Texas 2021 - 87th 3rd C.S.

Texas Senate Bill SB41 Compare Versions

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

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1	1	87S30235 JG/MM-D
2	2	By: Johnson S.B. No. 41
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;
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	(H) leverage available federal medical
69	69	assistance percentage funding, including funding available under
70	70	the American Rescue Plan Act of 2021 (Pub. L. No. 117-2); and
71	71	(2) allow for the operation of the program consistent
72	72	with the requirements of this chapter, except to the extent
73	73	deviation from the requirements is necessary to obtain federal
74	74	authorization of the waiver.
75	75	Sec. 537A.0052. FUNDING. Subject to approval of the waiver
76	76	described by Section 537A.0051, the commission shall implement the
77	77	program using federal funding available for that purpose, including
78	78	enhanced federal medical assistance percentage funding available
79	79	under the Patient Protection and Affordable Care Act (Pub. L.
80	80	No. 111-148) as amended by the Health Care and Education
81	81	Reconciliation Act of 2010 (Pub. L. No. 111-152).
82	82	Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
83	83	(a) This chapter does not establish an entitlement to health
84	84	benefit coverage or health care financial assistance under the
85	85	program for eligible individuals.
86	86	(b) The program terminates at the time federal funding
87	87	terminates under the Patient Protection and Affordable Care Act
88	88	(Pub. L. No. 111-148) as amended by the Health Care and Education
89	89	Reconciliation Act of 2010 (Pub. L. No. 111-152), unless a
90	90	successor program providing federal funding is created.
91	91	SUBCHAPTER C. PROGRAM ADMINISTRATION
92	92	Sec. 537A.0101. PROGRAM OBJECTIVE. The principal objective
93	93	of the program is to provide primary and preventative health care
94	94	through high deductible program health benefit plans to eligible
95	95	individuals.
96	96	Sec. 537A.0102. PROGRAM PROMOTION. The commission shall
97	97	promote and provide information about the program to individuals
98	98	who:
99	99	(1) are potentially eligible to participate in the
100	100	program; and
101	101	(2) live in medically underserved areas of this state.
102	102	Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH
103	103	BENEFIT PLAN PROVIDER CONTRACTS. The commission may:
104	104	(1) enter into contracts with health benefit plan
105	105	providers under Section 537A.0107;
106	106	(2) monitor program health benefit plan providers
107	107	through reporting requirements and other means to ensure contract
108	108	performance and quality delivery of services;
109	109	(3) monitor the quality of services delivered to
110	110	participants through outcome measurements; and
111	111	(4) provide payment under the contracts to program
112	112	health benefit plan providers.
113	113	Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO
114	114	ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
115	115	(1) accept applications for health benefit coverage
116	116	under the program and implement program eligibility screening and
117	117	enrollment procedures;
118	118	(2) resolve grievances related to eligibility
119	119	determinations; and
120	120	(3) to the extent possible, coordinate the program
121	121	with Medicaid.
122	122	Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR
123	123	PROGRAM IMPLEMENTATION. (a) In administering the program, the
124	124	commission may contract with a third-party administrator to provide
125	125	enrollment and related services.
126	126	(b) If the commission contracts with a third-party
127	127	administrator under this section, the commission may:
128	128	(1) monitor the third-party administrator through
129	129	reporting requirements and other means to ensure contract
130	130	performance and quality delivery of services; and
131	131	(2) provide payment under the contract to the
132	132	third-party administrator.
133	133	(c) The executive commissioner shall retain all
134	134	policymaking authority over the program.
135	135	(d) The commission shall procure each contract with a
136	136	third-party administrator, as applicable, through a competitive
137	137	procurement process that complies with all federal and state laws.
138	138	Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a)
139	139	At the commission's request, the Texas Department of Insurance
140	140	shall provide any necessary assistance with the program. The
141	141	department shall monitor the quality of the services provided by
142	142	program health benefit plan providers and resolve grievances
143	143	related to those providers.
144	144	(b) The commission and the Texas Department of Insurance may
145	145	adopt a memorandum of understanding that addresses the
146	146	responsibilities of each agency with respect to the program.
147	147	(c) The Texas Department of Insurance, in consultation with
148	148	the commission, shall adopt rules as necessary to implement this
149	149	section.
150	150	Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS.
