86R23947 JG-F
By: Klick H.B. No. 4533
Substitute the following for H.B. No. 4533:
By: Frank C.S.H.B. No. 4533
A BILL TO BE ENTITLED
AN ACT
relating to the system redesign for delivery of Medicaid acute care
services and long-term services and supports to persons with an
intellectual or developmental disability or with similar
functional needs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 534.001, Government Code, is amended by
amending Subdivision (3) and adding Subdivisions (3-a) and (11-a)
to read as follows:
(3) "Comprehensive long-term services and supports
provider" means a provider of long-term services and supports under
this chapter that ensures the coordinated, seamless delivery of the
full range of services in a recipient's program plan. The term
includes:
(A) a provider under the ICF-IID program; and
(B) a provider under a Medicaid waiver program
and certified in accordance with Section 534.252 ["Department"
means the Department of Aging and Disability Services].
(3-a) "Consumer direction model" has the meaning
assigned by Section 531.051.
(11-a) "Residential services" means services provided
to an individual with an intellectual or developmental disability
through a community-based ICF-IID, three- or four-person home or
host home setting under the home and community-based services (HCS)
waiver program, or a group home under the deaf-blind with multiple
disabilities (DBMD) waiver program.
SECTION 2. Sections 534.051 and 534.052, Government Code,
are amended to read as follows:
Sec. 534.051. ACUTE CARE SERVICES AND LONG-TERM SERVICES
AND SUPPORTS SYSTEM FOR INDIVIDUALS WITH AN INTELLECTUAL OR
DEVELOPMENTAL DISABILITY. In accordance with this chapter, the
commission [and the department] shall [jointly] design and
implement an acute care services and long-term services and
supports system for individuals with an intellectual or
developmental disability 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 and preferences in the
most integrated and least restrictive setting;
(2) improve individuals' access to services and
supports by ensuring that the individuals receive information about
all available programs and services, including employment and least
restrictive housing assistance, and how to apply for the programs
and services;
(3) improve the assessment of individuals' needs and
available supports, including the assessment of individuals'
functional needs;
(4) promote person-centered planning, self-direction,
self-determination, community inclusion, and customized,
integrated, competitive employment;
(5) promote individualized budgeting based on an
assessment of an individual's needs and person-centered planning;
(6) promote integrated service coordination of acute
care services and long-term services and supports;
(7) improve acute care and long-term services and
supports outcomes, including reducing unnecessary
institutionalization and potentially preventable events;
(8) promote high-quality care;
(9) provide fair hearing and appeals processes in
accordance with applicable federal law;
(10) ensure the availability of a local safety net
provider and local safety net services;
(11) promote independent service coordination and
independent ombudsmen services; and
(12) ensure that individuals with the most significant
needs are appropriately served in the community and that processes
are in place to prevent inappropriate institutionalization of
individuals.
Sec. 534.052. IMPLEMENTATION OF SYSTEM REDESIGN. The
commission [and department] shall, in consultation and
collaboration with the advisory committee, [jointly] implement the
acute care services and long-term services and supports system for
individuals with an intellectual or developmental disability in the
manner and in the stages described in this chapter.
SECTION 3. Sections 534.053(a) and (b), Government Code,
are amended to read as follows:
(a) The Intellectual and Developmental Disability System
Redesign Advisory Committee shall advise the commission [and the
department] on the implementation of the acute care services and
long-term services and supports system redesign under this
chapter. Subject to Subsection (b), the executive commissioner
[and the commissioner of aging and disability services] shall
[jointly] appoint members of the advisory committee who are
stakeholders from the intellectual and developmental disabilities
community, including:
(1) individuals with an intellectual or developmental
disability who are recipients of services under the Medicaid waiver
programs, individuals with an intellectual or developmental
disability who are recipients of services under the ICF-IID
program, and individuals who are advocates of those recipients,
including at least three representatives from intellectual and
developmental disability advocacy organizations;
(2) representatives of Medicaid managed care and
nonmanaged care health care providers, including:
(A) physicians who are primary care providers and
physicians who are specialty care providers;
(B) nonphysician mental health professionals;
and
(C) providers of long-term services and
supports, including direct service workers;
(3) representatives of entities with responsibilities
for the delivery of Medicaid long-term services and supports or
other Medicaid service delivery, including:
(A) representatives of aging and disability
resource centers established under the Aging and Disability
Resource Center initiative funded in part by the federal
Administration on Aging and the Centers for Medicare and Medicaid
Services;
(B) representatives of community mental health
and intellectual disability centers;
(C) representatives of and service coordinators
or case managers from private and public home and community-based
services providers that serve individuals with an intellectual or
developmental disability; and
(D) representatives of private and public
ICF-IID providers; and
(4) representatives of managed care organizations
contracting with the state to provide services to individuals with
an intellectual or developmental disability.
(b) To the greatest extent possible, the executive
commissioner [and the commissioner of aging and disability
services] shall appoint members of the advisory committee who
reflect the geographic diversity of the state and include members
who represent rural Medicaid recipients.
SECTION 4. Section 534.053(g), Government Code, as amended
by Chapters 837 (S.B. 200), 946 (S.B. 277), and 1117 (H.B. 3523),
Acts of the 84th Legislature, Regular Session, 2015, is reenacted
and amended to read as follows:
(g) On the second [one-year] anniversary of the date the
commission completes implementation of the transition required
under Section 534.202:
(1) the advisory committee is abolished; and
(2) this section expires.
