Texas 2021 - 87th Regular

Texas House Bill HB2658 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	H.B. No. 2658
	1	+	By: Frank (Senate Sponsor - Kolkhorst) H.B. No. 2658
	2	+	(In the Senate - Received from the House April 21, 2021;
	3	+	May 4, 2021, read first time and referred to Committee on Health &
	4	+	Human Services; May 21, 2021, reported adversely, with favorable
	5	+	Committee Substitute by the following vote: Yeas 8, Nays 0;
	6	+	May 21, 2021, sent to printer.)
	7	+	Click here to see the committee vote
	8	+	COMMITTEE SUBSTITUTE FOR H.B. No. 2658 By: Powell
2	9
3	10
	11	+	A BILL TO BE ENTITLED
4	12		AN ACT
5	13		relating to the Medicaid program, including the administration and
6	14		operation of the Medicaid managed care program.
7	15		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8	16		SECTION 1. Subchapter B, Chapter 531, Government Code, is
9		-	amended by adding Sections 531.0501 and 531.0512 to read as
10		-	follows:
	17	+	amended by adding Sections 531.024142, 531.02493, 531.0501,
	18	+	531.0512, and 531.0605 to read as follows:
	19	+	Sec. 531.024142. NONHOSPITAL AMBULANCE TRANSPORT AND
	20	+	TREATMENT PROGRAM. (a) The commission by rule shall develop and
	21	+	implement a program designed to improve quality of care and lower
	22	+	costs in Medicaid by:
	23	+	(1) reducing avoidable transports to hospital
	24	+	emergency departments and unnecessary hospitalizations;
	25	+	(2) encouraging transports to alternative care
	26	+	settings for appropriate care; and
	27	+	(3) providing greater flexibility to ambulance care
	28	+	providers to address the emergency health care needs of Medicaid
	29	+	recipients following a 9-1-1 emergency services call.
	30	+	(b) The program must be substantially similar to the Centers
	31	+	for Medicare and Medicaid Services' Emergency Triage, Treat, and
	32	+	Transport (ET3) model.
	33	+	Sec. 531.02493. CERTIFIED NURSE AIDE PROGRAM. (a) The
	34	+	commission shall study:
	35	+	(1) the cost-effectiveness of providing, as a Medicaid
	36	+	benefit through a certified nurse aide trained in the Grand-Aide
	37	+	curriculum or a substantially similar training program, in-home
	38	+	support to a Medicaid recipient's care team after the recipient's
	39	+	discharge from a hospital; and
	40	+	(2) the feasibility of allowing a Medicaid managed
	41	+	care organization to treat payments to certified nurse aides
	42	+	providing care as described by Subdivision (1) as quality
	43	+	improvement costs.
	44	+	(b) Not later than December 1, 2022, the commission shall
	45	+	prepare and submit a report to the governor and the legislature that
	46	+	summarizes the commission's findings and conclusions from the
	47	+	study.
	48	+	(c) This section expires September 1, 2023.
11	49		Sec. 531.0501. MEDICAID WAIVER PROGRAMS: INTEREST LIST
12	50		MANAGEMENT. (a) The commission, in consultation with the
13	51		Intellectual and Developmental Disability System Redesign Advisory
14		-	Committee established under Section 534.053, shall study the
15		-	feasibility of creating an online portal for individuals to request
16		-	to be placed and check the individual's placement on a Medicaid
17		-	waiver program interest list. As part of the study, the commission
18		-	shall determine the most cost-effective automated method for
19		-	determining the level of need of an individual seeking services
20		-	through a Medicaid waiver program.
	52	+	Committee established under Section 534.053 and the STAR Kids
	53	+	Managed Care Advisory Committee, shall study the feasibility of
	54	+	creating an online portal for individuals to request to be placed
	55	+	and check the individual's placement on a Medicaid waiver program
	56	+	interest list. As part of the study, the commission shall determine
	57	+	the most cost-effective automated method for determining the level
	58	+	of need of an individual seeking services through a Medicaid waiver
	59	+	program.
21	60		(b) Not later than January 1, 2023, the commission shall
22	61		prepare and submit a report to the governor, the lieutenant
23	62		governor, the speaker of the house of representatives, and the
24	63		standing legislative committees with primary jurisdiction over
25	64		health and human services that summarizes the commission's findings
26	65		and conclusions from the study.
27	66		(c) Subsections (a) and (b) and this subsection expire
28	67		September 1, 2023.
29	68		(d) The commission shall develop a protocol in the office of
30	69		the ombudsman to improve the capture and updating of contact
31	70		information for an individual who contacts the office of the
32	71		ombudsman regarding Medicaid waiver programs or services.
33	72		Sec. 531.0512. NOTIFICATION REGARDING CONSUMER DIRECTION
34	73		MODEL. The commission shall:
35	74		(1) develop a procedure to:
36	75		(A) verify that a Medicaid recipient or the
37	76		recipient's parent or legal guardian is informed regarding the
38	77		consumer direction model and provided the option to choose to
39	78		receive care under that model; and
40	79		(B) if the individual declines to receive care
41	80		under the consumer direction model, document the declination; and
42	81		(2) ensure that each Medicaid managed care
43	82		organization implements the procedure.
	83	+	Sec. 531.0605. ADVANCING CARE FOR EXCEPTIONAL KIDS PILOT
	84	+	PROGRAM. (a) The commission shall collaborate with Medicaid
	85	+	managed care organizations and the STAR Kids Managed Care Advisory
	86	+	Committee to develop and implement a pilot program that is
	87	+	substantially similar to the program described by Section 3,
	88	+	Medicaid Services Investment and Accountability Act of 2019 (Pub.
