By: Coleman H.B. No. 3845
A BILL TO BE ENTITLED
AN ACT
relating to a "Texas Way" to reforming and addressing issues
related to the Medicaid program, including the creation of an
alternative program designed to ensure health benefit plan coverage
to certain low-income individuals through the private marketplace;
authorizing a fee.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. LEGISLATIVE INTENT
SECTION 1.01. (a) The legislature finds that:
(1) over a million citizens of this state fall into a
health care coverage gap because they cannot qualify for Medicaid
in this state but do not earn enough to qualify for federal tax
credits that are available to assist those citizens with purchasing
health benefit plan coverage through the private marketplace;
(2) it is imperative that this state act to ensure that
these citizens no longer fall through the health care coverage gap;
and
(3) this state should seek to address the unique
health care needs of our citizens in the same way other states,
including Indiana and Arkansas, have addressed the health care
needs of their citizens.
(b) The legislative intent of this Act is to propose a
"Texas Way" to closing the health care coverage gap that allows this
state flexibility in addressing the needs of its citizens in a way
that will make the private marketplace accessible to uninsured
citizens of this state, promote personal responsibility,
effectively utilize this state's health care resources, reduce
expensive emergency room care, and protect citizens of this state
currently insured through the private marketplace from potentially
losing their federal tax credits.
ARTICLE 2. BLOCK GRANT FUNDING SYSTEM FOR STATE MEDICAID PROGRAM
SECTION 2.01. Subtitle I, Title 4, Government Code, is
amended by adding Chapter 540 to read as follows:
CHAPTER 540. BLOCK GRANT FUNDING SYSTEM FOR STATE MEDICAID PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 540.001. DEFINITIONS. In this chapter:
(1) "Health benefit exchange" means an American Health
Benefit Exchange administered by the federal government or an
exchange created under Section 1311(b) of the Patient Protection
and Affordable Care Act (42 U.S.C. Section 18031(b)).
(2) "Medicaid program" means the medical assistance
program established and operated under Title XIX, Social Security
Act (42 U.S.C. Section 1396 et seq.).
(3) "State Medicaid program" means the medical
assistance program provided by this state under the Medicaid
program.
Sec. 540.002. FEDERAL AUTHORIZATION TO REFORM MEDICAID
REQUIRED. If the federal government establishes, through
conversion or otherwise, a block grant funding system for the
Medicaid program or otherwise authorizes the state Medicaid program
to operate under a block grant funding system, including under a
Medicaid program waiver, the commission, in cooperation with
applicable health and human services agencies, shall, subject to
Section 540.003, administer and operate the state Medicaid program
in accordance with this chapter.
Sec. 540.003. CONFLICT WITH OTHER LAW. To the extent of a
conflict between a provision of this chapter and:
(1) another provision of state law, the provision of
this chapter controls, subject to Section 541.002(b); and
(2) a provision of federal law or any authorization
described under Section 540.002, the federal law or authorization
controls.
Sec. 540.004. ESTABLISHMENT OF REFORMED STATE MEDICAID
PROGRAM. The commission shall establish a state Medicaid program
that provides benefits under a risk-based Medicaid managed care
model.
Sec. 540.005. RULES. The executive commissioner shall
adopt rules necessary to implement this chapter.
SUBCHAPTER B. ACUTE CARE
Sec. 540.051. ELIGIBILITY FOR MEDICAID ACUTE CARE. (a) An
individual is eligible to receive acute care benefits under the
state Medicaid program if the individual:
(1) has a household income at or below 100 percent of
the federal poverty level;
(2) is under 19 years of age and:
(A) is receiving Supplemental Security Income
(SSI) under 42 U.S.C. Section 1381 et seq.; or
(B) is in foster care or resides in another
residential care setting under the conservatorship of the
Department of Family and Protective Services; or
(3) meets the eligibility requirements that were in
effect on September 1, 2013.
(b) The commission shall provide acute care benefits under
the state Medicaid program to each individual eligible under this
section through the most cost-effective means, as determined by the
commission.
(c) If an individual is not eligible for the state Medicaid
program under Subsection (a), the commission shall refer the
individual to the program established under Chapter 541 that helps
connect eligible residents with health benefit plan coverage
through private market solutions, a health benefit exchange, or any
other resource the commission determines appropriate.
Sec. 540.052. MEDICAID SLIDING SCALE SUBSIDIES. (a) An
individual who is eligible for the state Medicaid program under
Section 540.051 may receive a Medicaid sliding scale subsidy to
purchase a health benefit plan from an authorized health benefit
plan issuer.
(b) A sliding scale subsidy provided to an individual under
this section must:
(1) be based on:
(A) the average premium in the market; and
(B) a realistic assessment of the individual's
ability to pay a portion of the premium; and
(2) include an enhancement for individuals who choose
a high deductible health plan with a health savings account.
