Texas 2021 - 87th Regular

Texas House Bill HB3871 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	87R1927 JG/MM-D
2	2	By: Johnson of Dallas H.B. No. 3871
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the development and implementation of the Live Well
8	8	Texas program to provide health benefit coverage to certain
9	9	individuals; imposing penalties.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Subtitle I, Title 4, Government Code, is amended
12	12	by adding Chapter 537A to read as follows:
13	13	CHAPTER 537A. LIVE WELL TEXAS PROGRAM
14	14	SUBCHAPTER A. GENERAL PROVISIONS
15	15	Sec. 537A.0001. DEFINITIONS. In this chapter:
16	16	(1) "Basic plan" means the program health benefit plan
17	17	described by Section 537A.0202.
18	18	(2) "Eligible individual" means an individual who is
19	19	eligible to participate in the program.
20	20	(3) "Participant" means an individual who is:
21	21	(A) enrolled in a program health benefit plan; or
22	22	(B) receiving health care financial assistance
23	23	under Subchapter H.
24	24	(4) "Plus plan" means the program health benefit plan
25	25	described by Section 537A.0203.
26	26	(5) "POWER account" means a personal wellness and
27	27	responsibility account established for a participant under Section
28	28	537A.0251.
29	29	(6) "Program" means the Live Well Texas program
30	30	established under this chapter.
31	31	(7) "Program health benefit plan" includes:
32	32	(A) the basic plan; and
33	33	(B) the plus plan.
34	34	(8) "Program health benefit plan provider" means a
35	35	health benefit plan provider that contracts with the commission
36	36	under Section 537A.0107 to arrange for the provision of health care
37	37	services through a program health benefit plan.
38	38	SUBCHAPTER B. FEDERAL WAIVER FOR LIVE WELL TEXAS PROGRAM
39	39	Sec. 537A.0051. FEDERAL AUTHORIZATION FOR PROGRAM. (a)
40	40	Notwithstanding any other law, the executive commissioner shall
41	41	develop and seek a waiver under Section 1115 of the Social Security
42	42	Act (42 U.S.C. Section 1315) to the state Medicaid plan to implement
43	43	the Live Well Texas program to assist individuals in obtaining
44	44	health benefit coverage through a program health benefit plan or
45	45	health care financial assistance.
46	46	(b) The terms of a waiver the executive commissioner seeks
47	47	under this section must:
48	48	(1) be designed to:
49	49	(A) provide health benefit coverage options for
50	50	eligible individuals;
51	51	(B) produce better health outcomes for
52	52	participants;
53	53	(C) create incentives for participants to
54	54	transition from receiving public assistance benefits to achieving
55	55	stable employment;
56	56	(D) promote personal responsibility and engage
57	57	participants in making decisions regarding health care based on
58	58	cost and quality;
59	59	(E) support participants' self-sufficiency by
60	60	requiring unemployed participants to be referred to work search and
61	61	job training programs;
62	62	(F) support participants who become ineligible
63	63	to participate in a program health benefit plan in transitioning to
64	64	private health benefit coverage; and
65	65	(G) leverage enhanced federal medical assistance
66	66	percentage funding to minimize or eliminate the need for a program
67	67	enrollment cap; and
68	68	(2) allow for the operation of the program consistent
69	69	with the requirements of this chapter, except to the extent
70	70	deviation from the requirements is necessary to obtain federal
71	71	authorization of the waiver.
72	72	Sec. 537A.0052. FUNDING. Subject to approval of the waiver
73	73	described by Section 537A.0051, the commission shall implement the
74	74	program using enhanced federal medical assistance percentage
75	75	funding available under the Patient Protection and Affordable Care
76	76	Act (Pub. L. No. 111-148) as amended by the Health Care and
77	77	Education Reconciliation Act of 2010 (Pub. L. No. 111-152).
78	78	Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
79	79	(a) This chapter does not establish an entitlement to health
80	80	benefit coverage or health care financial assistance under the
81	81	program for eligible individuals.
82	82	(b) The program terminates at the time federal funding
83	83	terminates under the Patient Protection and Affordable Care Act
84	84	(Pub. L. No. 111-148) as amended by the Health Care and Education
85	85	Reconciliation Act of 2010 (Pub. L. No. 111-152), unless a
86	86	successor program providing federal funding is created.
87	87	SUBCHAPTER C. PROGRAM ADMINISTRATION
88	88	Sec. 537A.0101. PROGRAM OBJECTIVE. The principal objective
89	89	of the program is to provide primary and preventative health care
90	90	through high deductible program health benefit plans to eligible
91	91	individuals.