151	151	The commission shall select through a competitive procurement
152	152	process that complies with all federal and state laws and contract
153	153	with health benefit plan providers to provide health care services
154	154	under the program. To be eligible for a contract under this section,
155	155	an entity must:
156	156	(1) be a Medicaid managed care organization;
157	157	(2) hold a certificate of authority issued by the
158	158	Texas Department of Insurance that authorizes the entity to provide
159	159	the types of health care services offered under the program; and
160	160	(3) satisfy, except as provided by this chapter, any
161	161	applicable requirement of the Insurance Code or another insurance
162	162	law of this state.
163	163	Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care
164	164	provider who provides health care services under the program must
165	165	meet certification and licensure requirements required by
166	166	commission rules and other law.
167	167	(b) In adopting rules governing the program, the executive
168	168	commissioner shall ensure that a health care provider who provides
169	169	health care services under the program is reimbursed at a rate that
170	170	is at least equal to the rate paid under Medicare for the provision
171	171	of the same or substantially similar services.
172	172	Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTH CARE
173	173	PROVIDERS. The executive commissioner shall adopt rules that
174	174	prohibit a health care provider from providing health care services
175	175	under the program for a reasonable period, as determined by the
176	176	executive commissioner, if the health care provider:
177	177	(1) fails to repay overpayments made under the
178	178	program; or
179	179	(2) owns, controls, manages, or is otherwise
180	180	affiliated with and has financial, managerial, or administrative
181	181	influence over a health care provider who has been suspended or
182	182	prohibited from providing health care services under the program.
183	183	SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE
184	184	Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An
185	185	individual is eligible to enroll in a program health benefit plan
186	186	if:
187	187	(1) the individual is a resident of this state;
188	188	(2) the individual is 19 years of age or older but
189	189	younger than 65 years of age;
190	190	(3) applying the eligibility criteria in effect in
191	191	this state on December 31, 2020, the individual is not eligible for
192	192	Medicaid; and
193	193	(4) federal matching funds are available under the
194	194	Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as
195	195	amended by the Health Care and Education Reconciliation Act of 2010
196	196	(Pub. L. No. 111-152) or other successor law to provide benefits to
197	197	the individual under the federal medical assistance program
198	198	established under Title XIX, Social Security Act (42 U.S.C. Section
199	199	1396 et seq.).
200	200	(b) An individual who is a parent or caretaker relative to
201	201	whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a
202	202	program health benefit plan.
203	203	(c) In determining eligibility for the program, the
204	204	commission shall apply the same eligibility criteria regarding
205	205	residency and citizenship in effect for Medicaid in this state on
206	206	December 31, 2020.
207	207	Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall
208	208	ensure that an individual who is initially determined or
209	209	redetermined to be eligible to participate in the program and
210	210	enroll in a program health benefit plan will remain eligible for
211	211	coverage under the plan for a period of 12 months beginning on the
212	212	first day of the month following the date eligibility was
213	213	determined or redetermined, subject to Section 537A.0252(f).
214	214	Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The
215	215	executive commissioner shall adopt an application form and
216	216	application procedures for the program. The form and procedures
217	217	must be coordinated with forms and procedures under Medicaid to
218	218	ensure that there is a single consolidated application process to
219	219	seek health benefit coverage under the program or Medicaid.
220	220	(b) To the extent possible, the commission shall make the
221	221	application form available in languages other than English.
222	222	(c) The executive commissioner may permit an individual to
223	223	apply by mail, over the telephone, or through the Internet.
224	224	Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
225	225	The executive commissioner shall adopt eligibility screening and
226	226	enrollment procedures or use the Texas Integrated Enrollment
227	227	Services eligibility determination system or a compatible system to
228	228	screen individuals and enroll eligible individuals in the program.
229	229	(b) The eligibility screening and enrollment procedures
230	230	must ensure that an individual applying for the program who appears
231	231	eligible for Medicaid is identified and assisted with obtaining
232	232	Medicaid coverage. If the individual is denied Medicaid coverage
233	233	but is determined eligible to enroll in a program health benefit
234	234	plan, the commission shall enroll the individual in a program
235	235	health benefit plan of the individual's choosing and for which the
236	236	individual is eligible without further application or
237	237	qualification.