SECTION 5. Section 534.054(b), Government Code, is amended
to read as follows:
(b) This section expires on the second anniversary of the
date the commission completes implementation of the transition
required under Section 534.202 [January 1, 2026].
SECTION 6. The heading to Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
SUBCHAPTER C. STAGE ONE: PILOT PROGRAM FOR IMPROVING [PROGRAMS TO
IMPROVE] SERVICE DELIVERY MODELS
SECTION 7. Section 534.101, Government Code, is amended by
amending Subdivision (2) and adding Subdivision (3) to read as
follows:
(2) "Pilot program" means the pilot program
established under this subchapter ["Provider" means a person with
whom the commission contracts for the provision of long-term
services and supports under Medicaid to a specific population based
on capitation].
(3) "Pilot program workgroup" means the pilot program
workgroup established under Section 534.1015.
SECTION 8. Subchapter C, Chapter 534, Government Code, is
amended by adding Section 534.1015 to read as follows:
Sec. 534.1015. PILOT PROGRAM WORKGROUP. (a) The executive
commissioner, in consultation with the advisory committee, shall
establish a pilot program workgroup to provide assistance in
developing and advice concerning the operation of the pilot
program.
(b) The pilot program workgroup is composed of:
(1) representatives of the advisory committee;
(2) stakeholders representing individuals with an
intellectual or developmental disability;
(3) stakeholders representing individuals with
similar functional needs as those individuals described by
Subdivision (2); and
(4) representatives of managed care organizations
that contract with the commission to provide services under the
STAR+PLUS Medicaid managed care program.
(c) Chapter 2110 applies to the pilot program workgroup.
SECTION 9. Sections 534.102 and 534.103, Government Code,
are amended to read as follows:
Sec. 534.102. PILOT PROGRAM [PROGRAMS] TO TEST
PERSON-CENTERED MANAGED CARE STRATEGIES AND IMPROVEMENTS BASED ON
CAPITATION. The commission, in consultation and collaboration with
the advisory committee and pilot program workgroup, shall [and the
department may] develop and implement a pilot program [programs] in
accordance with this subchapter to test, through the STAR+PLUS
Medicaid managed care program, the delivery of [one or more service
delivery models involving a managed care strategy based on
capitation to deliver] long-term services and supports [under
Medicaid] to individuals participating in the pilot program [with
an intellectual or developmental disability].
Sec. 534.103. STAKEHOLDER INPUT. As part of developing and
implementing the [a] pilot program [under this subchapter], the
commission, in consultation and collaboration with the advisory
committee and pilot program workgroup, [department] shall develop a
process to receive and evaluate:
(1) input from statewide stakeholders and
stakeholders from a STAR+PLUS Medicaid managed care service area
[the region of the state] in which the pilot program will be
implemented; and
(2) other evaluations and data.
SECTION 10. Subchapter C, Chapter 534, Government Code, is
amended by adding Section 534.1035 to read as follows:
Sec. 534.1035. MANAGED CARE ORGANIZATION SELECTION. (a)
The commission, in consultation and collaboration with the advisory
committee and pilot program workgroup, shall develop criteria
regarding the selection of a managed care organization to
participate in the pilot program.
(b) The commission shall select and contract with not more
than two managed care organizations that contract with the
commission to provide services under the STAR+PLUS Medicaid managed
care program to participate in the pilot program.
SECTION 11. Section 534.104, Government Code, is amended to
read as follows:
Sec. 534.104. [MANAGED CARE STRATEGY PROPOSALS;] PILOT
PROGRAM DESIGN [SERVICE PROVIDERS]. (a) The [department, in
consultation and collaboration with the advisory committee, shall
identify private services providers or managed care organizations
that are good candidates to develop a service delivery model
involving a managed care strategy based on capitation and to test
the model in the provision of long-term services and supports under
Medicaid to individuals with an intellectual or developmental
disability through a pilot program established under this
subchapter.
[(b) The department shall solicit managed care strategy
proposals from the private services providers and managed care
organizations identified under Subsection (a). In addition, the
department may accept and approve a managed care strategy proposal
from any qualified entity that is a private services provider or
managed care organization if the proposal provides for a
comprehensive array of long-term services and supports, including
case management and service coordination.
[(c) A managed care strategy based on capitation developed
for implementation through a] pilot program [under this subchapter]
must be designed to:
(1) increase access to long-term services and
supports;
(2) improve quality of acute care services and
long-term services and supports;
(3) promote:
(A) informed choice and meaningful outcomes by
using person-centered planning, flexible consumer-directed
services, individualized budgeting, and self-determination;[,] and
(B) [promote] community inclusion and
engagement;
(4) promote integrated service coordination of acute
care services and long-term services and supports;
(5) promote efficiency and the best use of funding
based on an individual's needs and preferences;
(6) promote through housing supports and navigation
services stability [the placement of an individual] in housing that
is the most integrated and least restrictive based on [setting
appropriate to] the individual's needs and preferences;
(7) promote employment assistance and customized,
integrated, and competitive employment;
(8) provide fair hearing and appeals processes in
accordance with applicable federal and state law; [and]
(9) promote sufficient flexibility to achieve the
goals listed in this section through the pilot program;
(10) promote the use of innovative technologies and
benefits, including telemedicine, telemonitoring, the testing of
remote monitoring, transportation services, and other innovations
that support community integration;
(11) ensure an adequate provider network that includes
comprehensive long-term services and supports providers and ensure
that pilot program participants have a choice among those
providers;
(12) ensure the timely initiation and consistent
provision of long-term services and supports in accordance with an
individual's person-centered plan;
(13) ensure that individuals with complex behavioral,
medical, and physical needs are assessed and receive appropriate
services in the most integrated and least restrictive setting based
on the individuals' needs and preferences;
(14) increase access to, expand flexibility of, and
promote the use of the consumer direction model; and
(15) promote independence, self-determination, the
use of the consumer direction model, and decision making by
individuals participating in the pilot program by using
alternatives to guardianship, including a supported
decision-making agreement as defined by Section 1357.002, Estates
Code.