(c) The commission shall ensure that counselors are made
available to individuals receiving a subsidy to advise the
individuals on selecting a health benefit plan that meets the
individuals' needs.
(d) An individual receiving a subsidy under this section is
responsible for paying:
(1) any difference between the premium costs
associated with the purchase of a health benefit plan and the amount
of the individual's subsidy under this section; and
(2) any copayments associated with the health benefit
plan.
(e) If the amount of a subsidy received by an individual
under this section exceeds the premium costs associated with the
individual's purchase of a health benefit plan, the individual may
deposit the excess amount in a health savings account that may be
used only in the manner described by Section 540.054(b).
Sec. 540.053. ADDITIONAL COST-SHARING SUBSIDIES. In
addition to providing a subsidy to an individual under Section
540.052, the commission shall provide additional subsidies for
coinsurance payments, copayments, deductibles, and other
cost-sharing requirements associated with the individual's health
benefit plan. The commission shall provide the additional
subsidies on a sliding scale based on income.
Sec. 540.054. DELIVERY OF SUBSIDIES; HEALTH SAVINGS
ACCOUNTS. (a) The commission shall determine the most appropriate
manner for delivering and administering subsidies provided under
Sections 540.052 and 540.053. In determining the most appropriate
manner, the commission shall consider depositing subsidy amounts
for an individual in a health savings account established for that
individual.
(b) A health savings account established under this section
may be used only to:
(1) pay health benefit plan premiums and cost-sharing
amounts; and
(2) if appropriate, purchase health care-related
goods and services.
Sec. 540.055. MEDICAID HEALTH BENEFIT PLAN ISSUERS AND
MINIMUM COVERAGE. The commission shall allow any health benefit
plan issuer authorized to write health benefit plans in this state
to participate in the state Medicaid program. The commission in
consultation with the commissioner of insurance shall establish
minimum coverage requirements for a health benefit plan to be
eligible for purchase under the state Medicaid program, subject to
the requirements specified by this chapter.
Sec. 540.056. REINSURANCE FOR PARTICIPATING HEALTH BENEFIT
PLAN ISSUERS. (a) The commission in consultation with the
commissioner of insurance shall study a reinsurance program to
reinsure participating health benefit plan issuers.
(b) In examining options for a reinsurance program, the
commission and commissioner of insurance shall consider a plan
design under which:
(1) a participating health benefit plan is not charged
a premium for the reinsurance; and
(2) the health benefit plan issuer retains risk on a
sliding scale.
SUBCHAPTER C. LONG-TERM SERVICES AND SUPPORTS
Sec. 540.101. PLAN TO REFORM DELIVERY OF LONG-TERM SERVICES
AND SUPPORTS. The commission shall develop a comprehensive plan to
reform the delivery of long-term services and supports that is
designed to achieve the following objectives under the state
Medicaid program or any other program created as an alternative to
the state Medicaid program:
(1) encourage consumer direction;
(2) simplify and streamline the provision of services;
(3) provide flexibility to design benefits packages
that meet the needs of individuals receiving long-term services and
supports under the program;
(4) improve the cost-effectiveness and sustainability
of the provision of long-term services and supports;
(5) reduce reliance on institutional settings; and
(6) encourage cost sharing by family members when
appropriate.
ARTICLE 3. IMMEDIATE REFORM: PROGRAM TO ENSURE HEALTH BENEFIT
COVERAGE FOR CERTAIN INDIVIDUALS THROUGH PRIVATE MARKETPLACE
SECTION 3.01. Subtitle I, Title 4, Government Code, is
amended by adding Chapter 541 to read as follows:
CHAPTER 541. PROGRAM TO ENSURE HEALTH BENEFIT PLAN COVERAGE FOR
CERTAIN INDIVIDUALS THROUGH PRIVATE MARKET SOLUTIONS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 541.001. DEFINITION. In this chapter, "medical
assistance program" means the program established under Chapter 32,
Human Resources Code.
Sec. 541.002. CONFLICT WITH OTHER LAW. (a) Except as
provided by Subsection (b), to the extent of a conflict between a
provision of this chapter and:
(1) another provision of state law, the provision of
this chapter controls; and
(2) a provision of federal law or any authorization
described under Subchapter B, the federal law or authorization
controls.
(b) The program operated under this chapter is in addition
to any medical assistance program operated under a block grant
funding system under Chapter 540.
Sec. 541.003. PROGRAM FOR HEALTH BENEFIT PLAN COVERAGE
THROUGH PRIVATE MARKET SOLUTIONS. Subject to the requirements of
this chapter, the commission in consultation with the Texas
Department of Insurance shall develop and implement a program that
helps connect certain low-income residents of this state with
health benefit plan coverage through private market solutions.
