86R1044 LED-F
By: Hinojosa H.B. No. 4127
A BILL TO BE ENTITLED
AN ACT
relating to the Healthy Texas Program; authorizing a fee.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Title 8, Insurance Code, is amended by adding
Subtitle N to read as follows:
SUBTITLE N. HEALTHY TEXAS PROGRAM
CHAPTER 1698. HEALTHY TEXAS PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1698.001. DEFINITIONS. In this chapter:
(1) "Affordable Care Act" means the Patient Protection
and Affordable Care Act (Pub. L. No. 111-148), as amended by the
Health Care and Education Reconciliation Act of 2010 (Pub. L.
No. 111-152).
(2) "Allied health practitioner":
(A) means a health care professional who:
(i) works to prevent disease transmission,
or diagnose, treat, or rehabilitate individuals; and
(ii) delivers direct patient care,
rehabilitation, treatment, diagnostics, and health improvement
interventions to restore and maintain optimal physical, sensory,
psychological, cognitive, and social functions; and
(B) includes technical and support staff,
audiologists, occupational therapists, social workers, and
radiographers.
(3) "Board" means the Healthy Texas Board established
under Section 1698.051.
(4) "Care coordination" means the services described
by Section 1698.152.
(5) "Care coordinator" means a person approved by the
board to provide care coordination.
(6) "Child health plan program" means the state
children's health insurance program established under Title XXI,
Social Security Act (42 U.S.C. Section 1397aa et seq.), or the
programs established under Chapters 62 and 63, Health and Safety
Code, as appropriate.
(7) "Essential community provider" means a person
acting as a safety net clinic, safety net health care provider, or
rural hospital.
(8) "Federally matched public health program" means:
(A) Medicaid; or
(B) the child health plan program.
(9) "Fund" means the healthy Texas fund established
under Section 1698.252.
(10) "Health benefit plan issuer" means an insurance
company or health maintenance organization regulated by the
department and authorized to issue a health insurance policy or
other health benefit plan. The term includes:
(A) a stock life, health, or accident insurance
company;
(B) a mutual life, health, or accident insurance
company;
(C) a stock casualty insurance company;
(D) a mutual casualty insurance company;
(E) a Lloyd's plan;
(F) a reciprocal or interinsurance exchange;
(G) a fraternal benefit society;
(H) a stipulated premium company;
(I) a nonprofit hospital, medical, or dental
service corporation, including a company subject to Chapter 842;
and
(J) a health maintenance organization.
(11) "Health care organization" means a
not-for-profit or public organization that is approved by the board
to provide health care services to members under the program.
(12) "Health care provider" means a person that is
licensed, certified, or otherwise authorized by the laws of this
state to provide or render health care in the ordinary course of
business or practice of a profession.
(13) "Health care providers' representative" means a
third party that is authorized by health care providers to
negotiate on their behalf with the program related to terms and
conditions affecting those health care providers.
(14) "Health care service" means any health care
service, including care coordination, that is included as a benefit
under the program.
(15) "Integrated health care delivery system" means a
provider organization that is:
(A) fully integrated operationally and
clinically to provide a broad range of health care services,
including preventive care, prenatal and well-baby care,
immunizations, screening diagnostics, emergency services, hospital
and medical services, surgical services, and ancillary services;
and
(B) compensated by the program using capitation
or facility budgets for the provision of health care services.
(16) "Long-term care services" has the meaning
assigned by Section 22.0011, Human Resources Code.
(17) "Medicaid" means the medical assistance program
established under Title XIX, Social Security Act (42 U.S.C. Section
1396 et seq.), or the medical assistance program established under
Chapter 32, Human Resources Code, as appropriate.
(18) "Medicare" means the Health Insurance for the
Aged Act under Title XVIII of the Social Security Act (42 U.S.C.
Section 1395 et seq.).
(19) "Member" means an individual who is enrolled in
the program.
(20) "Out-of-state health care service":
(A) means a health care service that:
(i) is provided in person to a member while
the member is physically located outside this state; and
(ii) is:
(a) medically necessary to be
provided while the member is physically outside this state; or
(b) clinically appropriate and
necessary and cannot be provided in this state because the health
care service can be provided only by a particular health care
provider physically located outside this state; and
(B) does not include a health care service
provided to a member by a health care provider qualified under
Section 1698.151 that is physically located outside this state.
(21) "Participating provider" means:
(A) a person that is a health care provider
qualified under Section 1698.151 that provides health care services
to members under the program; or
(B) a health care organization.
(22) "Prescription drug" has the meaning assigned by
Section 551.003, Occupations Code.
(23) "Program" means the Healthy Texas Program
established under this chapter.
(24) "Resident" means an individual whose primary
place of residence is located in this state without regard to the
individual's immigration status.
Sec. 1698.002. COVERAGE NOT EXCLUSIVE. This chapter does
not preempt a political subdivision from adopting additional health
care coverage that provides additional protections and benefits to
residents in the political subdivision's jurisdiction.
Sec. 1698.003. CONFLICT WITH OTHER LAW. (a) To the extent
any provision of state law is inconsistent with this chapter, this
chapter prevails, except as explicitly provided otherwise by this
chapter.
(b) This chapter may not be construed to alter in any way the
professional practice of health care providers or licensure
standards established under Title 3, Occupations Code.
SUBCHAPTER B. HEALTHY TEXAS BOARD
Sec. 1698.051. HEALTHY TEXAS BOARD. The Healthy Texas
Board is an agency of this state.
Sec. 1698.052. COMPOSITION OF BOARD. The board is composed
of the following nine members:
(1) four appointed by the governor;
(2) two appointed by the lieutenant governor;
(3) two appointed by the speaker of the house of
representatives; and
(4) the executive commissioner of the Health and Human
Services Commission, or the executive commissioner's designee, who
serves as a voting, ex officio member.
Sec. 1698.053. TERM; VACANCY. (a) Board members other than
an ex officio member shall be appointed for a term of two years.
(b) A vacancy must be filled for the unexpired term in the
same manner as the original appointment.