(b) An individual is not required to use an innovative
technology described by Subsection (a)(10). If an individual
chooses to use an innovative technology described by that
subdivision, the commission shall ensure that services associated
with the technology are delivered in a manner that:
(1) ensures the individual's privacy, health, and
well-being;
(2) provides access to housing in the most integrated
and least restrictive environment;
(3) assesses individual needs and preferences to
promote autonomy, self-determination, the use of the consumer
direction model, and privacy;
(4) increases personal independence;
(5) specifies the extent to which the innovative
technology will be used, including:
(A) the times of day during which the technology
will be used;
(B) the place in which the technology may be
used;
(C) the types of telemonitoring or remote
monitoring that will be used; and
(D) for what purposes the technology will be
used;
(6) is consistent with and agreed on during the
person-centered planning process;
(7) ensures that staff overseeing the use of an
innovative technology:
(A) review the person-centered and
implementation plans for each individual before overseeing the use
of the innovative technology; and
(B) demonstrate competency regarding the support
needs of each individual using the innovative technology;
(8) ensures that an individual using an innovative
technology is able to request the removal of equipment relating to
the technology and, on receipt of a request for the removal, the
equipment is immediately removed; and
(9) ensures that an individual is not required to use
telemedicine at any point during the pilot program and, in the event
the individual refuses to use telemedicine, the managed care
organization providing health care services to the individual under
the pilot program arranges for services that do not include
telemedicine.
(c) The pilot program must be designed to test innovative
payment rates and methodologies for the provision of long-term
services and supports to achieve the goals of the pilot program by
using payment methodologies that include:
(1) the payment of a bundled amount without downside
risk to a comprehensive long-term services and supports provider
for some or all services delivered as part of a comprehensive array
of long-term services and supports;
(2) enhanced incentive payments to comprehensive
long-term services and supports providers based on the completion
of predetermined outcomes or quality metrics; and
(3) any other payment models approved by the
commission.
(d) An alternative payment rate or methodology described by
Subsection (c) may be used for a managed care organization and
comprehensive long-term services and supports provider only if the
organization and provider agree in advance and in writing to use the
rate or methodology [The department, in consultation and
collaboration with the advisory committee, shall evaluate each
submitted managed care strategy proposal and determine whether:
[(1) the proposed strategy satisfies the requirements
of this section; and
[(2) the private services provider or managed care
organization that submitted the proposal has a demonstrated ability
to provide the long-term services and supports appropriate to the
individuals who will receive services through the pilot program
based on the proposed strategy, if implemented].
(e) In developing an alternative payment rate or
methodology described by Subsection (c), the commission, managed
care organizations, and comprehensive long-term services and
supports providers shall consider:
(1) the historical costs of long-term services and
supports, including Medicaid fee-for-service rates;
(2) reasonable cost estimates for new services under
the pilot program; and
(3) whether an alternative payment rate or methodology
is sufficient to promote quality outcomes and ensure a provider's
continued participation in the pilot program [Based on the
evaluation performed under Subsection (d), the department may
select as pilot program service providers one or more private
services providers or managed care organizations with whom the
commission will contract].
(f) An alternative payment rate or methodology described by
Subsection (c) may not reduce the minimum payment received by a
provider for the delivery of long-term services and supports under
the pilot program below the fee-for-service reimbursement rate
received by the provider for the delivery of those services before
participating in the pilot program.
(g) The pilot program must allow a comprehensive long-term
services and supports provider for individuals with an intellectual
or developmental disability or similar functional needs to
voluntarily participate in the pilot program. A provider's choice
not to participate in the pilot program does not affect the
provider's status as a significant traditional provider.
(h) [(f) For each pilot program service provider, the
department shall develop and implement a pilot program.] Under the
[a] pilot program, a participating managed care organization [the
pilot program service provider] shall provide long-term services
and supports under Medicaid to persons with an intellectual or
developmental disability and persons with similar functional needs
to test its managed care strategy based on capitation.
(i) [(g)] The commission [department], in consultation and
collaboration with the advisory committee and pilot program
workgroup, shall analyze information provided by the managed care
organizations participating in the pilot program [service
providers] and any information collected by the commission
[department] during the operation of the pilot program [programs]
for purposes of making a recommendation about a system of programs
and services for implementation through future state legislation or
rules.
(j) [(h)] The analysis under Subsection (i) [(g)] must
include an assessment of the effect of the managed care strategies
implemented in the pilot program [programs] on the goals described
by this section [:
[(1) access to long-term services and supports;
[(2) the quality of acute care services and long-term
services and supports;
[(3) meaningful outcomes using person-centered
planning, individualized budgeting, and self-determination,
including a person's inclusion in the community;
[(4) the integration of service coordination of acute
care services and long-term services and supports;
[(5) the efficiency and use of funding;
[(6) the placement of individuals in housing that is
the least restrictive setting appropriate to an individual's needs;
[(7) employment assistance and customized,
integrated, competitive employment options; and
[(8) the number and types of fair hearing and appeals
processes in accordance with applicable federal law].
