By: Klick H.B. No. 4561
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 and a pilot for certain
populations with similar functional needs receiving services in
managed care.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 534.001, Subchapter A, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.001. DEFINITIONS. In this chapter:
(3) ["Department" means the Department of Aging and
Disability Services.] "Commission" means the Health and Human
Services Commission or an agency operating part of the state
Medicaid managed care program, as appropriate.
(4) "Comprehensive long term services and supports
provider" is defined as a provider of long term services and
supports specified under this chapter that ensures the coordinated,
seamless provision of the full range of services as approved in
participants' program plans as described under Section 534.1045
(b), (b-2),(c), and (d). A comprehensive service provider includes:
(A) an ICF/IID program provider who is authorized
to deliver services in the program defined under Section 534.001
(8), and
(B) a Medicaid waiver program provider who is
authorized to deliver services in the programs specified under
Section 534.001 (12) and certified in accordance with 534.301 (b).
[(4)] (5) "Functional need" means the measurement of
an individual's services and supports needs, including the
individual's intellectual, psychiatric, medical, and physical
support needs.
[(5)] (6) "Habilitation services" includes assistance
provided to an individual with acquiring, retaining, or improving:
(A) skills related to the activities of daily
living; and
(B) the social and adaptive skills necessary to
enable the individual to live and fully participate in the
community.
[(6)] (7) "ICF-IID" means the program under Medicaid
serving individuals with an intellectual or developmental
disability who receive care in intermediate care facilities other
than a state supported living center.
[(7)] (8) "ICF-IID program" means a program under
Medicaid serving individuals with an intellectual or developmental
disability who reside in and receive care from:
(A) intermediate care facilities licensed under
Chapter 252, Health and Safety Code; or
(B) community-based intermediate care facilities
operated by local intellectual and developmental disability
authorities.
[(8)] (9) "Local intellectual and developmental
disability authority" has the meaning assigned by Section 531.002,
Health and Safety Code.
[(9)] (11) "Managed care organization," "managed care
plan," and "potentially preventable event" have the meanings
assigned under Section 536.001.
(10) Repealed by Acts 2015, 84th Leg., R.S., Ch. 1,
Sec. 2.287(17), eff. April 2, 2015.
[(11)] (12) "Medicaid waiver program" means only the
following programs that are authorized under Section 1915(c) of the
federal Social Security Act (42 U.S.C. Section 1396n(c)) for the
provision of services to persons with an intellectual or
developmental disability:
(A) the community living assistance and support
services (CLASS) waiver program;
(B) the home and community-based services (HCS)
waiver program;
(C) the deaf-blind with multiple disabilities
(DBMD) waiver program; and
(D) the Texas home living (TxHmL) waiver program.
(13) "Residential Services" means services provided
for an individual with intellectual or developmental disability in
a community-based ICF/IID, a three or four persons home and host
home/companion service offered through the 1915(c) home and
community-based waiver services program, or a group home in the
Deaf Blind Multiple Disabilities program.
[(12)] (14) "State supported living center" has the
meaning assigned by Section 531.002, Health and Safety Code.
SECTION 2. Section 534.051, Subchapter B, Chapter 534,
Government Code, is 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;
SECTION 3. Section 534.052, Subchapter B, Chapter 534,
Government Code, is amended to read as follows:
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 4. Section 534.053, Subchapter B, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.053. INTELLECTUAL AND DEVELOPMENTAL DISABILITY
SYSTEM REDESIGN ADVISORY COMMITTEE. (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:
(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.
(e-1) The advisory committee may establish work groups that
meet at other times for purposes of studying and making
recommendations on issues the committee considers appropriate.
[(g) On January 1, 2026:
(1) the advisory committee is abolished ; and
(2) this section expires].
(g) On the [one year] two-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, Subchapter B, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.054. ANNUAL REPORT ON IMPLEMENTATION.
(b) On the two-year anniversary of the date the commission
completes implementation of the transition required under Section
534.202 this [This] section expires [January 1, 2026].
SECTION 6. Section 534.101, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.101. Pilot Program Workgroup [DEFINITIONS]. In
accordance with Section 534.053 (e-1), for puposes of [In] this
subchapter the advisory committee shall establish a h Workgroup
that includes representatives from the advisory committee,
stakeholders representing individuals with an intellectual and
developmental disability, individuals with similar functional
needs, and the STAR+PLUS managed care organizations. [:]
[(1) "Capitation" means a method of compensating a
provider on a monthly basis for providing or coordinating the
provision of a defined set of services and supports that is based on
a predetermined payment per services recipient.]
