing
care to individuals with behavioral health needs based on awareness
that a history of trauma or the presence of trauma symptoms may
create the behavioral health needs of the individual.
SECTION 3.03. (a) The Health and Human Services Commission
and the Department of Aging and Disability Services shall conduct a
study to identify crisis intervention programs currently available
to, evaluate the need for appropriate housing for, and develop
strategies for serving the needs of persons in this state with
Prader-Willi syndrome.
(b) In conducting the study, the Health and Human Services
Commission and the Department of Aging and Disability Services
shall seek stakeholder input.
(c) Not later than December 1, 2014, the Health and Human
Services Commission shall submit a report to the governor, the
lieutenant governor, the speaker of the house of representatives,
and the presiding officers of the standing committees of the senate
and house of representatives having jurisdiction over the Medicaid
program regarding the study required by this section.
(d) This section expires September 1, 2015.
ARTICLE 4. QUALITY-BASED OUTCOMES AND PAYMENT PROVISIONS
SECTION 4.01. Subchapter A, Chapter 533, Government Code,
is amended by adding Section 533.00254 to read as follows:
Sec. 533.00254. MANAGED CARE CLINICAL IMPROVEMENT PROGRAM.
(a) In consultation with the Medicaid and CHIP Quality-Based
Payment Advisory Committee established under Section 536.002 and
other appropriate stakeholders with an interest in the provision of
acute care services and long-term services and supports under the
Medicaid managed care program, the commission shall:
(1) establish a clinical improvement program to
identify goals designed to improve quality of care and care
management and to reduce potentially preventable events, as defined
by Section 536.001; and
(2) require managed care organizations to develop and
implement collaborative program improvement strategies to address
the goals.
(b) Goals established under this section may be set by
geographical region and program type.
SECTION 4.02. Subsections (a) and (g), Section 533.0051,
Government Code, are amended to read as follows:
(a) The commission shall establish outcome-based
performance measures and incentives to include in each contract
between a health maintenance organization and the commission for
the provision of health care services to recipients that is
procured and managed under a value-based purchasing model. The
performance measures and incentives must:
(1) be designed to facilitate and increase recipients'
access to appropriate health care services; and
(2) to the extent possible, align with other state and
regional quality care improvement initiatives.
(g) In performing the commission's duties under Subsection
(d) with respect to assessing feasibility and cost-effectiveness,
the commission may consult with participating Medicaid providers
[physicians], including those with expertise in quality
improvement and performance measurement[, and hospitals].
SECTION 4.03. Subchapter A, Chapter 533, Government Code,
is amended by adding Section 533.00511 to read as follows:
Sec. 533.00511. QUALITY-BASED ENROLLMENT INCENTIVE PROGRAM
FOR MANAGED CARE ORGANIZATIONS. (a) In this section, "potentially
preventable event" has the meaning assigned by Section 536.001.
(b) The commission shall create an incentive program that
automatically enrolls a greater percentage of recipients who did
not actively choose their managed care plan in a managed care plan,
based on:
(1) the quality of care provided through the managed
care organization offering that managed care plan;
(2) the organization's ability to efficiently and
effectively provide services, taking into consideration the acuity
of populations primarily served by the organization; and
(3) the organization's performance with respect to
exceeding, or failing to achieve, appropriate outcome and process
measures developed by the commission, including measures based on
all potentially preventable events.
SECTION 4.04. 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 and process requirements for the
managed care organizations and providers, 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;
(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 acute care services and long-term services and supports
claims; 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 4.05. Section 533.014, Government Code, is amended
by amending Subsection (b) and adding Subsection (c) to read as
follows:
(b) Except as provided by Subsection (c), any [Any] amount
received by the state under this section shall be deposited in the
general revenue fund for the purpose of funding the state Medicaid
program.
(c) If cost-effective, the commission may use amounts
received by the state under this section to provide incentives to
specific managed care organizations to promote quality of care,
encourage payment reform, reward local service delivery reform,
increase efficiency, and reduce inappropriate or preventable
service utilization.