(k) Before implementing the pilot program, the commission,
in consultation and collaboration with the advisory committee and
pilot program workgroup, shall develop and implement a process to
ensure pilot program participants remain eligible for Medicaid
benefits for 12 consecutive months during the pilot program.
SECTION 12. Subchapter C, Chapter 534, Government Code, is
amended by adding Section 534.1045 to read as follows:
Sec. 534.1045. PILOT PROGRAM BENEFITS AND PROVIDER
QUALIFICATIONS. (a) Subject to Subsection (b), the commission
shall ensure that a managed care organization participating in the
pilot program provides:
(1) all Medicaid state plan acute care benefits
available under the STAR+PLUS Medicaid managed care program;
(2) long-term services and supports under the Medicaid
state plan, including:
(A) Community First Choice services;
(B) personal assistance services;
(C) day activity health services; and
(D) habilitation services;
(3) long-term services and supports under the home and
community-based services (HCS) waiver program, including:
(A) assisted living services;
(B) personal assistance services;
(C) employment assistance;
(D) supported employment;
(E) adult foster care;
(F) dental care;
(G) nursing care;
(H) respite care;
(I) home-delivered meals;
(J) cognitive rehabilitative therapy;
(K) physical therapy;
(L) occupational therapy;
(M) speech-language pathology;
(N) medical supplies;
(O) minor home modifications; and
(P) adaptive aids;
(4) long-term services and supports under other
Medicaid waiver programs, including:
(A) enhanced behavioral health services;
(B) behavioral supports;
(C) day habilitation; and
(D) community support transportation;
(5) the following additional long-term services and
supports:
(A) housing supports;
(B) behavioral health crisis intervention
services; and
(C) high medical needs services; and
(6) other nonresidential long-term services and
supports that the commission, in consultation and collaboration
with the advisory committee and pilot program workgroup, determines
are appropriate and consistent with applicable requirements
governing the Medicaid waiver programs, person-centered
approaches, home and community-based setting requirements, and
achieving the most integrated and least restrictive setting based
on an individual's needs and preferences.
(b) A comprehensive long-term services and supports
provider may deliver services listed under the following provisions
only if the provider also delivers the services under a Medicaid
waiver program:
(1) Subsections (a)(2)(A) and (D);
(2) Subsections (a)(3)(B), (C), (D), (G), (H), (J),
(K), (L), and (M); and
(3) Subsection (a)(4).
(c) A comprehensive long-term services and supports
provider may deliver services listed under Subsections (a)(5) and
(6) only if the managed care organization in the network of which
the provider participates agrees to, in a contract with the
provider, the provision of those services.
(d) Day habilitation services listed under Subsection
(a)(4)(C) may be delivered by a provider who delivers services
under a Medicaid waiver program or the ICF-IID program.
(e) A comprehensive long-term services and supports
provider participating in the pilot program shall work in
coordination with the care coordinators of a managed care
organization participating in the pilot program to ensure the
seamless delivery of acute care and long-term services and supports
on a daily basis in accordance with an individual's plan of care. A
comprehensive long-term services and supports provider may be
reimbursed by a managed care organization for coordinating with
care coordinators under this subsection.
(f) Before implementing the pilot program, the commission,
in consultation and collaboration with the advisory committee and
pilot program workgroup, shall:
(1) for purposes of the pilot program only, develop
recommendations to modify adult foster care and supported
employment and employment assistance benefits to increase access to
and availability of those services; and
(2) as necessary, define services listed under
Subsections (a)(4) and (5) and any other services determined to be
appropriate under Subsection (a)(6).
SECTION 13. Sections 534.105, 534.106, 534.1065, 534.107,
534.108, and 534.109, Government Code, are amended to read as
follows:
Sec. 534.105. PILOT PROGRAM: MEASURABLE GOALS. (a) The
commission [department], in consultation and collaboration with
the advisory committee and pilot program workgroup and using
national core indicators, the National Quality Forum long-term
services and supports measures, and other appropriate Consumer
Assessment of Healthcare Providers and Systems measures, shall
identify measurable goals to be achieved by the [each] pilot
program [implemented under this subchapter. The identified goals
must:
[(1) align with information that will be collected
under Section 534.108(a); and
[(2) be designed to improve the quality of outcomes
for individuals receiving services through the pilot program].
(b) The commission [department], in consultation and
collaboration with the advisory committee and pilot program
workgroup, shall develop [propose] specific strategies and
performance measures 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.
(c) The commission, in consultation and collaboration with
the advisory committee and pilot program workgroup, shall ensure
that mechanisms to report, track, and assess specific strategies
and performance measures for achieving the identified goals are
established before implementing the pilot program.
Sec. 534.106. IMPLEMENTATION, LOCATION, AND DURATION. (a)
The commission [and the department] shall implement the [any] pilot
program on [programs established under this subchapter not later
than] September 1, 2023 [2017].
(b) The [A] pilot program [established under this
subchapter] shall [may] operate for at least [up to] 24 months. [A
pilot program may cease operation if the pilot program service
provider terminates the contract with the commission before the
agreed-to termination date.]