[(2) "Provider" means a person with whom the
commission contracts for the provision of long-term services and
supports under Medicaid to a specific population based on
capitation.]
SECTION 7. Section 534.102, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.102. PILOT PROGRAM [S] TO TEST PERSON-CENTERED
MANAGED CARE STRATEGIES AND IMPROVEMENTS BASED ON CAPITATION. The
commission [and the department may] ,in consultation and
collaboration with the advisory committee and Pilot Program
Workgroup, shall develop and implement a pilot program[s] 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] long term services and supports [a
managed care strategy based on capitation to deliver long-term
services and supports under Medicaid] to individuals [with an
intellectual or developmental disability]specified under Section
534.1065.
SECTION 8. Section 534.103, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.103. STAKEHOLDER INPUT. As part of developing and
implementing a pilot program under this subchapter, the
[department] commission, in consultation and collaboration with
the advisory committee and Pilot Program Workgroup, shall develop a
process to receive and evaluate input from statewide stakeholders
and stakeholders from the STAR+PLUS service area [region] of the
state in which the pilot program will be implemented and other
evaluations and data.
SECTION 9. Chaoter 534, Government Code is amended to add
new Section 534.1035, SELECTION OF MANAGED CARE ORGANIZATION
VENDORS, to read as follows:
Sec.534.1035. SELECTON OF MANAGED CARE ORGANIZATION PILOT
VENDORS. (a) The commission shall select and contract with no more
than two managed care organizations contracted to provide services
under the STAR+PLUS Medicaid managed care program to participate in
the pilot.
(b) The commission, in consultation and collaboration with
the advisory committee and Pilot Program Workgroup, shall develop
criteria regarding the selection of managed care organizations to
conduct the pilot program.
SECTION 10. Section 534.104, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.104. PILOT DESIGN [MANAGED CARE STRATEGY
PROPOSALS; PILOT PROGRAM 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) [A managed care strategy based on capitation
developed for implementation through a] The 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 informed choice and meaningful outcomes by
using person-centered planning, flexible consumer directed
services, individualized budgeting, and self-determination, and
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 the individual's needs and preferences;
(6) promote [the placement of an individual in]
housing stability through housing supports and navigation services
that is the most integrated and least restrictive 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 technology and
benefits, including telemonitoring and testing of remote
monitoring for individuals participating in the pilot. The remote
monitoring and telemonitoring is voluntary and shall ensure an
individual's privacy and health and welfare and allow access to
housing in the most integrated and least restrictive environment.
Innovations may include transportation and other innovations that
support community integration. If a pilot participant voluntarily
decides to use telemonitoring or remote monitoring or other
innovative technologies, the managed care organization providing
the pilot services shall deliver the telemonitoring, remote
monitoring and/or innovative technology services in a way that:
(A) assesses individual needs and preferences in
a manner that promotes autonomy, self-determination, consumer
directed services, privacy and increases personal independence;
(B) determines the extent in which remote
monitoring, telemedicine and other innovative technologies will be
used, including but not limited to, times of day, where the
equipment can be used, what types of telemonitoring and/or remote
monitoring, for what tasks;
(C) is identified and agreed to through the
person centered planning process;
(D) ensures the staff overseeing remote
monitoring, telemedicine and other innovative technologies review
person-centered plans and implementation plans of each individual
they are monitoring prior to monitoring that individual and
demonstrate competency regarding the support needs of each
individual they are monitoring; and
(E) ensures an individual can request to remove
the remote monitoring and other innovative technology equipment at
any point during the IDD pilot and the managed care organizations
must remove the equipment immediately.
(F) ensures individuals can choose not to use
telemedicine at any point during participation in the pilot and
that the pilot participating managed care organization must arrange
for services that do not require the use of telemedicine.
(11) ensure an adequate provider network that includes
comprehensive long term services and supports providers as
described in Section 534.001 (4) and Section 534.107 (a)(2) and
choice from among these providers;
(12) ensure timely initiation and consistent
provision of long term services and supports in accordance with an
individual's person centered care plan;
(13) ensure individuals with complex behavioral,
medical and physical needs receive services based on assessed needs
and in the most integrated, least restrictive setting according to
the each individual's needs and preferences;
(14) increase, expand flexibility and promote use of
the consumer directed services model ; and
(15) promote independence, self-determination,
consumer directed services and decision making by using
alternatives to guardianship, including supported decision-making
agreements under Chapter 1357, Estates Code.
