83R27897 KFF-D
By: Nelson, et al. S.B. No. 7
(Raymond)
Substitute the following for S.B. No. 7: No.
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) "Functional need" means the measurement of an
individual's services and supports needs, including the
individual's intellectual, psychiatric, medical, and physical
support needs.
(5) "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.
(6) "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.
(7) "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.
(8) "Local intellectual and developmental disability
authority" means an authority defined by Section 531.002(11),
Health and Safety Code.
(9) "Managed care organization," "managed care plan,"
and "potentially preventable event" have the meanings assigned
under Section 536.001.
(10) "Medicaid program" means the medical assistance
program established under Chapter 32, Human Resources Code.
(11) "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.
(12) "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, including the assessment of individuals'
functional needs;
(4) promote person-centered planning, self-direction,
self-determination, community inclusion, and customized,
integrated, competitive 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;
(10) ensure the availability of a local safety net
provider and local safety net services;
(11) promote independent service coordination and
independent ombudsmen services; and
(12) ensure that individuals with the most significant
needs are appropriately served in the community and that processes
are in place to prevent inappropriate institutionalization of
individuals.
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 services under the Medicaid
waiver programs or the Medicaid ICF-IID program and individuals who
are advocates of those recipients, including at least three
representatives from intellectual and developmental disability
advocacy organizations;
(2) representatives of Medicaid managed care and
nonmanaged care health care providers, 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) representatives of 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;
(B) representatives of community mental health
and intellectual disability centers;
(C) representatives of and service coordinators
or case managers from private and public home and community-based
services providers that serve individuals with intellectual and
developmental disabilities; and
(D) representatives of private and public
ICF-IID providers; 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 September 30 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, integrated, competitive 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, 2017.
(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. 534.1065. RECIPIENT PARTICIPATION IN PROGRAM
VOLUNTARY. Participation in a pilot program established under this
subchapter by an individual with an intellectual or developmental
disability is voluntary, and the decision whether to participate in
a program and receive long-term services and supports from a
provider through that program may be made only by the individual or
the individual's legally authorized representative.
Sec. 534.107. COORDINATING SERVICES. In providing
long-term services and supports under the Medicaid program to
individuals with intellectual and developmental disabilities, a
pilot program service provider shall:
(1) coordinate through the pilot program
institutional and community-based services available to the
individuals, 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 monthly 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, 2017, and December 1, 2018, 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 an intellectual or developmental disability 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, 2019:
(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. (a)
Subject to Section 533.0025, 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 and monitor the provision of those
benefits.
(b) A managed care organization that contracts with the
commission to provide acute care services in accordance with this
section shall provide an acute care services coordinator to each
individual with an intellectual or developmental disability during
the individual's transition to 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 MEDICAID MANAGED CARE PROGRAM. (a) The commission shall:
(1) 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 Medicaid managed care program that maximizes
federal funding for the delivery of services for that program and
other similar programs; and
(2) provide voluntary training to individuals
receiving services under the STAR + PLUS Medicaid managed care
program or their legally authorized representatives regarding how
to select, manage, and dismiss personal attendants providing basic
attendant and habilitation services under the program.
(b) The commission shall require that each managed care
organization that contracts with the commission for the provision
of basic attendant and habilitation services under the STAR + PLUS
Medicaid managed care program in accordance with this section:
(1) include in the organization's provider network for
the provision of those services:
(A) home and community support services agencies
licensed under Chapter 142, Health and Safety Code, with which the
department has a contract to provide services under the community
living assistance and support services (CLASS) waiver program; and
(B) persons exempted from licensing under
Section 142.003(a)(19), Health and Safety Code, with which the
department has a contract to provide services under:
(i) the home and community-based services
(HCS) waiver program; or
(ii) the Texas home living (TxHmL) waiver
program;
(2) review and consider any assessment conducted by a
local intellectual and developmental disability authority
providing intellectual and developmental disability service
coordination under Subsection (c); and
(3) enter into a written agreement with each local
intellectual and developmental disability authority in the service
area regarding the processes the organization and the authority
will use to coordinate the services of individuals with
intellectual and developmental disabilities.
(c) The department shall contract with and make contract
payments to local intellectual and developmental disability
authorities to conduct the following activities under this section:
(1) provide intellectual and developmental disability
service coordination to individuals with intellectual and
developmental disabilities under the STAR + PLUS Medicaid managed
care program by assisting those individuals who are eligible to
receive services in a community-based setting, including
individuals transitioning to a community-based setting;
(2) provide an assessment to the appropriate managed
care organization regarding whether an individual with an
intellectual or developmental disability needs attendant or
habilitation services, based on the individual's functional need,
risk factors, and desired outcomes;
(3) assist individuals with intellectual and
developmental disabilities with developing the individuals' plans
of care under the STAR + PLUS Medicaid managed care program,
including with making any changes resulting from periodic
reassessments of the plans;
(4) provide to the appropriate managed care
organization and the department information regarding the
recommended plans of care with which the authorities provide
assistance as provided by Subdivision (3), including documentation
necessary to demonstrate the need for care described by a plan; and
(5) on an annual basis, provide to the appropriate
managed care organization and the department a description of
outcomes based on an individual's plan of care.