92	92	Sec. 537A.0102. PROGRAM PROMOTION. The commission shall
93	93	promote and provide information about the program to individuals
94	94	who:
95	95	(1) are potentially eligible to participate in the
96	96	program; and
97	97	(2) live in medically underserved areas of this state.
98	98	Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH
99	99	BENEFIT PLAN PROVIDER CONTRACTS. The commission may:
100	100	(1) enter into contracts with health benefit plan
101	101	providers under Section 537A.0107;
102	102	(2) monitor program health benefit plan providers
103	103	through reporting requirements and other means to ensure contract
104	104	performance and quality delivery of services;
105	105	(3) monitor the quality of services delivered to
106	106	participants through outcome measurements; and
107	107	(4) provide payment under the contracts to program
108	108	health benefit plan providers.
109	109	Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO
110	110	ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
111	111	(1) accept applications for health benefit coverage
112	112	under the program and implement program eligibility screening and
113	113	enrollment procedures;
114	114	(2) resolve grievances related to eligibility
115	115	determinations; and
116	116	(3) to the extent possible, coordinate the program
117	117	with Medicaid.
118	118	Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR
119	119	PROGRAM IMPLEMENTATION. (a) In administering the program, the
120	120	commission may contract with a third-party administrator to provide
121	121	enrollment and related services.
122	122	(b) If the commission contracts with a third-party
123	123	administrator under this section, the commission may:
124	124	(1) monitor the third-party administrator through
125	125	reporting requirements and other means to ensure contract
126	126	performance and quality delivery of services; and
127	127	(2) provide payment under the contract to the
128	128	third-party administrator.
129	129	(c) The executive commissioner shall retain all
130	130	policymaking authority over the program.
131	131	(d) The commission shall procure each contract with a
132	132	third-party administrator, as applicable, through a competitive
133	133	procurement process that complies with all federal and state laws.
134	134	Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a)
135	135	At the commission's request, the Texas Department of Insurance
136	136	shall provide any necessary assistance with the program. The
137	137	department shall monitor the quality of the services provided by
138	138	program health benefit plan providers and resolve grievances
139	139	related to those providers.
140	140	(b) The commission and the Texas Department of Insurance may
141	141	adopt a memorandum of understanding that addresses the
142	142	responsibilities of each agency with respect to the program.
143	143	(c) The Texas Department of Insurance, in consultation with
144	144	the commission, shall adopt rules as necessary to implement this
145	145	section.
146	146	Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS.
147	147	The commission shall select through a competitive procurement
148	148	process that complies with all federal and state laws and contract
149	149	with health benefit plan providers to provide health care services
150	150	under the program. To be eligible for a contract under this section,
151	151	an entity must:
152	152	(1) be a Medicaid managed care organization;
153	153	(2) hold a certificate of authority issued by the
154	154	Texas Department of Insurance that authorizes the entity to provide
155	155	the types of health care services offered under the program; and
156	156	(3) satisfy, except as provided by this chapter, any
157	157	applicable requirement of the Insurance Code or another insurance
158	158	law of this state.
159	159	Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care
160	160	provider who provides health care services under the program must
161	161	meet certification and licensure requirements required by
162	162	commission rules and other law.
163	163	(b) In adopting rules governing the program, the executive
164	164	commissioner shall ensure that a health care provider who provides
165	165	health care services under the program is reimbursed at a rate that
166	166	is at least equal to the rate paid under Medicare for the provision
167	167	of the same or substantially similar services.
168	168	Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTH CARE
169	169	PROVIDERS. The executive commissioner shall adopt rules that
170	170	prohibit a health care provider from providing health care services
171	171	under the program for a reasonable period, as determined by the
172	172	executive commissioner, if the health care provider:
173	173	(1) fails to repay overpayments made under the
174	174	program; or
175	175	(2) owns, controls, manages, or is otherwise
176	176	affiliated with and has financial, managerial, or administrative
177	177	influence over a health care provider who has been suspended or
178	178	prohibited from providing health care services under the program.
179	179	SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE
180	180	Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An
181	181	individual is eligible to enroll in a program health benefit plan
182	182	if:
183	183	(1) the individual is a resident of this state;
184	184	(2) the individual is 19 years of age or older but
185	185	younger than 65 years of age;
186	186	(3) applying the eligibility criteria in effect in
187	187	this state on December 31, 2020, the individual is not eligible for
188	188	Medicaid; and
189	189	(4) federal matching funds are available under the
190	190	Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as
191	191	amended by the Health Care and Education Reconciliation Act of 2010
192	192	(Pub. L. No. 111-152) to provide benefits to the individual under
193	193	the federal medical assistance program established under Title XIX,
194	194	Social Security Act (42 U.S.C. Section 1396 et seq.).
