H.B. No. 2658
AN ACT
relating to the Medicaid program, including the administration and
operation of the Medicaid managed care program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 531, Government Code, is
amended by adding Sections 531.0501 and 531.0512 to read as
follows:
Sec. 531.0501. MEDICAID WAIVER PROGRAMS: INTEREST LIST
MANAGEMENT. (a) The commission, in consultation with the
Intellectual and Developmental Disability System Redesign Advisory
Committee established under Section 534.053, shall study the
feasibility of creating an online portal for individuals to request
to be placed and check the individual's placement on a Medicaid
waiver program interest list. As part of the study, the commission
shall determine the most cost-effective automated method for
determining the level of need of an individual seeking services
through a Medicaid waiver program.
(b) Not later than January 1, 2023, the commission shall
prepare and submit a report to the governor, the lieutenant
governor, the speaker of the house of representatives, and the
standing legislative committees with primary jurisdiction over
health and human services that summarizes the commission's findings
and conclusions from the study.
(c) Subsections (a) and (b) and this subsection expire
September 1, 2023.
(d) The commission shall develop a protocol in the office of
the ombudsman to improve the capture and updating of contact
information for an individual who contacts the office of the
ombudsman regarding Medicaid waiver programs or services.
Sec. 531.0512. NOTIFICATION REGARDING CONSUMER DIRECTION
MODEL. The commission shall:
(1) develop a procedure to:
(A) verify that a Medicaid recipient or the
recipient's parent or legal guardian is informed regarding the
consumer direction model and provided the option to choose to
receive care under that model; and
(B) if the individual declines to receive care
under the consumer direction model, document the declination; and
(2) ensure that each Medicaid managed care
organization implements the procedure.
SECTION 2. Section 533.00251, Government Code, is amended
by adding Subsection (h) to read as follows:
(h) In addition to the minimum performance standards the
commission establishes for nursing facility providers seeking to
participate in the STAR+PLUS Medicaid managed care program, the
executive commissioner shall adopt rules establishing minimum
performance standards applicable to nursing facility providers
that participate in the program. The commission is responsible for
monitoring provider performance in accordance with the standards
and requiring corrective actions, as the commission determines
necessary, from providers that do not meet the standards. The
commission shall share data regarding the requirements of this
subsection with STAR+PLUS Medicaid managed care organizations as
appropriate.
SECTION 3. Section 533.005(a), Government Code, is amended
to read as follows:
(a) A contract between a managed care organization and the
commission for the organization to provide health care services to
recipients must contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation rates that:
(A) include acuity and risk adjustment
methodologies that consider the costs of providing acute care
services and long-term services and supports, including private
duty nursing services, provided under the plan; and
(B) ensure the cost-effective provision of
quality health care;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan on any claim for
payment that is received with documentation reasonably necessary
for the managed care organization to process the claim:
(A) not later than:
(i) the 10th day after the date the claim is
received if the claim relates to services provided by a nursing
facility, intermediate care facility, or group home;
(ii) the 30th day after the date the claim
is received if the claim relates to the provision of long-term
services and supports not subject to Subparagraph (i); and
(iii) the 45th day after the date the claim
is received if the claim is not subject to Subparagraph (i) or (ii);
or
(B) within a period, not to exceed 60 days,
specified by a written agreement between the physician or provider
and the managed care organization;
(7-a) a requirement that the managed care organization
demonstrate to the commission that the organization pays claims
described by Subdivision (7)(A)(ii) on average not later than the
21st day after the date the claim is received by the organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the managed
care organization, inform the organization of the recipient's
Medicaid certification date;
(9) a requirement that the managed care organization
comply with Section 533.006 as a condition of contract retention
and renewal;
(10) a requirement that the managed care organization
provide the information required by Section 533.012 and otherwise
comply and cooperate with the commission's office of inspector
general and the office of the attorney general;
(11) a requirement that the managed care
organization's usages of out-of-network providers or groups of
out-of-network providers may not exceed limits for those usages
relating to total inpatient admissions, total outpatient services,
and emergency room admissions determined by the commission;
(12) if the commission finds that a managed care
organization has violated Subdivision (11), a requirement that the