(d) Local intellectual and developmental disability
authorities providing service coordination under this section may
not also provide attendant and habilitation services under this
section.
(e) During the first three years basic attendant and
habilitation services are provided to individuals with
intellectual and developmental disabilities under the STAR + PLUS
Medicaid managed care program in accordance with this section,
providers eligible to participate in the home and community-based
services (HCS) waiver program, the Texas home living (TxHmL) waiver
program, or the community living assistance and support services
(CLASS) waiver program on September 1, 2013, are considered
significant traditional providers.
(f) A local intellectual and developmental disability
authority with which the department contracts under Subsection (c)
may subcontract with an eligible person, including a nonprofit
entity, to coordinate the services of individuals with intellectual
and developmental disabilities under this section. The executive
commissioner by rule shall establish minimum qualifications a
person must meet to be considered an "eligible person" under this
subsection.
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, 2018, 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.
(f) In addition to the requirements of Section 533.005, a
contract between a managed care organization and the commission for
the organization to provide Medicaid program benefits under this
section must contain a requirement that the organization implement
a process for individuals with intellectual and developmental
disabilities that:
(1) ensures that the individuals have a choice among
providers; and
(2) to the greatest extent possible, protects those
individuals' continuity of care with respect to access to primary
care providers, including the use of single-case agreements with
out-of-network providers.
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, 2021, 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 Subsections (c)(1) and (g).
(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 ICF-IID program only for purposes of providing, if applicable:
(A) supplemental long-term services and supports
not available under the managed care program delivery model
selected by the commission; or
(B) long-term services and supports to Medicaid
waiver program recipients who choose to continue receiving benefits
under the waiver program as provided by Subsection (g); or
(2) subject to Subsection (g), provide all or a
portion of the long-term services and supports previously available
only under the Medicaid waiver programs or 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.
Before transitioning the provision of Medicaid program benefits for
adults with intellectual and developmental disabilities 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 adults with intellectual and
developmental disabilities.
(g) If the commission determines that all or a portion of
the long-term services and supports previously available only under
the Medicaid waiver programs should be provided through a managed
care program delivery model under Subsection (c)(2), the commission
shall, at the time of the transition, allow each recipient
receiving long-term services and supports under a Medicaid waiver
program the option of:
(1) continuing to receive the services and supports
under the Medicaid waiver program; or
(2) receiving the services and supports through the
managed care program delivery model selected by the commission.
(h) A recipient who chooses to receive long-term services
and supports through a managed care program delivery model under
Subsection (g) may not, at a later time, choose to receive the
services and supports under a Medicaid waiver program.
(i) In addition to the requirements of Section 533.005, a
contract between a managed care organization and the commission for
the organization to provide Medicaid program benefits under this
section must contain a requirement that the organization implement
a process for individuals with intellectual and developmental
disabilities that:
(1) ensures that the individuals have a choice among
providers; and
(2) to the greatest extent possible, protects those
individuals' continuity of care with respect to access to primary
care providers, including the use of single-case agreements with
out-of-network providers.
SECTION 1.02. Subsection (a), Section 142.003, Health and
Safety Code, is amended to read as follows:
(a) The following persons need not be licensed under this
chapter:
(1) a physician, dentist, registered nurse,
occupational therapist, or physical therapist licensed under the
laws of this state who provides home health services to a client
only as a part of and incidental to that person's private office
practice;
(2) a registered nurse, licensed vocational nurse,
physical therapist, occupational therapist, speech therapist,
medical social worker, or any other health care professional as
determined by the department who provides home health services as a
sole practitioner;
(3) a registry that operates solely as a clearinghouse
to put consumers in contact with persons who provide home health,
hospice, or personal assistance services and that does not maintain
official client records, direct client services, or compensate the
person who is providing the service;
(4) an individual whose permanent residence is in the
client's residence;
(5) an employee of a person licensed under this
chapter who provides home health, hospice, or personal assistance
services only as an employee of the license holder and who receives
no benefit for providing the services, other than wages from the
license holder;
(6) a home, nursing home, convalescent home, assisted
living facility, special care facility, or other institution for
individuals who are elderly or who have disabilities that provides
home health or personal assistance services only to residents of
the home or institution;
(7) a person who provides one health service through a
contract with a person licensed under this chapter;
(8) a durable medical equipment supply company;
(9) a pharmacy or wholesale medical supply company
that does not furnish services, other than supplies, to a person at
the person's house;
(10) a hospital or other licensed health care facility
that provides home health or personal assistance services only to
inpatient residents of the hospital or facility;
(11) a person providing home health or personal
assistance services to an injured employee under Title 5, Labor
Code;
(12) a visiting nurse service that:
(A) is conducted by and for the adherents of a
well-recognized church or religious denomination; and
(B) provides nursing services by a person exempt
from licensing by Section 301.004, Occupations Code, because the
person furnishes nursing care in which treatment is only by prayer
or spiritual means;
(13) an individual hired and paid directly by the
client or the client's family or legal guardian to provide home
health or personal assistance services;
(14) a business, school, camp, or other organization
that provides home health or personal assistance services,
incidental to the organization's primary purpose, to individuals
employed by or participating in programs offered by the business,
school, or camp that enable the individual to participate fully in
the business's, school's, or camp's programs;
(15) a person or organization providing
sitter-companion services or chore or household services that do
not involve personal care, health, or health-related services;
(16) a licensed health care facility that provides
hospice services under a contract with a hospice;
(17) a person delivering residential acquired immune
deficiency syndrome hospice care who is licensed and designated as
a residential AIDS hospice under Chapter 248;
(18) the Texas Department of Criminal Justice;
(19) a person that provides home health, hospice, or
personal assistance services only to persons receiving benefits
under:
(A) the home and community-based services (HCS)
waiver program;
(B) the Texas home living (TxHmL) waiver program;
or
(C) Section 534.152, Government Code [enrolled
in a program funded wholly or partly by the Texas Department of
Mental Health and Mental Retardation and monitored by the Texas
Department of Mental Health and Mental Retardation or its
designated local authority in accordance with standards set by the
Texas Department of Mental Health and Mental Retardation]; or
(20) an individual who provides home health or
personal assistance services as the employee of a consumer or an
entity or employee of an entity acting as a consumer's fiscal agent
under Section 531.051, Government Code.