Sec. 1698.054. BOARD MEMBER QUALIFICATIONS. (a) Each
board member must:
(1) be a resident; and
(2) have demonstrated and acknowledged expertise in
health care.
(b) An individual may not be a board member unless the
individual is a member of the program. This subsection does not
apply to an ex officio member.
(c) Of the eight board members appointed by the governor,
lieutenant governor, and speaker of the house of representatives:
(1) at least one board member must represent a labor
organization representing registered nurses;
(2) at least one board member must represent the
general public;
(3) at least one board member must represent a labor
organization; and
(4) at least one board member must represent the
medical provider community.
(d) The governor, lieutenant governor, and speaker of the
house of representatives shall consider:
(1) the expertise of each board member and attempt to
make appointments so that the board's composition reflects a
diversity of expertise in the various aspects of health care; and
(2) the cultural, ethnic, and geographic diversity of
the state and attempt to make appointments so that the board's
composition reflects the communities of Texas.
(e) Each board member shall:
(1) meet the requirements of this chapter, the
Affordable Care Act, and all applicable state and federal laws and
regulations;
(2) serve the public interest of the individuals,
employers, and taxpayers seeking health care coverage through the
program; and
(3) ensure the operational well-being and fiscal
solvency of the program.
(f) A board member or employee of the board may not:
(1) be employed by, a consultant to, a member of the
board of directors of, affiliated with, or otherwise a
representative of a health care provider, a health care facility,
or a health clinic while serving on the board or as an employee of
the board;
(2) be a member, a board member, or an employee of a
trade association of health care facilities, health clinics, or
health care providers while serving on the board or as an employee
of the board; or
(3) be a health care provider unless the board member
or employee receives no compensation for rendering services as a
health care provider and does not have an ownership interest in a
health care practice.
Sec. 1698.055. BOARD MEMBER COMPENSATION. A board member
may not receive compensation but is entitled to reimbursement of
the travel expenses incurred by the board member while conducting
the business of the board, as provided in the General
Appropriations Act.
Sec. 1698.056. CONFLICT OF INTEREST. (a) A board member
may not make, participate in making, or in any way attempt to make
use of the board member's official position to influence the making
of a decision the board member knows or has reason to know will have
a material financial effect, distinguishable from its effect on the
public generally, on:
(1) the board member or a member of the board member's
immediate family;
(2) a person or entity that was the source of a benefit
or benefits aggregating $250 or more in value received by or
promised to the board member within 12 months before the date the
decision is made; or
(3) a business entity in which the board member is a
director, officer, partner, trustee, or employee, or holds any
position of management.
(b) For purposes of Subsection (a), "benefit" has the
meaning assigned by Section 36.01, Penal Code, but does not
include:
(1) a gift; or
(2) a loan by a commercial lending institution in the
regular course of business on terms available to the public.
Sec. 1698.057. IMMUNITY. The following persons are not
liable, and a cause of action does not arise against any of the
following persons, for a good faith act or omission in exercising
powers and performing duties under this chapter:
(1) the board;
(2) a board member; or
(3) an officer or employee of the board.
Sec. 1698.058. BOARD ELECTION. The board annually shall
elect a chairperson.
Sec. 1698.059. EXECUTIVE DIRECTOR. The board shall hire an
executive director to organize, administer, and manage the program
and the operations of the board. The executive director serves at
the pleasure of the board.
Sec. 1698.060. OPEN MEETINGS; OPEN RECORDS. The board is
subject to Chapters 551 and 552, Government Code. The board may
conduct a closed meeting to deliberate:
(1) business and financial issues relating to a
contract being negotiated; or
(2) rates to be paid under the program.
Sec. 1698.061. RULES. (a) The board may adopt rules
necessary to implement and enforce this chapter.
(b) The board by rule shall set fees in amounts reasonable
and necessary to implement this chapter.
(c) The board by rule shall establish dispute resolution
procedures to address member disputes. Dispute resolution
procedures must:
(1) include a patient advocate to assist members in
the dispute resolution process; and
(2) provide for a member to withdraw from the program.
(d) The board may adopt narrowly focused rules relating
solely to health care organizations for the specific purpose of
ensuring consistent compliance with this chapter.
Sec. 1698.062. ADVISORY COMMITTEE. (a) The executive
commissioner of the Health and Human Services Commission shall
establish an advisory committee to advise the board on all policy
matters for the program.
(b) The advisory committee is composed of 22 members
appointed by the governor, lieutenant governor, or speaker of the
house of representatives as follows:
(1) the governor shall appoint:
(A) one board-certified physician;
(B) one dentist;
(C) one representative of private hospitals;
(D) one representative of public hospitals;
(E) one representative of an integrated health
care delivery system;
(F) two consumers of health care, one of whom is a
person with a disability; and
(G) one representative of a business that employs
fewer than 25 people;
(2) the lieutenant governor shall appoint:
(A) one board-certified physician;
(B) two registered nurses;
(C) one mental health care provider;
(D) one consumer of health care who is at least 65
years of age;
(E) one representative of essential community
providers; and
(F) one member of organized labor; and
(3) the speaker of the house shall appoint:
(A) two board-certified physicians, both of whom
must be primary care providers;
(B) one allied health practitioner who holds a
license to practice a health care profession;
(C) one pharmacist;
(D) one consumer of health care;
(E) one representative of organized labor; and
(F) one representative of a business that employs
more than 250 people.
(c) Of the board-certified physicians appointed under
Subsections (b)(1)(A), (b)(2)(A), and (b)(3)(A), at least one must
be a psychiatrist.
(d) In making appointments under this section, the
governor, lieutenant governor, and speaker of the house of
representatives shall attempt to reflect the geographic and
economic diversity of the state. Appointments to the committee
shall be made without regard to the race, color, sex, religion, age,
or national origin of the appointees.
(e) A committee member serves a four-year term and may be
reappointed.