238	238	(c) Not later than the 30th day after the date an individual
239	239	submits a complete application form and unless the individual is
240	240	identified and assisted with obtaining Medicaid coverage under
241	241	Subsection (b), the commission shall ensure that the individual's
242	242	eligibility to participate in the program is determined and that
243	243	the individual is provided with information on program health
244	244	benefit plans and program health benefit plan providers. The
245	245	commission shall enroll the individual in the program health
246	246	benefit plan and with the program health benefit plan provider of
247	247	the individual's choosing in a timely manner, as determined by the
248	248	commission.
249	249	(d) The executive commissioner may establish enrollment
250	250	periods for the program.
251	251	Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS;
252	252	DISENROLLMENT. (a) Not later than the 90th day before the
253	253	expiration of a participant's coverage period, the commission shall
254	254	notify the participant regarding the eligibility redetermination
255	255	process and request documentation necessary to redetermine the
256	256	participant's eligibility.
257	257	(b) The commission shall provide written notice of
258	258	termination of eligibility to a participant not later than the 30th
259	259	day before the date the participant's eligibility will terminate.
260	260	The commission shall disenroll the participant from the program if:
261	261	(1) the participant does not submit the requested
262	262	eligibility redetermination documentation before the last day of
263	263	the participant's coverage period; or
264	264	(2) the commission, based on the submitted
265	265	documentation, determines the participant is no longer eligible for
266	266	the program, subject to Subchapter H.
267	267	(c) An individual may submit the requested eligibility
268	268	redetermination documentation not later than the 90th day after the
269	269	date the individual is disenrolled from the program. If the
270	270	commission determines that the individual continues to meet program
271	271	eligibility requirements, the commission shall reenroll the
272	272	individual in the program without any additional application
273	273	requirements.
274	274	(d) An individual who does not complete the eligibility
275	275	redetermination process in accordance with this section and who is
276	276	disenrolled from the program may not participate in the program for
277	277	a period of 180 days beginning on the date of disenrollment. This
278	278	subsection does not apply to an individual described by Section
279	279	537A.0206 or 537A.0208 or an individual who is pregnant or is
280	280	younger than 21 years of age.
281	281	(e) At the time a participant is disenrolled from the
282	282	program under this section, the commission shall provide to the
283	283	participant:
284	284	(1) notice that the participant may be eligible to
285	285	receive health care financial assistance under Subchapter H in
286	286	transitioning to private health benefit coverage; and
287	287	(2) information on and the eligibility requirements
288	288	for that financial assistance.
289	289	SUBCHAPTER E. BASIC AND PLUS PLANS
290	290	Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY.
291	291	(a) The basic and plus plans offered under the program must:
292	292	(1) comply with this subchapter and coverage
293	293	requirements prescribed by other law; and
294	294	(2) at a minimum, provide coverage for essential
295	295	health benefits required under 42 U.S.C. Section 18022(b).
296	296	(b) In modifying covered health benefits under the basic and
297	297	plus plans, the executive commissioner shall consider the health
298	298	care needs of healthy individuals and individuals with special
299	299	health care needs.
300	300	(c) The basic and plus plans must allow a participant with a
301	301	chronic, disabling, or life-threatening illness to select an
302	302	appropriate specialist as the participant's primary care
303	303	physician.
304	304	Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME
305	305	ELIGIBILITY. (a) The program must include a basic plan that is
306	306	sufficient to meet the basic health care needs of individuals who
307	307	enroll in the plan.
308	308	(b) The covered health benefits under the basic plan must
309	309	include:
310	310	(1) primary care physician services;
311	311	(2) prenatal and postpartum care;
312	312	(3) specialty care physician visits;
313	313	(4) home health services, not to exceed 100 visits per
314	314	year;
315	315	(5) outpatient surgery;
316	316	(6) allergy testing;
317	317	(7) chemotherapy;
318	318	(8) intravenous infusion services;
319	319	(9) radiation therapy;
320	320	(10) dialysis;
321	321	(11) emergency care hospital services;
322	322	(12) emergency transportation, including ambulance
323	323	and air ambulance;
324	324	(13) urgent care clinic services;
325	325	(14) hospitalization, including for:
326	326	(A) general inpatient hospital care;
327	327	(B) inpatient physician services;
328	328	(C) inpatient surgical services;
329	329	(D) non-cosmetic reconstructive surgery;
330	330	(E) a transplant;
331	331	(F) treatment for a congenital abnormality;
332	332	(G) anesthesia;
333	333	(H) hospice care; and
334	334	(I) care in a skilled nursing facility for a
335	335	period not to exceed 100 days per occurrence;
336	336	(15) inpatient and outpatient behavioral health
337	337	services;
338	338	(16) inpatient, outpatient, and residential substance
339	339	use treatment;
340	340	(17) prescription drugs, including tobacco cessation
341	341	drugs;
342	342	(18) inpatient and outpatient rehabilitative and
343	343	habilitative care, including physical, occupational, and speech
344	344	therapy, not to exceed 60 combined visits per year;
345	345	(19) medical equipment, appliances, and assistive
346	346	technology, including prosthetics and hearing aids, and the repair,
347	347	technical support, and customization needed for individual use;
348	348	(20) laboratory and pathology tests and services;
349	349	(21) diagnostic imaging, including x-rays, magnetic
350	350	resonance imaging, computed tomography, and positron emission
351	351	tomography;
352	352	(22) preventative care services as described by
353	353	Section 537A.0204; and
354	354	(23) services under the early and periodic screening,
355	355	diagnostic, and treatment program for participants who are younger
356	356	than 21 years of age.