SECTION 4.06. Subsection (b), Section 536.002, Government
Code, is amended to read as follows:
(b) The executive commissioner shall appoint the members of
the advisory committee. The committee must consist of physicians
and other health care providers, representatives of health care
facilities, representatives of managed care organizations, and
other stakeholders interested in health care services provided in
this state, including:
(1) at least one member who is a physician with
clinical practice experience in obstetrics and gynecology;
(2) at least one member who is a physician with
clinical practice experience in pediatrics;
(3) at least one member who is a physician with
clinical practice experience in internal medicine or family
medicine;
(4) at least one member who is a physician with
clinical practice experience in geriatric medicine;
(5) at least three members [one member] who are [is] or
who represent [represents] a health care provider that primarily
provides long-term [care] services and supports;
(6) at least one member who is a consumer
representative; and
(7) at least one member who is a member of the Advisory
Panel on Health Care-Associated Infections and Preventable Adverse
Events who meets the qualifications prescribed by Section
98.052(a)(4), Health and Safety Code.
SECTION 4.07. Section 536.003, Government Code, is amended
by amending Subsections (a) and (b) and adding Subsection (a-1) to
read as follows:
(a) The commission, in consultation with the advisory
committee, shall develop quality-based outcome and process
measures that promote the provision of efficient, quality health
care and that can be used in the child health plan and Medicaid
programs to implement quality-based payments for acute [and
long-term] care services and long-term services and supports across
all delivery models and payment systems, including
[fee-for-service and] managed care payment systems. Subject to
Subsection (a-1), the [The] commission, in developing outcome and
process measures under this section, must include measures that are
based on all [consider measures addressing] potentially
preventable events and that advance quality improvement and
innovation. The commission may change measures developed:
(1) to promote continuous system reform, improved
quality, and reduced costs; and
(2) to account for managed care organizations added to
a service area.
(a-1) The outcome measures based on potentially preventable
events must:
(1) allow for rate-based determination of health care
provider performance compared to statewide norms; and
(2) be risk-adjusted to account for the severity of
the illnesses of patients served by the provider.
(b) To the extent feasible, the commission shall develop
outcome and process measures:
(1) consistently across all child health plan and
Medicaid program delivery models and payment systems;
(2) in a manner that takes into account appropriate
patient risk factors, including the burden of chronic illness on a
patient and the severity of a patient's illness;
(3) that will have the greatest effect on improving
quality of care and the efficient use of services, including acute
care services and long-term services and supports; [and]
(4) that are similar to outcome and process measures
used in the private sector, as appropriate;
(5) that reflect effective coordination of acute care
services and long-term services and supports;
(6) that can be tied to expenditures; and
(7) that reduce preventable health care utilization
and costs.
SECTION 4.08. Subsection (a), Section 536.004, Government
Code, is amended to read as follows:
(a) Using quality-based outcome and process measures
developed under Section 536.003 and subject to this section, the
commission, after consulting with the advisory committee and other
appropriate stakeholders with an interest in the provision of acute
care and long-term services and supports under the child health
plan and Medicaid programs, shall develop quality-based payment
systems, and require managed care organizations to develop
quality-based payment systems, for compensating a physician or
other health care provider participating in the child health plan
or Medicaid program that:
(1) align payment incentives with high-quality,
cost-effective health care;
(2) reward the use of evidence-based best practices;
(3) promote the coordination of health care;
(4) encourage appropriate physician and other health
care provider collaboration;
(5) promote effective health care delivery models; and
(6) take into account the specific needs of the child
health plan program enrollee and Medicaid recipient populations.
SECTION 4.09. Section 536.005, Government Code, is amended
by adding Subsection (c) to read as follows:
(c) Notwithstanding Subsection (a) and to the extent
possible, the commission shall convert outpatient hospital
reimbursement systems under the child health plan and Medicaid
programs to an appropriate prospective payment system that will
allow the commission to:
(1) more accurately classify the full range of
outpatient service episodes;
(2) more accurately account for the intensity of
services provided; and
(3) motivate outpatient service providers to increase
efficiency and effectiveness.