	89	+	L. No. 116-16), to provide coordinated care through a health home
	90	+	to children with complex medical conditions.
	91	+	(b) The commission shall seek guidance from the Centers for
	92	+	Medicare and Medicaid Services and the United States Department of
	93	+	Health and Human Services regarding the design of the program and,
	94	+	based on the guidance, may actively seek and apply for federal
	95	+	funding to implement the program.
	96	+	(c) Not later than December 31, 2024, the commission shall
	97	+	prepare and submit a report to the legislature that includes:
	98	+	(1) a summary of the commission's implementation of
	99	+	the pilot program; and
	100	+	(2) if the pilot program has been operating for a
	101	+	period sufficient to obtain necessary data, a summary of the
	102	+	commission's evaluation of the effect of the pilot program on the
	103	+	coordination of care for children with complex medical conditions
	104	+	and a recommendation as to whether the pilot program should be
	105	+	continued, expanded, or terminated.
	106	+	(d) The pilot program terminates and this section expires
	107	+	September 1, 2025.
44	108		SECTION 2. Section 533.00251, Government Code, is amended
45	109		by adding Subsection (h) to read as follows:
46	110		(h) In addition to the minimum performance standards the
47	111		commission establishes for nursing facility providers seeking to
48	112		participate in the STAR+PLUS Medicaid managed care program, the
49	113		executive commissioner shall adopt rules establishing minimum
50	114		performance standards applicable to nursing facility providers
51	115		that participate in the program. The commission is responsible for
52	116		monitoring provider performance in accordance with the standards
53	117		and requiring corrective actions, as the commission determines
54	118		necessary, from providers that do not meet the standards. The
55	119		commission shall share data regarding the requirements of this
56	120		subsection with STAR+PLUS Medicaid managed care organizations as
57	121		appropriate.
58	122		SECTION 3. Section 533.005(a), Government Code, is amended
59	123		to read as follows:
60	124		(a) A contract between a managed care organization and the
61	125		commission for the organization to provide health care services to
62	126		recipients must contain:
63	127		(1) procedures to ensure accountability to the state
64	128		for the provision of health care services, including procedures for
65	129		financial reporting, quality assurance, utilization review, and
66	130		assurance of contract and subcontract compliance;
67	131		(2) capitation rates that:
68	132		(A) include acuity and risk adjustment
69	133		methodologies that consider the costs of providing acute care
70	134		services and long-term services and supports, including private
71	135		duty nursing services, provided under the plan; and
72	136		(B) ensure the cost-effective provision of
73	137		quality health care;
74	138		(3) a requirement that the managed care organization
75	139		provide ready access to a person who assists recipients in
76	140		resolving issues relating to enrollment, plan administration,
77	141		education and training, access to services, and grievance
78	142		procedures;
79	143		(4) a requirement that the managed care organization
80	144		provide ready access to a person who assists providers in resolving
81	145		issues relating to payment, plan administration, education and
82	146		training, and grievance procedures;
83	147		(5) a requirement that the managed care organization
84	148		provide information and referral about the availability of
85	149		educational, social, and other community services that could
86	150		benefit a recipient;
87	151		(6) procedures for recipient outreach and education;
88	152		(7) a requirement that the managed care organization
89	153		make payment to a physician or provider for health care services
90	154		rendered to a recipient under a managed care plan on any claim for
91	155		payment that is received with documentation reasonably necessary
92	156		for the managed care organization to process the claim:
93	157		(A) not later than:
94	158		(i) the 10th day after the date the claim is
95	159		received if the claim relates to services provided by a nursing
96	160		facility, intermediate care facility, or group home;
97	161		(ii) the 30th day after the date the claim
98	162		is received if the claim relates to the provision of long-term
99	163		services and supports not subject to Subparagraph (i); and
100	164		(iii) the 45th day after the date the claim
101	165		is received if the claim is not subject to Subparagraph (i) or (ii);
102	166		or
103	167		(B) within a period, not to exceed 60 days,
104	168		specified by a written agreement between the physician or provider
105	169		and the managed care organization;
106	170		(7-a) a requirement that the managed care organization
107	171		demonstrate to the commission that the organization pays claims
108	172		described by Subdivision (7)(A)(ii) on average not later than the
109	173		21st day after the date the claim is received by the organization;
110	174		(8) a requirement that the commission, on the date of a
111	175		recipient's enrollment in a managed care plan issued by the managed
112	176		care organization, inform the organization of the recipient's
113	177		Medicaid certification date;
114	178		(9) a requirement that the managed care organization
115	179		comply with Section 533.006 as a condition of contract retention
116	180		and renewal;
117	181		(10) a requirement that the managed care organization
118	182		provide the information required by Section 533.012 and otherwise
119	183		comply and cooperate with the commission's office of inspector
120	184		general and the office of the attorney general;
121	185		(11) a requirement that the managed care
122	186		organization's usages of out-of-network providers or groups of
123	187		out-of-network providers may not exceed limits for those usages
124	188		relating to total inpatient admissions, total outpatient services,
125	189		and emergency room admissions determined by the commission;
126	190		(12) if the commission finds that a managed care
127	191		organization has violated Subdivision (11), a requirement that the
128	192		managed care organization reimburse an out-of-network provider for
129	193		health care services at a rate that is equal to the allowable rate
130	194		for those services, as determined under Sections 32.028 and
131	195		32.0281, Human Resources Code;
132	196		(13) a requirement that, notwithstanding any other
133	197		law, including Sections 843.312 and 1301.052, Insurance Code, the
