2013S0058-2 01/15/13
By: Nelson S.B. No. 7
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 care 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 CARE 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 CARE SERVICES AND SUPPORTS TO PERSONS WITH
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 534.001. DEFINITIONS. In this chapter:
(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) "Department" means the Department of Aging and
Disability Services.
(3) "ICF-IID" means the Medicaid program serving
individuals with intellectual and developmental disabilities who
receive care in intermediate care facilities, but does not include
a state supported living center, as defined by Section 531.002,
Health and Safety Code.
(4) "Local intellectual and developmental disability
authority" means a local mental retardation authority described by
Section 533.035, Health and Safety Code.
(5) "Managed care organization," "managed care plan,"
and "potentially preventable event" have the meanings assigned
under Section 536.001.
(6) "Medicaid program" means the medical assistance
program established under Chapter 32, Human Resources Code.
(7) "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, and multiple disabilities
(DBMD) waiver program; and
(D) the Texas home living (TxHmL) waiver program.
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.
[Sections 534.003-534.050 reserved for expansion]
SUBCHAPTER B. ACUTE CARE SERVICES AND LONG-TERM CARE SERVICES AND
SUPPORTS SYSTEM
Sec. 534.051. ACUTE CARE SERVICES AND LONG-TERM CARE
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 care
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 by
ensuring that the individuals receive information about all
available programs and services and how to apply for the programs
and services;
(3) improve the assessment of individuals' needs and
available supports;
(4) promote integrated coordinated case management of
acute care services and long-term care services and supports;
(5) improve the coordination of acute care services
and long-term care services and supports;
(6) improve acute care and long-term care outcomes,
including reducing potentially preventable events;
(7) promote high-quality care; and
(8) promote person-centered planning and
self-direction.
Sec. 534.052. IMPLEMENTATION OF SYSTEM. The commission and
department shall jointly implement the acute care services and
long-term care 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. ANNUAL REPORT ON IMPLEMENTATION. (a) Not
later than September 1 of each year, the commission shall submit a
report to the legislature regarding:
(1) the implementation of the system required by this
chapter, including appropriate information regarding the provision
of acute care services and long-term care 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, 2019.
[Sections 534.054-534.100 reserved for expansion]
SUBCHAPTER C. STAGE ONE: PROGRAMS TO IMPROVE SERVICE DELIVERY
MODELS
Sec. 534.101. 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 care
services and supports under the Medicaid program to individuals
with intellectual and developmental disabilities.
Sec. 534.102. STAKEHOLDER INPUT. In developing and
implementing pilot programs under this subchapter, the department
shall develop a process for statewide stakeholder input to be
received and evaluated.
Sec. 534.103. PILOT PROGRAM PROVIDERS. (a) The department
shall identify local intellectual and developmental disability
authorities and private care 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 care 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 local intellectual and developmental disability
authorities and private care 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 care services and
supports;
(2) improve quality and promote integrated
coordinated case management of acute care services and long-term
services and supports;
(3) promote person-centered planning and
self-direction; and
(4) promote efficiency and the best use of funding.
(d) The department shall evaluate each submitted managed
care strategy proposal and determine whether:
(1) the proposed strategy satisfies the requirements
of this section; and
(2) the local intellectual and developmental
disability authority or private care provider that submitted the
proposal is likely able to provide the long-term care services and
supports appropriate to the individuals who will receive care
through the program.
(e) Based on the evaluation performed by the department
under Subsection (d), the department may select as pilot program
service providers one intellectual and developmental disability
authority and one private care provider.
(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 care
services and supports under the Medicaid program to persons with
intellectual and developmental disabilities to test its managed
care strategy based on capitation.
Sec. 534.104. PILOT PROGRAM GOALS. (a) The department
shall identify measurable goals to be achieved by each pilot
program implemented under this subchapter.
(b) The department 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. 534.105. IMPLEMENTATION, LOCATION, AND DURATION.
(a) The commission and department shall implement any pilot
programs established under this subchapter not later than September
1, 2014.
(b) A pilot program established under this subchapter must
operate for not less than 24 months.
(c) A pilot program established under this subchapter shall
be conducted in one or more regions selected by the department.