SECTION 4.10. Section 536.006, Government Code, is amended
to read as follows:
Sec. 536.006. TRANSPARENCY. (a) The commission and the
advisory committee shall:
(1) ensure transparency in the development and
establishment of:
(A) quality-based payment and reimbursement
systems under Section 536.004 and Subchapters B, C, and D,
including the development of outcome and process measures under
Section 536.003; and
(B) quality-based payment initiatives under
Subchapter E, including the development of quality of care and
cost-efficiency benchmarks under Section 536.204(a) and efficiency
performance standards under Section 536.204(b);
(2) develop guidelines establishing procedures for
providing notice and information to, and receiving input from,
managed care organizations, health care providers, including
physicians and experts in the various medical specialty fields, and
other stakeholders, as appropriate, for purposes of developing and
establishing the quality-based payment and reimbursement systems
and initiatives described under Subdivision (1); [and]
(3) in developing and establishing the quality-based
payment and reimbursement systems and initiatives described under
Subdivision (1), consider that as the performance of a managed care
organization or physician or other health care provider improves
with respect to an outcome or process measure, quality of care and
cost-efficiency benchmark, or efficiency performance standard, as
applicable, there will be a diminishing rate of improved
performance over time; and
(4) develop web-based capability to provide managed
care organizations and health care providers with data on their
clinical and utilization performance, including comparisons to
peer organizations and providers located in this state and in the
provider's respective region.
(b) The web-based capability required by Subsection (a)(4)
must support the requirements of the electronic health information
exchange system under Sections 531.907 through 531.909.
SECTION 4.11. Section 536.008, Government Code, is amended
to read as follows:
Sec. 536.008. ANNUAL REPORT. (a) The commission shall
submit to the legislature and make available to the public an annual
report [to the legislature] regarding:
(1) the quality-based outcome and process measures
developed under Section 536.003, including measures based on each
potentially preventable event; and
(2) the progress of the implementation of
quality-based payment systems and other payment initiatives
implemented under this chapter.
(b) As appropriate, the [The] commission shall report
outcome and process measures under Subsection (a)(1) by:
(1) geographic location, which may require reporting
by county, health care service region, or other appropriately
defined geographic area;
(2) recipient population or eligibility group served;
(3) type of health care provider, such as acute care or
long-term care provider;
(4) number of recipients who relocated to a
community-based setting from a less integrated setting;
(5) quality-based payment system; and
(6) service delivery model.
(c) The report required under this section may not identify
specific health care providers.
SECTION 4.12. Subsection (a), Section 536.051, Government
Code, is amended to read as follows:
(a) Subject to Section 1903(m)(2)(A), Social Security Act
(42 U.S.C. Section 1396b(m)(2)(A)), and other applicable federal
law, the commission shall base a percentage of the premiums paid to
a managed care organization participating in the child health plan
or Medicaid program on the organization's performance with respect
to outcome and process measures developed under Section 536.003
that address all[, including outcome measures addressing]
potentially preventable events. The percentage of the premiums
paid may increase each year.
SECTION 4.13. Subsection (a), Section 536.052, Government
Code, is amended to read as follows:
(a) The commission may allow a managed care organization
participating in the child health plan or Medicaid program
increased flexibility to implement quality initiatives in a managed
care plan offered by the organization, including flexibility with
respect to financial arrangements, in order to:
(1) achieve high-quality, cost-effective health care;
(2) increase the use of high-quality, cost-effective
delivery models; [and]
(3) reduce the incidence of unnecessary
institutionalization and potentially preventable events; and
(4) increase the use of alternative payment systems,
including shared savings models, in collaboration with physicians
and other health care providers.
SECTION 4.14. Section 536.151, Government Code, is amended
by amending Subsections (a), (b), and (c) and adding Subsections
(a-1) and (d) to read as follows:
(a) The executive commissioner shall adopt rules for
identifying:
(1) potentially preventable admissions and
readmissions of child health plan program enrollees and Medicaid
recipients, including preventable admissions to long-term care
facilities;
(2) potentially preventable ancillary services
provided to or ordered for child health plan program enrollees and
Medicaid recipients;
(3) potentially preventable emergency room visits by
child health plan program enrollees and Medicaid recipients; and
(4) potentially preventable complications experienced
by child health plan program enrollees and Medicaid recipients.
(a-1) The commission shall collect data from hospitals on
present-on-admission indicators for purposes of this section.