(f) The executive commissioner of the Health and Human
Services Commission shall notify the appropriate appointing
authority of any expected vacancies on the advisory committee. If a
vacancy occurs on the committee, the appropriate appointing
authority shall appoint a successor, in the same manner as the
original appointment, to serve for the remainder of the unexpired
term. The appropriate appointing authority shall appoint the
successor not later than the 30th day after the date the vacancy
occurs.
(g) A committee member:
(1) may not receive compensation for serving on the
committee;
(2) is entitled to reimbursement for travel expenses
incurred by the committee member while conducting the business of
the committee; and
(3) is entitled to the per diem provided by the General
Appropriations Act for attending meetings of the committee.
(h) The advisory committee shall meet at least six times per
year in a place convenient to the public.
(i) The advisory committee is subject to Chapters 551 and
552, Government Code.
(j) The advisory committee shall elect a chairperson who
shall serve for two years and may be reelected for an additional two
years.
(k) To be eligible for appointment to the advisory
committee, an individual must have worked in the field the
individual represents on the committee for a period of at least two
years before being appointed to the committee.
(l) An advisory committee member or individual working with
or for a committee member may not use for personal benefit any
information that is filed with or obtained by the committee and that
is not generally available to the public.
(m) The board shall provide administrative support,
including staff, for the advisory committee.
(n) The advisory committee is not subject to Chapter 2110,
Government Code.
Sec. 1698.063. POWERS AND DUTIES OF BOARD; HEALTHY TEXAS
PROGRAM. (a) The board has all the powers and duties necessary to
establish and implement the program.
(b) The board shall, to the extent possible, organize,
administer, and market the program and services as a comprehensive
universal single-payer program under the name "Healthy Texas
Program" or any other name the board adopts. The program shall be
administered regardless of the law or source in which the
definition of a benefit is found, including, subject to the
election of the retiree, retiree health benefits.
(c) In implementing this chapter, the board shall avoid
jeopardizing federal financial participation in the federally
supported programs that are incorporated into the program.
(d) The board shall promote public understanding and
awareness of available benefits and programs.
(e) The board may consider any matter necessary to implement
this chapter and the purposes of this chapter. The board does not
have any executive, administrative, or appointive duties except as
provided by this chapter or other law.
(f) The board shall employ necessary staff and authorize
reasonable expenditures, as necessary, from the fund to pay program
expenses and to administer the program.
(g) The board may:
(1) sue and be sued;
(2) receive and accept gifts, grants, or donations of
money from any agency of the federal government, any agency of this
state, or any municipality, county, or other political subdivision
of this state;
(3) receive and accept gifts, grants, or donations
from individuals, associations, private foundations, or
corporations, in compliance with the conflict-of-interest
provisions adopted by board rule; and
(4) share information with relevant state
governmental entities, in a manner that is consistent with the
confidentiality provisions in this chapter, necessary for
administering the program.
Sec. 1698.064. CONTRACTS. (a) The board may enter into any
necessary contracts, including contracts with health care
providers, integrated health care delivery systems, and care
coordinators.
(b) The board may contract with a not-for-profit
organization to provide assistance to:
(1) consumers with respect to selecting a care
coordinator or health care organization, enrolling to obtain
services available through the program, obtaining health care
services, withdrawing from the program or from an aspect of the
program, and other matters relating to the program; or
(2) health care providers providing, seeking, or
considering whether to provide health care services under the
program with respect to participating in a health care organization
and interacting with a health care organization.
Sec. 1698.065. DATA TRANSPARENCY. (a) To promote
transparency, assess adherence to patient care standards, compare
patient outcomes, and review use of health care services paid for by
the program, the board shall provide for the collection and
availability of:
(1) inpatient discharge data, including acuity and
risk of mortality;
(2) emergency department and ambulatory surgery data,
including charge data, length of stay, and patients' unit of
observation; and
(3) hospital annual financial data, including:
(A) community benefits by hospital in dollar
value;
(B) number and classification of employees by
hospital unit;
(C) number of hours worked by hospital unit;
(D) employee wage information by job title and
hospital unit;
(E) number of registered nurses per staffed bed
by hospital unit;
(F) type and value of health information
technology; and
(G) annual spending on health information
technology, including purchases, upgrades, and maintenance.
(b) The board shall make all disclosed data collected under
Subsection (a) publicly available and searchable on an Internet
website established and maintained by the Department of State
Health Services.
(c) The board shall, directly and through grants to
not-for-profit entities, conduct programs using data collected
through the program to promote and protect public, environmental,
and occupational health, including cooperation with other data
collection and research programs of the Department of State Health
Services and the Health and Human Services Commission, consistent
with this chapter and other applicable law.
Sec. 1698.066. DISCLOSURE OF PERSONALLY IDENTIFIABLE
INFORMATION. (a) Notwithstanding any other law, the board, the
program, a state or local agency, or a public employee acting under
color of law may not provide or disclose to anyone, including the
federal government, any personally identifiable information
obtained under this chapter, including an individual's religious
beliefs, practices, or affiliation, national origin, ethnicity, or
immigration status for law enforcement or immigration purposes.
(b) Notwithstanding any other law, a law enforcement agency
may not use the money, facilities, property, equipment, or
personnel of the board or the program to investigate, enforce, or
assist in the investigation or enforcement of any criminal, civil,
or administrative violation or warrant for a violation of any
requirement that individuals register with the federal government
or any federal agency based on religion, national origin,
ethnicity, or immigration status.
SUBCHAPTER C. ELIGIBILITY AND ENROLLMENT
Sec. 1698.101. ELIGIBILITY AND ENROLLMENT. (a) Every
resident is eligible and entitled to enroll as a member under the
program.
(b) A member may not be required to pay:
(1) any fee, payment, or other charge for enrolling in
or being a member under the program; or
(2) any premium, co-payment, coinsurance, deductible,
or any other form of cost sharing for all covered benefits.
(c) A college, university, or other institution of higher
education in this state may purchase coverage under the program for
a student, or a student's dependent, who is not a resident.