managed care organization reimburse an out-of-network provider for
health care services at a rate that is equal to the allowable rate
for those services, as determined under Sections 32.028 and
32.0281, Human Resources Code;
(13) a requirement that, notwithstanding any other
law, including Sections 843.312 and 1301.052, Insurance Code, the
organization:
(A) use advanced practice registered nurses and
physician assistants in addition to physicians as primary care
providers to increase the availability of primary care providers in
the organization's provider network; and
(B) treat advanced practice registered nurses
and physician assistants in the same manner as primary care
physicians with regard to:
(i) selection and assignment as primary
care providers;
(ii) inclusion as primary care providers in
the organization's provider network; and
(iii) inclusion as primary care providers
in any provider network directory maintained by the organization;
(14) a requirement that the managed care organization
reimburse a federally qualified health center or rural health
clinic for health care services provided to a recipient outside of
regular business hours, including on a weekend day or holiday, at a
rate that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician;
(15) a requirement that the managed care organization
develop, implement, and maintain a system for tracking and
resolving all provider appeals related to claims payment, including
a process that will require:
(A) a tracking mechanism to document the status
and final disposition of each provider's claims payment appeal;
(B) the contracting with physicians who are not
network providers and who are of the same or related specialty as
the appealing physician to resolve claims disputes related to
denial on the basis of medical necessity that remain unresolved
subsequent to a provider appeal;
(C) the determination of the physician resolving
the dispute to be binding on the managed care organization and
provider; and
(D) the managed care organization to allow a
provider with a claim that has not been paid before the time
prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
claim;
(16) a requirement that a medical director who is
authorized to make medical necessity determinations is available to
the region where the managed care organization provides health care
services;
(17) a requirement that the managed care organization
ensure that a medical director and patient care coordinators and
provider and recipient support services personnel are located in
the South Texas service region, if the managed care organization
provides a managed care plan in that region;
(18) a requirement that the managed care organization
provide special programs and materials for recipients with limited
English proficiency or low literacy skills;
(19) a requirement that the managed care organization
develop and establish a process for responding to provider appeals
in the region where the organization provides health care services;
(20) a requirement that the managed care organization:
(A) develop and submit to the commission, before
the organization begins to provide health care services to
recipients, a comprehensive plan that describes how the
organization's provider network complies with the provider access
standards established under Section 533.0061;
(B) as a condition of contract retention and
renewal:
(i) continue to comply with the provider
access standards established under Section 533.0061; and
(ii) make substantial efforts, as
determined by the commission, to mitigate or remedy any
noncompliance with the provider access standards established under
Section 533.0061;
(C) pay liquidated damages for each failure, as
determined by the commission, to comply with the provider access
standards established under Section 533.0061 in amounts that are
reasonably related to the noncompliance; and
(D) regularly, as determined by the commission,
submit to the commission and make available to the public a report
containing data on the sufficiency of the organization's provider
network with regard to providing the care and services described
under Section 533.0061(a) and specific data with respect to access
to primary care, specialty care, long-term services and supports,
nursing services, and therapy services on the average length of
time between:
(i) the date a provider requests prior
authorization for the care or service and the date the organization
approves or denies the request; and
(ii) the date the organization approves a
request for prior authorization for the care or service and the date
the care or service is initiated;
(21) a requirement that the managed care organization
demonstrate to the commission, before the organization begins to
provide health care services to recipients, that, subject to the
provider access standards established under Section 533.0061:
(A) the organization's provider network has the
capacity to serve the number of recipients expected to enroll in a
managed care plan offered by the organization;
(B) the organization's provider network
includes:
(i) a sufficient number of primary care
providers;
(ii) a sufficient variety of provider
types;
(iii) a sufficient number of providers of
long-term services and supports and specialty pediatric care
providers of home and community-based services; and
