87R6749 KFF-D
By: Shaheen H.B. No. 2603
A BILL TO BE ENTITLED
AN ACT
relating to a direct primary care model pilot program for Medicaid.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.024151 to read as follows:
Sec. 531.024151. DIRECT PRIMARY CARE MODEL PILOT PROGRAM
FOR MEDICAID. (a) In this section:
(1) "Direct fee" means a fee charged by a physician to
a patient or a patient's designee for primary medical care services
provided by, or to be provided by, the physician to the
patient. The term includes a fee in any form, including a:
(A) retainer;
(B) membership fee;
(C) subscription fee; or
(D) fee paid under a medical service agreement.
(2) "Direct primary care," "medical service
agreement," "physician," and "primary medical care service" have
the meanings assigned by Section 162.251, Occupations Code.
(3) "Participating physician" means a physician
participating in the pilot program.
(4) "Participating recipient" means a Medicaid
recipient participating in the pilot program.
(5) "Pilot program" means the direct primary care
model pilot program established under this section.
(b) The commission shall develop a pilot program to
implement a direct primary care model in Medicaid through which a
Medicaid recipient enters into a medical service agreement with a
physician for the provision of primary medical care services in
exchange for a direct fee that is paid on a monthly basis.
(c) The commission shall implement the pilot program
statewide.
(d) Under the pilot program, a participating physician:
(1) is not required to enroll as a Medicaid provider;
and
(2) notwithstanding Subdivision (1), has the
authority of ordering, referring, and prescribing Medicaid
providers for purposes of the pilot program.
(e) To be eligible to participate in the pilot program, a
physician must be practicing under a direct primary care model that
does not accept payment or otherwise seek reimbursement for primary
medical care services from a third-party insurer or managed care
organization.
(f) A Medicaid recipient must be younger than 65 years of
age to be eligible to participate in the pilot program. The
recipient or the recipient's parent or legally authorized
representative on behalf of the recipient must enter into a medical
service agreement with a physician eligible to participate in the
pilot program. After the commission verifies that the recipient or
the recipient's parent or legally authorized representative has
entered into the agreement, the commission shall pay the lesser of:
(1) the amount of the direct fee required under the
agreement; or
(2) $40 per month for a recipient who is 18 years of
age or younger, or $70 per month for a recipient who is at least 19
years of age but younger than 65 years of age.
(g) A participating recipient shall pay the amount of the
direct fee required under the medical service agreement that
exceeds the maximum fee amount the commission pays under Subsection
(f).
(h) The commission may pay the amount of the direct fee
under a medical service agreement directly to the participating
recipient, who is then responsible for paying the participating
physician under the agreement, or may establish a system under
which the commission pays the fee directly to the physician, either
by depositing the fee into an account established for the physician
for that purpose or by another means the commission determines most
appropriate. If cost-effective, the commission may issue an
electronic benefits transfer card to a participating recipient who
shall use the card to pay the amount of the direct fee under an
agreement.
(i) To the extent permitted by the contract entered into
between the commission and a Medicaid managed care organization,
the commission shall fund the direct fee required under a medical
service agreement by making an appropriate reduction in the
capitation rate paid to the organization that issued the managed
care plan in which the participating recipient is enrolled.
(j) A participating recipient shall immediately notify the
commission when a medical service agreement terminates.
(k) Not later than December 31, 2024, the commission shall
prepare and submit a report to the legislature that includes:
(1) a summary of the commission's evaluation of the
effect of the pilot program on the provision of primary medical care
services and Medicaid costs; and
(2) a recommendation as to whether the pilot program
should be continued or terminated.
(l) The executive commissioner shall adopt rules as
necessary to implement this section.
(m) The pilot program terminates and this section expires
September 1, 2025.
SECTION 2. 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 3. This Act takes effect September 1, 2021.