134	198		organization:
135	199		(A) use advanced practice registered nurses and
136	200		physician assistants in addition to physicians as primary care
137	201		providers to increase the availability of primary care providers in
138	202		the organization's provider network; and
139	203		(B) treat advanced practice registered nurses
140	204		and physician assistants in the same manner as primary care
141	205		physicians with regard to:
142	206		(i) selection and assignment as primary
143	207		care providers;
144	208		(ii) inclusion as primary care providers in
145	209		the organization's provider network; and
146	210		(iii) inclusion as primary care providers
147	211		in any provider network directory maintained by the organization;
148	212		(14) a requirement that the managed care organization
149	213		reimburse a federally qualified health center or rural health
150	214		clinic for health care services provided to a recipient outside of
151	215		regular business hours, including on a weekend day or holiday, at a
152	216		rate that is equal to the allowable rate for those services as
153	217		determined under Section 32.028, Human Resources Code, if the
154	218		recipient does not have a referral from the recipient's primary
155	219		care physician;
156	220		(15) a requirement that the managed care organization
157	221		develop, implement, and maintain a system for tracking and
158	222		resolving all provider appeals related to claims payment, including
159	223		a process that will require:
160	224		(A) a tracking mechanism to document the status
161	225		and final disposition of each provider's claims payment appeal;
162	226		(B) the contracting with physicians who are not
163	227		network providers and who are of the same or related specialty as
164	228		the appealing physician to resolve claims disputes related to
165	229		denial on the basis of medical necessity that remain unresolved
166	230		subsequent to a provider appeal;
167	231		(C) the determination of the physician resolving
168	232		the dispute to be binding on the managed care organization and
169	233		provider; and
170	234		(D) the managed care organization to allow a
171	235		provider with a claim that has not been paid before the time
172	236		prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
173	237		claim;
174	238		(16) a requirement that a medical director who is
175	239		authorized to make medical necessity determinations is available to
176	240		the region where the managed care organization provides health care
177	241		services;
178	242		(17) a requirement that the managed care organization
179	243		ensure that a medical director and patient care coordinators and
180	244		provider and recipient support services personnel are located in
181	245		the South Texas service region, if the managed care organization
182	246		provides a managed care plan in that region;
183	247		(18) a requirement that the managed care organization
184	248		provide special programs and materials for recipients with limited
185	249		English proficiency or low literacy skills;
186	250		(19) a requirement that the managed care organization
187	251		develop and establish a process for responding to provider appeals
188	252		in the region where the organization provides health care services;
189	253		(20) a requirement that the managed care organization:
190	254		(A) develop and submit to the commission, before
191	255		the organization begins to provide health care services to
192	256		recipients, a comprehensive plan that describes how the
193	257		organization's provider network complies with the provider access
194	258		standards established under Section 533.0061;
195	259		(B) as a condition of contract retention and
196	260		renewal:
197	261		(i) continue to comply with the provider
198	262		access standards established under Section 533.0061; and
199	263		(ii) make substantial efforts, as
200	264		determined by the commission, to mitigate or remedy any
201	265		noncompliance with the provider access standards established under
202	266		Section 533.0061;
203	267		(C) pay liquidated damages for each failure, as
204	268		determined by the commission, to comply with the provider access
205	269		standards established under Section 533.0061 in amounts that are
206	270		reasonably related to the noncompliance; and
207	271		(D) regularly, as determined by the commission,
208	272		submit to the commission and make available to the public a report
209	273		containing data on the sufficiency of the organization's provider
210	274		network with regard to providing the care and services described
211	275		under Section 533.0061(a) and specific data with respect to access
212	276		to primary care, specialty care, long-term services and supports,
213	277		nursing services, and therapy services on the average length of
214	278		time between:
215	279		(i) the date a provider requests prior
216	280		authorization for the care or service and the date the organization
217	281		approves or denies the request; and
218	282		(ii) the date the organization approves a
219	283		request for prior authorization for the care or service and the date
220	284		the care or service is initiated;
221	285		(21) a requirement that the managed care organization
222	286		demonstrate to the commission, before the organization begins to
223	287		provide health care services to recipients, that, subject to the
224	288		provider access standards established under Section 533.0061:
225	289		(A) the organization's provider network has the
226	290		capacity to serve the number of recipients expected to enroll in a
227	291		managed care plan offered by the organization;
228	292		(B) the organization's provider network
229	293		includes:
230	294		(i) a sufficient number of primary care
231	295		providers;
232	296		(ii) a sufficient variety of provider
233	297		types;
234	298		(iii) a sufficient number of providers of
235	299		long-term services and supports and specialty pediatric care
236	300		providers of home and community-based services; and
237	301		(iv) providers located throughout the
238	302		region where the organization will provide health care services;
239	303		and
240	304		(C) health care services will be accessible to
241	305		recipients through the organization's provider network to a
242	306		comparable extent that health care services would be available to
243	307		recipients under a fee-for-service or primary care case management
244	308		model of Medicaid managed care;
245	309		(22) a requirement that the managed care organization
246	310		develop a monitoring program for measuring the quality of the