SECTION 1.03. 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 1.04. (a) In this section, "health and human
services agencies" has the meaning assigned by Section 531.001,
Government Code.
(b) The Health and Human Services Commission and any other
health and human services agency implementing a provision of this
Act that affects individuals with intellectual and developmental
disabilities shall consult with the Intellectual and Developmental
Disability System Redesign Advisory Committee established under
Section 534.053, Government Code, as added by this article,
regarding implementation of the provision.
SECTION 1.05. The Health and Human Services Commission
shall submit:
(1) the initial report on the implementation of the
Medicaid acute care services and long-term services and supports
delivery system for individuals with intellectual and
developmental disabilities as required by Section 534.054,
Government Code, as added by this article, not later than September
30, 2014; and
(2) the final report under that section not later than
September 30, 2023.
SECTION 1.06. 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 Medicaid managed care program
under Section 534.152, Government Code, as added by this article.
SECTION 1.07. 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 1.08. (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 September 30 of 2019, 2020, and 2021, 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 Subsection (a) and adding Subsections (f), (g), and (h)
to read as follows:
(a) In this section and Sections 533.00251, 533.002515,
533.00252, 533.00253, and 533.00254, "medical assistance" has the
meaning assigned by Section 32.003, Human Resources Code.
(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, 533.002515, 533.00252,
533.00253, and 533.00254 to read as follows:
Sec. 533.00251. DELIVERY OF CERTAIN BENEFITS, INCLUDING
NURSING FACILITY BENEFITS, THROUGH STAR + PLUS MEDICAID MANAGED
CARE PROGRAM. (a) In this section and Sections 533.002515 and
533.00252:
(1) "Advisory committee" means the STAR + PLUS Nursing
Facility Advisory Committee established under Section 533.00252.
(2) "Clean claim" means a claim that meets the same
criteria for a clean claim used by the Department of Aging and
Disability Services for the reimbursement of nursing facility
claims.
(3) "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.
(4) "Potentially preventable event" has the meaning
assigned by Section 536.001.
(b) Subject to Section 533.0025, 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) Subject to Section 533.0025 and 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
consistent with criteria adopted by the commission;
(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:
(A) assists in collecting applied income from
recipients; and
(B) 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;
(7) the establishment of a portal through which
nursing facility providers participating in the STAR + PLUS
Medicaid managed care program may submit claims to any
participating managed care organization; and
(8) that rules and procedures relating to the
certification and decertification of nursing facility beds under
the medical assistance program are not affected.
(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, 2017. This subsection expires September
1, 2018.
(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 that are consistent with adopted federal and state
standards. 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.
(f) This section expires September 1, 2019.
Sec. 533.002515. PLANNED PREPARATION FOR DELIVERY OF
NURSING FACILITY BENEFITS THROUGH STAR + PLUS MEDICAID MANAGED CARE
PROGRAM. (a) The commission shall develop a plan in preparation for
implementing the requirement under Section 533.00251(c) that the
commission provide benefits under the medical assistance program to
recipients who reside in nursing facilities through the STAR + PLUS
Medicaid managed care program. The plan required by this section
must be completed in two phases as follows:
(1) phase one: contract planning phase; and
(2) phase two: initial testing phase.
(b) In phase one, the commission shall develop a contract
template to be used by the commission when the commission contracts
with a managed care organization to provide nursing facility
services under the STAR + PLUS Medicaid managed care program. In
addition to the requirements of Section 533.005 and any other
applicable law, the template must include:
(1) nursing home credentialing requirements;
(2) appeals processes;
(3) termination provisions;
(4) prompt payment requirements and a liquidated
damages provision that contains financial penalties for failure to
meet prompt payment requirements;
(5) a description of medical necessity criteria;
(6) a requirement that the managed care organization
provide recipients and recipients' families freedom of choice in
selecting a nursing facility; and
(7) a description of the managed care organization's
role in discharge planning and imposing prior authorization
requirements.