SUBCHAPTER D. BENEFITS
Sec. 1698.121. BENEFITS. (a) Covered health care benefits
under the program include all medical care determined to be
medically appropriate by a member's health care provider.
(b) Covered health care benefits for a member include:
(1) inpatient and outpatient medical and health
facility services;
(2) inpatient and outpatient professional health care
provider medical services;
(3) diagnostic imaging, laboratory services, and
other diagnostic and evaluative services;
(4) medical equipment, appliances, and assistive
technology, including prosthetics, eyeglasses, and hearing aids
and the repair, technical support, and customization needed for
individual use;
(5) inpatient and outpatient rehabilitative care;
(6) emergency care services;
(7) emergency transportation;
(8) necessary transportation for health care services
for an individual with a disability or who may qualify as low
income;
(9) child and adult immunizations and preventive care;
(10) health and wellness education;
(11) hospice care;
(12) care in a skilled nursing facility;
(13) home health care, including health care provided
in an assisted living facility;
(14) mental health services;
(15) substance abuse treatment;
(16) dental care;
(17) vision care;
(18) prescription drugs;
(19) pediatric care;
(20) prenatal and postnatal care;
(21) podiatric care;
(22) chiropractic care;
(23) acupuncture;
(24) therapies that are shown by the National
Institutes of Health, National Center for Complementary and
Integrative Health to be safe and effective;
(25) blood and blood products;
(26) dialysis;
(27) adult day care;
(28) rehabilitative and habilitative services;
(29) ancillary health care or social services covered
by a local health care system before the effective date of the
program;
(30) ancillary health care or social services covered
by a community center for persons with developmental disabilities
under Chapter 534, Health and Safety Code, before the effective
date of the program;
(31) case management and care coordination;
(32) language interpretation and translation for
health care services, including sign language, Braille, or other
services needed for individuals with communication barriers; and
(33) health care and long-term supportive services
covered under Medicaid or the child health plan program before the
effective date of the program.
(c) Covered health care benefits for a member also include
all health care services required to be covered under any of the
following programs or by the following providers, without regard to
whether the member would otherwise be eligible for or covered by the
program or source listed:
(1) the child health plan program;
(2) Medicaid;
(3) Medicare;
(4) a health benefit plan issuer under this code;
(5) any additional health care service authorized to
be added to the program's benefits by the board; and
(6) all essential health benefits mandated by the
Affordable Care Act.
Sec. 1698.122. BENEFITS OFFERED BY A HEALTH BENEFIT PLAN
ISSUER. (a) Except as provided by Subsection (b), a health benefit
plan issuer may not offer benefits or cover any services for which
coverage is offered to individuals under the program but may, if
otherwise authorized, offer benefits to cover health care services
that are not offered to individuals under the program.
(b) This chapter does not prohibit a health benefit plan
issuer from offering benefits to or for individuals, including
their families, who are employed or self-employed in this state but
who are not residents.
SUBCHAPTER E. DELIVERY OF CARE
Sec. 1698.151. HEALTH CARE PROVIDERS. (a) A health care
provider may participate in the program to perform services in this
state.
(b) The board shall establish and maintain procedures and
standards for recognizing health care providers physically located
outside this state to provide coverage under the program for
members who require out-of-state health care services while
temporarily located outside this state.
(c) A participating provider may provide covered health
care services under the program that the provider is authorized to
perform for the member under the applicable circumstances.
(d) A member may choose to receive health care services
under the program from any participating provider, consistent with:
(1) this chapter;
(2) the willingness or availability of the provider,
subject to provisions of this chapter relating to discrimination;
and
(3) the applicable clinically relevant circumstances.
(e) Subject to Subsection (f), a member who chooses to
enroll with an integrated health care delivery system, group
medical practice, or essential community provider that offers
comprehensive services must retain membership with the system,
practice, or provider until the first anniversary of the date an
initial 90-day evaluation period expires. The member may withdraw
from the system, practice, or provider for any reason during the
evaluation period. The initial 90-day evaluation period commences
on the date the member first sees a primary care provider.
(f) A member who wants to withdraw after the initial 90-day
evaluation period must request a withdrawal under the dispute
resolution procedures established by the board and may request
assistance from the patient advocate in resolving the dispute. The
dispute must be resolved in a timely manner and may not have an
adverse effect on the care the member receives.
Sec. 1698.152. CARE COORDINATION. (a) A member's care
coordinator shall provide care coordination to the member. A care
coordinator may employ or use the services of other individuals or
entities to assist in providing care coordination for the member
consistent with board rules, statutory requirements, and
applicable occupational regulations.
(b) Care coordination includes administrative tracking and
medical recordkeeping services for members, except as otherwise
specified for integrated health care delivery systems.
(c) Care coordination administrative tracking and medical
recordkeeping services for members may not be required to use a
certified electronic health record, meet any other requirements of
the Health Information Technology for Economic and Clinical Health
Act, enacted under the American Recovery and Reinvestment Act of
2009 (Pub. L. No. 111-5), or meet certification requirements of the
Centers for Medicare and Medicaid Services' electronic health
record incentive programs, including meaningful use requirements.
(d) A referral from a care coordinator is not required for a
member to see an eligible provider.
Sec. 1698.153. CARE COORDINATORS. (a) A care coordinator
shall comply with all federal and state privacy laws, including:
(1) the Health Insurance Portability and
Accountability Act of 1996 (Pub. L. No. 104-191) and regulations
adopted under that Act;
(2) state law relating to the confidentiality of
medical information, including Chapter 181, Health and Safety Code;
(3) Subtitle D, Title 5; and
(4) Title 11, Business & Commerce Code.