(iv) providers located throughout the
region where the organization will provide health care services;
and
(C) health care services will be accessible to
recipients through the organization's provider network to a
comparable extent that health care services would be available to
recipients under a fee-for-service or primary care case management
model of Medicaid managed care;
(22) a requirement that the managed care organization
develop a monitoring program for measuring the quality of the
health care services provided by the organization's provider
network that:
(A) incorporates the National Committee for
Quality Assurance's Healthcare Effectiveness Data and Information
Set (HEDIS) measures or, as applicable, the national core
indicators adult consumer survey and the national core indicators
child family survey for individuals with an intellectual or
developmental disability;
(B) focuses on measuring outcomes; and
(C) includes the collection and analysis of
clinical data relating to prenatal care, preventive care, mental
health care, and the treatment of acute and chronic health
conditions and substance abuse;
(23) subject to Subsection (a-1), a requirement that
the managed care organization develop, implement, and maintain an
outpatient pharmacy benefit plan for its enrolled recipients:
(A) that, except as provided by Paragraph
(L)(ii), exclusively employs the vendor drug program formulary and
preserves the state's ability to reduce waste, fraud, and abuse
under Medicaid;
(B) that adheres to the applicable preferred drug
list adopted by the commission under Section 531.072;
(C) that, except as provided by Paragraph (L)(i),
includes the prior authorization procedures and requirements
prescribed by or implemented under Sections 531.073(b), (c), and
(g) for the vendor drug program;
(C-1) that does not require a clinical,
nonpreferred, or other prior authorization for any antiretroviral
drug, as defined by Section 531.073, or a step therapy or other
protocol, that could restrict or delay the dispensing of the drug
except to minimize fraud, waste, or abuse;
(D) for purposes of which the managed care
organization:
(i) may not negotiate or collect rebates
associated with pharmacy products on the vendor drug program
formulary; and
(ii) may not receive drug rebate or pricing
information that is confidential under Section 531.071;
(E) that complies with the prohibition under
Section 531.089;
(F) under which the managed care organization may
not prohibit, limit, or interfere with a recipient's selection of a
pharmacy or pharmacist of the recipient's choice for the provision
of pharmaceutical services under the plan through the imposition of
different copayments;
(G) that allows the managed care organization or
any subcontracted pharmacy benefit manager to contract with a
pharmacist or pharmacy providers separately for specialty pharmacy
services, except that:
(i) the managed care organization and
pharmacy benefit manager are prohibited from allowing exclusive
contracts with a specialty pharmacy owned wholly or partly by the
pharmacy benefit manager responsible for the administration of the
pharmacy benefit program; and
(ii) the managed care organization and
pharmacy benefit manager must adopt policies and procedures for
reclassifying prescription drugs from retail to specialty drugs,
and those policies and procedures must be consistent with rules
adopted by the executive commissioner and include notice to network
pharmacy providers from the managed care organization;
(H) under which the managed care organization may
not prevent a pharmacy or pharmacist from participating as a
provider if the pharmacy or pharmacist agrees to comply with the
financial terms and conditions of the contract as well as other
reasonable administrative and professional terms and conditions of
the contract;
(I) under which the managed care organization may
include mail-order pharmacies in its networks, but may not require
enrolled recipients to use those pharmacies, and may not charge an
enrolled recipient who opts to use this service a fee, including
postage and handling fees;
(J) under which the managed care organization or
pharmacy benefit manager, as applicable, must pay claims in
accordance with Section 843.339, Insurance Code;
(K) under which the managed care organization or
pharmacy benefit manager, as applicable:
(i) to place a drug on a maximum allowable
cost list, must ensure that:
(a) the drug is listed as "A" or "B"
rated in the most recent version of the United States Food and Drug
Administration's Approved Drug Products with Therapeutic
Equivalence Evaluations, also known as the Orange Book, has an "NR"
or "NA" rating or a similar rating by a nationally recognized
reference; and
(b) the drug is generally available
for purchase by pharmacies in the state from national or regional
wholesalers and is not obsolete;
(ii) must provide to a network pharmacy
provider, at the time a contract is entered into or renewed with the
network pharmacy provider, the sources used to determine the
maximum allowable cost pricing for the maximum allowable cost list
specific to that provider;
(iii) must review and update maximum
allowable cost price information at least once every seven days to
reflect any modification of maximum allowable cost pricing;
(iv) must, in formulating the maximum
allowable cost price for a drug, use only the price of the drug and