(c) In phase two, the commission shall:
(1) design and test the portal required under Section
533.00251(c)(7);
(2) establish and inform managed care organizations of
the minimum technological or system requirements needed to use the
portal required under Section 533.00251(c)(7);
(3) establish operating policies that require that
managed care organizations maintain a portal through which
providers may confirm recipient eligibility on a monthly basis; and
(4) establish the manner in which managed care
organizations are to assist the commission in collecting from
recipients applied income or cost-sharing payments, including
copayments, as applicable.
(d) This section expires September 1, 2015.
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 governor, lieutenant governor, and speaker of the
house of representatives shall each appoint five members of the
advisory committee as follows:
(1) one member who is a physician and medical director
of a nursing facility provider with experience providing the
long-term continuum of care, including home care and hospice;
(2) one member who is a nonprofit nursing facility
provider;
(3) one member who is a for-profit nursing facility
provider;
(4) one member who is a consumer representative; and
(5) 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, 2017:
(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) "Advisory committee" means the STAR Kids Managed
Care Advisory Committee established under Section 533.00254.
(2) "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.
(3) "Potentially preventable event" has the meaning
assigned by Section 536.001.
(b) Subject to Section 533.0025, the commission shall, in
consultation with the advisory committee and the Children's Policy
Council established under Section 22.035, Human Resources Code,
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;
(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; and
(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.
(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:
(1) ensure that the STAR Kids managed care program
provides all of the benefits provided under the medically dependent
children (MDCP) waiver program to the extent necessary to implement
this subsection;
(2) contract with local intellectual and
developmental disability authorities to provide service
coordination to the children described by this subsection; and
(3) monitor the provision of benefits to children
described by 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.
(e) A local intellectual and developmental disability
authority with which the commission contracts under this section
may subcontract with an eligible person, including a nonprofit
entity, to provide service coordination under Subsection (c)(2).
The executive commissioner by rule shall establish minimum
qualifications a person must meet to be considered an "eligible
person" under this subsection.
(f) A managed care organization that contracts with the
commission to provide acute care services under this section shall
provide an acute care services coordinator to each child with a
disability during the child's transition to the STAR Kids capitated
managed care program.
(g) The commission shall seek ongoing input from the
Children's Policy Council regarding the establishment and
implementation of the STAR Kids managed care program.
Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
(a) The STAR Kids Managed Care Advisory Committee is established
to advise the commission on the establishment and implementation of
the STAR Kids managed care program under Section 533.00253.
(b) The executive commissioner shall appoint the members of
the advisory committee. The committee must consist of:
(1) families whose children will receive private duty
nursing under the program;
(2) health care providers;
(3) providers of home and community-based services,
including at least one private duty nursing provider and one
pediatric therapy provider; and
(4) other stakeholders as the executive commissioner
determines appropriate.
(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, 2017:
(1) the advisory committee is abolished; and
(2) this section expires.
SECTION 2.03. Subchapter A, Chapter 533, Government Code,
is amended by adding Section 533.00285 to read as follows:
Sec. 533.00285. STAR + PLUS QUALITY COUNCIL. (a) The STAR
+ PLUS Quality Council is established to advise the commission on
the development of policy recommendations that will ensure eligible
recipients receive quality, person-centered, consumer-directed
acute care services and long-term services and supports in an
integrated setting under the STAR + PLUS Medicaid managed care
program.
(b) The executive commissioner shall appoint the members of
the council, who must be stakeholders from the acute care services
and long-term services and supports community, including:
(1) representatives of health and human services
agencies;
(2) recipients under the STAR + PLUS Medicaid managed
care program;
(3) representatives of advocacy groups representing
individuals with disabilities and seniors who are recipients under
the STAR + PLUS Medicaid managed care program;
(4) representatives of service providers for
individuals with disabilities; and
(5) representatives of health maintenance
organizations.
(c) The executive commissioner shall appoint the presiding
officer of the council.
(d) The council shall meet at least quarterly or more
frequently if the presiding officer determines that it is necessary
to carry out the responsibilities of the council.
(e) Not later than November 1 of each year, the council
shall submit a report to the executive commissioner and the
Department of Aging and Disability Services that includes:
(1) an analysis and assessment of the quality of acute
care services and long-term services and supports provided under
the STAR + PLUS Medicaid managed care program;
(2) recommendations regarding how to improve the
quality of acute care services and long-term services and supports
provided under the program; and
(3) recommendations regarding how to ensure that
recipients eligible to receive services and supports under the
program receive person-centered, consumer-directed care in the
most integrated setting achievable.
(f) Not later than December 1 of each even-numbered year,
the Department of Aging and Disability Services, in consultation
with the council, shall submit a report to the legislature
regarding the assessments and recommendations contained in any
report submitted by the council under Subsection (e) during the
most recent state fiscal biennium.