(b) The pilot program shall be designed to test innovations
and payment models for the provision of long-term services and
supports to achieve the goals outlined in subsection (a) utilizing
methods such as:
(1) payment of a bundled amount without downside risk
to a 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 providers of long
term services and supports based on meeting pre-determined outcome
or quality metrics; and
(3) any other payment models approved by the
commission.
(c) The alternative payment rates or methodologies tested
under subsection (b) must be agreed to in writing by the managed
care organization and participating long term services and supports
provider. In developing the alternative payment rates or
methodologies, the parties must utilize:
(1) the historical costs of long term services and
supports, including Medicaid fee-for-service rates; and
(2) reasonable cost estimates for new pilot program
services; and
(3) whether alternative payment rates or
methodologies are sufficient to ensure the provider's continued
participation in the pilot program and promote quality outcomes.
(d) For long term services and supports delivered under the
pilot, the alternative payment models tested under subsection (b)
shall not reduce the minimum payment to providers below the current
fee for service reimbursement rates.
(e) The pilot program must allow existing providers of
long-term services and supports for persons with intellectual and
developmental disabilities, as defined in Section 534.001 (4), and
providers of long term services and supports for persons with
similar functional needs to voluntarily participate in one or more
pilot projects. Failure to participate in a pilot project does not
affect the contracting status of any provider as a significant
traditional provider.
[(d) 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) 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) [For each pilot program service provider, the
department__shall develop and implement a pilot program.] Under a
pilot program, the [pilot program service provider] the
participating managed care organizations shall provide long-term
services and supports under Medicaid to persons with an
intellectual or developmental disability, and other individuals
with disabilities with similar functional needs, to test its
managed care strategy based on capitation.
(g) The [department] commission, in consultation and
collaboration with the advisory committee and Pilot Program
Workgroup, shall analyze information provided by the [pilot program
service providers] participating managed care organizations and
any information collected by the [department] commission during the
operation of the pilot program[s] for purposes of making a
recommendation about a system of programs and services for
implementation through future state legislation or rules.
(h) The analysis under Subsection (g) must include an
assessment of the effect of the managed care strategies implemented
in the pilot program[s] on the goals specified under Subsections
(a), (b), (c) and (d). [:]
[(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.]
(i) Prior to implementation of the pilot program, the
commission, in consultation and collaboration with the advisory
committee and Pilot Program Workgroup, shall develop a process to
ensure 12 months continuous Medicaid eligibility for pilot
participants.
SECTION 11. Chapter 534, Government Code is amended to add
new section 534.1045, PILOT BENEFITS AND PROVIDER QUALIFICATIONS as
follows:
Sec. 534.1045. PILOT BENEFITS AND PROVIDER QUALIFICATIONS.
(a) The pilot program must ensure that participating managed care
organizations provide:
(1) all Medicaid state plan acute care benefits
available under the STAR+PLUS program;
(2) long term services and supports in the Medicaid
state plan, including:
(A) Community First Choice services;
(B) Personal Assistant services;
(C) Day Activity Health Services;
(D) Habilitation services defined under Section
534/001 (6);
(3) long term services and supports in the STAR+PLUS
home and community-based services waiver, including:
(A) assisted living
(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) cogniticve rehabilitative therapy;
(K) physical therapy;
(L) occupational therapy;
(M) speech-language pathology;
(N) medical supplies;
(O) minor home modifcations;
(P) adaptive aids;
(4) long term services and supports available in the
Medicaid waiver programs defined in Section 534.001 (12),
including:
(A) enhanced behavioral health services;
(B) behavioral supports;
(C) day habilitation;
(D) community support transporation;
(5) additional long term services and supports,
including:
(A) housing supports;
(B) behavioral health crisis intervention;
(C) high medical needs services; and
(6) Other non-residential long term services and
supports the commission, in consultation and coordination with the
advisory committee and Pilot Program Workgroup, determines
appropriate and consistent with the regulations governing the 1915
(c) waiver programs defined in Section 534.001 (12),
person-centered approaches, home and community-based settings
requirements, and the most integrated and least restrictive setting
according to an individual's needs and preferences.
(b) A comprehensive long term services and supports
provider is authorized to deliver services listed under under
subsections (a)(2)(A), (a)(2)(D), (a)(3)(B), (a)(3)(C), (a)(3)(D),
(a)(3)(G), (a)(3)(H), (a)(3)(J), (a)(3)(K), (a)(3)(L), (a)(3)(M),
and (a)(3)(4),if they also deliver the service in a Medicaid waiver
defined under Section 534.001 (12).