(c) The [A] pilot program [established under this
subchapter] shall be conducted in a STAR+PLUS Medicaid managed care
service area [one or more regions] selected by the commission
[department].
Sec. 534.1065. RECIPIENT ENROLLMENT, PARTICIPATION, AND
ELIGIBILITY [IN PROGRAM VOLUNTARY]. (a) An individual who is
eligible for the pilot program will be enrolled automatically
[Participation in a pilot program established under this subchapter
by an individual with an intellectual or developmental disability
is voluntary], and the decision whether to opt out of participation
[participate] in the pilot [a] program and not receive long-term
services and supports under the pilot [from a provider through
that] program may be made only by the individual or the individual's
legally authorized representative.
(b) To ensure prospective pilot program participants are
able to make an informed decision on whether to participate in the
pilot program, the commission, in consultation and collaboration
with the advisory committee and pilot program workgroup, shall
develop and distribute informational materials on the pilot program
that describe the pilot program's benefits, the pilot program's
impact on current services, and other related information. The
commission shall establish a timeline and process for the
development and distribution of the materials and shall ensure:
(1) the materials are developed and distributed to
individuals eligible to participate in the pilot program with
sufficient time to educate the individuals, their families, and
other persons actively involved in their lives regarding the pilot
program;
(2) individuals eligible to participate in the pilot
program, including individuals enrolled in the STAR+PLUS Medicaid
managed care program, their families, and other persons actively
involved in their lives, receive the materials and oral information
on the pilot program;
(3) the materials contain clear, simple language
presented in a manner that is easy to understand; and
(4) the materials explain, at a minimum, that:
(A) on conclusion of the pilot program, pilot
program participants will be asked to provide feedback on their
experience, including feedback on whether the pilot program was
able to meet their unique support needs;
(B) participation in the pilot program does not
remove individuals from any Medicaid waiver program interest list;
(C) individuals who choose to participate in the
pilot program and who, during the pilot program's operation, are
offered enrollment in a Medicaid waiver program may accept the
enrollment, transition, or diversion offer; and
(D) pilot program participants have a choice
among acute care and comprehensive long-term services and supports
providers and service delivery options, including the consumer
direction model and comprehensive services model.
(c) The commission, in consultation and collaboration with
the advisory committee and pilot program workgroup, shall develop
pilot program participant eligibility criteria. The criteria must
ensure pilot program participants:
(1) include individuals with an intellectual or
developmental disability or a cognitive disability, including:
(A) individuals with autism;
(B) individuals with significant complex
behavioral, medical, and physical needs who are receiving home and
community-based services through the STAR+PLUS Medicaid managed
care program;
(C) individuals enrolled in the STAR+PLUS
Medicaid managed care program who:
(i) are on a Medicaid waiver program
interest list;
(ii) meet the criteria for an intellectual
disability; or
(iii) have a traumatic brain injury that
occurred after the age of 21; and
(D) other individuals with disabilities who have
similar functional needs without regard to the age of onset or
diagnosis; and
(2) do not include individuals who are receiving only
acute care services under the STAR+PLUS Medicaid managed care
program and are enrolled in the community-based ICF-IID program or
another Medicaid waiver program.
Sec. 534.107. COMMISSION RESPONSIBILITIES [COORDINATING
SERVICES]. (a) The commission [In providing long-term services
and supports under Medicaid to individuals with an intellectual or
developmental disability, a pilot program service provider] shall
require that a managed care organization participating in the pilot
program:
(1) ensures that individuals participating in the
pilot program have a choice among acute care and comprehensive
long-term services and supports providers and service delivery
options, including the consumer direction model [coordinate
through the pilot program institutional and community-based
services available to the individuals, including services provided
through:
[(A) a facility licensed under Chapter 252,
Health and Safety Code;
[(B) a Medicaid waiver program; or
[(C) a community-based ICF-IID operated by local
authorities];
(2) demonstrates to the commission's satisfaction that
the organization's network of acute care and comprehensive
long-term services and supports providers have experience and
expertise in providing services for individuals with an
intellectual or developmental disability and individuals with
similar functional needs [collaborate with managed care
organizations to provide integrated coordination of acute care
services and long-term services and supports, including discharge
planning from acute care services to community-based long-term
services and supports];
(3) has [have] a process for preventing inappropriate
institutionalizations of individuals; and
(4) ensures the timely initiation and consistent
provision of services in accordance with an individual's
person-centered plan [accept the risk of inappropriate
institutionalizations of individuals previously residing in
community settings].
(b) For the duration of the pilot program, the commission
shall ensure that comprehensive long-term services and supports
providers are considered significant traditional providers and
included in the provider network of a managed care organization
participating in the pilot program.