195	195	(b) An individual who is a parent or caretaker relative to
196	196	whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a
197	197	program health benefit plan.
198	198	(c) In determining eligibility for the program, the
199	199	commission shall apply the same eligibility criteria regarding
200	200	residency and citizenship in effect for Medicaid in this state on
201	201	December 31, 2020.
202	202	Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall
203	203	ensure that an individual who is initially determined or
204	204	redetermined to be eligible to participate in the program and
205	205	enroll in a program health benefit plan will remain eligible for
206	206	coverage under the plan for a period of 12 months beginning on the
207	207	first day of the month following the date eligibility was
208	208	determined or redetermined, subject to Section 537A.0252(f).
209	209	Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The
210	210	executive commissioner shall adopt an application form and
211	211	application procedures for the program. The form and procedures
212	212	must be coordinated with forms and procedures under Medicaid to
213	213	ensure that there is a single consolidated application process to
214	214	seek health benefit coverage under the program or Medicaid.
215	215	(b) To the extent possible, the commission shall make the
216	216	application form available in languages other than English.
217	217	(c) The executive commissioner may permit an individual to
218	218	apply by mail, over the telephone, or through the Internet.
219	219	Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
220	220	The executive commissioner shall adopt eligibility screening and
221	221	enrollment procedures or use the Texas Integrated Enrollment
222	222	Services eligibility determination system or a compatible system to
223	223	screen individuals and enroll eligible individuals in the program.
224	224	(b) The eligibility screening and enrollment procedures
225	225	must ensure that an individual applying for the program who appears
226	226	eligible for Medicaid is identified and assisted with obtaining
227	227	Medicaid coverage. If the individual is denied Medicaid coverage
228	228	but is determined eligible to enroll in a program health benefit
229	229	plan, the commission shall enroll the individual in a program
230	230	health benefit plan of the individual's choosing and for which the
231	231	individual is eligible without further application or
232	232	qualification.
233	233	(c) Not later than the 30th day after the date an individual
234	234	submits a complete application form and unless the individual is
235	235	identified and assisted with obtaining Medicaid coverage under
236	236	Subsection (b), the commission shall ensure that the individual's
237	237	eligibility to participate in the program is determined and that
238	238	the individual is provided with information on program health
239	239	benefit plans and program health benefit plan providers. The
240	240	commission shall enroll the individual in the program health
241	241	benefit plan and with the program health benefit plan provider of
242	242	the individual's choosing in a timely manner, as determined by the
243	243	commission.
244	244	(d) The executive commissioner may establish enrollment
245	245	periods for the program.
246	246	Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS;
247	247	DISENROLLMENT. (a) Not later than the 90th day before the
248	248	expiration of a participant's coverage period, the commission shall
249	249	notify the participant regarding the eligibility redetermination
250	250	process and request documentation necessary to redetermine the
251	251	participant's eligibility.
252	252	(b) The commission shall provide written notice of
253	253	termination of eligibility to a participant not later than the 30th
254	254	day before the date the participant's eligibility will terminate.
255	255	The commission shall disenroll the participant from the program if:
256	256	(1) the participant does not submit the requested
257	257	eligibility redetermination documentation before the last day of
258	258	the participant's coverage period; or
259	259	(2) the commission, based on the submitted
260	260	documentation, determines the participant is no longer eligible for
261	261	the program, subject to Subchapter H.
262	262	(c) An individual may submit the requested eligibility
263	263	redetermination documentation not later than the 90th day after the
264	264	date the individual is disenrolled from the program. If the
265	265	commission determines that the individual continues to meet program
266	266	eligibility requirements, the commission shall reenroll the
267	267	individual in the program without any additional application
268	268	requirements.
269	269	(d) An individual who does not complete the eligibility
270	270	redetermination process in accordance with this section and who is
271	271	disenrolled from the program may not participate in the program for
272	272	a period of 180 days beginning on the date of disenrollment. This
273	273	subsection does not apply to an individual described by Section
274	274	537A.0206 or 537A.0208 or an individual who is pregnant or is
275	275	younger than 21 years of age.
276	276	(e) At the time a participant is disenrolled from the
277	277	program under this section, the commission shall provide to the
278	278	participant:
279	279	(1) notice that the participant may be eligible to
280	280	receive health care financial assistance under Subchapter H in
281	281	transitioning to private health benefit coverage; and
282	282	(2) information on and the eligibility requirements
283	283	for that financial assistance.
284	284	SUBCHAPTER E. BASIC AND PLUS PLANS
285	285	Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY.
286	286	(a) The basic and plus plans offered under the program must:
287	287	(1) comply with this subchapter and coverage
288	288	requirements prescribed by other law; and
289	289	(2) at a minimum, provide coverage for essential
290	290	health benefits required under 42 U.S.C. Section 18022(b).