(b-2) A comprehensive long term services and supports
provider may deliver services under subsections (a)(5) and (a)(6)
if agreed to under contract with the pilot participating managed
care organization.
(c) Day habilitation services under (a)(4)(c) may be
delivered by a provider who is contracted or subcontracted under a
1915 (c) Medicaid waiver as defined under Section 534.001 (12) or an
ICF/IID program as defined under Section 534.001 (8).
(d) A comprehensive long term services and supports
provider works in consultation with the pilot participating managed
care organization's care coordinators to ensure the seamless
delivery of acute care and long term services and supports on a
day-to-day basis in accordance with an individual's plan of care
and may be reimbursed by the managed care organization for this
coordination.
(e) Prior to implementation of the pilot program, the
commission, in consultation and collaboration with the advisory
committee and Pilot Program Workgroup, shall:
(1) develop recommendations to modify, for the pilot
program only, the Adult Foster Care, Supported Employment and
Employment Assistance benefits to ensure increased access to and
availability of this service, and
(2) as needed, definitions for services described
under subsection (a)(4) and (5), and any services added under
subsection (6).
SECTION 12. Section 534.105, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.105. PILOT PROGRAM: MEASURABLE GOALS. (a) The
[department] commission, in consultation and collaboration with
the advisory committee and Pilot Program Workgroup, shall identify
measurable goals using National Core Indicators, National Quality
Forum LTSS measures and other appropriate CAHPS measures to be
achieved by [each] the pilot program implemented under this
subchapter. [The identified goals must:
(1) align with information that will be collected
under Section 534.108(a); and
(2) be designed to improve the quality of outcomes for
individuals receiving services through the pilot program.]
(b) The [department] commission, in consultation and
collaboration with the advisory committee and Pilot Program
Workgroup, shall [propose] develop 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 the mechanisms to report, track and assess the specific
strategies and performance measures for achieving the identified
goals are established prior to implementation of the pilot program.
SECTION 13. Section 534.106, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.106. IMPLEMENTATION, LOCATION, AND DURATION. (a)
The commission [and the department] shall implement [any] the pilot
program[s] established under this subchapter [not later than] on
September 1, [2017] 2023.
(b) A pilot program established under this subchapter [may]
shall 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) A pilot program established under this subchapter shall
be conducted in [one or more] the STAR+PLUS service area [regions]
selected by the [department] commission.
SECTION 14. Section 534.1065, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.1065. RECIPIENT ENROLLMENT, PARTICIPATION AND
ELIGIBILITY [IN PROGRAM VOLUNTARY]. (a) Enrollment
[Participation]in a pilot program established under this
subchapter by an individual [with an intellectual or developmental
disability] shall occur using an opt-out process [is voluntary,
and] with the decision whether to participate in a program and
receive long-term services and supports from a provider through
that program [may] to be made only by the individual or the
individual's legally authorized representative.
(1) The commission, in consultation and collaboration
with the advisory committee and Pilot Program Workgroup, shall
develop a timeline and process for and informational materials
related to educating pilot participants about the pilot including
its benefits, impact on current services and other related
information to ensure prospective pilot participants are able to
make an informed decision regarding participation. The process must
ensure:
(A) the timeline for development and
distribution of the pilot informational materials allows for
sufficient advance notification to and education of individuals
eligible for pilot participation, their families and other
individuals actively involved in their lives;
(B) individuals eligible for pilot
participation, including new and current STAR+PLUS enrollees and
other individuals specified in subsection (a) (1) (A), receive oral
and written information about the pilot prior to participation,
(C) the information provided is written in clear,
simple language and presented in a manner individuals are able to
understand and, at a minimum, explains that:
(i) upon conclusion of the pilot,
individuals will be requested to provide input on their pilot
participation experience, including whether the pilot was able to
meet their unique support needs;
(ii) participation in the pilot does not
remove individuals from any Interest List or, in accordance with
Section 534.1065 (c), the right to select an enrollment, transition
or diversion offer; and
(iii) individuals have choice among acute
care and long term services providers, including the consumer
directed services model and the comprehensive services model.
(b) The commission, in consultation and coordination with
the advisory committee and Pilot Program Workgroup, shall develop
pilot program participant eligibility criteria. The criteria must
ensure pilot participants include:
(1) individuals with an intellectual and
developmental disability including autism and individuals with
significant complex behavioral, medical and physical needs
receiving home and community-based services through STAR+PLUS or a
STAR+PLUS member who is also on a Medicaid Waiver Interest List or
is a STAR+PLUS member meeting criteria for intellectual
disabilities. It does not include individuals who are receiving
only acute care services under STAR+PLUS and enrolled in the
community-based ICF/IID program or one of the Medicaid waiver
programs defined under Section 534.001 (12).