Sec. 534.108. PILOT PROGRAM INFORMATION. (a) The
commission, in consultation and collaboration with the advisory
committee and pilot program workgroup, [and the department] shall
determine which information will be collected from a managed care
organization participating in the pilot program to use in
conducting the evaluation and preparing the report under Section
534.112 [collect and compute the following information with respect
to each pilot program implemented under this subchapter to the
extent it is available:
[(1) the difference between the average monthly cost
per person for all acute care services and long-term services and
supports received by individuals participating in the pilot program
while the program is operating, including services provided through
the pilot program and other services with which pilot program
services are coordinated as described by Section 534.107, and the
average monthly cost per person for all services received by the
individuals before the operation of the pilot program;
[(2) the percentage of individuals receiving services
through the pilot program who begin receiving services in a
nonresidential setting instead of from a facility licensed under
Chapter 252, Health and Safety Code, or any other residential
setting;
[(3) the difference between the percentage of
individuals receiving services through the pilot program who live
in non-provider-owned housing during the operation of the pilot
program and the percentage of individuals receiving services
through the pilot program who lived in non-provider-owned housing
before the operation of the pilot program;
[(4) the difference between the average total Medicaid
cost, by level of need, for individuals in various residential
settings receiving services through the pilot program during the
operation of the program and the average total Medicaid cost, by
level of need, for those individuals before the operation of the
program;
[(5) the difference between the percentage of
individuals receiving services through the pilot program who obtain
and maintain employment in meaningful, integrated settings during
the operation of the program and the percentage of individuals
receiving services through the program who obtained and maintained
employment in meaningful, integrated settings before the operation
of the program;
[(6) the difference between the percentage of
individuals receiving services through the pilot program whose
behavioral, medical, life-activity, and other personal outcomes
have improved since the beginning of the program and the percentage
of individuals receiving services through the program whose
behavioral, medical, life-activity, and other personal outcomes
improved before the operation of the program, as measured over a
comparable period; and
[(7) a comparison of the overall client satisfaction
with services received through the pilot program, including for
individuals who leave the program after a determination is made in
the individuals' cases at hearings or on appeal, and the overall
client satisfaction with services received before the individuals
entered the pilot program].
(b) For the duration of the pilot program, a managed care
organization participating in the pilot program shall submit to the
commission and the advisory committee quarterly reports on the
services provided to each pilot program participant that include
information on:
(1) the level of each requested service and the
authorization and utilization rates for those services;
(2) timelines of:
(A) the delivery of each requested service;
(B) authorization of each requested service;
(C) the initiation of each requested service; and
(D) each unplanned break in the delivery of
requested services and the duration of the break;
(3) the number of pilot program participants using
employment assistance and supported employment services;
(4) the number of service denials and fair hearings
and the dispositions of fair hearings;
(5) the number of complaints and inquiries received by
the managed care organization and the outcome of each complaint;
and
(6) the number of pilot program participants who
choose the consumer direction model and the reasons why other
participants did not choose the consumer direction model [The pilot
program service provider shall collect any information described by
Subsection (a) that is available to the provider and provide the
information to the department and the commission not later than the
30th day before the date the program's operation concludes].
(c) The commission shall ensure that the mechanisms to
report and track the information and data required by this section
are established before implementing the pilot program [In addition
to the information described by Subsection (a), the pilot program
service provider shall collect any information specified by the
department for use by the department in making an evaluation under
Section 534.104(g).
[(d) The commission and the department, in consultation and
collaboration with the advisory committee, shall review and
evaluate the progress and outcomes of each pilot program
implemented under this subchapter and submit, as part of the annual
report to the legislature required by Section 534.054, a report to
the legislature during the operation of the pilot programs. Each
report must include recommendations for program improvement and
continued implementation].
Sec. 534.109. PERSON-CENTERED PLANNING. The commission, in
consultation and collaboration [cooperation] with the advisory
committee and pilot program workgroup [department], shall ensure
that each individual [with an intellectual or developmental
disability] who receives services and supports under Medicaid
through the [a] pilot program [established under this subchapter],
or the individual's legally authorized representative, has access
to a comprehensive, facilitated, person-centered plan that
identifies outcomes for the individual and drives the development
of the individualized budget. The consumer direction model must be
an available option for individuals to achieve self-determination,
choice, and control[, as defined by Section 531.051, may be an
outcome of the plan].
SECTION 14. Section 534.110, Government Code, is amended to
read as follows:
Sec. 534.110. TRANSITION BETWEEN PROGRAMS; CONTINUITY OF
SERVICES. (a) Following the evaluation of the pilot program
required under Section 534.112, the [The] commission may continue
the pilot program to ensure continuity of care for pilot program
participants. If the commission does not continue the pilot
program following the evaluation, the commission shall ensure that
there is a comprehensive plan for transitioning the provision of
Medicaid benefits for pilot program participants to the benefits
provided before participating in the pilot program [between a
Medicaid waiver program or an ICF-IID program and a pilot program
under this subchapter to protect continuity of care].
(b) A [The] transition plan under Subsection (a) shall be
developed in consultation and collaboration with the advisory
committee and pilot program workgroup and with stakeholder input as
described by Section 534.103.
SECTION 15. Section 534.111, Government Code, is amended to
read as follows:
Sec. 534.111. CONCLUSION OF PILOT PROGRAM [PROGRAMS;
EXPIRATION]. (a) On September 1, 2025, the pilot program is
concluded unless the commission continues the pilot program under
Section 534.110 [2019:
[(1) each pilot program established under this
subchapter that is still in operation must conclude; and
[(2) this subchapter expires].
(b) If the commission continues the pilot program under
Section 534.110, the commission shall publish notice of the pilot
program's continuance in the Texas Register not later than
September 1, 2025.
SECTION 16. Subchapter C, Chapter 534, Government Code, is
amended by adding Section 534.112 to read as follows:
Sec. 534.112. PILOT PROGRAM EVALUATIONS AND REPORTS. (a)
The commission, in consultation and collaboration with the advisory
committee and pilot program workgroup, shall review and evaluate
the progress and outcomes of the pilot program and submit, as part
of the annual report required under Section 534.054, a report on the
pilot program's status that includes recommendations for improving
the program.