291	291	(b) In modifying covered health benefits under the basic and
292	292	plus plans, the executive commissioner shall consider the health
293	293	care needs of healthy individuals and individuals with special
294	294	health care needs.
295	295	(c) The basic and plus plans must allow a participant with a
296	296	chronic, disabling, or life-threatening illness to select an
297	297	appropriate specialist as the participant's primary care
298	298	physician.
299	299	Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME
300	300	ELIGIBILITY. (a) The program must include a basic plan that is
301	301	sufficient to meet the basic health care needs of individuals who
302	302	enroll in the plan.
303	303	(b) The covered health benefits under the basic plan must
304	304	include:
305	305	(1) primary care physician services;
306	306	(2) prenatal and postpartum care;
307	307	(3) specialty care physician visits;
308	308	(4) home health services, not to exceed 100 visits per
309	309	year;
310	310	(5) outpatient surgery;
311	311	(6) allergy testing;
312	312	(7) chemotherapy;
313	313	(8) intravenous infusion services;
314	314	(9) radiation therapy;
315	315	(10) dialysis;
316	316	(11) emergency care hospital services;
317	317	(12) emergency transportation, including ambulance
318	318	and air ambulance;
319	319	(13) urgent care clinic services;
320	320	(14) hospitalization, including for:
321	321	(A) general inpatient hospital care;
322	322	(B) inpatient physician services;
323	323	(C) inpatient surgical services;
324	324	(D) non-cosmetic reconstructive surgery;
325	325	(E) a transplant;
326	326	(F) treatment for a congenital abnormality;
327	327	(G) anesthesia;
328	328	(H) hospice care; and
329	329	(I) care in a skilled nursing facility for a
330	330	period not to exceed 100 days per occurrence;
331	331	(15) inpatient and outpatient behavioral health
332	332	services;
333	333	(16) inpatient, outpatient, and residential substance
334	334	use treatment;
335	335	(17) prescription drugs, including tobacco cessation
336	336	drugs;
337	337	(18) inpatient and outpatient rehabilitative and
338	338	habilitative care, including physical, occupational, and speech
339	339	therapy, not to exceed 60 combined visits per year;
340	340	(19) medical equipment, appliances, and assistive
341	341	technology, including prosthetics and hearing aids, and the repair,
342	342	technical support, and customization needed for individual use;
343	343	(20) laboratory and pathology tests and services;
344	344	(21) diagnostic imaging, including x-rays, magnetic
345	345	resonance imaging, computed tomography, and positron emission
346	346	tomography;
347	347	(22) preventative care services as described by
348	348	Section 537A.0204; and
349	349	(23) services under the early and periodic screening,
350	350	diagnostic, and treatment program for participants who are younger
351	351	than 21 years of age.
352	352	(c) To be eligible for health care benefits under the basic
353	353	plan, an individual who is eligible for the program must have an
354	354	annual household income that is equal to or less than 100 percent of
355	355	the federal poverty level.
356	356	Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY.
357	357	(a) The program must include a plus plan that includes the covered
358	358	health benefits listed in Section 537A.0202 and the following
359	359	additional enhanced health benefits:
360	360	(1) services related to the treatment of conditions
361	361	affecting the temporomandibular joint;
362	362	(2) dental care;
363	363	(3) vision care;
364	364	(4) notwithstanding Section 537A.0202(b)(18),
365	365	inpatient and outpatient rehabilitative and habilitative care,
366	366	including physical, occupational, and speech therapy, not to exceed
367	367	75 combined visits per year;
368	368	(5) bariatric surgery; and
369	369	(6) other services the commission considers
370	370	appropriate.
371	371	(b) An individual who is eligible for the program and whose
372	372	annual household income exceeds 100 percent of the federal poverty
373	373	level will automatically be enrolled in and receive health benefits
374	374	under the plus plan. An individual who is eligible for the program
375	375	and whose annual household income is equal to or less than 100
376	376	percent of the federal poverty level may choose to enroll in the
377	377	plus plan.
378	378	(c) A participant enrolled in the plus plan is required to
379	379	make POWER account contributions in accordance with Section
380	380	537A.0252.
381	381	Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The
382	382	commission shall provide to each participant a list of health care
383	383	services that qualify as preventative care services based on the
384	384	age, gender, and preexisting conditions of the participant. In
385	385	developing the list, the commission shall consult with the federal
386	386	Centers for Disease Control and Prevention.
387	387	(b) A program health benefit plan shall, at no cost to the
388	388	participant, provide coverage for:
389	389	(1) preventative care services described by 42 U.S.C.