(2) individuals receiving services under the
STAR+PLUS Medicaid managed care program who have a traumatic brain
injury that occurred after the age of 22; and
(3) other individuals with disabilities who have
similar functional needs independent of age of onset or diagnosis.
(c) Individuals participating in the pilot who, during the
pilot's implementation, are offered enrollment in one of the 1915
(c) Medicaid waiver programs defined under Section 534.001 (12)
shall be eligible to accept the enrollment, transition or diversion
offer.
SECTION 15. Section 534.107, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.107. [COORDINATING SERVICES] COMMISSION
RESPONSIBILTIES. (a) [In providing long-term services and supports
under Medicaid to individuals with an intellectual or developmental
disability,] The commission [a pilot program service provider]
shall require managed care organizations participating in the pilot
program to:
(1) ensure individuals participating in the pilot have
choice among acute care and comprehensive long term services and
supports providers and service delivery options including the
consumer directed services model as specified under Section
534.109. [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) demonstrate to the satisfaction of the commission
that their network of acute care, long term services and supports
and comprehensive service providers have experience and expertise
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) have a process for preventing inappropriate
institutionalizations of individuals; and
(4) ensure 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 the commission must ensure
that comprehensive long term services and supports providers as
defined under Section 534.001(4) are deemed significant
traditional providers and included in the provider network of the
managed care organizations participating in the pilot.
SECTION 16. Section 534.108, Subchapter C., Chapter 534,
Government Code, is amended to read as follows:
Section 534.108. Pilot Program Information. (a) The
commission [and the department, in consultation and coordination
with the advisory committee and Pilot Program Workgroup, shall
determine the information to be collected from each managed care
organization participating in the pilot for use in the evaluation
and reports required under Section 534.121. [collect and compute
the following information with respect to each pilot program
implemented under this subchapter to the extent it is available:]
(b) For the duration of the pilot each managed care
organization participating in the pilot shall submit to the
commission and the advisory committee a quarterly report on the
services provided to each pilot participant that includes the
following information:
(A) the level of services requested, and the
authorization and utilization rates of services for each pilot
service;
(B) timeliness of services requested,
authorized, initiated, and number and duration of unplanned service
breaks;
(C) number of pilot participants using
employment assistance and supported employment services;
(D) number of service denials and fair hearings,
and disposition of fair hearings;
(E) number of complaints and inquiries received
by the commission and managed care organizations participating in
the pilot and the outcome of the complaints; and
(F) number of participants who select the
consumer directed services model and reasons participants did not
select the service model.
(c) The commission shall ensure that the mechanisms to
report and track the information and data required in subsections
(a) and (b) are established prior to implementation of the pilot
program.
[(1) the difference between the average monthly cost
per person for all acute care services and long-term services and
supports received by individuals participating in the pilot program
while the program is operating, including services provided through
the pilot program and other services with which pilot program
services are coordinated as described by Section 534.107, and the
average monthly cost per person for all services received by the
individuals before the operation of the pilot program;
(2) the percentage of individuals receiving services
through the pilot program who begin receiving services in a
nonresidential setting instead of from a facility licensed under
Chapter 252, Health and Safety Code, or any other residential
setting;
(3) the difference between the percentage of
individuals receiving services through the pilot program who live
in non-provider-owned housing during the operation of the pilot
program and the percentage of individuals receiving services
through the pilot program who lived in non-provider-owned housing
before the operation of the pilot program;
(4) the difference between the average total Medicaid
cost, by level of need, for individuals in various residential
settings receiving services through the pilot program during the
operation of the program and the average total Medicaid cost, by
level of need, for those individuals before the operation of the
program;
(5) the difference between the percentage of
individuals receiving services through the pilot program who obtain
and maintain employment in meaningful, integrated settings during
the operation of the program and the percentage of individuals
receiving services through the program who obtained and maintained
employment in meaningful, integrated settings before the operation
of the program;
(6) the difference between the percentage of
individuals receiving services through the pilot program whose
behavioral, medical, life-activity, and other personal outcomes
have improved since the beginning of the program and the percentage
of individuals receiving services through the program whose
behavioral, medical, life-activity, and other personal outcomes
improved before the operation of the program, as measured over a
comparable period; and
(7) a comparison of the overall client satisfaction
with services received through the pilot program, including for
individuals who leave the program after a determination is made in
the individuals' cases at hearings or on appeal, and the overall
client satisfaction with services received before the individuals
entered the pilot program.