drugs listed as therapeutically equivalent in the most recent
version of the United States Food and Drug Administration's
Approved Drug Products with Therapeutic Equivalence Evaluations,
also known as the Orange Book;
(v) must establish a process for
eliminating products from the maximum allowable cost list or
modifying maximum allowable cost prices in a timely manner to
remain consistent with pricing changes and product availability in
the marketplace;
(vi) must:
(a) provide a procedure under which a
network pharmacy provider may challenge a listed maximum allowable
cost price for a drug;
(b) respond to a challenge not later
than the 15th day after the date the challenge is made;
(c) if the challenge is successful,
make an adjustment in the drug price effective on the date the
challenge is resolved and make the adjustment applicable to all
similarly situated network pharmacy providers, as determined by the
managed care organization or pharmacy benefit manager, as
appropriate;
(d) if the challenge is denied,
provide the reason for the denial; and
(e) report to the commission every 90
days the total number of challenges that were made and denied in the
preceding 90-day period for each maximum allowable cost list drug
for which a challenge was denied during the period;
(vii) must notify the commission not later
than the 21st day after implementing a practice of using a maximum
allowable cost list for drugs dispensed at retail but not by mail;
and
(viii) must provide a process for each of
its network pharmacy providers to readily access the maximum
allowable cost list specific to that provider; and
(L) under which the managed care organization or
pharmacy benefit manager, as applicable:
(i) may not require a prior authorization,
other than a clinical prior authorization or a prior authorization
imposed by the commission to minimize the opportunity for waste,
fraud, or abuse, for or impose any other barriers to a drug that is
prescribed to a child enrolled in the STAR Kids managed care program
for a particular disease or treatment and that is on the vendor drug
program formulary or require additional prior authorization for a
drug included in the preferred drug list adopted under Section
531.072;
(ii) must provide for continued access to a
drug prescribed to a child enrolled in the STAR Kids managed care
program, regardless of whether the drug is on the vendor drug
program formulary or, if applicable on or after August 31, 2023, the
managed care organization's formulary;
(iii) may not use a protocol that requires a
child enrolled in the STAR Kids managed care program to use a
prescription drug or sequence of prescription drugs other than the
drug that the child's physician recommends for the child's
treatment before the managed care organization provides coverage
for the recommended drug; and
(iv) must pay liquidated damages to the
commission for each failure, as determined by the commission, to
comply with this paragraph in an amount that is a reasonable
forecast of the damages caused by the noncompliance;
(24) a requirement that the managed care organization
and any entity with which the managed care organization contracts
for the performance of services under a managed care plan disclose,
at no cost, to the commission and, on request, the office of the
attorney general all discounts, incentives, rebates, fees, free
goods, bundling arrangements, and other agreements affecting the
net cost of goods or services provided under the plan;
(25) a requirement that the managed care organization
not implement significant, nonnegotiated, across-the-board
provider reimbursement rate reductions unless:
(A) subject to Subsection (a-3), the
organization has the prior approval of the commission to make the
reductions; or
(B) the rate reductions are based on changes to
the Medicaid fee schedule or cost containment initiatives
implemented by the commission; and
(26) a requirement that the managed care organization
make initial and subsequent primary care provider assignments and
changes.
SECTION 4. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.00515 to read as follows:
Sec. 533.00515. MEDICATION THERAPY MANAGEMENT. The
executive commissioner shall collaborate with Medicaid managed
care organizations to implement medication therapy management
services to lower costs and improve quality outcomes for recipients
by reducing adverse drug events.
SECTION 5. Section 533.009(c), Government Code, is amended
to read as follows:
(c) The executive commissioner, by rule, shall prescribe
the minimum requirements that a managed care organization, in
providing a disease management program, must meet to be eligible to
receive a contract under this section. The managed care
organization must, at a minimum, be required to:
(1) provide disease management services that have
performance measures for particular diseases that are comparable to
the relevant performance measures applicable to a provider of
disease management services under Section 32.057, Human Resources
Code; [and]
(2) show evidence of ability to manage complex
diseases in the Medicaid population; and
(3) if a disease management program provided by the
organization has low active participation rates, identify the
reason for the low rates and develop an approach to increase active
participation in disease management programs for high-risk
recipients.