(b) On conclusion of the pilot program, the commission, in
consultation and collaboration with the advisory committee and
pilot program workgroup, shall prepare and submit to the
legislature a written report that evaluates the pilot program based
on a comprehensive analysis. The analysis must:
(1) assess the effect of the pilot program on:
(A) access to and quality of long-term services
and supports;
(B) informed choice and meaningful outcomes
using person-centered planning, flexible consumer-directed
services, individualized budgeting, and self-determination,
including a pilot program participant's inclusion in the community;
(C) the integration of service coordination of
acute care services and long-term services and supports;
(D) employment assistance and customized,
integrated, competitive employment options;
(E) the number, types, and dispositions of fair
hearings and appeals in accordance with applicable federal and
state law;
(F) increasing the use and flexibility of the
consumer direction model;
(G) increasing the use of alternatives to
guardianship, including supported decision-making agreements as
defined by Section 1357.002, Estates Code;
(H) achieving the best and most cost-effective
use of funding based on a pilot program participant's needs and
preferences; and
(I) attendant recruitment and retention;
(2) analyze the experiences and outcomes of the
following systems changes:
(A) the comprehensive assessment instrument
described by Section 533A.0335, Health and Safety Code;
(B) the 21st Century Cures Act (Pub. L. No.
114-255);
(C) implementation of the federal rule
establishing the home and community-based settings that are
eligible for reimbursement under the STAR+PLUS home and
community-based services (HCS) waiver program;
(D) the provision of basic attendant and
habilitation services under Section 534.152; and
(E) the benefits of providing STAR+PLUS Medicaid
managed care services to persons based on functional needs;
(3) include feedback on the pilot program based on the
personal experiences of:
(A) individuals with an intellectual or
developmental disability and individuals with similar functional
needs who participated in the pilot program;
(B) families of and other persons actively
involved in the lives of individuals described by Paragraph (A);
and
(C) comprehensive long-term services and
supports providers who delivered services under the pilot program;
(4) be incorporated in the annual report required
under Section 534.054; and
(5) include recommendations on:
(A) a system of programs and services for
consideration by the legislature;
(B) necessary statutory changes; and
(C) whether to implement the pilot program
statewide under the STAR+PLUS Medicaid managed care program for
eligible individuals.
SECTION 17. The heading to Subchapter E, Chapter 534,
Government Code, is amended to read as follows:
SUBCHAPTER E. STAGE TWO: TRANSITION OF ICF-IID PROGRAM RECIPIENTS
AND LONG-TERM CARE MEDICAID WAIVER PROGRAM RECIPIENTS TO INTEGRATED
MANAGED CARE SYSTEM
SECTION 18. The heading to Section 534.202, Government
Code, is amended to read as follows:
Sec. 534.202. DETERMINATION TO TRANSITION [OF] ICF-IID
PROGRAM RECIPIENTS AND CERTAIN OTHER MEDICAID WAIVER PROGRAM
RECIPIENTS TO MANAGED CARE PROGRAM.
SECTION 19. Sections 534.202(a), (b), (c), (e), and (i),
Government Code, are amended to read as follows:
(a) This section applies to individuals with an
intellectual or developmental disability who[, on the date the
commission implements the transition described by Subsection (b),]
are receiving long-term services and supports under:
(1) a Medicaid waiver program [other than the Texas
home living (TxHmL) waiver program]; or
(2) an ICF-IID program.
(b) Subject to Subsection (g), after [After] implementing
the pilot program under Subchapter C and completing the evaluation
under Section 534.112 [transition required by Section 534.201, on
September 1, 2021], the commission, in consultation and
collaboration with the advisory committee, shall develop a plan for
the transition of all or a portion of the services provided through
an ICF-IID program or a Medicaid waiver program that were not
included in the pilot program to a Medicaid managed care model. The
plan must include:
(1) a process for transitioning the services in phases
as follows:
(A) beginning September 1, 2027, the Texas home
living (TxHmL) waiver program services;
(B) beginning September 1, 2029, the community
living assistance and support services (CLASS) waiver program
services;
(C) beginning September 1, 2031, nonresidential
services provided under the home and community-based services (HCS)
waiver program and the deaf-blind with multiple disabilities (DBMD)
waiver program; and
(D) subject to Subdivision (2), the residential
services provided under an ICF-IID program, the home and
community-based services (HCS) waiver program, and the deaf-blind
with multiple disabilities (DBMD) waiver program; and
(2) a process, based on the evaluation completed under
Section 534.112, for evaluating and determining the feasibility and
cost efficiency of transitioning residential services described by
Subdivision (1)(D) to a Medicaid managed care model [transition the
provision of Medicaid benefits to individuals to whom this section
applies to the STAR + PLUS Medicaid managed care program delivery
model or the most appropriate integrated capitated managed care
program delivery model, as determined by the commission based on
cost-effectiveness and the experience of the transition of Texas
home living (TxHmL) waiver program recipients to a managed care
program delivery model under Section 534.201, subject to
Subsections (c)(1) and (g)].
(c) Before implementing the [At the time of the] transition
described by Subsection (b), the commission shall, subject to
Subsection (g), determine whether to:
(1) continue operation of the Medicaid waiver programs
or ICF-IID program only for purposes of providing, if applicable:
(A) supplemental long-term services and supports
not available under the managed care program delivery model
selected by the commission; or
(B) long-term services and supports to Medicaid
waiver program recipients who choose to continue receiving benefits
under the waiver programs [program] as provided by Subsection (g);
or
(2) [subject to Subsection (g),] provide all or a
portion of the long-term services and supports previously available
under the Medicaid waiver programs or ICF-IID program through the
managed care program delivery model selected by the commission.