(b) A care coordinator may be an individual or entity
approved by the program that is:
(1) a health care practitioner who is:
(A) the member's primary care provider;
(B) the member's provider of primary
gynecological care; or
(C) at the option of a member who has a chronic
condition that requires specialty care, a specialist health care
practitioner who regularly and continually provides treatment to
the member for that condition;
(2) an entity that is:
(A) a health facility;
(B) a health maintenance organization;
(C) a nursing facility or assisted living
facility under Chapter 242 or 247, Health and Safety Code, or a
program for long-term care services coverage developed by the
board;
(D) a county medical facility;
(E) a residential care facility for individuals
with chronic, life-threatening illness;
(F) an Alzheimer's day care resource center;
(G) a residential care facility for the elderly;
(H) a home health agency;
(I) a private duty nursing agency;
(J) a hospice;
(K) a pediatric day health and respite care
facility;
(L) a home care service; or
(M) a mental health care provider;
(3) a health care organization;
(4) a jointly managed trust authorized under 29 U.S.C.
Section 141 et seq. that contains a plan of benefits for employees
that is negotiated in a collective bargaining agreement governing
wages, hours, and working conditions of the employer that is
authorized under 29 U.S.C. Section 157; or
(5) a not-for-profit or governmental entity approved
by the program.
(c) Subsection (b)(4) does not preclude a trust described by
Subsection (b)(4) from becoming a care coordinator under Subsection
(b)(5) or a health care organization under Section 1698.158.
(d) To maintain approval as a care coordinator under the
program, a care coordinator must:
(1) renew its license every three years as prescribed
by board rule; and
(2) provide to the program any data required by the
Department of State Health Services under Chapter 108, Health and
Safety Code, that would enable the board to evaluate the impact of
care coordinators on quality, outcomes, and cost of health care.
(e) An individual or entity may not be a care coordinator
unless the services included in care coordination are within the
individual's professional scope of practice or the entity's legal
authority.
Sec. 1698.154. ENROLLMENT WITH CARE COORDINATOR. (a)
Before receiving health care services to be paid for under the
program, a member must be encouraged to enroll with a care
coordinator that agrees to provide care coordination. If a member
receives health care services before choosing a care coordinator,
the program shall assist the member, when appropriate, with
choosing a care coordinator. The member must remain enrolled with
that care coordinator until the member becomes enrolled with a
different care coordinator or ceases to be a member. A member may
change care coordinators on terms at least as permissive as those
under Medicaid relating to an individual changing primary care
providers or managed care organizations.
(b) A health care provider may be reimbursed for services
only if the member is enrolled with a care coordinator at the time
the health care service is provided.
(c) A health care organization may establish rules relating
to care coordination for its members that are different from this
subchapter but otherwise consistent with this chapter and other
applicable laws.
Sec. 1698.155. PROCEDURES AND STANDARDS FOR CARE
COORDINATION. (a) The board by rule shall develop and implement
procedures and standards for an individual or entity to be approved
as a care coordinator in the program, including procedures and
standards relating to the revocation, suspension, limitation, or
annulment of approval on a determination that the individual or
entity:
(1) is incompetent to be a care coordinator;
(2) has exhibited a course of conduct that is
inconsistent with program standards and rules;
(3) exhibits an unwillingness to comply with program
standards and rules; or
(4) is a potential threat to the public health or
safety.
(b) The procedures and standards adopted by the board must
be consistent with professional practice, licensure standards, and
rules established under the Government Code, Health and Safety
Code, Human Resources Code, Insurance Code, and Occupations Code,
as applicable.
(c) In developing and implementing standards of approval of
care coordinators for individuals receiving chronic mental health
care services, the board shall consult with the Health and Human
Services Commission.
Sec. 1698.156. OCCUPATIONAL LAWS NOT AFFECTED. Nothing in
Section 1698.152, 1698.153, 1698.154, or 1698.155 authorizes an
individual to engage in any act in violation of Title 3, Occupations
Code.
Sec. 1698.157. PAYMENT FOR HEALTH CARE SERVICES AND CARE
COORDINATION. (a) The board shall adopt rules related to
contracting and establishing payment methodologies for covered
health care services and care coordination provided to members
under the program by participating providers, care coordinators,
and health care organizations. A variety of different payment
methodologies may be used, including those established on a
demonstration basis. All payment rates under the program shall be
reasonable and reasonably related to the cost of efficiently
providing the health care service and ensuring an adequate and
accessible supply of health care services.
(b) Health care services provided to a member under the
program, except for care coordination, must be paid for on a
fee-for-service basis unless the board establishes another payment
methodology.
(c) Notwithstanding Subsection (b), integrated health care
delivery systems, essential community providers, and group medical
practices that provide comprehensive, coordinated services may
choose to be reimbursed on the basis of a capitated system operating
budget or a non-capitated system operating budget that covers all
costs of providing health care services.
(d) The program shall engage in good faith negotiations with
health care providers' representatives under Subchapter H,
including in relation to rates of payment for health care services,
rates of payment for prescription and nonprescription drugs, and
payment methodologies. Those negotiations shall be through a single
entity on behalf of the entire program for prescription and
nonprescription drugs.
(e) Payment for health care services established under this
chapter is considered payment in full. A participating provider may
not charge a rate in excess of the payment established under this
chapter for any health care service provided to a member under the
program and may not solicit or accept payment from any member or
third party for any health care service, except as provided under a
federal program. This section does not preclude the program from
acting as a primary or secondary payer in conjunction with another
third-party payer when permitted by a federal program.
(f) The board by rule may adopt payment methodologies for
the payment of capital-related expenses for specifically
identified capital expenditures incurred by not-for-profit or
governmental entities that are health facilities under Subtitle B,
Title 4, Health and Safety Code. Any capital-related expense
generated by a capital expenditure that requires prior approval
must have received that approval before being paid by the program.
The approval must be based on achievement of the program standards
described by Subchapter F.
(g) Payment methodologies and payment rates must include a
distinct component of reimbursement for direct and indirect
graduate medical education.
(h) The board by rule shall adopt payment methodologies and
procedures for paying for health care services provided to a member
while the member is located outside this state.
Sec. 1698.158. HEALTH CARE ORGANIZATIONS. (a) A member may
choose to enroll with and receive program care coordination and
ancillary health care services from a health care organization.
(b) The health care organization must be a not-for-profit or
governmental entity that is approved by the board and is:
(1) a local health care system; or
(2) a community center for persons with developmental
disabilities under Chapter 534, Health and Safety Code.