(b) The commission shall establish a program to provide a
confidential report to each hospital in this state that
participates in the child health plan or Medicaid program regarding
the hospital's performance with respect to each potentially
preventable event described under Subsection (a) [readmissions and
potentially preventable complications]. To the extent possible, a
report provided under this section should include all potentially
preventable events [readmissions and potentially preventable
complications information] across all child health plan and
Medicaid program payment systems. A hospital shall distribute the
information contained in the report to physicians and other health
care providers providing services at the hospital.
(c) Except as provided by Subsection (d), a [A] report
provided to a hospital under this section is confidential and is not
subject to Chapter 552.
(d) The commission shall release the information in the
report described by Subsection (b):
(1) not earlier than one year after the date the report
is submitted to the hospital; and
(2) only after receiving and evaluating interested
stakeholder input regarding the public release of information under
this section generally.
SECTION 4.15. Subsection (a), Section 536.152, Government
Code, is amended to read as follows:
(a) Subject to Subsection (b), using the data collected
under Section 536.151 and the diagnosis-related groups (DRG)
methodology implemented under Section 536.005, if applicable, the
commission, after consulting with the advisory committee, shall to
the extent feasible adjust child health plan and Medicaid
reimbursements to hospitals, including payments made under the
disproportionate share hospitals and upper payment limit
supplemental payment programs, [in a manner that may reward or
penalize a hospital] based on the hospital's performance with
respect to exceeding, or failing to achieve, outcome and process
measures developed under Section 536.003 that address the rates of
potentially preventable readmissions and potentially preventable
complications.
SECTION 4.16. Subsection (a), Section 536.202, Government
Code, is amended to read as follows:
(a) The commission shall, after consulting with the
advisory committee, establish payment initiatives to test the
effectiveness of quality-based payment systems, alternative
payment methodologies, and high-quality, cost-effective health
care delivery models that provide incentives to physicians and
other health care providers to develop health care interventions
for child health plan program enrollees or Medicaid recipients, or
both, that will:
(1) improve the quality of health care provided to the
enrollees or recipients;
(2) reduce potentially preventable events;
(3) promote prevention and wellness;
(4) increase the use of evidence-based best practices;
(5) increase appropriate physician and other health
care provider collaboration; [and]
(6) contain costs; and
(7) improve integration of acute care services and
long-term services and supports, including discharge planning from
acute care services to community-based long-term services and
supports.
SECTION 4.17. Chapter 536, Government Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. QUALITY-BASED LONG-TERM SERVICES AND SUPPORTS
PAYMENT SYSTEMS
Sec. 536.251. QUALITY-BASED LONG-TERM SERVICES AND
SUPPORTS PAYMENTS. (a) Subject to this subchapter, the
commission, after consulting with the advisory committee and other
appropriate stakeholders representing nursing facility providers
with an interest in the provision of long-term services and
supports, may develop and implement quality-based payment systems
for Medicaid long-term services and supports providers designed to
improve quality of care and reduce the provision of unnecessary
services. A quality-based payment system developed under this
section must base payments to providers on quality and efficiency
measures that may include measurable wellness and prevention
criteria and use of evidence-based best practices, sharing a
portion of any realized cost savings achieved by the provider, and
ensuring quality of care outcomes, including a reduction in
potentially preventable events.
(b) The commission may develop a quality-based payment
system for Medicaid long-term services and supports providers under
this subchapter only if implementing the system would be feasible
and cost-effective.
Sec. 536.252. EVALUATION OF DATA SETS. To ensure that the
commission is using the best data to inform the development and
implementation of quality-based payment systems under Section
536.251, the commission shall evaluate the reliability, validity,
and functionality of post-acute and long-term services and supports
data sets. The commission's evaluation under this section should
assess:
(1) to what degree data sets relied on by the
commission meet a standard:
(A) for integrating care;
(B) for developing coordinated care plans; and
(C) that would allow for the meaningful
development of risk adjustment techniques;
(2) whether the data sets will provide value for
outcome or performance measures and cost containment; and
(3) how classification systems and data sets used for
Medicaid long-term services and supports providers can be
standardized and, where possible, simplified.
Sec. 536.253. COLLECTION AND REPORTING OF CERTAIN
INFORMATION. (a) The executive commissioner shall adopt rules for
identifying the incidence of potentially preventable admissions,
potentially preventable readmissions, and potentially preventable
emergency room visits by Medicaid long-term services and supports
recipients.