Sec. 534.106. COORDINATING SERVICES. In providing
long-term care services and supports under the Medicaid program to
an individual with intellectual or developmental disabilities, a
pilot program service provider shall:
(1) coordinate through the pilot program
institutional and community-based services available to the
individual, including services provided through:
(A) a facility licensed under Chapter 252, Health
and Safety Code;
(B) a Medicaid waiver program; or
(C) a community-based ICF-IID operated by local
authorities; and
(2) coordinate with managed care organizations to
promote integrated coordinated case management of acute care
services and long-term care services and supports.
Sec. 534.107. PILOT PROGRAM INFORMATION. (a) The
commission and the department shall collect and compute the
following information with respect to each pilot program
established under this subchapter to the extent it is available:
(1) the difference between the average monthly cost
per person for all services 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 534.106, and the average cost per person for all services
received by the individuals before the operation of the pilot
program;
(2) the percentage of individuals receiving services
through the pilot program who begin receiving services in a
non-residential 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 care 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 care 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; and
(6) the difference between the percentage of
individuals receiving services through the pilot program whose
behavioral outcomes have improved since the beginning of the
program and the percentage of individuals receiving services
through the program whose behavioral outcomes improved before the
operation of the program, as measured over a comparable period.
(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.
Sec. 534.108. PERSON-CENTERED PLANNING. The commission, in
cooperation with the department, shall ensure that each individual
with intellectual or developmental disabilities who receives
services and supports under the Medicaid program through a pilot
program established under this subchapter has choice, direction,
and control over Medicaid benefits should the individual choose the
consumer direction model, as defined by Section 531.051.
Sec. 534.109. TRANSITION BETWEEN PROGRAMS. The commission
shall ensure that there is a comprehensive plan for transitioning
services from the Medicaid waiver program to another program to
protect continuity of care.
Sec. 534.110. CONCLUSION OF PILOT PROGRAMS; EXPIRATION. On
September 1, 2018:
(1) each pilot program established under this
subchapter that is still in operation must conclude; and
(2) this subchapter expires.
[Sections 534.111-534.150 reserved for expansion]
SUBCHAPTER D. STAGE ONE: PROVISION OF ACUTE CARE AND
CERTAIN OTHER SERVICES
Sec. 534.151. DELIVERY OF ACUTE CARE SERVICES FOR
INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES. The
commission shall provide Medicaid program benefits for acute care
services to individuals with intellectual and developmental
disabilities through:
(1) the STAR Medicaid managed care program, or the
most appropriate capitated managed care program delivery model, if
the individual receives long-term care Medicaid waiver program
services or ICF-IID services not integrated into the STAR + PLUS
Medicaid managed care delivery model or other managed care delivery
model under Section 534.201 or 534.202; and
(2) the STAR + PLUS Medicaid managed care program or
the most appropriate integrated capitated managed care program
delivery model, if the individual is eligible to receive medical
assistance for acute care services and is not receiving medical
assistance under a Medicaid waiver program.
Sec. 534.152. DELIVERY OF CERTAIN OTHER SERVICES UNDER STAR
+ PLUS MEDICAID MANAGED CARE PROGRAM. The commission shall
implement the most cost-effective option for the delivery of basic
attendant and habilitation services for individuals with
intellectual and developmental disabilities under the STAR + PLUS
Medicaid managed care program that maximizes federal funding for
the delivery of services across that and other similar programs.
Sec. 534.153. STAKEHOLDER INPUT. In implementing the most
cost-effective option under this subchapter, the commission shall
develop a process for statewide stakeholder input to be received
and evaluated.
[Sections 534.154-534.200 reserved for expansion]
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 care 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, 2016, 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 the cost effectiveness and
the experience of the STAR + PLUS Medicaid managed care program in
providing basic attendant and habilitation services and 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 care services and supports not available under the
managed care program delivery model selected by the commission; or
(2) cease operation of the Texas home living (TxHmL)
waiver program and expand all or a portion of the long-term care
services and supports previously available under the waiver program
to 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 for statewide
stakeholder input to be received and evaluated.
(e) The commission shall ensure that there is a
comprehensive plan for transitioning services from the Texas home
living (TxHmL) waiver program to another program to protect
continuity of care.