247	311		health care services provided by the organization's provider
248	312		network that:
249	313		(A) incorporates the National Committee for
250	314		Quality Assurance's Healthcare Effectiveness Data and Information
251	315		Set (HEDIS) measures or, as applicable, the national core
252	316		indicators adult consumer survey and the national core indicators
253	317		child family survey for individuals with an intellectual or
254	318		developmental disability;
255	319		(B) focuses on measuring outcomes; and
256	320		(C) includes the collection and analysis of
257	321		clinical data relating to prenatal care, preventive care, mental
258	322		health care, and the treatment of acute and chronic health
259	323		conditions and substance abuse;
260	324		(23) subject to Subsection (a-1), a requirement that
261	325		the managed care organization develop, implement, and maintain an
262	326		outpatient pharmacy benefit plan for its enrolled recipients:
263	327		(A) that, except as provided by Paragraph
264	328		(L)(ii), exclusively employs the vendor drug program formulary and
265	329		preserves the state's ability to reduce waste, fraud, and abuse
266	330		under Medicaid;
267	331		(B) that adheres to the applicable preferred drug
268	332		list adopted by the commission under Section 531.072;
269	333		(C) that, except as provided by Paragraph (L)(i),
270	334		includes the prior authorization procedures and requirements
271	335		prescribed by or implemented under Sections 531.073(b), (c), and
272	336		(g) for the vendor drug program;
273	337		(C-1) that does not require a clinical,
274	338		nonpreferred, or other prior authorization for any antiretroviral
275	339		drug, as defined by Section 531.073, or a step therapy or other
276	340		protocol, that could restrict or delay the dispensing of the drug
277	341		except to minimize fraud, waste, or abuse;
278	342		(D) for purposes of which the managed care
279	343		organization:
280	344		(i) may not negotiate or collect rebates
281	345		associated with pharmacy products on the vendor drug program
282	346		formulary; and
283	347		(ii) may not receive drug rebate or pricing
284	348		information that is confidential under Section 531.071;
285	349		(E) that complies with the prohibition under
286	350		Section 531.089;
287	351		(F) under which the managed care organization may
288	352		not prohibit, limit, or interfere with a recipient's selection of a
289	353		pharmacy or pharmacist of the recipient's choice for the provision
290	354		of pharmaceutical services under the plan through the imposition of
291	355		different copayments;
292	356		(G) that allows the managed care organization or
293	357		any subcontracted pharmacy benefit manager to contract with a
294	358		pharmacist or pharmacy providers separately for specialty pharmacy
295	359		services, except that:
296	360		(i) the managed care organization and
297	361		pharmacy benefit manager are prohibited from allowing exclusive
298	362		contracts with a specialty pharmacy owned wholly or partly by the
299	363		pharmacy benefit manager responsible for the administration of the
300	364		pharmacy benefit program; and
301	365		(ii) the managed care organization and
302	366		pharmacy benefit manager must adopt policies and procedures for
303	367		reclassifying prescription drugs from retail to specialty drugs,
304	368		and those policies and procedures must be consistent with rules
305	369		adopted by the executive commissioner and include notice to network
306	370		pharmacy providers from the managed care organization;
307	371		(H) under which the managed care organization may
308	372		not prevent a pharmacy or pharmacist from participating as a
309	373		provider if the pharmacy or pharmacist agrees to comply with the
310	374		financial terms and conditions of the contract as well as other
311	375		reasonable administrative and professional terms and conditions of
312	376		the contract;
313	377		(I) under which the managed care organization may
314	378		include mail-order pharmacies in its networks, but may not require
315	379		enrolled recipients to use those pharmacies, and may not charge an
316	380		enrolled recipient who opts to use this service a fee, including
317	381		postage and handling fees;
318	382		(J) under which the managed care organization or
319	383		pharmacy benefit manager, as applicable, must pay claims in
320	384		accordance with Section 843.339, Insurance Code;
321	385		(K) under which the managed care organization or
322	386		pharmacy benefit manager, as applicable:
323	387		(i) to place a drug on a maximum allowable
324	388		cost list, must ensure that:
325	389		(a) the drug is listed as "A" or "B"
326	390		rated in the most recent version of the United States Food and Drug
327	391		Administration's Approved Drug Products with Therapeutic
328	392		Equivalence Evaluations, also known as the Orange Book, has an "NR"
329	393		or "NA" rating or a similar rating by a nationally recognized
330	394		reference; and
331	395		(b) the drug is generally available
332	396		for purchase by pharmacies in the state from national or regional
333	397		wholesalers and is not obsolete;
334	398		(ii) must provide to a network pharmacy
335	399		provider, at the time a contract is entered into or renewed with the
336	400		network pharmacy provider, the sources used to determine the
337	401		maximum allowable cost pricing for the maximum allowable cost list
338	402		specific to that provider;
339	403		(iii) must review and update maximum
340	404		allowable cost price information at least once every seven days to
341	405		reflect any modification of maximum allowable cost pricing;
342	406		(iv) must, in formulating the maximum
343	407		allowable cost price for a drug, use only the price of the drug and
344	408		drugs listed as therapeutically equivalent in the most recent
345	409		version of the United States Food and Drug Administration's
346	410		Approved Drug Products with Therapeutic Equivalence Evaluations,
347	411		also known as the Orange Book;
348	412		(v) must establish a process for
349	413		eliminating products from the maximum allowable cost list or
350	414		modifying maximum allowable cost prices in a timely manner to
351	415		remain consistent with pricing changes and product availability in
352	416		the marketplace;
353	417		(vi) must:
354	418		(a) provide a procedure under which a
355	419		network pharmacy provider may challenge a listed maximum allowable
356	420		cost price for a drug;
357	421		(b) respond to a challenge not later
358	422		than the 15th day after the date the challenge is made;
359	423		(c) if the challenge is successful,
360	424		make an adjustment in the drug price effective on the date the