(c) To maintain approval under the program, a health care
organization must:
(1) renew the approval as frequently as prescribed by
board rule; and
(2) provide to the program any data required by the
Department of State Health Services under Chapter 108, Health and
Safety Code, that would enable the board to evaluate the impact of
health care organizations on quality outcomes, and cost of health
care.
Sec. 1698.159. PROCEDURES AND STANDARDS FOR HEALTH CARE
ORGANIZATIONS. (a) The board by rule shall develop and implement
procedures and standards for an entity to be approved as a health
care organization in the program, including procedures and
standards relating to the revocation, suspension, limitation, or
annulment of approval on a determination that the entity:
(1) is incompetent to be a health care organization;
(2) has exhibited a course of conduct that is
inconsistent with program standards and rules;
(3) exhibits an unwillingness to comply with program
standards and rules; or
(4) is a potential threat to the public health or
safety.
(b) The procedures and standards adopted by the board must
be consistent with professional practice, licensure standards, and
rules established under the Government Code, Health and Safety
Code, Human Resources Code, Insurance Code, and Occupations Code,
as applicable.
(c) In developing and implementing standards of approval of
health care organizations, the board shall consult with the Health
and Human Services Commission.
Sec. 1698.160. BEST INTEREST OF THE PATIENT. A health care
organization may not use health information technology or clinical
practice guidelines that limit the effective exercise of the
professional judgment of physicians and registered nurses.
Physicians and registered nurses shall be free to override health
information technology and clinical practice guidelines if, in
their professional judgment, it is in the best interest of the
patient and consistent with the patient's wishes.
SUBCHAPTER F. PROGRAM STANDARDS
Sec. 1698.201. PROGRAM STANDARDS. (a) The board by rule
shall establish requirements and standards for the program and for
health care organizations, care coordinators, and health care
providers, consistent with this chapter and applicable
professional practice, licensure standards, and rules of health
care providers and health care professionals established under the
Government Code, Health and Safety Code, Human Resources Code,
Insurance Code, and Occupations Code, including requirements and
standards related to:
(1) the scope, quality, and accessibility of health
care services;
(2) relations between health care organizations or
health care providers and members; and
(3) relations between health care organizations and
health care providers, including credentialing and participation
in the health care organization, and terms, methods, and rates of
payment.
(b) The board by rule shall establish requirements and
standards under the program that include provisions to promote:
(1) simplification, transparency, uniformity, and
fairness in health care provider credentialing and participation in
health care organization networks, referrals, payment procedures
and rates, claims processing, and approval of health care services,
as applicable;
(2) in-person primary and preventive care, care
coordination, efficient and effective health care services,
quality assurance, and promotion of public, environmental, and
occupational health;
(3) elimination of health care disparities;
(4) nondiscrimination with respect to members and
health care providers on the basis of race, color, ancestry,
national origin, religion, citizenship, immigration status,
primary language, mental or physical disability, age, sex, gender,
sexual orientation, gender identity or expression, medical
condition, genetic information, marital status, familial status,
military or veteran status, or source of income;
(5) accessibility of care coordination, health care
organization services, and health care services, including
accessibility for people with disabilities and people with limited
ability to speak or understand English; and
(6) the provision of care coordination, health care
organization services, and health care services in a culturally
competent manner.
(c) Notwithstanding Subsection (b)(4), health care services
provided under the program must be appropriate to the member's
clinically relevant circumstances.
(d) The board by rule shall establish requirements and
standards, to the extent authorized by federal law, for replacing
and merging with the program health care services and ancillary
services currently provided by other programs, including:
(1) Medicare;
(2) the Affordable Care Act; and
(3) other federally matched public health programs.
Sec. 1698.202. EQUAL REQUIREMENTS AND STANDARDS. Any
participating provider or care coordinator that is organized as a
for-profit entity shall meet the same requirements and standards as
entities organized as not-for-profit entities, and payments under
the program paid to for-profit entities may not be calculated to
accommodate the generation of profit, revenue for dividends, or
other return on investment or the payment of taxes that would not be
paid by a not-for-profit entity.
Sec. 1698.203. INFORMATION REQUIRED. Each participating
provider shall furnish information as required by the Department of
State Health Services under Chapter 108, Health and Safety Code,
and permit examination of that information by the program as may be
reasonably required for purposes of reviewing accessibility and use
of health care services, quality assurance, cost containment, the
making of payments, and statistical or other studies of the
operation of the program or for protection and promotion of public,
environmental, and occupational health.
Sec. 1698.204. CONSULTATION ON POLICY DETERMINATIONS. In
developing requirements and standards and making other policy
determinations under this subchapter, the board shall consult with
representatives of members, health care providers, care
coordinators, health care organizations, labor organizations
representing health care employees, and other interested parties.
SUBCHAPTER G. FUNDING
Sec. 1698.251. FEDERAL HEALTH PROGRAMS AND FUNDING. (a)
The board shall seek any federal waiver or other federal approval
and arrangement and submit each state plan amendment necessary to
operate the program.
(b) The board shall apply to the United States secretary of
health and human services or other appropriate federal official for
any waiver of a requirement and make any other arrangement under
Medicare, any federally matched public health program, the
Affordable Care Act, and any other federal program that provides
federal money for payment for health care services necessary so
that:
(1) each member receives all benefits under the
program through the program;
(2) the state may implement this chapter; and
(3) the state receives all federal payments under the
applicable program, including money that may be provided in lieu of
premium tax credits, cost-sharing subsidies, and small business tax
credits.
(c) The state shall deposit money received under Subsection
(b)(3) in the state treasury to the credit of the fund and shall use
that money for the program and to implement this chapter.
(d) To the extent possible, the board shall negotiate
arrangements with the federal government to ensure that federal
payments are paid to the program in place of federal funding of, or
tax benefits for, federally matched public health programs or
federal health programs.