390	390	Section 300gg-13; and
391	391	(2) a maximum of $500 per year of preventative care
392	392	services other than those described by Subdivision (1).
393	393	(c) A participant who receives preventative care services
394	394	not described by Subsection (b) that are covered under the
395	395	participant's program health benefit plan is subject to deductible
396	396	and copayment requirements for the services in accordance with the
397	397	terms of the plan.
398	398	Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in
399	399	the basic plan shall pay a copayment for each covered health benefit
400	400	except for a preventative care or family planning service. The
401	401	executive commissioner by rule shall adopt a copayment schedule for
402	402	basic plan services, subject to Subsection (c).
403	403	(b) Except as provided by Subsection (c), a participant
404	404	enrolled in the plus plan may not be required to pay a copayment for
405	405	a covered service.
406	406	(c) A participant enrolled in the basic or plus plan shall
407	407	pay a copayment in an amount set by commission rule not to exceed
408	408	$25 for nonemergency use of hospital emergency department services
409	409	unless:
410	410	(1) the participant has met the cost-sharing maximum
411	411	for the calendar quarter, as prescribed by commission rule;
412	412	(2) the participant is referred to the hospital
413	413	emergency department by a health care provider;
414	414	(3) the visit is a true emergency, as defined by
415	415	commission rule; or
416	416	(4) the participant is pregnant.
417	417	Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE
418	418	MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R.
419	419	Section 440.315 who is enrolled in the basic or plus plan is
420	420	entitled to receive under the program all health benefits that
421	421	would be available under the state Medicaid plan.
422	422	(b) A participant to which this section applies is subject
423	423	to the cost-sharing requirements, including copayment and POWER
424	424	account contribution requirements, of the program health benefit
425	425	plan in which the participant is enrolled.
426	426	(c) The commission shall develop screening measures to
427	427	identify participants to which this section applies.
428	428	Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant
429	429	who becomes pregnant while enrolled in the program and who meets the
430	430	eligibility requirements for Medicaid may choose to remain in the
431	431	program or enroll in Medicaid.
432	432	(b) A pregnant participant described by Subsection (a) who
433	433	is enrolled in the basic or plus plan and who remains in the program
434	434	is:
435	435	(1) notwithstanding Section 537A.0205, not subject to
436	436	any cost-sharing requirements, including copayment and POWER
437	437	account contribution requirements, of the program health benefit
438	438	plan in which the participant is enrolled until the expiration of
439	439	the second month following the month in which the pregnancy ends;
440	440	(2) entitled to receive as a Medicaid wrap-around
441	441	benefit all Medicaid services a pregnant woman enrolled in Medicaid
442	442	is entitled to receive, including a pharmacy benefit, when the
443	443	participant exceeds coverage limits under the participant's
444	444	program health benefit plan or if a service is not covered by the
445	445	plan; and
446	446	(3) eligible for additional vision and dental care
447	447	benefits.
448	448	Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A
449	449	parent or caretaker relative to whom 42 C.F.R. Section 435.110
450	450	applies is entitled to receive as a Medicaid wrap-around benefit
451	451	all Medicaid services to which the individual would be entitled
452	452	under the state Medicaid plan that are not covered under the
453	453	individual's program health benefit plan or exceed the plan's
454	454	coverage limits.
455	455	(b) An individual described by Subsection (a) who chooses to
456	456	participate in the program is subject to the cost-sharing
457	457	requirements, including copayment and POWER account contribution
458	458	requirements, of the program health benefit plan in which the
459	459	individual is enrolled.
460	460	SUBCHAPTER F. PERSONAL WELLNESS AND RESPONSIBILITY (POWER)
461	461	ACCOUNTS
462	462	Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF POWER
463	463	ACCOUNTS. (a) The commission shall establish a personal wellness
464	464	and responsibility (POWER) account for each participant who is
465	465	enrolled in a program health benefit plan that is funded with money
466	466	contributed in accordance with this subchapter.
467	467	(b) The commission shall enable each participant to access
468	468	and manage money in and information regarding the participant's
469	469	POWER account through an electronic system. The commission may
470	470	contract with an entity that has appropriate experience and
471	471	expertise to establish, implement, or administer the electronic
472	472	system.
473	473	(c) Except as otherwise provided by Section 537A.0252, the
474	474	commission shall require each participant to contribute to the
475	475	participant's POWER account in amounts described by that section.
476	476	Sec. 537A.0252. POWER ACCOUNT CONTRIBUTIONS; DEDUCTIBLE.
477	477	(a) The executive commissioner by rule shall establish an annual
478	478	universal deductible for each participant enrolled in the basic or
479	479	plus plan.