361	425		challenge is resolved and make the adjustment applicable to all
362	426		similarly situated network pharmacy providers, as determined by the
363	427		managed care organization or pharmacy benefit manager, as
364	428		appropriate;
365	429		(d) if the challenge is denied,
366	430		provide the reason for the denial; and
367	431		(e) report to the commission every 90
368	432		days the total number of challenges that were made and denied in the
369	433		preceding 90-day period for each maximum allowable cost list drug
370	434		for which a challenge was denied during the period;
371	435		(vii) must notify the commission not later
372	436		than the 21st day after implementing a practice of using a maximum
373	437		allowable cost list for drugs dispensed at retail but not by mail;
374	438		and
375	439		(viii) must provide a process for each of
376	440		its network pharmacy providers to readily access the maximum
377	441		allowable cost list specific to that provider; and
378	442		(L) under which the managed care organization or
379	443		pharmacy benefit manager, as applicable:
380	444		(i) may not require a prior authorization,
381	445		other than a clinical prior authorization or a prior authorization
382	446		imposed by the commission to minimize the opportunity for waste,
383	447		fraud, or abuse, for or impose any other barriers to a drug that is
384	448		prescribed to a child enrolled in the STAR Kids managed care program
385	449		for a particular disease or treatment and that is on the vendor drug
386	450		program formulary or require additional prior authorization for a
387	451		drug included in the preferred drug list adopted under Section
388	452		531.072;
389	453		(ii) must provide for continued access to a
390	454		drug prescribed to a child enrolled in the STAR Kids managed care
391	455		program, regardless of whether the drug is on the vendor drug
392	456		program formulary or, if applicable on or after August 31, 2023, the
393	457		managed care organization's formulary;
394	458		(iii) may not use a protocol that requires a
395	459		child enrolled in the STAR Kids managed care program to use a
396	460		prescription drug or sequence of prescription drugs other than the
397	461		drug that the child's physician recommends for the child's
398	462		treatment before the managed care organization provides coverage
399	463		for the recommended drug; and
400	464		(iv) must pay liquidated damages to the
401	465		commission for each failure, as determined by the commission, to
402	466		comply with this paragraph in an amount that is a reasonable
403	467		forecast of the damages caused by the noncompliance;
404	468		(24) a requirement that the managed care organization
405	469		and any entity with which the managed care organization contracts
406	470		for the performance of services under a managed care plan disclose,
407	471		at no cost, to the commission and, on request, the office of the
408	472		attorney general all discounts, incentives, rebates, fees, free
409	473		goods, bundling arrangements, and other agreements affecting the
410	474		net cost of goods or services provided under the plan;
411	475		(25) a requirement that the managed care organization
412	476		not implement significant, nonnegotiated, across-the-board
413	477		provider reimbursement rate reductions unless:
414	478		(A) subject to Subsection (a-3), the
415	479		organization has the prior approval of the commission to make the
416	480		reductions; or
417	481		(B) the rate reductions are based on changes to
418	482		the Medicaid fee schedule or cost containment initiatives
419	483		implemented by the commission; and
420	484		(26) a requirement that the managed care organization
421	485		make initial and subsequent primary care provider assignments and
422	486		changes.
423	487		SECTION 4. Subchapter A, Chapter 533, Government Code, is
424	488		amended by adding Section 533.00515 to read as follows:
425	489		Sec. 533.00515. MEDICATION THERAPY MANAGEMENT. The
426	490		executive commissioner shall collaborate with Medicaid managed
427	491		care organizations to implement medication therapy management
428	492		services to lower costs and improve quality outcomes for recipients
429	493		by reducing adverse drug events.
430	494		SECTION 5. Section 533.009(c), Government Code, is amended
431	495		to read as follows:
432	496		(c) The executive commissioner, by rule, shall prescribe
433	497		the minimum requirements that a managed care organization, in
434	498		providing a disease management program, must meet to be eligible to
435	499		receive a contract under this section. The managed care
436	500		organization must, at a minimum, be required to:
437	501		(1) provide disease management services that have
438	502		performance measures for particular diseases that are comparable to
439	503		the relevant performance measures applicable to a provider of
440	504		disease management services under Section 32.057, Human Resources
441	505		Code; [and]
442	506		(2) show evidence of ability to manage complex
443	507		diseases in the Medicaid population; and
444	508		(3) if a disease management program provided by the
445	509		organization has low active participation rates, identify the
446	510		reason for the low rates and develop an approach to increase active
447	511		participation in disease management programs for high-risk
448	512		recipients.
449		-	SECTION 6. Section 32.054, Human Resources Code, is amended
	513	+	SECTION 6. Section 32.028, Human Resources Code, is amended
	514	+	by adding Subsection (p) to read as follows:
	515	+	(p) The executive commissioner shall establish a
	516	+	reimbursement rate for medication therapy management services.
	517	+	SECTION 7. Section 32.054, Human Resources Code, is amended
450	518		by adding Subsection (f) to read as follows:
451	519		(f) To prevent serious medical conditions and reduce
452	520		emergency room visits necessitated by complications resulting from
453	521		a lack of access to dental care, the commission shall provide
454	522		medical assistance reimbursement for preventive dental services,
455		-	including reimbursement for one preventive dental care visit per
456		-	year, for an adult recipient with a disability who is enrolled in
457		-	the STAR+PLUS Medicaid managed care program. This subsection does
458		-	not apply to an adult recipient who is enrolled in the STAR+PLUS
459		-	home and community-based services (HCBS) waiver program. This
460		-	subsection may not be construed to reduce dental services available
461		-	to persons with disabilities that are otherwise reimbursable under
462		-	the medical assistance program.