(e) The board may require members or applicants to provide
information necessary for the program to comply with any waiver or
arrangement under this chapter. Information provided by a member
to the board for the purposes of this subsection may not be used for
any other purpose.
(f) The board may take any additional actions necessary to
effectively fund implementation of the program to the extent
possible as a single-payer program consistent with this chapter.
(g) The board may take actions consistent with this
subchapter to enable the program to administer Medicare in this
state, and the program shall be a provider of Medicare Part B
supplemental insurance coverage and shall provide premium
assistance drug coverage under Medicare Part D for eligible members
of the program.
(h) The board may waive or modify the applicability of any
provision of this section relating to any federally matched public
health program or Medicare, as necessary, to implement any waiver
or arrangement under this section or to maximize the federal
benefits to the program under this section, provided that the
board, in consultation with the comptroller, determines that the
waiver or modification is in the best interest of the state and
members affected by the action.
(i) The board may apply for coverage for, and enroll, any
eligible member under any federally matched public health program
or Medicare. Enrollment in a federally matched public health
program or Medicare may not cause any member to lose any health care
service provided by the federal program or Medicare or diminish any
right the member would otherwise have.
(j) Notwithstanding Subsection (i) or any other law, the
board by rule shall increase the income eligibility level, increase
or eliminate the resource test for eligibility, simplify any
procedural or documentation requirement for enrollment, and
increase the benefits for any federally matched public health
program and for any program to reduce or eliminate an individual's
coinsurance, cost-sharing, or premium obligations or increase an
individual's eligibility for any federal financial support related
to Medicare or the Affordable Care Act. The board may act under
this subsection on a finding approved by the comptroller and the
board that the action:
(1) will help increase the number of members who are:
(A) eligible for and enrolled in federally
matched public health programs; or
(B) eligible for any program to reduce or
eliminate an individual's coinsurance, cost-sharing, or premium
obligations or increase an individual's eligibility for any federal
financial support related to Medicare or the Affordable Care Act;
(2) will not diminish any individual's access to any
health care service or right the individual would otherwise have;
(3) is in the interest of the program; and
(4) does not require or has received any necessary
federal waiver or approval to ensure federal financial
participation.
(k) Any action taken under Subsection (j) may not apply to
eligibility for payment for long-term care services.
(l) To enable the board to apply for coverage for and enroll
any eligible member under any federally matched public health
program or Medicare, the board may require that each member or
applicant provide the information necessary to enable the board to
determine whether the applicant is eligible for a federally matched
public health program or for Medicare, or any program or benefit
under Medicare.
(m) As a condition of continued eligibility for health care
services under the program, a member who is eligible for benefits
under Medicare must enroll in Medicare, including Parts A, B, and D.
(n) The program shall provide premium assistance for each
member enrolling in a Medicare Part D drug coverage plan under 42
U.S.C. Section 1395w-101 et seq., limited to the low-income
benchmark premium amount established by the Centers for Medicare
and Medicaid Services and any other amount the federal agency
establishes under its de minimis premium policy, except that those
payments made on behalf of a member enrolled in a Medicare advantage
plan may exceed the low-income benchmark premium amount if
determined to be cost effective to the program.
(o) If the board has reasonable grounds to believe that a
member may be eligible for an income-related subsidy under 42
U.S.C. Section 1395w-114, the member shall provide, and authorize
the program to obtain, any information or documentation required to
establish the member's eligibility for that subsidy. Before
requesting information or documentation from a member under this
section, the board shall attempt to obtain as much of the
information and documentation as possible from records that are
available to the board.
(p) The program shall make a reasonable effort to notify
each member of the member's obligations under this section. After a
reasonable effort has been made to contact the member, the member
shall be notified in writing that the member has 60 days to provide
the required information. If the member does not provide the
required information within the 60-day period, the member's
coverage under the program may be terminated. Information provided
by a member to the board for the purposes of this section may not be
used for any other purpose.
(q) The board shall assume responsibility for all benefits
and services paid for by the federal government with that money.
Sec. 1698.252. FUND; ADMINISTRATION. (a) The healthy
Texas fund is a special fund in the state treasury outside the
general revenue fund.
(b) In conjunction with the enactment of the General
Appropriations Act, the legislature shall develop a revenue plan,
taking into consideration anticipated federal revenue available
for the program, and appropriate money for the program as
necessary. In developing the revenue plan, members of the
legislature shall consult with appropriate officials and
stakeholders.
(c) Notwithstanding any other law, money in the fund may not
be loaned to or borrowed by any other special fund or the general
revenue fund.
(d) The board shall establish and maintain a prudent reserve
in the fund.
(e) The board or staff of the board may not use any money
intended for the administrative and operational expenses of the
board for staff retreats, promotional giveaways, excessive
executive compensation, or promotion of federal or state
legislative or regulatory modifications.
(f) Notwithstanding any other law, all interest earned on
the money that has been deposited into the fund is retained in the
fund and used for purposes consistent with the fund.
(g) The fund consists of:
(1) federal payments received as a result of any
waiver of requirements granted or other arrangement agreed to by
the United States secretary of health and human services or other
appropriate federal official for health care programs established
under Medicare, any federally matched public health program, or the
Affordable Care Act;
(2) amounts paid by the Health and Human Services
Commission that are equivalent to the amounts that are paid on
behalf of residents under Medicare, any federally matched public
health program, or the Affordable Care Act for health benefits that
are equivalent to health benefits covered under the program;
(3) federal and state money for purposes of the
provision of services authorized under Title XX of the Social
Security Act (42 U.S.C. Section 1397 et seq.) that would otherwise
be covered under the program; and
(4) state money that would otherwise be appropriated
to any governmental agency, office, program, instrumentality, or
institution that provides health care services for services and
benefits covered under the program.
(h) Money in the fund may be used only for the purposes
established in this chapter.
SUBCHAPTER H. COLLECTIVE NEGOTIATION AND BARGAINING
Sec. 1698.301. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies to a health care provider that is:
(1) an individual who practices that profession as a
health care provider or as an independent contractor;
(2) an owner, officer, shareholder, or proprietor of a
health care provider; or
(3) an entity that employs or uses health care
providers to provide health care services, including a health
facility licensed under the Health and Safety Code.