(g) The council is subject to the requirements of Chapter
551.
(h) A member of the council serves without compensation.
(i) On January 1, 2017:
(1) the council is abolished; and
(2) this section expires.
SECTION 2.04. 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 on any [not later
than the 45th day after the date a] claim for payment that is
received with documentation reasonably necessary for the managed
care organization to process the claim:
(A) not later than:
(i) the 10th day after the date the claim is
received if the claim relates to services provided by a nursing
facility, intermediate care facility, or home and community-based
services provider;
(ii) the 21st day after the date the claim
is received if the claim relates to the provision of long-term
services and supports not subject to Subparagraph (i); and
(iii) the 45th day after the date the claim
is received if the claim is not subject to Subparagraph (i) or
(ii);[,] or
(B) 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 and the office of the attorney 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;
(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;
(16) a requirement that a medical director who is
authorized to make medical necessity determinations is available to
the region where the managed care organization provides health care
services;
(17) a requirement that the managed care organization
ensure that a medical director and patient care coordinators and
provider and recipient support services personnel are located in
the South Texas service region, if the managed care organization
provides a managed care plan in that region;
(18) a requirement that the managed care organization
provide special programs and materials for recipients with limited
English proficiency or low literacy skills;
(19) 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;
(20) a requirement that the managed care organization:
(A) 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:
(i) [(A)] preventive care;
(ii) [(B)] primary care;
(iii) [(C)] specialty care;
(iv) [(D)] after-hours urgent care; [and]
(v) [(E)] chronic care;
(vi) long-term services and supports;
(vii) nursing services; and
(viii) therapy services, including
services provided in a clinical setting or in a home or
community-based setting; and
(B) regularly, as determined by the commission,
submit to the commission and make available to the public a report
containing data on the sufficiency of the organization's provider
network with regard to providing the care and services described
under Paragraph (A) and specific data with respect to Paragraphs
(A)(iii), (vi), (vii), and (viii) on the average length of time
between:
(i) the date a provider makes a referral for
the care or service and the date the organization approves or denies
the referral; and
(ii) the date the organization approves a
referral for the care or service and the date the care or service is
initiated;
(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) a sufficient number of providers of
long-term services and supports and specialty pediatric care
providers of home and community-based services; and
(iv) 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 a
comparable 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;
(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;
(23) [subject to Subsection (a-1),] a requirement that
the managed care organization develop, implement, and maintain an
outpatient pharmacy benefit plan for its enrolled recipients:
(A) that exclusively employs the vendor drug
program formulary and preserves the state's ability to reduce
waste, fraud, and abuse under the Medicaid program;
(B) that adheres to the applicable preferred drug
list adopted by the commission under Section 531.072;
(C) that includes the prior authorization
procedures and requirements prescribed by or implemented under
Sections 531.073(b), (c), and (g) for the vendor drug program;
(D) for purposes of which the managed care
organization:
(i) may not negotiate or collect rebates
associated with pharmacy products on the vendor drug program
formulary; and
(ii) may not receive drug rebate or pricing
information that is confidential under Section 531.071;
(E) that complies with the prohibition under
Section 531.089;
(F) under which the managed care organization may
not prohibit, limit, or interfere with a recipient's selection of a
pharmacy or pharmacist of the recipient's choice for the provision
of pharmaceutical services under the plan through the imposition of
different copayments;
(G) that allows the managed care organization or
any subcontracted pharmacy benefit manager to contract with a
pharmacist or pharmacy providers separately for specialty pharmacy
services, except that:
(i) the managed care organization and
pharmacy benefit manager are prohibited from allowing exclusive
contracts with a specialty pharmacy owned wholly or partly by the
pharmacy benefit manager responsible for the administration of the
pharmacy benefit program; and
(ii) the managed care organization and
pharmacy benefit manager must adopt policies and procedures for
reclassifying prescription drugs from retail to specialty drugs,
and those policies and procedures must be consistent with rules
adopted by the executive commissioner and include notice to network
pharmacy providers from the managed care organization;
(H) under which the managed care organization may
not prevent a pharmacy or pharmacist from participating as a
provider if the pharmacy or pharmacist agrees to comply with the
financial terms and conditions of the contract as well as other
reasonable administrative and professional terms and conditions of
the contract;
(I) under which the managed care organization may
include mail-order pharmacies in its networks, but may not require
enrolled recipients to use those pharmacies, and may not charge an
enrolled recipient who opts to use this service a fee, including
postage and handling fees; and
(J) under which the managed care organization or
pharmacy benefit manager, as applicable, must pay claims in
accordance with Section 843.339, Insurance Code; [and]
(24) a requirement that the managed care organization
and any entity with which the managed care organization contracts
for the performance of services under a managed care plan disclose,
at no cost, to the commission and, on request, the office of the
attorney general all discounts, incentives, rebates, fees, free
goods, bundling arrangements, and other agreements affecting the
net cost of goods or services provided under the plan; and
(25) a requirement that the managed care organization
not implement significant, nonnegotiated, across-the-board
provider reimbursement rate reductions unless the organization has
the prior approval of the commission to make the reduction.