463		-	SECTION 7. Subchapter B, Chapter 32, Human Resources Code,
464		-	is amended by adding Section 32.0317 to read as follows:
	523	+	including reimbursement for at least one preventive dental care
	524	+	visit per year, for an adult recipient with a disability who is
	525	+	enrolled in the STAR+PLUS Medicaid managed care program. This
	526	+	subsection does not apply to an adult recipient who is enrolled in
	527	+	the STAR+PLUS home and community-based services (HCBS) waiver
	528	+	program. This subsection may not be construed to reduce dental
	529	+	services available to persons with disabilities that are otherwise
	530	+	reimbursable under the medical assistance program.
	531	+	SECTION 8. Subchapter B, Chapter 32, Human Resources Code,
	532	+	is amended by adding Sections 32.0317 and 32.0611 to read as
	533	+	follows:
465	534		Sec. 32.0317. REIMBURSEMENT FOR SERVICES PROVIDED UNDER
466	535		SCHOOL HEALTH AND RELATED SERVICES PROGRAM. The executive
467	536		commissioner shall adopt rules requiring parental consent for
468	537		services provided under the school health and related services
469	538		program in order for a school district to receive reimbursement for
470	539		the services. The rules must allow a school district to seek a
471	540		waiver to receive reimbursement for services provided to a student
472	541		who does not have a parent or legal guardian who can provide
473	542		consent.
474		-	SECTION 8. Section 32.0261, Human Resources Code, is
475		-	amended to read as follows:
476		-	Sec. 32.0261. CONTINUOUS ELIGIBILITY. (a) This section
477		-	applies only to a child younger than 19 years of age who is
478		-	determined eligible for medical assistance under this chapter.
479		-	(b) The executive commissioner shall adopt rules in
480		-	accordance with 42 U.S.C. Section 1396a(e)(12), as amended, to
481		-	provide for two consecutive periods of [a period of continuous]
482		-	eligibility for a child between each certification and
483		-	recertification of the child's eligibility, subject to Subsections
484		-	(f) and (h) [under 19 years of age who is determined to be eligible
485		-	for medical assistance under this chapter].
486		-	(c) The first of the two consecutive periods of eligibility
487		-	described by Subsection (b) must be continuous in accordance with
488		-	Subsection (d). The second of the two consecutive periods of
489		-	eligibility is not continuous and may be affected by changes in a
490		-	child's household income, regardless of whether those changes
491		-	occurred or whether the commission became aware of the changes
492		-	during the first or second of the two consecutive periods of
493		-	eligibility.
494		-	(d) A [The rules shall provide that the] child remains
495		-	eligible for medical assistance during the first of the two
496		-	consecutive periods of eligibility, without additional review by
497		-	the commission and regardless of changes in the child's household
498		-	[resources or] income, until [the earlier of:
499		-	[(1)] the end of the six-month period following the
500		-	date on which the child's eligibility was determined, except as
501		-	provided by Subsections (f)(1) and (h) [; or
502		-	[(2) the child's 19th birthday].
503		-	(e) During the sixth month following the date on which a
504		-	child's eligibility for medical assistance is certified or
505		-	recertified, the commission shall, in a manner that complies with
506		-	federal law, including verification plan requirements under 42
507		-	C.F.R. Section 435.945(j), review the child's household income
508		-	using electronic income data available to the commission. The
509		-	commission may conduct this review only once during the child's two
510		-	consecutive periods of eligibility. Based on the review:
511		-	(1) the commission shall, if the review indicates that
512		-	the child's household income does not exceed the maximum income for
513		-	eligibility for the medical assistance program, provide for a
514		-	second consecutive period of eligibility for the child until the
515		-	child's required annual recertification, except as provided by
516		-	Subsection (h) and subject to Subsection (c); or
517		-	(2) the commission may, if the review indicates that
518		-	the child's household income exceeds the maximum income for
519		-	eligibility for the medical assistance program, request additional
520		-	documentation to verify the child's household income in a manner
521		-	that complies with federal law.
522		-	(f) If, after reviewing a child's household income under
523		-	Subsection (e), the commission determines that the household income
524		-	exceeds the maximum income for eligibility for the medical
525		-	assistance program, the commission shall continue to provide
526		-	medical assistance to the child until:
527		-	(1) the commission provides the child's parent or
528		-	guardian with a period of not less than 30 days to provide
529		-	documentation demonstrating that the child's household income does
530		-	not exceed the maximum income for eligibility; and
531		-	(2) the child's parent or guardian fails to provide the
532		-	documentation during the period described by Subdivision (1).
533		-	(g) If a child's parent or guardian provides to the
534		-	commission within the period described by Subsection (f)
535		-	documentation demonstrating that the child's household income does
536		-	not exceed the maximum income for eligibility for the medical
537		-	assistance program, the commission shall provide for a second
538		-	consecutive period of eligibility for the child until the child's
539		-	required annual recertification, except as provided by Subsection
540		-	(h) and subject to Subsection (c).
541		-	(h) Notwithstanding any other period prescribed by this
542		-	section, a child's eligibility for medical assistance ends on the
543		-	child's 19th birthday.
544		-	(i) The commission may not recertify a child's eligibility
545		-	for medical assistance more frequently than every 12 months as
546		-	required by federal law.