(b) A health care provider under Title 3, Occupations Code,
who practices as an employee of a health care provider is not a
health care provider for purposes of this subchapter.
Sec. 1698.302. COLLECTIVE NEGOTIATION AUTHORIZED. (a)
Health care providers may meet and communicate for the purpose of
collectively negotiating with the program on any matter relating to
the program, including rates of payment for health care services,
rates of payment for prescription and nonprescription drugs, and
payment methodologies.
(b) This subchapter may not be construed to allow or
authorize:
(1) an alteration of the terms of the internal and
external review procedures prescribed by law;
(2) a strike of the program by health care providers
related to the collective negotiations; or
(3) terms or conditions that would impede the ability
of the program to obtain or retain accreditation by the National
Committee for Quality Assurance or a similar body, or to comply with
applicable state or federal law.
Sec. 1698.303. COLLECTIVE NEGOTIATION. (a) Collective
negotiation rights granted by this subchapter must provide that:
(1) a health care provider may communicate with other
health care providers regarding the terms and conditions to be
negotiated with the program;
(2) a health care provider may communicate with a
health care providers' representative;
(3) a health care providers' representative is the
only party authorized to negotiate with the program on behalf of the
health care providers as a group;
(4) a health care provider may be bound by the terms
and conditions negotiated by the health care providers'
representative; and
(5) in communicating or negotiating with the health
care providers' representative, the program is entitled to offer
and provide different terms and conditions to individual competing
health care providers.
(b) This subchapter does not affect or limit:
(1) the right of a health care provider or group of
health care providers to collectively petition a governmental
entity for a change in a law or board rule; or
(2) collective action or collective bargaining on the
part of a health care provider with that health care provider's
employer or any other lawful collective action or collective
bargaining.
Sec. 1698.304. DUTIES OF HEALTH CARE PROVIDERS'
REPRESENTATIVE. (a) Before engaging in collective negotiations
with the program on behalf of health care providers, a health care
providers' representative shall file with the board, in the manner
prescribed by the board, information identifying the
representative, the representative's plan of operation, and the
representative's procedures to ensure compliance with this
subchapter.
(b) Each person who acts as the representative of a
negotiating party under this subchapter shall pay a fee, as adopted
by board rule, to the board to act as a representative.
Sec. 1698.305. PROHIBITED COLLECTIVE ACTION. (a) This
subchapter does not authorize competing health care providers to
act in concert in response to a health care providers'
representative's discussions or negotiations with the program,
except as authorized by other law.
(b) A health care providers' representative may not
negotiate any agreement that excludes, limits the participation or
reimbursement of, or otherwise limits the scope of services to be
provided by any health care provider or group of health care
providers with respect to the performance of services that are
within the health care provider's scope of practice, license,
registration, or certificate.
SECTION 2. Not later than two years after the effective date
of this Act, the Healthy Texas Board created by this Act shall:
(1) in consultation with an advisory committee
appointed by the chairperson of the board, including
representatives of consumers and potential consumers of long-term
care services, providers of long-term care services, members of
organized labor, and other interested parties, develop a proposal
consistent with the principles of Chapter 1698, Insurance Code, as
added by this Act, for providing and funding long-term care
services coverage by the Healthy Texas Program;
(2) develop a proposal for accommodating employer
retiree health benefits for people who have been members of the
Healthy Texas Program but live as retirees outside this state;
(3) develop a proposal for accommodating employer
retiree health benefits for people who earned or accrued those
benefits while residing in this state before the implementation of
the Healthy Texas Program and live as retirees outside this state;
and
(4) develop a proposal for Healthy Texas Program
coverage of health care services currently covered under the
workers' compensation system, including whether and how to continue
funding for those services under that system and whether and how to
incorporate an element of experience rating.
SECTION 3. (a) The Healthy Texas Board created by this Act
shall determine when individuals may begin enrolling in the Healthy
Texas Program. An implementation period begins on the date that
individuals may begin enrolling in the program and ends on a date
determined by the board. During the implementation period, the
Healthy Texas Program is subject to special eligibility and
financing provisions determined by the board until the program is
fully implemented.
(b) This Act does not prohibit a health benefit plan issuer
from offering any benefits during the implementation period to
individuals who enrolled or may enroll as members of the Healthy
Texas Program.
(c) Before full implementation of the Healthy Texas
Program, the board shall provide for the collection and
availability of data on the number of patients served by hospitals
and the dollar value of the care provided, at cost, for the
following categories:
(1) patients receiving charity care;
(2) contractual adjustments of county and indigent
programs, including traditional and managed care; and
(3) bad debts.
(d) Notwithstanding Section 1698.054(b), Insurance Code, as
added by this Act, a board member is not required to enroll as a
member of the Healthy Texas Program until the implementation period
has ended.
SECTION 4. The Healthy Texas Board created by this Act shall
provide money from the healthy Texas fund established by Section
1698.252, Insurance Code, as added by this Act or from funds
otherwise appropriated for this purpose to the Texas Workforce
Commission for a program for retraining and assisting job
transition for individuals employed or previously employed in the
fields of health insurance, health care service plans, and other
third-party payments for health care or those individuals providing
services to health care providers to deal with third-party payers
for health care, whose jobs may be ending or have ended as a result
of the implementation of the Healthy Texas Program.
SECTION 5. (a) Notwithstanding any other law, Chapter 1698,
Insurance Code, as added by this Act, may not be implemented until
the date the executive commissioner of the Health and Human
Services Commission notifies the secretary of the Texas Senate and
the chief clerk of the Texas House of Representatives in writing
that the executive commissioner has determined that the healthy
Texas fund has the revenue to fund the costs of implementing Chapter
1698.
(b) The Health and Human Services Commission shall publish a
copy of the notice required by Subsection (a) of this section on the
commission's Internet website.
SECTION 6. This Act takes effect September 1, 2019.