SECTION 6. Section 32.054, Human Resources Code, is amended
by adding Subsection (f) to read as follows:
(f) To prevent serious medical conditions and reduce
emergency room visits necessitated by complications resulting from
a lack of access to dental care, the commission shall provide
medical assistance reimbursement for preventive dental services,
including reimbursement for one preventive dental care visit per
year, for an adult recipient with a disability who is enrolled in
the STAR+PLUS Medicaid managed care program. This subsection does
not apply to an adult recipient who is enrolled in the STAR+PLUS
home and community-based services (HCBS) waiver program. This
subsection may not be construed to reduce dental services available
to persons with disabilities that are otherwise reimbursable under
the medical assistance program.
SECTION 7. Subchapter B, Chapter 32, Human Resources Code,
is amended by adding Section 32.0317 to read as follows:
Sec. 32.0317. REIMBURSEMENT FOR SERVICES PROVIDED UNDER
SCHOOL HEALTH AND RELATED SERVICES PROGRAM. The executive
commissioner shall adopt rules requiring parental consent for
services provided under the school health and related services
program in order for a school district to receive reimbursement for
the services. The rules must allow a school district to seek a
waiver to receive reimbursement for services provided to a student
who does not have a parent or legal guardian who can provide
consent.
SECTION 8. Section 32.0261, Human Resources Code, is
amended to read as follows:
Sec. 32.0261. CONTINUOUS ELIGIBILITY. (a) This section
applies only to a child younger than 19 years of age who is
determined eligible for medical assistance under this chapter.
(b) The executive commissioner shall adopt rules in
accordance with 42 U.S.C. Section 1396a(e)(12), as amended, to
provide for two consecutive periods of [a period of continuous]
eligibility for a child between each certification and
recertification of the child's eligibility, subject to Subsections
(f) and (h) [under 19 years of age who is determined to be eligible
for medical assistance under this chapter].
(c) The first of the two consecutive periods of eligibility
described by Subsection (b) must be continuous in accordance with
Subsection (d). The second of the two consecutive periods of
eligibility is not continuous and may be affected by changes in a
child's household income, regardless of whether those changes
occurred or whether the commission became aware of the changes
during the first or second of the two consecutive periods of
eligibility.
(d) A [The rules shall provide that the] child remains
eligible for medical assistance during the first of the two
consecutive periods of eligibility, without additional review by
the commission and regardless of changes in the child's household
[resources or] income, until [the earlier of:
[(1)] the end of the six-month period following the
date on which the child's eligibility was determined, except as
provided by Subsections (f)(1) and (h) [; or
[(2) the child's 19th birthday].
(e) During the sixth month following the date on which a
child's eligibility for medical assistance is certified or
recertified, the commission shall, in a manner that complies with
federal law, including verification plan requirements under 42
C.F.R. Section 435.945(j), review the child's household income
using electronic income data available to the commission. The
commission may conduct this review only once during the child's two
consecutive periods of eligibility. Based on the review:
(1) the commission shall, if the review indicates that
the child's household income does not exceed the maximum income for
eligibility for the medical assistance program, provide for a
second consecutive period of eligibility for the child until the
child's required annual recertification, except as provided by
Subsection (h) and subject to Subsection (c); or
(2) the commission may, if the review indicates that
the child's household income exceeds the maximum income for
eligibility for the medical assistance program, request additional
documentation to verify the child's household income in a manner
that complies with federal law.
(f) If, after reviewing a child's household income under
Subsection (e), the commission determines that the household income
exceeds the maximum income for eligibility for the medical
assistance program, the commission shall continue to provide
medical assistance to the child until:
(1) the commission provides the child's parent or
guardian with a period of not less than 30 days to provide
documentation demonstrating that the child's household income does
not exceed the maximum income for eligibility; and
(2) the child's parent or guardian fails to provide the
documentation during the period described by Subdivision (1).