547		-	(j) If a child's parent or guardian fails to provide to the
548		-	commission within the period described by Subsection (f)
549		-	documentation demonstrating that the child's household income does
550		-	not exceed the maximum income for eligibility for the medical
551		-	assistance program, the commission shall provide the child's parent
552		-	or guardian with written notice of termination following that
553		-	period. The notice must include a statement that the child may be
554		-	eligible for enrollment in the child health plan under Chapter 62,
555		-	Health and Safety Code.
556		-	(k) In developing the notice, the commission shall consult
557		-	with health care providers, children's health care advocates,
558		-	family members of children enrolled in the medical assistance
559		-	program, and other stakeholders to determine the most user-friendly
560		-	method to provide the notice to a child's parent or guardian.
561		-	(l) The executive commissioner may adopt rules as necessary
562		-	to implement this section.
	543	+	Sec. 32.0611. COMMUNITY ATTENDANT SERVICES: QUALITY
	544	+	INITIATIVES AND EDUCATION INCENTIVES. (a) The commission shall
	545	+	develop specific quality initiatives for attendants providing
	546	+	community attendant services to improve quality outcomes for
	547	+	recipients.
	548	+	(b) The commission shall coordinate with the Texas Higher
	549	+	Education Coordinating Board and the Texas Workforce Commission to
	550	+	develop a program to facilitate the award of academic or workforce
	551	+	education credit for programs of study or courses of instruction
	552	+	leading to a degree, certificate, or credential in a health-related
	553	+	field based on an attendant's work experience providing community
	554	+	attendant services.
563	555		SECTION 9. (a) In this section, "commission," "executive
564	556		commissioner," and "Medicaid" have the meanings assigned by Section
565	557		531.001, Government Code.
566	558		(b) Using existing resources, the commission shall:
567	559		(1) review the commission's staff rate enhancement
568	560		programs to:
569	561		(A) identify and evaluate methods for improving
570	562		administration of those programs to reduce administrative barriers
571	563		that prevent an increase in direct care staffing and direct care
572	564		wages and benefits in nursing homes; and
573	565		(B) develop recommendations for increasing
574	566		participation in the programs;
575	567		(2) revise the commission's policies regarding the
576	568		quality incentive payment program (QIPP) to require improvements to
577	569		staff-to-patient ratios in nursing facilities participating in the
578		-	program by January 1, 2025; and
579		-	(3) identify factors influencing active participation
	570	+	program by January 1, 2023;
	571	+	(3) examine, in collaboration with the Department of
	572	+	Family and Protective Services, implementation in other states of
	573	+	the Centers for Medicare and Medicaid Services' Integrated Care for
	574	+	Kids (InCK) Model to determine whether implementing the model could
	575	+	benefit children in this state, including children enrolled in the
	576	+	STAR Health Medicaid managed care program; and
	577	+	(4) identify factors influencing active participation
580	578		by Medicaid recipients in disease management programs by examining
581	579		variations in:
582	580		(A) eligibility criteria for the programs; and
583	581		(B) participation rates by health plan, disease
584	582		management program, and year.
585	583		(c) The executive commissioner may approve a capitation
586	584		payment system that provides for reimbursement for physicians under
587	585		a primary care capitation model or total care capitation model.
588	586		SECTION 10. (a) In this section, "commission" and
589	587		"Medicaid" have the meanings assigned by Section 531.001,
590	588		Government Code.
591	589		(b) As soon as practicable after the effective date of this
592	590		Act, the commission shall conduct a study to determine the
593	591		cost-effectiveness and feasibility of providing to Medicaid
594	592		recipients who have been diagnosed with diabetes, including Type 1
595	593		diabetes, Type 2 diabetes, and gestational diabetes:
596	594		(1) diabetes self-management education and support
597	595		services that follow the National Standards for Diabetes
598	596		Self-Management Education and Support and that may be delivered by
599	597		a certified diabetes educator; and
600	598		(2) medical nutrition therapy services.
601	599		(c) If the commission determines that providing one or both
602	600		of the types of services described by Subsection (b) of this section
603	601		would improve health outcomes for Medicaid recipients and lower
604	602		Medicaid costs, the commission shall, notwithstanding Section
605	603		32.057, Human Resources Code, or Section 533.009, Government Code,
606	604		and to the extent allowed by federal law develop a program to
607	605		provide the benefits and seek prior approval from the Legislative
608	606		Budget Board before implementing the program.
609	607		SECTION 11. (a) In this section, "commission" and
610	608		"Medicaid" have the meanings assigned by Section 531.001,
611	609		Government Code.
612	610		(b) As soon as practicable after the effective date of this
613	611		Act, the commission shall conduct a study to:
614		-	(1) identify benefits and services provided under
615		-	Medicaid that are not provided in this state under the Medicaid
616		-	managed care model; and
	612	+	(1) identify benefits and services, other than
	613	+	long-term services and supports, provided under Medicaid that are
	614	+	not provided in this state under the Medicaid managed care model;
	615	+	and
617	616		(2) evaluate the feasibility, cost-effectiveness, and
618	617		impact on Medicaid recipients of providing the benefits and
619	618		services identified under Subdivision (1) of this subsection
620	619		through the Medicaid managed care model.
621	620		(c) Not later than December 1, 2022, the commission shall
622	621		prepare and submit a report to the legislature that includes:
623	622		(1) a summary of the commission's evaluation under
624	623		Subsection (b)(2) of this section; and
625	624		(2) a recommendation as to whether the commission
626	625		should implement providing benefits and services identified under
627	626		Subsection (b)(1) of this section through the Medicaid managed care
628	627		model.