(e) The commission shall ensure that there is a
comprehensive plan for transitioning the provision of Medicaid
benefits under this section that protects the continuity of care
provided to individuals to whom this section applies and ensures
individuals have a choice among acute care and comprehensive
long-term services and supports providers and service delivery
options, including the consumer direction model.
(i) In addition to the requirements of Section 533.005, a
contract between a managed care organization and the commission for
the organization to provide Medicaid benefits under this section
must contain a requirement that the organization implement a
process for individuals with an intellectual or developmental
disability that:
(1) ensures that the individuals have a choice among
acute care and comprehensive long-term services and supports
providers and service delivery options, including the consumer
direction model;
(2) to the greatest extent possible, protects those
individuals' continuity of care with respect to access to primary
care providers, including the use of single-case agreements with
out-of-network providers; and
(3) provides access to a member services phone line
for individuals or their legally authorized representatives to
obtain information on and assistance with accessing services
through network providers, including providers of primary,
specialty, and other long-term services and supports.
SECTION 20. Section 534.203, Government Code, is amended to
read as follows:
Sec. 534.203. RESPONSIBILITIES OF COMMISSION UNDER
SUBCHAPTER. In administering this subchapter, the commission shall
ensure, on making a determination to transition services under
Section 534.202:
(1) that the commission is responsible for setting the
minimum reimbursement rate paid to a provider of ICF-IID services
or a group home provider under the integrated managed care system,
including the staff rate enhancement paid to a provider of ICF-IID
services or a group home provider;
(2) that an ICF-IID service provider or a group home
provider is paid not later than the 10th day after the date the
provider submits a clean claim in accordance with the criteria used
by the commission [department] for the reimbursement of ICF-IID
service providers or a group home provider, as applicable; [and]
(3) the establishment of an electronic portal through
which a provider of ICF-IID services or a group home provider
participating in the STAR+PLUS [STAR + PLUS] Medicaid managed care
program delivery model or the most appropriate integrated capitated
managed care program delivery model, as appropriate, may submit
long-term services and supports claims to any participating managed
care organization; and
(4) that the consumer direction model is an available
option for each individual with an intellectual or developmental
disability who receives Medicaid benefits in accordance with this
subchapter to achieve self-determination, choice, and control, and
that the individual or the individual's legally authorized
representative has access to a comprehensive, facilitated,
person-centered plan that identifies outcomes for the individual.
SECTION 21. Chapter 534, Government Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. OTHER IMPLEMENTATION REQUIREMENTS AND
RESPONSIBILITIES
Sec. 534.251. DELAYED IMPLEMENTATION AUTHORIZED.
Notwithstanding any other law, the commission may delay
implementation of a provision of this chapter without further
investigation, adjustments, or legislative action if the
commission determines the provision adversely affects the system of
services and supports to persons and programs to which this chapter
applies.
Sec. 534.252. REQUIREMENTS REGARDING TRANSITION OF
SERVICES. (a) For purposes of implementing the pilot program under
Subchapter C and transitioning the provision of services provided
to recipients under certain Medicaid waiver programs to a Medicaid
managed care delivery model following completion of the pilot
program, the commission shall:
(1) implement and maintain a certification process for
and maintain regulatory oversight over providers under the Texas
home living (TxHmL) and home and community-based services (HCS)
waiver programs; and
(2) require managed care organizations to include in
the organizations' provider networks qualified comprehensive
long-term services and supports providers and providers under the
Texas home living (TxHmL) and home and community-based services
(HCS) waiver programs that specialize in services for persons with
intellectual disabilities.
(b) For purposes of implementing the pilot program under
Subchapter C and transitioning the provision of services described
by Section 534.202 to the STAR+PLUS Medicaid managed care program,
a comprehensive long-term services and supports provider:
(1) must report to the managed care organization in
the network of which the provider participates each encounter of
any directly contracted service;
(2) must provide to the managed care organization
quarterly reports on:
(A) coordinated services and time frames for the
delivery of those services; and
(B) the goals and objectives outlined in an
individual's person-centered plan and progress made toward meeting
those goals and objectives; and
(3) may not be held accountable for the provision of
services specified in an individual's service plan that are not
authorized or subsequently denied by the managed care organization.
(c) On transitioning services under a Medicaid waiver
program to a Medicaid managed care delivery model, the commission
shall ensure that individuals do not lose benefits they receive
under the Medicaid waiver program.
SECTION 22. Section 534.201, Government Code, is repealed.
SECTION 23. Not later than September 1, 2020, and only if
the Health and Human Services Commission determines it would be
cost effective, the executive commissioner of the Health and Human
Services Commission shall seek a waiver under Section 1115 of the
federal Social Security Act (42 U.S.C. Section 1315) to provide
Medicaid benefits to medically fragile individuals:
(1) who are 21 years of age or older; and
(2) whose health care costs exceed cost limits under
appropriate Medicaid waiver programs, as defined by Section
534.001, Government Code.
SECTION 24. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall adopt rules as necessary to implement the
changes in law made by this Act.
SECTION 25. 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 26. This Act takes effect September 1, 2019.