SECTION 2.05. Section 533.041, Government Code, is amended
by amending Subsection (a) and adding Subsections (c) and (d) to
read as follows:
(a) The executive commissioner [commission] shall appoint a
state Medicaid managed care advisory committee. The advisory
committee consists of representatives of:
(1) hospitals;
(2) managed care organizations and participating
health care providers;
(3) primary care providers and specialty care
providers;
(4) state agencies;
(5) low-income recipients or consumer advocates
representing low-income recipients;
(6) recipients with disabilities, including
recipients with intellectual and developmental disabilities or
physical disabilities, or consumer advocates representing those
recipients [with a disability];
(7) parents of children who are recipients;
(8) rural providers;
(9) advocates for children with special health care
needs;
(10) pediatric health care providers, including
specialty providers;
(11) long-term services and supports [care]
providers, including nursing facility [home] providers and direct
service workers;
(12) obstetrical care providers;
(13) community-based organizations serving low-income
children and their families; [and]
(14) community-based organizations engaged in
perinatal services and outreach;
(15) recipients who are 65 years of age or older;
(16) recipients with mental illness;
(17) nonphysician mental health providers
participating in the Medicaid managed care program; and
(18) entities with responsibilities for the delivery
of 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.
(c) The executive commissioner shall appoint the presiding
officer of the advisory committee.
(d) To the greatest extent possible, the executive
commissioner shall appoint members of the advisory committee who
reflect the geographic diversity of the state and include members
who represent rural Medicaid program recipients.
SECTION 2.06. Section 533.042, Government Code, is amended
to read as follows:
Sec. 533.042. MEETINGS. (a) The advisory committee shall
meet at the call of the presiding officer at least semiannually, but
no more frequently than quarterly.
(b) The advisory committee:
(1) [,] shall develop procedures that provide the
public with reasonable opportunity to appear before the committee
[committtee] and speak on any issue under the jurisdiction of the
committee;[,] and
(2) is subject to Chapter 551.
SECTION 2.07. Section 533.043, Government Code, is amended
to read as follows:
Sec. 533.043. POWERS AND DUTIES. (a) The advisory
committee shall:
(1) provide recommendations and ongoing advisory
input to the commission on the statewide implementation and
operation of Medicaid managed care, including:
(A) program design and benefits;
(B) systemic concerns from consumers and
providers;
(C) the efficiency and quality of services
delivered by Medicaid managed care organizations;
(D) contract requirements for Medicaid managed
care organizations;
(E) Medicaid managed care provider network
adequacy; and
(F) other issues as requested by the executive
commissioner;
(2) assist the commission with issues relevant to
Medicaid managed care to improve the policies established for and
programs operating under Medicaid managed care, including the early
and periodic screening, diagnosis, and treatment program, provider
and patient education issues, and patient eligibility issues; and
(3) disseminate or make available to each regional
advisory committee appointed under Subchapter B information on best
practices with respect to Medicaid managed care that is obtained
from a regional advisory committee.
(b) The commission and the Department of Aging and
Disability Services shall ensure coordination and communication
between the advisory committee, regional Medicaid managed care
advisory committees appointed by the commission under Subchapter B,
and other advisory committees or groups that perform functions
related to Medicaid managed care, including the Intellectual and
Developmental Disability System Redesign Advisory Committee
established under Section 534.053, in a manner that enables the
state Medicaid managed care advisory committee to act as a central
source of agency information and stakeholder input relevant to the
implementation and operation of Medicaid managed care.
(c) The advisory committee may establish work groups that
meet at other times for purposes of studying and making
recommendations on issues the committee determines appropriate.
SECTION 2.08. Section 533.044, Government Code, is amended
to read as follows:
Sec. 533.044. OTHER LAW. (a) Except as provided by
Subsection (b) and other provisions of this subchapter, the
advisory committee is subject to Chapter 2110.
(b) Section 2110.008 does not apply to the advisory
committee.
SECTION 2.09. Subchapter C, Chapter 533, Government Code,
is amended by adding Section 533.045 to read as follows:
Sec. 533.045. COMPENSATION; REIMBURSEMENT. (a) Except as
provided by Subsection (b), a member of the advisory committee is
not entitled to receive compensation or reimbursement for travel
expenses.
(b) 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.
SECTION 2.10. Subsection (a-1), Section 533.005,
Government Code, is repealed.
SECTION 2.11. (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, 2017, 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 2017
and until December 1, 2021, submit additional reports that include
the information described by Subdivision (1) of this subsection.
(b) This section expires September 1, 2022.
SECTION 2.12. (a) Not later than October 1, 2013, the
executive commissioner of the Health and Human Services Commission
shall appoint the members of the STAR + PLUS Quality Council as
required by Section 533.00285, Government Code, as added by this
article.
(b) The STAR + PLUS Quality Council shall submit:
(1) the initial report required under Subsection (e),
Section 533.00285, Government Code, as added by this article, not
later than November 1, 2014; and
(2) the final report required under that subsection
not later than November 1, 2016.