(b) The pilot program service provider shall collect any
information described by Subsection (a) that is available to the
provider and provide the information to the department and the
commission not later than the 30th day before the date the program's
operation concludes.
(c) In addition to the information described by Subsection
(a), the pilot program service provider shall collect any
information specified by the department for use by the department
in making an evaluation under Section 534.104(g).
(d) 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.]
SECTION 17. Section 534.109, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.109. PERSON-CENTERED PLANNING. The commission, in
consultation and collaboration [cooperation] with the [department]
advisory committee and Pilot Program Workgroup, shall ensure that
each individual[with an intellectual or developmental disability]
who receives services and supports under Medicaid through 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 directed services[direction] model, as defined by
Section 531.051, [may be an outcome of the plan] must be an
available option for individuals to achieve self-determination,
choice and control.
SECTION 18. Section 534.110, Subchapter C., Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.110. TRANSITION BETWEEN PROGRAMS; CONTINUITY OF
SERVICES. (a) During the evaluation of the pilot required under
Section 534.121,[The] the commission may continue the pilot to
protect continuity of care. If the commission determines not to
continue the pilot during the evaluation, the commission, in
consultation and collaboration with the advisory committee and
Pilot Program Workgroup, shall ensure that there is a comprehensive
plan for transitioning the provision of Medicaid benefits provided
to pilot participants to the services provided before the pilot.
[between a Medicaid waiver program or an ICF-IID program and a pilot
program under this subchapter to protect continuity of care.]
(b) The transition plan shall be developed in consultation
and collaboration with the advisory committee and with stakeholder
input as described by Section 534.103.
SECTION 19. Section 534.111, Subchapter C, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.111. CONCLUSION OF PILOT PROGRAM[S]; EXPIRATION.
Contingent on the decision made under Section 534.110, [On] on
September 1, [2019] 2025:
(1) [each] the pilot program established under this
subchapter [that is still in operation] either continues or must
conclude. [; and
(2) this subchapter expires.]
SECTION 21. Chapter 534, Government Code,is amended to add
new Subchapter C-1 to read as follows: SUBCHAPTER C-1. PILOT
EVALUATION AND REPORT
Section 534.121. EVALUATION OF AND REPORT ON PILOT PROGRAM.
(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 implemented
under Subchapter C of this Chapter and submit, as part of the annual
report required by Section 534.054, a report on the status of the
pilot program. The report must include recommendations for program
improvement.
(b) Upon conclusion of the pilot program required under
Subchapter C, the commission, in consultation and collaboration
with the advisory committee and Pilot Program Workgroup, shall
evaluate the pilot program and prepare and submit a report to the
legislature based on a comprehensive analysis of the pilot.
(c) The comprehensive analysis must:
(1) include an assessment of the effect of the pilot
on:
(A) access to and improved 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 person'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
hearing and appeals processes in accordance with applicable federal
and state law;
(F) increasing use and flexibility of the
consumer directed service model;
(G) increasing use of alternatives to
guardianship, including supported decision-making agreements under
Chapter 1357, Estates Code;
(H) achieving cost effectiveness and best use of
funding based on individuals' needs and preferences; and
(I) attendant recruitment and retention;
(2) provide an analysis of the experience and outcome
of the following systems changes:
(A) the IDD assessment tool required under
Chapter 533, Subchapter B, Section 533.0335, Health and Safety
Code;
(B) the 21st Century Cures Act;
(C) implementation of the federal HCBS Settings
regulations; and
(D) the provision of basic attendant and
habilitation services required under Section 534.152 of this
Chapter, and
(E) the benefits of providing STAR+PLUS services
to persons based on functional needs;
(3) include input from the individuals with
intellectual and developmental disabilities and participants of
similar functional needs, families and other individuals actively
involved in the lives of the individuals; and providers of long term
services and supports programs defined under Section 534.001 (8)
and (12) who participated in the pilot about their experiences;
(4) be incorporated into the annual report to the
legislature required under Section 534.054; and
(5) include recommendations about a system of programs
and services for consideration by the legislature, including
recommendations for needed statutory changes and whether to
transition the pilot to a statewide program under the STAR+PLUS
program for individuals who meet the eligibility criteria specified
in Section 534.1065.