629	628		SECTION 12. (a) In this section:
630	629		(1) "Commission," "Medicaid," and "Medicaid managed
631	630		care organization" have the meanings assigned by Section 531.001,
632	631		Government Code.
633	632		(2) "Dually eligible individual" has the meaning
634	633		assigned by Section 531.0392, Government Code.
635	634		(b) The commission shall conduct a study regarding dually
636	635		eligible individuals who are enrolled in the Medicaid managed care
637	636		program. The study must include an evaluation of:
638	637		(1) Medicare cost-sharing requirements for those
639	638		individuals;
640	639		(2) the cost-effectiveness for a Medicaid managed care
641	640		organization to provide all Medicaid-eligible services not covered
642	641		under Medicare and require cost-sharing for those services; and
643	642		(3) the impact on dually eligible individuals and
644	643		Medicaid providers that would result from the implementation of
645	644		Subdivision (2) of this subsection.
646	645		(c) Not later than September 1, 2022, the commission shall
647	646		prepare and submit a report to the legislature that includes:
648	647		(1) a summary of the commission's findings from the
649	648		study conducted under Subsection (b) of this section; and
650	649		(2) a recommendation as to whether the commission
651	650		should implement Subsection (b)(2) of this section.
652	651		SECTION 13. (a) Using existing resources, the Health and
653	652		Human Services Commission shall conduct a study to assess the
654	653		impact of revising the capitation rate setting strategy used to
655	654		cover long-term care services and supports provided to recipients
656	655		under the STAR+PLUS Medicaid managed care program from a strategy
657	656		based on the setting in which services are provided to a strategy
658	657		based on a blended rate. The study must:
659	658		(1) assess the potential impact using a blended
660	659		capitation rate would have on recipients' choice of setting;
661	660		(2) include an actuarial analysis of the impact using
662	661		a blended capitation rate would have on program spending; and
663	662		(3) consider the experience of other states that use a
664	663		blended capitation rate to reimburse managed care organizations for
665	664		the provision of long-term care services and supports under
666	665		Medicaid.
667	666		(b) Not later than September 1, 2022, the Health and Human
668	667		Services Commission shall prepare and submit a report that
669	668		summarizes the findings of the study conducted under Subsection (a)
670	669		of this section to the governor, the lieutenant governor, the
671	670		speaker of the house of representatives, the House Human Services
672	671		Committee, and the Senate Health and Human Services Committee.
673	672		SECTION 14. Notwithstanding Section 2, Chapter 1117 (H.B.
674	673		3523), Acts of the 84th Legislature, Regular Session, 2015, Section
675	674		533.00251(c), Government Code, as amended by Section 2 of that Act,
676	675		takes effect September 1, 2023.
677	676		SECTION 15. (a) Section 533.005(a), Government Code, as
678	677		amended by this Act, applies only to a contract between the Health
679	678		and Human Services Commission and a managed care organization that
680	679		is entered into or renewed on or after the effective date of this
681	680		Act.
682	681		(b) To the extent permitted by the terms of the contract,
683	682		the Health and Human Services Commission shall seek to amend a
684	683		contract entered into before the effective date of this Act with a
685	684		managed care organization to comply with Section 533.005(a),
686	685		Government Code, as amended by this Act.
687	686		SECTION 16. As soon as practicable after the effective date
688	687		of this Act, the Health and Human Services Commission shall conduct
689	688		the study and make the determination required by Section
690	689		531.0501(a), Government Code, as added by this Act.
691	690		SECTION 17. If before implementing any provision of this
692	691		Act a state agency determines that a waiver or authorization from a
693	692		federal agency is necessary for implementation of that provision,
694	693		the agency affected by the provision shall request the waiver or
695	694		authorization and may delay implementing that provision until the
696	695		waiver or authorization is granted.
697	696		SECTION 18. The Health and Human Services Commission is
698	697		required to implement this Act only if the legislature appropriates
699	698		money specifically for that purpose. If the legislature does not
700	699		appropriate money specifically for that purpose, the commission
701	700		may, but is not required to, implement this Act using other
702	701		appropriations available for the purpose.
703	702		SECTION 19. This Act takes effect September 1, 2021.
704		-	______________________________ ______________________________
705		-	President of the Senate Speaker of the House
706		-	I certify that H.B. No. 2658 was passed by the House on April
707		-	21, 2021, by the following vote: Yeas 147, Nays 0, 2 present, not
708		-	voting; that the House refused to concur in Senate amendments to
709		-	H.B. No. 2658 on May 27, 2021, and requested the appointment of a
710		-	conference committee to consider the differences between the two
711		-	houses; and that the House adopted the conference committee report
712		-	on H.B. No. 2658 on May 30, 2021, by the following vote: Yeas 135,
713		-	Nays 0, 2 present, not voting.
714		-	______________________________
715		-	Chief Clerk of the House
716		-	I certify that H.B. No. 2658 was passed by the Senate, with
717		-	amendments, on May 22, 2021, by the following vote: Yeas 31, Nays
718		-	0; at the request of the House, the Senate appointed a conference
719		-	committee to consider the differences between the two houses; and
720		-	that the Senate adopted the conference committee report on H.B. No.
721		-	2658 on May 30, 2021, by the following vote: Yeas 31, Nays 0.
722		-	______________________________
723		-	Secretary of the Senate
724		-	APPROVED: __________________
725		-	Date
726		-	__________________
727		-	Governor
	703	+	* * * * *