Sec. 534.202. TRANSITION OF ICF-IID RECIPIENTS AND CERTAIN
OTHER MEDICAID WAIVER PROGRAM RECIPIENTS TO MANAGED CARE PROGRAM.
(a) This section applies to individuals with intellectual and
developmental disabilities who are receiving long-term services
and supports and who, on the date the commission implements the
transition described by Subsection (b):
(1) meet the eligibility criteria required to receive
long-term care services and supports under a Medicaid waiver
program other than the Texas home living (TxHmL) waiver program; or
(2) reside in a facility licensed under Chapter 252,
Health and Safety Code, or in a community-based ICF-IID operated by
local authorities.
(b) After implementing the transition required by Section
534.201 but 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 an
evaluation of the experience of the transition of Texas home living
(TxHmL) waiver program recipients to a managed care program
delivery model under Section 534.201, subject to Subsection (c)(1).
(c) At the time of the transition described by Subsection
(b), the commission shall determine whether to:
(1) continue operation of the Medicaid waiver programs
for purposes of providing supplemental long-term care services and
supports not available under the managed care program delivery
model selected by the commission; or
(2) cease operation of the Medicaid waiver programs
and expand all or a portion of the long-term care services and
supports previously available under the waiver programs to 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 for statewide
stakeholder input to be received and evaluated.
(e) The commission shall ensure that there is a
comprehensive plan for transitioning services from the Medicaid
waiver program to another program to protect continuity of care.
SECTION 1.02. The Health and Human Services Commission
shall submit:
(1) the initial report on the implementation of the
acute care services and long-term care services and supports system
for individuals with intellectual and developmental disabilities
as required by Section 534.053, Government Code, as added by this
Act, not later than September 1, 2014; and
(2) the final report under that section not later than
September 1, 2018.
SECTION 1.03. 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 Act, as soon as practicable after
the effective date of this Act.
ARTICLE 2. MEDICAID MANAGED CARE EXPANSION
SECTION 2.01. Subsection (b), Section 533.0025, Government
Code, is amended to read as follows:
(b) Notwithstanding [Except as otherwise provided by this
section and notwithstanding] any other law, the commission shall
provide medical assistance for acute care services through the most
cost-effective model of Medicaid capitated managed care as
determined by the commission. The [If the] commission shall
require mandatory participation in a Medicaid capitated managed
care program for all persons eligible for acute care [determines
that it is more cost-effective, the commission may provide] medical
assistance benefits [for acute care in a certain part of this state
or to a certain population of recipients using:
[(1) a health maintenance organization model,
including the acute care portion of Medicaid Star + Plus pilot
programs;
[(2) a primary care case management model;
[(3) a prepaid health plan model;
[(4) an exclusive provider organization model; or
[(5) another Medicaid managed care model or
arrangement].
SECTION 2.02. Subchapter A, Chapter 533, Government Code,
is amended by adding Sections 533.00251 and 533.00252 to read as
follows:
Sec. 533.00251. DELIVERY OF SERVICES THROUGH STAR + PLUS
MEDICAID MANAGED CARE PROGRAM. (a) In this section:
(1) "Nursing facility" has the meaning assigned by
Section 531.912.
(2) "Potentially preventable event" has the meaning
assigned by Section 536.001.
(b) The commission shall expand the STAR + PLUS Medicaid
managed care program to all areas of this state to serve individuals
eligible for acute care services and long-term care services and
supports under the medical assistance program.
(c) Notwithstanding any other law, the commission 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
reimbursement rate paid to a nursing facility under the managed
care program;
(2) that a nursing facility is paid not later than the
10th day after the date the facility submits a proper claim;
(3) the appropriate utilization of services;
(4) a reduction in the incidence of potentially
preventable events; and
(5) that a managed care organization providing
services under the managed care program provides payment incentives
to nursing facility providers that reward reductions in preventable
acute care costs and encourage transformative efforts in the
delivery of nursing facility services.
Sec. 533.00252. STAR KIDS MEDICAID MANAGED CARE PROGRAM.
(a) In this section:
(1) "Health home" means a primary care provider
practice or, if appropriate, a specialty care provider practice,
incorporating several features, including comprehensive care
coordination, family-centered care, and data management, that are
focused on improving outcome-based quality of care and increasing
patient and provider satisfaction under the medical assistance
program.