(g) If a child's parent or guardian provides to the
commission within the period described by Subsection (f)
documentation demonstrating that the child's household income does
not exceed the maximum income for eligibility for the medical
assistance program, the commission shall provide for a second
consecutive period of eligibility for the child until the child's
required annual recertification, except as provided by Subsection
(h) and subject to Subsection (c).
(h) Notwithstanding any other period prescribed by this
section, a child's eligibility for medical assistance ends on the
child's 19th birthday.
(i) The commission may not recertify a child's eligibility
for medical assistance more frequently than every 12 months as
required by federal law.
(j) If a child's parent or guardian fails to provide to the
commission within the period described by Subsection (f)
documentation demonstrating that the child's household income does
not exceed the maximum income for eligibility for the medical
assistance program, the commission shall provide the child's parent
or guardian with written notice of termination following that
period. The notice must include a statement that the child may be
eligible for enrollment in the child health plan under Chapter 62,
Health and Safety Code.
(k) In developing the notice, the commission shall consult
with health care providers, children's health care advocates,
family members of children enrolled in the medical assistance
program, and other stakeholders to determine the most user-friendly
method to provide the notice to a child's parent or guardian.
(l) The executive commissioner may adopt rules as necessary
to implement this section.
SECTION 9. (a) In this section, "commission," "executive
commissioner," and "Medicaid" have the meanings assigned by Section
531.001, Government Code.
(b) Using existing resources, the commission shall:
(1) review the commission's staff rate enhancement
programs to:
(A) identify and evaluate methods for improving
administration of those programs to reduce administrative barriers
that prevent an increase in direct care staffing and direct care
wages and benefits in nursing homes; and
(B) develop recommendations for increasing
participation in the programs;
(2) revise the commission's policies regarding the
quality incentive payment program (QIPP) to require improvements to
staff-to-patient ratios in nursing facilities participating in the
program by January 1, 2025; and
(3) identify factors influencing active participation
by Medicaid recipients in disease management programs by examining
variations in:
(A) eligibility criteria for the programs; and
(B) participation rates by health plan, disease
management program, and year.
(c) The executive commissioner may approve a capitation
payment system that provides for reimbursement for physicians under
a primary care capitation model or total care capitation model.
SECTION 10. (a) In this section, "commission" and
"Medicaid" have the meanings assigned by Section 531.001,
Government Code.
(b) As soon as practicable after the effective date of this
Act, the commission shall conduct a study to determine the
cost-effectiveness and feasibility of providing to Medicaid
recipients who have been diagnosed with diabetes, including Type 1
diabetes, Type 2 diabetes, and gestational diabetes:
(1) diabetes self-management education and support
services that follow the National Standards for Diabetes
Self-Management Education and Support and that may be delivered by
a certified diabetes educator; and
(2) medical nutrition therapy services.
(c) If the commission determines that providing one or both
of the types of services described by Subsection (b) of this section
would improve health outcomes for Medicaid recipients and lower
Medicaid costs, the commission shall, notwithstanding Section
32.057, Human Resources Code, or Section 533.009, Government Code,
and to the extent allowed by federal law develop a program to
provide the benefits and seek prior approval from the Legislative
Budget Board before implementing the program.
SECTION 11. (a) In this section, "commission" and
"Medicaid" have the meanings assigned by Section 531.001,
Government Code.
(b) As soon as practicable after the effective date of this
Act, the commission shall conduct a study to:
(1) identify benefits and services provided under
Medicaid that are not provided in this state under the Medicaid
managed care model; and
(2) evaluate the feasibility, cost-effectiveness, and
impact on Medicaid recipients of providing the benefits and
services identified under Subdivision (1) of this subsection
through the Medicaid managed care model.
(c) Not later than December 1, 2022, the commission shall
prepare and submit a report to the legislature that includes:
(1) a summary of the commission's evaluation under
Subsection (b)(2) of this section; and
(2) a recommendation as to whether the commission
should implement providing benefits and services identified under
Subsection (b)(1) of this section through the Medicaid managed care
model.