480	480	(b) To ensure each participant's POWER account contains a
481	481	sufficient amount of money at the beginning of a coverage period,
482	482	the commission shall, before the beginning of that period, fund
483	483	each account with the following amounts:
484	484	(1) for a participant enrolled in the basic plan, the
485	485	annual universal deductible amount; and
486	486	(2) for a participant enrolled in the plus plan, the
487	487	difference between the annual universal deductible amount and the
488	488	participant's required annual contribution as determined by the
489	489	schedule established under Subsection (c).
490	490	(c) The executive commissioner by rule shall establish a
491	491	graduated annual POWER account contribution schedule for
492	492	participants enrolled in the plus plan that:
493	493	(1) is based on a participant's annual household
494	494	income, with participants whose annual household incomes are less
495	495	than the federal poverty level paying progressively less and
496	496	participants whose annual household incomes are equal to or greater
497	497	than the federal poverty level paying progressively more; and
498	498	(2) may not require a participant to contribute more
499	499	than a total of five percent of the participant's annual household
500	500	income to the participant's POWER account.
501	501	(d) A participant's employer may contribute on behalf of the
502	502	participant any amount of the participant's annual POWER account
503	503	contribution. A nonprofit organization may contribute on behalf of
504	504	a participant any amount of the participant's annual POWER account
505	505	contribution.
506	506	(e) Subject to the contribution cap described by Subsection
507	507	(c)(2) and not before the expiration of the participant's first
508	508	coverage period, the commission shall require a participant who
509	509	uses one or more tobacco products to contribute to the
510	510	participant's POWER account an annual POWER account contribution
511	511	amount that is one percent more than the participant would
512	512	otherwise be required to contribute under the schedule established
513	513	under Subsection (c).
514	514	(f) An annual POWER account contribution must be paid by or
515	515	on behalf of a participant monthly in installments that are at least
516	516	equal to one-twelfth of the total required contribution. The
517	517	coverage period for a participant whose annual household income
518	518	exceeds 100 percent of the federal poverty level may not begin until
519	519	the first day of the first month following the month in which the
520	520	first monthly installment is received.
521	521	Sec. 537A.0253. USE OF POWER ACCOUNT MONEY. A participant
522	522	may use money in the participant's POWER account to pay copayments
523	523	and deductible costs required under the participant's program
524	524	health benefit plan. The commission shall issue to each
525	525	participant an electronic payment card that allows the participant
526	526	to use the card to pay the program health benefit plan costs.
527	527	Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER
528	528	REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS;
529	529	SMOKING CESSATION INITIATIVE. (a) A program health benefit plan
530	530	provider shall establish a rewards program through which a
531	531	participant receiving health care through a program health benefit
532	532	plan offered by the program health benefit plan provider may earn
533	533	money to be contributed to the participant's POWER account.
534	534	(b) Under a rewards program, a program health benefit plan
535	535	provider shall contribute money to a participant's POWER account if
536	536	the participant engages in certain healthy behaviors. The
537	537	executive commissioner by rule shall determine:
538	538	(1) the behaviors in which a participant must engage
539	539	to receive a contribution, which must include behaviors related to:
540	540	(A) completion of a health risk assessment;
541	541	(B) smoking cessation; and
542	542	(C) as applicable, chronic disease management;
543	543	and
544	544	(2) the amount of money a program health benefit plan
545	545	provider shall contribute for each behavior described by
546	546	Subdivision (1).
547	547	(c) Subsection (b) does not prevent a program health benefit
548	548	plan provider from contributing money to a participant's POWER
549	549	account if the participant engages in a behavior not specified by
550	550	that subsection or a rule adopted in accordance with that
551	551	subsection. If a program health benefit plan provider chooses to
552	552	contribute money under this subsection, the program health benefit
553	553	plan provider shall determine the amount of money to be contributed
554	554	for the behavior.
555	555	(d) A participant may use contributions a program health
556	556	benefit plan provider makes under a rewards program to offset a
557	557	maximum of 50 percent of the participant's required annual POWER
558	558	account contribution established under Section 537A.0252.
559	559	(e) Contributions a program health benefit plan provider
560	560	makes under a rewards program that result in a participant's POWER
561	561	account balance exceeding the participant's required annual POWER
562	562	account contribution may be rolled over into the next coverage
563	563	period in accordance with Section 537A.0256.
564	564	(f) During the first coverage period of a participant who
565	565	uses one or more tobacco products, a program health benefit plan
566	566	provider shall actively attempt to engage the participant in and
567	567	provide educational materials to the participant on:
568	568	(1) smoking cessation activities for which the
569	569	participant may receive a monetary contribution under this section;
570	570	and
571	571	(2) other smoking cessation programs or resources
572	572	available to the participant.