(c) The Department of Aging and Disability Services shall
submit:
(1) the initial report required under Subsection (f),
Section 533.00285, Government Code, as added by this article, not
later than December 1, 2014; and
(2) the final report required under that subsection
not later than December 1, 2016.
SECTION 2.13. (a) 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, require
that the managed care organization comply with applicable
provisions of Subsection (a), Section 533.005, Government Code, as
amended by this article.
(b) The Health and Human Services Commission shall seek to
amend contracts entered into with managed care organizations under
Chapter 533, Government Code, before the effective date of this Act
to require those managed care organizations to comply with
applicable provisions of Subsection (a), Section 533.005,
Government Code, as amended by this article. To the extent of a
conflict between the applicable provisions of that subsection and a
provision of a contract with a managed care organization entered
into before the effective date of this Act, the contract provision
prevails.
SECTION 2.14. Not later than September 15, 2013, the
governor, lieutenant governor, and speaker of the house of
representatives shall appoint the members of the STAR + PLUS
Nursing Facility Advisory Committee as required by Section
533.00252, Government Code, as added by this article.
SECTION 2.15. (a) Not later than October 1, 2013, the Health
and Human Services Commission shall:
(1) complete phase one of the plan required under
Section 533.002515, Government Code, as added by this article; and
(2) submit a report regarding the implementation of
phase one of the plan together with a copy of the contract template
required by that section to the STAR + PLUS Nursing Facility
Advisory Committee established under Section 533.00252, Government
Code, as added by this article.
(b) Not later than July 15, 2014, the Health and Human
Services Commission shall:
(1) complete phase two of the plan required under
Section 533.002515, Government Code, as added by this article; and
(2) submit a report regarding the implementation of
phase two to the STAR + PLUS Nursing Facility Advisory Committee
established under Section 533.00252, Government Code, as added by
this article.
SECTION 2.16. (a) The Health and Human Services Commission
may not:
(1) implement Paragraph (B), Subdivision (6),
Subsection (c), Section 533.00251, Government Code, as added by
this article, unless the commission seeks and obtains a waiver or
other authorization from the federal Centers for Medicare and
Medicaid Services or other appropriate entity that ensures a
significant portion, but not more than 80 percent, of accrued
savings to the Medicare program as a result of reduced
hospitalizations and institutionalizations and other care and
efficiency improvements to nursing facilities participating in the
medical assistance program in this state will be returned to this
state and distributed to those facilities; and
(2) begin providing medical assistance benefits to
recipients under Section 533.00251, Government Code, as added by
this article, before September 1, 2014.
(b) As soon as practicable after the implementation date of
Section 533.00251, Government Code, as added by this article, the
Health and Human Services Commission shall provide a 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 2.17. (a) Not later than October 1, 2013, the
executive commissioner of the Health and Human Services Commission
shall appoint additional members to the state Medicaid managed care
advisory committee to comply with Section 533.041, Government Code,
as amended by this article.
(b) Not later than December 1, 2013, the presiding officer
of the state Medicaid managed care advisory committee shall convene
the first meeting of the advisory committee following appointment
of additional members as required by Subsection (a) of this
section.
SECTION 2.18. As soon as practicable after the effective
date of this Act, but not later than January 1, 2015, the executive
commissioner of the Health and Human Services Commission shall
adopt rules and managed care contracting guidelines governing the
transition of appropriate duties and functions from the commission
and other health and human services agencies to managed care
organizations that are required as a result of the changes in law
made by this article.
SECTION 2.19. 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," "ICF-IID program," and
"Medicaid waiver program" have the meanings assigned those terms 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 for individuals with
intellectual and developmental disabilities as needed to ensure
that each individual with an intellectual or developmental
disability receives the type, intensity, and range of services that
are both appropriate and available, based on the functional needs
of that individual, if the individual receives services through one
of the following:
(1) a Medicaid waiver program;
(2) the ICF-IID program; or
(3) an intermediate care facility operated by the
state and providing services for individuals with intellectual and
developmental disabilities.
(b-1) In developing a comprehensive assessment instrument
for purposes of Subsection (b), the department shall evaluate any
assessment instrument in use by the department. In addition, the
department may implement an evidence-based, nationally recognized,
comprehensive assessment instrument that assesses the functional
needs of an individual with intellectual and developmental
disabilities as the comprehensive assessment instrument required
by Subsection (b). This subsection expires September 1, 2015.
(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 established under
Section 534.053, Government Code, 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.
SECTION 3.04. (a) In this section:
(1) "Medicaid program" means the medical assistance
program established under Chapter 32, Human Resources Code.
(2) "Section 1915(c) waiver program" has the meaning
assigned by Section 531.001, Government Code.
(b) The Health and Human Services Commission shall conduct a
study to evaluate the need for applying income disregards to
persons with intellectual and developmental disabilities receiving
benefits under the medical assistance program, including through a
Section 1915(c) waiver program.