SECTION 12. (a) In this section:
(1) "Commission," "Medicaid," and "Medicaid managed
care organization" have the meanings assigned by Section 531.001,
Government Code.
(2) "Dually eligible individual" has the meaning
assigned by Section 531.0392, Government Code.
(b) The commission shall conduct a study regarding dually
eligible individuals who are enrolled in the Medicaid managed care
program. The study must include an evaluation of:
(1) Medicare cost-sharing requirements for those
individuals;
(2) the cost-effectiveness for a Medicaid managed care
organization to provide all Medicaid-eligible services not covered
under Medicare and require cost-sharing for those services; and
(3) the impact on dually eligible individuals and
Medicaid providers that would result from the implementation of
Subdivision (2) of this subsection.
(c) Not later than September 1, 2022, the commission shall
prepare and submit a report to the legislature that includes:
(1) a summary of the commission's findings from the
study conducted under Subsection (b) of this section; and
(2) a recommendation as to whether the commission
should implement Subsection (b)(2) of this section.
SECTION 13. (a) Using existing resources, the Health and
Human Services Commission shall conduct a study to assess the
impact of revising the capitation rate setting strategy used to
cover long-term care services and supports provided to recipients
under the STAR+PLUS Medicaid managed care program from a strategy
based on the setting in which services are provided to a strategy
based on a blended rate. The study must:
(1) assess the potential impact using a blended
capitation rate would have on recipients' choice of setting;
(2) include an actuarial analysis of the impact using
a blended capitation rate would have on program spending; and
(3) consider the experience of other states that use a
blended capitation rate to reimburse managed care organizations for
the provision of long-term care services and supports under
Medicaid.
(b) Not later than September 1, 2022, the Health and Human
Services Commission shall prepare and submit a report that
summarizes the findings of the study conducted under Subsection (a)
of this section to the governor, the lieutenant governor, the
speaker of the house of representatives, the House Human Services
Committee, and the Senate Health and Human Services Committee.
SECTION 14. Notwithstanding Section 2, Chapter 1117 (H.B.
3523), Acts of the 84th Legislature, Regular Session, 2015, Section
533.00251(c), Government Code, as amended by Section 2 of that Act,
takes effect September 1, 2023.
SECTION 15. (a) Section 533.005(a), Government Code, as
amended by this Act, applies only to a contract between the Health
and Human Services Commission and a managed care organization that
is entered into or renewed on or after the effective date of this
Act.
(b) To the extent permitted by the terms of the contract,
the Health and Human Services Commission shall seek to amend a
contract entered into before the effective date of this Act with a
managed care organization to comply with Section 533.005(a),
Government Code, as amended by this Act.
SECTION 16. As soon as practicable after the effective date
of this Act, the Health and Human Services Commission shall conduct
the study and make the determination required by Section
531.0501(a), Government Code, as added by this Act.
SECTION 17. 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 18. The Health and Human Services Commission is
required to implement this Act only if the legislature appropriates
money specifically for that purpose. If the legislature does not
appropriate money specifically for that purpose, the commission
may, but is not required to, implement this Act using other
appropriations available for the purpose.
SECTION 19. This Act takes effect September 1, 2021.
______________________________ ______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 2658 was passed by the House on April
21, 2021, by the following vote: Yeas 147, Nays 0, 2 present, not
voting; that the House refused to concur in Senate amendments to
H.B. No. 2658 on May 27, 2021, and requested the appointment of a
conference committee to consider the differences between the two
houses; and that the House adopted the conference committee report
on H.B. No. 2658 on May 30, 2021, by the following vote: Yeas 135,
Nays 0, 2 present, not voting.
______________________________
Chief Clerk of the House
I certify that H.B. No. 2658 was passed by the Senate, with
amendments, on May 22, 2021, by the following vote: Yeas 31, Nays
0; at the request of the House, the Senate appointed a conference
committee to consider the differences between the two houses; and
that the Senate adopted the conference committee report on H.B. No.
2658 on May 30, 2021, by the following vote: Yeas 31, Nays 0.
______________________________
Secretary of the Senate
APPROVED: __________________
Date
__________________
Governor