SECTION 22. 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 23. Section 534.201, Subchapter E, Chapter 534,
Government Code, is repealed:
[Sec. 534.201. TRANSITION OF RECIPIENTS UNDER TEXAS HOME
LIVING (TxHmL) WAIVER PROGRAM TO MANAGED CARE PROGRAM.] [(a)[This
section applies to individuals with an intellectual or
developmental disability who are receiving long-term services and
supports under the Texas home living (TxHmL) waiver program on the
date the commission implements the transition described by
Subsection (b).]
[(b) On September 1, 2020, the commission shall 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 STAR + PLUS
Medicaid managed care program in providing basic attendant and
habilitation services and of the pilot programs established under
Subchapter C, subject to Subsection (c)(1).]
[(c) At the time of the transition described by Subsection
(b), the commission shall determine whether to:
(1) continue operation of the Texas home living
(TxHmL) waiver program for purposes of providing supplemental
long-term services and supports not available under the managed
care program delivery model selected by the commission; or
(2) provide all or a portion of the long-term services
and supports previously available under the Texas home living
(TxHmL) waiver program through the managed care program delivery
model selected by the commission.]
[(d) In implementing the transition described by Subsection
(b), the commission, in consultation and collaboration with the
advisory committee, shall develop a process to receive and evaluate
input from interested statewide stakeholders.]
[(e) The commission, in consultation and collaboration with
the advisory committee, 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.]
[(f) In addition to the requirements of Section 533.005, a
contract between a managed care organization and the commission for
the organization to provide Medicaid 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 of
providers;
(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].
[(g)] [The commission, in consultation and collaboration
with the advisory committee, shall analyze the outcomes of the
transition of the long-term services and supports under the Texas
home living (TxHmL) Medicaid waiver program to a managed care
program delivery model.] [The analysis must:]
[(1) include an assessment of the effect of the
transition on:]
[(A) access to long-term services and supports;]
[(B) meaningful outcomes using person-centered
planning, individualized budgeting, and self-determination,
including a person'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; and]
[(E) the number and types of fair hearing and
appeals processes in accordance with applicable federal law;]
[(2) be incorporated into the annual report to the
legislature required under Section 534.054; and]
(3) include recommendations for improvements to the
transition implementation for consideration by the legislature,
including recommendations for needed statutory changes.]
SECTION 24. Section 534.202, Subchapter E, Chapter 534,
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. (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 as defined under Section
534.001 (12) [other than the Texas home living (TxHmL) waiver
program]; or
(2) an ICF-IID program.
(b) After implementing the pilot [transition] required by
Subchapter C of this Chapter, completing the evaluation required
under Section 534.121, and subject to subsection (g)[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 the programs
defined in Sections 534.001 (8) and (12) which were not included in
the pilot under Subchapter C. The plan must include:
(1) The process for transitioning the services in the
programs defined in Sections 534.001 (8) and (12) in a phased-in
manner as follows:
(A) Texas Home Living;
(B) CLASS;
(C) non-residential services provided through
the 1915 (c) Home and Community-based Services and DBMD waivers;
and
(D) subject to subsection (b) (3), the
residential services offered through the ICF/IID program and the
HCS and DBMD waiver programs.
(2) With the exception of the residential services
provided through the programs specified in subsection (b) (1)(D),
the schedule for transitioning the services and individuals into
managed care must occur in the order specified under subsection
(b)(1)beginning with TxHmL on September 1, 2027; CLASS on September
1, 2029,; and the non-residential services provided through the
Home and Community-based services and DBMD waivers on September 1,
2031.
(3) The process for evaluating the feasibility and
cost efficiency of transitioning the residential services offered
through the ICF/IID program and the HCS and DBMD waiver programs,
and, as appropriate, transitioning to the managed care program.
(A) The process for determining the transition of
the residential services must be based on an evaluation of a two
year pilot.
[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) [At the time of] Prior to the transition [described by]
dates specified under Subsection (b) (2) and subject to subsection
(g), the commission shall determine whether to:
(1) continue operation of the Medicaid waiver programs
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 who choose to continue receiving benefits
under the waiver program as provided by Subsection (g); or
(2) subject to Subsection (g), provide all or a
portion of the long-term services and supports previously available
under the Medicaid waiver programs through the managed care program
delivery model selected by the commission.
(d) In implementing the transition described by Subsection
(b)(2), the commission shall develop a process to receive and
evaluate input from interested statewide stakeholders that is in
addition to the input provided by the advisory committee.