573	573	Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall
574	574	distribute to each participant with a POWER account a monthly
575	575	statement that includes information on:
576	576	(1) the participant's POWER account activity during
577	577	the preceding month, including information on the cost of health
578	578	care services delivered to the participant during that month;
579	579	(2) the balance of money available in the POWER
580	580	account at the time the statement is issued; and
581	581	(3) the amount of any contributions due from the
582	582	participant.
583	583	Sec. 537A.0256. POWER ACCOUNT ROLL OVER. (a) The executive
584	584	commissioner by rule shall establish a process in accordance with
585	585	this section to roll over money in a participant's POWER account to
586	586	the succeeding coverage period. The commission shall calculate the
587	587	amount to be rolled over at the time the participant's program
588	588	eligibility is redetermined.
589	589	(b) For a participant enrolled in the basic plan, the
590	590	commission shall calculate the amount to be rolled over to a
591	591	subsequent coverage period POWER account from the participant's
592	592	current coverage period POWER account based on:
593	593	(1) the amount of money remaining in the participant's
594	594	POWER account from the current coverage period; and
595	595	(2) whether the participant received recommended
596	596	preventative care services during the current coverage period.
597	597	(c) For a participant enrolled in the plus plan who, as
598	598	determined by the commission, timely makes POWER account
599	599	contributions in accordance with this subchapter, the commission
600	600	shall calculate the amount to be rolled over to a subsequent
601	601	coverage period POWER account from the participant's current
602	602	coverage period POWER account based on:
603	603	(1) the amount of money remaining in the participant's
604	604	POWER account from the current coverage period;
605	605	(2) the total amount of money the participant
606	606	contributed to the participant's POWER account during the current
607	607	coverage period; and
608	608	(3) whether the participant received recommended
609	609	preventative care services during the current coverage period.
610	610	(d) Except as provided by Subsection (e), a participant may
611	611	use money rolled over into the participant's POWER account for the
612	612	succeeding coverage period to offset required annual POWER account
613	613	contributions, as applicable, during that coverage period.
614	614	(e) A participant enrolled in the basic plan who rolls over
615	615	money into the participant's POWER account for the succeeding
616	616	coverage period and who chooses to enroll in the plus plan for that
617	617	coverage period may use the money rolled over to offset a maximum of
618	618	50 percent of the required annual POWER account contributions for
619	619	that coverage period.
620	620	Sec. 537A.0257. REFUND. If at the end of a participant's
621	621	coverage period the participant chooses to cease participating in a
622	622	program health benefit plan or is no longer eligible to participate
623	623	in a program health benefit plan, or if a participant is terminated
624	624	from the program health benefit plan under Section 537A.0258 for
625	625	failure to pay required contributions, the commission shall refund
626	626	to the participant any money the participant contributed that
627	627	remains in the participant's POWER account at the end of the
628	628	coverage period or on the termination date.
629	629	Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE POWER ACCOUNT
630	630	CONTRIBUTIONS. (a) For a participant whose annual household
631	631	income exceeds 100 percent of the federal poverty level and who
632	632	fails to make a contribution in accordance with Section 537A.0252,
633	633	the commission shall provide a 60-day grace period during which the
634	634	participant may make the contribution without penalty. If the
635	635	participant fails to make the contribution during the grace period,
636	636	the participant will be disenrolled from the program health benefit
637	637	plan in which the participant is enrolled and may not reenroll in a
638	638	program health benefit plan until:
639	639	(1) the 181st day after the date the participant is
640	640	disenrolled; and
641	641	(2) the participant pays any debt accrued due to the
642	642	participant's failure to make the contribution.
643	643	(b) For a participant enrolled in the plus plan whose annual
644	644	household income is equal to or less than 100 percent of the federal
645	645	poverty level and who fails to make a contribution in accordance
646	646	with Section 537A.0252, the commission shall disenroll the
647	647	participant from the plus plan and enroll the participant in the
648	648	basic plan. A participant enrolled in the basic plan under this
649	649	subsection may not change enrollment to the plus plan until the
650	650	participant's program eligibility is redetermined.
651	651	SUBCHAPTER G. EMPLOYMENT INITIATIVE
652	652	Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The
653	653	commission shall develop and implement a gateway to work program
654	654	to:
655	655	(1) integrate existing job training and job search
656	656	programs available in this state through the Texas Workforce
657	657	Commission or other appropriate state agencies with the Live Well
658	658	Texas program; and
659	659	(2) provide each participant with general information
660	660	on the job training and job search programs.
661	661	(b) Under the gateway to work program, the commission shall
662	662	refer each participant who is unemployed or working less than 20
663	663	hours a week to available job search and job training programs.