(c) Not later than January 15, 2015, 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 533.00256 to read as follows:
Sec. 533.00256. 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
geographic 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 may 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 deleting any data that relates to a
hospital's performance with respect to particular
diagnosis-related groups or individual patients.
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 may 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 provider; and
(2) only after deleting any data that relates to a
provider's performance with respect to particular resource
utilization groups or individual recipients.
SECTION 4.18. As soon as practicable after the effective
date of this Act, the Health and Human Services Commission shall
provide a 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.
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 federal law
and notwithstanding any provision of Chapter 191 or 192, Health and
Safety Code, 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 531.024115 to read as follows:
Sec. 531.024115. SERVICE DELIVERY AREA ALIGNMENT.
Notwithstanding Section 533.0025(e) or any other law, to the extent
possible, the commission shall align service delivery areas under
the Medicaid and child health plan programs.
SECTION 6.04. 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.
SECTION 6.05. Section 531.024115, Government Code, as added
by this article:
(1) applies only with respect to a contract between
the Health and Human Services Commission and a managed care
organization, service provider, or other person or entity under the
medical assistance program, including Chapter 533, Government
Code, or the child health plan program established under Chapter
62, Health and Safety Code, that is entered into or renewed on or
after the effective date of this Act; and
(2) does not authorize the Health and Human Services
Commission to alter the terms of a contract that was entered into or
renewed before the effective date of this Act.
SECTION 6.06. Section 533.0354, Health and Safety Code, is
amended by amending Subsections (a) and (b) and adding Subsection
(a-1) to read as follows:
(a) A local mental health authority shall ensure the
provision of assessment services, crisis services, and intensive
and comprehensive services using disease management practices for
children with serious emotional, behavioral, or mental disturbance
and adults with severe mental illness who are experiencing
significant functional impairment due to a mental health disorder
defined by the Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (DSM-5), including:
(1) bipolar disorder;
(2) [,] schizophrenia;
(3) major depressive disorder, including single
episode or recurrent major depressive disorder;
(4) post-traumatic stress disorder;
(5) schizoaffective disorder, including bipolar and
depressive types;
(6) obsessive compulsive disorder;
(7) anxiety disorder;
(8) attention deficit disorder;
(9) delusional disorder;
(10) bulimia nervosa, anorexia nervosa, or other
eating disorders not otherwise specified; or
(11) any other diagnosed mental health disorder [, or
clinically severe depression and for children with serious
emotional illnesses].
(a-1) The local mental health authority shall ensure that
individuals are engaged with treatment services that are:
(1) ongoing and matched to the needs of the individual
in type, duration, and intensity;
(2) focused on a process of recovery designed to allow
the individual to progress through levels of service;
(3) guided by evidence-based protocols and a
strength-based paradigm of service; and
(4) monitored by a system that holds the local
authority accountable for specific outcomes, while allowing
flexibility to maximize local resources.
(b) The department shall require each local mental health
authority to incorporate jail diversion strategies into the
authority's disease management practices to reduce the involvement
of the criminal justice system in [for] managing adults with the
following mental health disorders as defined by the Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition (DSM-5):
(1) schizophrenia;
(2) [and] bipolar disorder;
(3) post-traumatic stress disorder;
(4) schizoaffective disorder, including bipolar and
depressive types;
(5) anxiety disorder; or
(6) delusional disorder [to reduce the involvement of
those client populations with the criminal justice system].
SECTION 6.07. Subchapter B, Chapter 32, Human Resources
Code, is amended by adding Section 32.0284 to read as follows:
Sec. 32.0284. CALCULATION OF PAYMENTS UNDER CERTAIN
SUPPLEMENTAL HOSPITAL PAYMENT PROGRAMS. (a) In this section:
(1) "Commission" means the Health and Human Services
Commission.
(2) "Supplemental hospital payment program" means:
(A) the disproportionate share hospitals
supplemental payment program administered according to 42 U.S.C.
Section 1396r-4; and
(B) the uncompensated care payment program
established under the Texas Healthcare Transformation and Quality
Improvement Program waiver issued under Section 1115 of the federal
Social Security Act (42 U.S.C. Section 1315).
(b) For purposes of calculating the hospital-specific limit
used to determine a hospital's uncompensated care payment under a
supplemental hospital payment program, the commission shall ensure
that to the extent a third-party commercial payment exceeds the
Medicaid allowable cost for a service provided to a recipient and
for which reimbursement was not paid under the medical assistance
program, the payment is not considered a medical assistance
payment.
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. If the Health and Human Services Commission
determines that it is cost-effective, the commission shall apply
for and actively seek a waiver or authorization from the
appropriate federal agency to allow the state to provide medical
assistance under the waiver or authorization to medically fragile
individuals:
(1) who are at least 21 years of age; and
(2) whose costs to receive care exceed cost limits
under existing Medicaid waiver programs.
SECTION 7.04. 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 7.05. (a) Except as provided by Subsection (b) of
this section, this Act takes effect September 1, 2013.
(b) Section 533.0354, Health and Safety Code, as amended by
this Act, takes effect January 1, 2014.