(2) "Medical assistance" has the meaning assigned by
Section 32.003, Human Resources Code.
(3) "Potentially preventable event" has the meaning
assigned by Section 536.001.
(b) The commission shall establish a mandatory STAR Kids
capitated managed care program tailored to provide medical
assistance benefits to children with disabilities who are not
otherwise enrolled in the STAR + PLUS Medicaid managed care
program. 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 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 care services 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 ensure that the STAR Kids managed care program provides all or
a portion of the benefits provided under the medically dependent
children (MDCP) waiver program to the extent necessary to implement
this subsection.
SECTION 2.03. Section 32.0212, Human Resources Code, is
amended to read as follows:
Sec. 32.0212. DELIVERY OF MEDICAL ASSISTANCE.
Notwithstanding any other law [and subject to Section 533.0025,
Government Code], the department shall provide medical assistance
for acute care services through the Medicaid managed care system
implemented under Chapter 533, Government Code, or another Medicaid
capitated managed care program.
SECTION 2.04. Subsections (c) and (d), Section 533.0025,
Government Code, and Subchapter D, Chapter 533, Government Code,
are repealed.
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) "Department" means the Department of Aging and
Disability Services.
(2) "Medicaid waiver program" has the meaning assigned
by Section 534.001, Government Code.
(b) Subject to the availability of federal funding, the
department shall develop and implement a comprehensive assessment
instrument and a resource allocation process. The assessment
instrument and resource allocation process must be designed to
recommend for each individual with intellectual and developmental
disabilities enrolled in a Medicaid waiver program the type,
intensity, and range of services that are both appropriate and
available, based on the functional needs of that individual.
(c) The department may satisfy the requirement to implement
the comprehensive assessment instrument and the resource
allocation process developed under Subsection (b) by implementing
the instrument and process only for purposes of pilot programs
established under Subchapter C, Chapter 534, Government Code. This
subsection expires on the date Subchapter C, Chapter 534,
Government Code, expires.
(d) The department shall establish a prior authorization
process for requests for placement of an individual with
intellectual and developmental disabilities in a group home. The
process must ensure that placement in a group home is available only
to individuals for whom a more independent setting is not
appropriate or available.
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 RESIDENTIAL 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) congregate living arrangements, such as houses,
condominiums, or rental properties that may be in close proximity
to each other;
(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, 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 for statewide stakeholder input to ensure the
most comprehensive review of opportunities and options for
residential services.
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.
(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. An intervention team may include one or more
professionals such as a:
(1) psychiatrist or psychologist;
(2) physician;
(3) registered nurse;
(4) behavior analyst;
(5) social worker; or
(6) crisis coordinator.
(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 an individual
remains in the community and avoids institutionalization;
(2) focus on stabilizing the individual and assessing
the individual for 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.
ARTICLE 4. QUALITY-BASED OUTCOMES AND PAYMENTS PROVISIONS
SECTION 4.01. 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 admission," "potentially preventable ancillary
service," "potentially preventable complication," "potentially
preventable emergency room visit," "potentially preventable
readmission," and "potentially preventable event" have the
meanings 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, to 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 4.02. Section 533.013, Government Code, is amended
by adding Subsection (e) to read as follows:
(e) The commission shall pursue premium rate-setting
strategies that encourage payment reform to providers and more
efficient service delivery and provider practices. In this effort,
the commission shall review strategies employed or being considered
by other states and, if necessary, shall submit a waiver to the
federal Centers for Medicare and Medicaid Services.
SECTION 4.03. 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 allocate shared
profits earned by managed care organizations to provide incentives
to specific managed care organizations in order to promote quality
of care, encourage payment reform, reward local service delivery
reform, increase efficiency, and reduce inappropriate or
preventable service utilization.
SECTION 4.04. 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 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 based on all [consider measures addressing]
potentially preventable events.
(a-1) The outcome measures based on potentially preventable
events must be risk-adjusted and allow for rate-based performance
among health care providers.
(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
and long-term care services; [and]
(4) that are similar to outcome and process measures
used in the private sector, as appropriate;
(5) that reflect effective coordination of acute and
long-term care services;
(6) that can be tied to expenditures; and
(7) that reduce preventable health care utilization
and costs.