664	664	SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN
665	665	PARTICIPANTS
666	666	Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR
667	667	CONTINUITY OF CARE. (a) The commission shall ensure continuity of
668	668	care by providing health care financial assistance in accordance
669	669	with and in the manner described by this subchapter for a
670	670	participant who:
671	671	(1) is disenrolled from a program health benefit plan
672	672	in accordance with Section 537A.0155 because the participant's
673	673	annual household income exceeds the income eligibility
674	674	requirements for enrollment in a program health benefit plan; and
675	675	(2) seeks and obtains private health benefit coverage
676	676	within 12 months following the date of disenrollment.
677	677	(b) To receive health care financial assistance under this
678	678	subchapter, a participant must provide to the commission, in the
679	679	form and manner required by the commission, documentation showing
680	680	the participant has obtained or is actively seeking private health
681	681	benefit coverage.
682	682	(c) The commission may not impose an upper income
683	683	eligibility limit on a participant to receive health care financial
684	684	assistance under this subchapter.
685	685	Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE
686	686	FINANCIAL ASSISTANCE. (a) A participant described by Section
687	687	537A.0351 may receive health care financial assistance under this
688	688	subchapter until the first anniversary of the date the participant
689	689	was disenrolled from a program health benefit plan.
690	690	(b) Health care financial assistance made available to a
691	691	participant under this subchapter:
692	692	(1) may not exceed the amount described by Section
693	693	537A.0353; and
694	694	(2) is limited to payment for eligible services
695	695	described by Section 537A.0354.
696	696	Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The
697	697	commission shall establish a bridge account for each participant
698	698	eligible to receive health care financial assistance under Section
699	699	537A.0351. The account is funded with money the commission
700	700	contributes in accordance with this section.
701	701	(b) The commission shall enable each participant for whom a
702	702	bridge account is established to access and manage money in and
703	703	information regarding the participant's account through an
704	704	electronic system. The commission may contract with the same
705	705	entity described by Section 537A.0251(b) or another entity with
706	706	appropriate experience and expertise to establish, implement, or
707	707	administer the electronic system.
708	708	(c) The commission shall fund each bridge account in an
709	709	amount equal to $1,000 using money the commission retains or
710	710	recoups during the roll over process described by Section 537A.0256
711	711	or following the issuance of a refund as described by Section
712	712	537A.0257.
713	713	(d) The commission may not require a participant to
714	714	contribute money to the participant's bridge account.
715	715	(e) The commission shall retain or recoup any unexpended
716	716	money in a participant's bridge account at the end of the period for
717	717	which the participant is eligible to receive health care financial
718	718	assistance under this subchapter for the purpose of funding another
719	719	participant's POWER account under Subchapter F or bridge account
720	720	under this subchapter.
721	721	Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The
722	722	commission shall issue to each participant for whom a bridge
723	723	account is established an electronic payment card that allows the
724	724	participant to use the card to pay costs for eligible services
725	725	described by Subsection (b).
726	726	(b) A participant may use money in the participant's bridge
727	727	account to pay:
728	728	(1) premium costs incurred during the private health
729	729	benefit coverage enrollment process and coverage period; and
730	730	(2) copayments, deductible costs, and coinsurance
731	731	associated with the private health benefit coverage obtained by the
732	732	participant for health care services that would otherwise be
733	733	reimbursable under Medicaid.
734	734	(c) Costs described by Subsection (b)(2) associated with
735	735	eligible services delivered to a participant may be paid by:
736	736	(1) a participant using the electronic payment card
737	737	issued under Subsection (a); or
738	738	(2) a health care provider directly charging and
739	739	receiving payment from the participant's bridge account.
740	740	Sec. 537A.0355. ENROLLMENT COUNSELING. The commission
741	741	shall provide enrollment counseling to an individual who is seeking
742	742	private health benefit coverage and who is otherwise eligible to
743	743	receive health care financial assistance under this subchapter.
744	744	SECTION 2. As soon as practicable after the effective date
745	745	of this Act, the executive commissioner of the Health and Human
746	746	Services Commission shall apply for and actively pursue from the
747	747	federal Centers for Medicare and Medicaid Services or another
748	748	appropriate federal agency the waiver as required by Section
749	749	537A.0051, Government Code, as added by this Act. The commission
750	750	may delay implementing this Act until the waiver applied for under
751	751	that section is granted.
752	752	SECTION 3. This Act takes effect immediately if it receives
753	753	a vote of two-thirds of all the members elected to each house, as
754	754	provided by Section 39, Article III, Texas Constitution. If this
755	755	Act does not receive the vote necessary for immediate effect, this
756	756	Act takes effect September 1, 2021.