(b) The commission shall establish a program to provide a
report to each Medicaid long-term services and supports provider in
this state regarding the provider's performance with respect to
potentially preventable admissions, potentially preventable
readmissions, and potentially preventable emergency room visits.
To the extent possible, a report provided under this section should
include applicable potentially preventable events information
across all Medicaid program payment systems.
(c) Subject to Subsection (d), a report provided to a
provider under this section is confidential and is not subject to
Chapter 552.
(d) The commission shall release the information in the
report described by Subsection (c):
(1) not earlier than one year after the date the report
is submitted to the provider; and
(2) only after receiving and evaluating interested
stakeholder input regarding the public release of information under
this section generally.
SECTION 4.18. As soon as practicable after the effective
date of this Act, the Health and Human Services Commission shall
provide a single portal through which providers in any managed care
organization's provider network may submit acute care services and
long-term services and supports claims as required by Paragraph
(E), Subdivision (4), Section 533.0071, Government Code, as amended
by this article.
SECTION 4.19. Not later than September 1, 2013, the Health
and Human Services Commission shall convert outpatient hospital
reimbursement systems as required by Subsection (c), Section
536.005, Government Code, as added by this article.
ARTICLE 5. SPECIFIC PROVISIONS RELATING TO PREMIUMS UNDER THE
MEDICAL ASSISTANCE PROGRAM
SECTION 5.01. Section 533.013, Government Code, is amended
by adding Subsection (e) to read as follows:
(e) The commission shall pursue and, if appropriate,
implement premium rate-setting strategies that encourage provider
payment reform and more efficient service delivery and provider
practices. In pursuing premium rate-setting strategies under this
section, the commission shall review and consider strategies
employed or under consideration by other states. If necessary, the
commission may request a waiver or other authorization from a
federal agency to implement strategies identified under this
subsection.
SECTION 5.02. Subchapter B, Chapter 32, Human Resources
Code, is amended by adding Section 32.0642 to read as follows:
Sec. 32.0642. PREMIUM REQUIREMENT FOR RECEIPT OF CERTAIN
SERVICES. To the extent permitted under and in a manner that is
consistent with 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 and
implement in the most cost-effective manner a premium for long-term
services and supports provided to a child under the medical
assistance program to be paid by the child's parent or other legal
guardian.
ARTICLE 6. ADDITIONAL PROVISIONS RELATING TO QUALITY AND DELIVERY
OF HEALTH AND HUMAN SERVICES
SECTION 6.01. The heading to Section 531.024, Government
Code, is amended to read as follows:
Sec. 531.024. PLANNING AND DELIVERY OF HEALTH AND HUMAN
SERVICES; DATA SHARING.
SECTION 6.02. Section 531.024, Government Code, is amended
by adding Subsection (a-1) to read as follows:
(a-1) To the extent permitted under applicable law, the
commission and other health and human services agencies shall share
data to facilitate patient care coordination, quality improvement,
and cost savings in the Medicaid program, child health plan
program, and other health and human services programs funded using
money appropriated from the general revenue fund.
SECTION 6.03. Subchapter B, Chapter 531, Government Code,
is amended by adding Section 531.0981 to read as follows:
Sec. 531.0981. WELLNESS SCREENING PROGRAM. If
cost-effective, the commission may implement a wellness screening
program for Medicaid recipients designed to evaluate a recipient's
risk for having certain diseases and medical conditions for
purposes of establishing a health baseline for each recipient that
may be used to tailor the recipient's treatment plan or for
establishing the recipient's health goals.
ARTICLE 7. FEDERAL AUTHORIZATIONS, FUNDING, AND EFFECTIVE DATE
SECTION 7.01. 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 7.02. As soon as practicable after the effective
date of this Act, the Health and Human Services Commission shall
apply for and actively seek a waiver or authorization from the
appropriate federal agency to waive, with respect to a person who is
dually eligible for Medicare and Medicaid, the requirement under 42
C.F.R. Section 409.30 that the person be hospitalized for at least
three consecutive calendar days before Medicare covers
posthospital skilled nursing facility care for the person.
SECTION 7.03. The Health and Human Services Commission may
use any available revenue, including legislative appropriations
and available federal funds, for purposes of implementing any
provision of this Act.
SECTION 7.04. This Act takes effect September 1, 2013.
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