SECTION 4.05. Subchapter A, Chapter 536, Government Code,
is amended by adding Sections 536.0031 and 536.0032 to read as
follows:
Sec. 536.0031. SHARING OF DATA AMONG HEALTH AND HUMAN
SERVICES AGENCIES. To the extent permitted under state and federal
requirements, 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, CHIP
program, and other programs supported by general revenue.
Sec. 536.0032. MANAGED CARE COLLABORATIVE PROGRAM
IMPROVEMENT PLANS. In consultation with the Medicaid and CHIP
Quality-Based Payment Advisory Committee, the commission shall
establish a clinical improvement program to establish goals, and
the commission shall require managed care organizations to develop
and implement collaborative program improvement strategies to
address these goals. Clinical goals established under the program
may be targeted by region and program type.
SECTION 4.06. 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, 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 4.07. 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 4.08. Section 536.006, Government Code, is amended
to read as follows:
Sec. 536.006. TRANSPARENCY. 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 a web-based capability to provide managed
care organizations and providers with data on their clinical and
utilization performance, including comparisons to other peer
organizations and providers in Texas and in their region; this
capability must support the requirements of the electronic health
information exchange system described in Sections 531.907-531.909.
SECTION 4.09. 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) quality-based payment system; and
(5) service delivery model.
(c) The annual report may not identify specific health care
providers.
SECTION 4.10. 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, which may increase
from one year to the next, 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 and that advance quality improvement and
innovation. The measures utilized should change over time in order
to promote continuous system reform, improved quality, and reduced
costs. The commission may adjust measures to account for managed
care organizations new to a service area.
SECTION 4.11. 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 potentially preventable events; and
(4) increase the use of alternative payment systems.
SECTION 4.12. Section 536.151, Government Code, is amended
by amending Subsections (a) and (b) and adding Subsection (a-1) 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;
(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.
SECTION 4.13. 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 4.14. 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 care services and supports.
SECTION 4.15. Chapter 536, Government Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. QUALITY-BASED LONG-TERM CARE PAYMENT SYSTEMS
Sec. 536.251. QUALITY-BASED LONG-TERM CARE PAYMENTS.
(a) Subject to this subchapter, the commission, after consulting
with the advisory committee, may develop and implement
quality-based payment systems for Medicaid long-term care 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 care 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 care 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; and
(2) whether the data sets will provide value for
outcome or performance measures and cost containment.
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 care services and
supports recipients.
(b) The commission shall establish a program to provide a
confidential report to each Medicaid long-term care 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) A report provided to a provider under this section is
confidential and is not subject to Chapter 552.
SECTION 4.16. 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 Act.
ARTICLE 5. SPECIFIC PROVISIONS RELATING TO PREMIUMS UNDER THE
MEDICAL ASSISTANCE PROGRAM
SECTION 5.01. Subchapter A, Chapter 533, Government Code,
is amended by adding Section 533.0133 to read as follows:
Sec. 533.0133. INCLUSION OF RETROACTIVE FEE-FOR-SERVICE
PAYMENTS IN PREMIUMS PAID. If the commission determines that it is
cost-effective, the commission shall include all or a portion of
any retroactive fee-for-service payments payable under the medical
assistance program in the premium paid to a managed care
organization under a managed care plan, including retroactive
fee-for-service payments owed for services provided to a recipient
before the recipient's enrollment in the medical assistance program
or the managed care program, as applicable.
SECTION 5.02. Subchapter B, Chapter 32, Human Resources
Code, is amended by adding Section 32.0642 to read as follows:
Sec. 32.0642. PREMIUM REQUIREMENT FOR RECEIPT OF CERTAIN
SERVICES. To the extent permitted under and in a manner that is
consistent with Title XIX, Social Security Act (42 U.S.C. Section
1396 et seq.), and any other applicable law or regulation or under a
federal waiver or other authorization, the executive commissioner
of the Health and Human Services Commission shall adopt and
implement in the most cost-effective manner a premium for long-term
care services provided to a child under the medical assistance
program to be paid by the child's parent or other legal guardian.
ARTICLE 6. FEDERAL AUTHORIZATION, FUNDING, AND EFFECTIVE DATE
SECTION 6.01. 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 6.02. 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 6.03. This Act takes effect September 1, 2013.