Sec. 541.004. NOT AN ENTITLEMENT. This chapter does not
establish an entitlement to assistance in obtaining health benefit
plan coverage.
Sec. 541.005. RULES. The executive commissioner shall
adopt rules necessary to implement this chapter.
SUBCHAPTER B. FEDERAL AUTHORIZATION
Sec. 541.051. FEDERAL AUTHORIZATION FOR FLEXIBILITY TO
ESTABLISH PROGRAM. (a) The commission in consultation with the
Texas Department of Insurance shall negotiate with the United
States secretary of health and human services, the federal Centers
for Medicare and Medicaid Services, and other appropriate persons
for purposes of seeking a waiver or other authorization necessary
to obtain the flexibility to use federal matching funds to help
provide, in accordance with Subchapter C, health benefit plan
coverage to certain low-income individuals through private market
solutions.
(b) Any agreement reached under this section must:
(1) create a program that is made cost neutral to this
state by:
(A) leveraging premium tax revenues; and
(B) achieving cost savings through offsets to
general revenue health care costs or the implementation of other
cost savings mechanisms;
(2) create more efficient health benefit plan coverage
options for eligible individuals through:
(A) program changes that may be made without the
need for additional federal approval; and
(B) program changes that require additional
federal approval;
(3) require the commission to achieve efficiency and
reduce unnecessary utilization, including duplication, of health
care services;
(4) be designed with the goals of:
(A) relieving local tax burdens;
(B) reducing general revenue reliance so as to
make general revenue available for other state priorities; and
(C) minimizing the impact of any federal health
care laws on Texas-based businesses; and
(5) afford this state the opportunity to develop a
state-specific way with benefits that specifically meet the unique
needs of this state's population.
(c) An agreement reached under this section may be:
(1) limited in duration; and
(2) contingent on continued funding by the federal
government.
SUBCHAPTER C. PROGRAM REQUIREMENTS
Sec. 541.101. ENROLLMENT ELIGIBILITY. (a) Subject to
Subsection (b), an individual may be eligible to enroll in a program
designed and established under this chapter if the person:
(1) is younger than 65;
(2) has a household income at or below 133 percent of
the federal poverty level; and
(3) is not otherwise eligible to receive benefits
under the medical assistance program, including through a program
operated under Chapter 540 through a block grant funding system or a
waiver, other than one granted under this chapter, to the program.
(b) The executive commissioner may amend or further define
the eligibility requirements of this section if the commission
determines it necessary to reach an agreement under Subchapter B.
Sec. 541.102. MINIMUM PROGRAM REQUIREMENTS. A program
designed and established under this chapter must:
(1) if cost-effective for this state, provide premium
assistance to purchase health benefit plan coverage in the private
market, including health benefit plan coverage offered through a
managed care delivery model;
(2) provide enrollees with access to health benefits,
including benefits provided through a managed care delivery model,
that:
(A) are tailored to the enrollees;
(B) provide levels of coverage that are
customized to meet health care needs of individuals within defined
categories of the enrolled population; and
(C) emphasize personal responsibility and
accountability through flexible and meaningful cost-sharing
requirements and wellness initiatives, including through
incentives for compliance with health, wellness, and treatment
strategies and disincentives for noncompliance;
(3) include pay-for-performance initiatives for
private health benefit plan issuers that participate in the
program;
(4) use technology to maximize the efficiency with
which the commission and any health benefit plan issuer, health
care provider, or managed care organization participating in the
program manages enrollee participation;
(5) allow recipients under the medical assistance
program to enroll in the program to receive premium assistance as an
alternative to the medical assistance program;
(6) encourage eligible individuals to enroll in other
private or employer-sponsored health benefit plan coverage, if
available and appropriate;
(7) encourage the utilization of health care services
in the most appropriate low-cost settings; and
(8) establish health savings accounts for enrollees,
as appropriate.
SECTION 3.02. The Health and Human Services Commission in
consultation with the Texas Department of Insurance and the
Medicaid Reform Task Force shall actively develop a proposal for
the authorization from the appropriate federal entity as required
by Subchapter B, Chapter 541, Government Code, as added by this
article. As soon as possible after the effective date of this Act,
the Health and Human Services Commission shall request and actively
pursue obtaining the authorization from the appropriate federal
entity.
ARTICLE 4. FEDERAL AUTHORIZATION AND EFFECTIVE DATE
SECTION 6.01. Subject to Section 3.02 of this Act, if before
implementing any provision of this Act a state agency determines
that a waiver or authorization from a federal agency is necessary
for implementation of that provision, the agency affected by the
provision shall request the waiver or authorization and may delay
implementing that provision until the waiver or authorization is
granted.
SECTION 6.02. This Act takes effect September 1, 2015.