(e) The commission shall ensure that there is a
comprehensive plan for transitioning the provision of Medicaid
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 directed services model as specified under
Subsection (i).
(f) Before transitioning the provision of Medicaid benefits
for children under this section, a managed care organization
providing services under the managed care program delivery model
selected by the commission must demonstrate to the satisfaction of
the commission that the organization's network of providers has
experience and expertise in the provision of services to children
with an intellectual or developmental disability. Before
transitioning the provision of Medicaid benefits for adults with an
intellectual or developmental disability under this section, a
managed care organization providing services under the managed care
program delivery model selected by the commission must demonstrate
to the satisfaction of the commission that the organization's
network of providers has experience and expertise in the provision
of services to adults with an intellectual or developmental
disability.
(g) If the commission determines that all or a portion of
the long-term services and supports previously available under the
Medicaid waiver programs should be provided through a managed care
program delivery model under Subsection (c)(1), the commission
shall, at the time of the transition, allow each recipient
receiving long-term services and supports under a Medicaid waiver
program the option of:
(1) continuing to receive the services and supports
under the Medicaid waiver program; or
(2) receiving the services and supports through the
managed care program delivery model selected by the commission.
(h) A recipient who chooses to receive long-term services
and supports through a managed care program delivery model under
Subsection (g) may not, at a later time, choose to receive the
services and supports under a Medicaid waiver program.
(i) In addition to the requirements of Section 533.005, a
contract between a managed care organization and the commission for
the organization to provide Medicaid 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
directed services 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 25. Section 534.203, Subchapter E, Chapter 534,
Government Code, is amended to read as follows:
Sec. 534.203. RESPONSIBILITIES OF COMMISSION UNDER
SUBCHAPTER. In administering this subchapter, the commission shall
ensure that upon a determination to transition services in the
programs defined under Sections 534.001 (8) and (12):
(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 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 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 each individual with an intellectual or
developmental disability and the individual's legally authorized
representative has access to a comprehensive facilitated,
person-centered plan that identifies outcomes for the individual.
The consumer directed services model must be promoted as an
available option for individuals to achieve self-determination,
choice and control.
SECTION 26. Chapter 534, Government Code, is amended to add
Subchapter F. to read as follows:
SUBCHAPTER F. OTHER IMPLEMENTATION REQUIREMENTS AND
RESPONSIBILITIES UNDER THIS CHAPTER
Sec. 534.301. IMPLEMENTATION AND RESPONSIBILITIES UNDER
THIS CHAPTER. (a) The commission is authorized to delay
implementation of this Chapter or its subchapters without further
investigation or adjustments or legislative intervention, if it
determines any provision under the Chapter or other related mandate
or initiative integral to implementation adversely affects the
system of services and supports to persons and programs to which the
Chapter applies.
(b) For purpose of the pilot under Subchpater C. of this
Chapter and any subsequent transition of recipients receiving
services under certain Medicaid waiver programs defined under
Section 534.001 (12) to a managed care program as specified under
Section 534.202 (c), the commission must:
(1) maintain a certification process and regulatory
oversight of Texas Home Living and Home and Community-based
Services providers; and
(2) require managed care organizations include in
their network of qualified long term services and supports
providers certified Texas Home Living and Home and Community-based
Services providers that specialize in services for persons with
intellectual disabilities.
(c) Subject to Section 534.202 (b) and (c), upon a decision
to transition the long term services and supports under a Medicaid
waiver program defined under Section 534.001 (12), the commission
shall ensure individuals do not lose the benefits they are
receiving through these Medicaid waiver programs.
(d) For purposes of the pilot under Subchapter C. and any
future transition of services specified under Section 534.202 into
the STAR+PLUS program, the comprehensive long term services and
supports provider defined in Section 534.001 (4):
(1) must report encounters of any directly contracted
services to the managed care organization; provide quarterly
reporting of coordinated services and timeframes to the managed
care organization, and provide quarterly progress on goals and
objectives set by an individual's person centered plan; and
(2) will not be held accountable for the provision of
services on an individual's service plan for which a managed care
organization denies or does not authorize access to in a timely
manner.
SECTION 27. 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 28. If the Health and Human Services Commission
determines that it is cost effective, the commission shall apply
for and actively seek a waiver or authorization from the
appropriate federal agency to allow the state to provide medical
assistance under the waiver or authorization to medically fragile
individuals;
(1) Who are at least 21 years of age; and
(2) Whose costs to receive care exceed cost limits
under existing Medicaid waiver programs.
SECTION 29. This act takes effect September 1, 2019.