357	357	(c) To be eligible for health care benefits under the basic
358	358	plan, an individual who is eligible for the program must have an
359	359	annual household income that is equal to or less than 100 percent of
360	360	the federal poverty level.
361	361	Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY.
362	362	(a) The program must include a plus plan that includes the covered
363	363	health benefits listed in Section 537A.0202 and the following
364	364	additional enhanced health benefits:
365	365	(1) services related to the treatment of conditions
366	366	affecting the temporomandibular joint;
367	367	(2) dental care;
368	368	(3) vision care;
369	369	(4) notwithstanding Section 537A.0202(b)(18),
370	370	inpatient and outpatient rehabilitative and habilitative care,
371	371	including physical, occupational, and speech therapy, not to exceed
372	372	75 combined visits per year;
373	373	(5) bariatric surgery; and
374	374	(6) other services the commission considers
375	375	appropriate.
376	376	(b) An individual who is eligible for the program and whose
377	377	annual household income exceeds 100 percent of the federal poverty
378	378	level will automatically be enrolled in and receive health benefits
379	379	under the plus plan. An individual who is eligible for the program
380	380	and whose annual household income is equal to or less than 100
381	381	percent of the federal poverty level may choose to enroll in the
382	382	plus plan.
383	383	(c) A participant enrolled in the plus plan is required to
384	384	make POWER account contributions in accordance with Section
385	385	537A.0252.
386	386	Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The
387	387	commission shall provide to each participant a list of health care
388	388	services that qualify as preventative care services based on the
389	389	age, gender, and preexisting conditions of the participant. In
390	390	developing the list, the commission shall consult with the federal
391	391	Centers for Disease Control and Prevention.
392	392	(b) A program health benefit plan shall, at no cost to the
393	393	participant, provide coverage for:
394	394	(1) preventative care services described by 42 U.S.C.
395	395	Section 300gg-13; and
396	396	(2) a maximum of $500 per year of preventative care
397	397	services other than those described by Subdivision (1).
398	398	(c) A participant who receives preventative care services
399	399	not described by Subsection (b) that are covered under the
400	400	participant's program health benefit plan is subject to deductible
401	401	and copayment requirements for the services in accordance with the
402	402	terms of the plan.
403	403	Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in
404	404	the basic plan shall pay a copayment for each covered health benefit
405	405	except for a preventative care or family planning service. The
406	406	executive commissioner by rule shall adopt a copayment schedule for
407	407	basic plan services, subject to Subsection (c).
408	408	(b) Except as provided by Subsection (c), a participant
409	409	enrolled in the plus plan may not be required to pay a copayment for
410	410	a covered service.
411	411	(c) A participant enrolled in the basic or plus plan shall
412	412	pay a copayment in an amount set by commission rule not to exceed
413	413	$25 for nonemergency use of hospital emergency department services
414	414	unless:
415	415	(1) the participant has met the cost-sharing maximum
416	416	for the calendar quarter, as prescribed by commission rule;
417	417	(2) the participant is referred to the hospital
418	418	emergency department by a health care provider;
419	419	(3) the visit is a true emergency, as defined by
420	420	commission rule; or
421	421	(4) the participant is pregnant.
422	422	Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE
423	423	MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R.
424	424	Section 440.315 who is enrolled in the basic or plus plan is
425	425	entitled to receive under the program all health benefits that
426	426	would be available under the state Medicaid plan.
427	427	(b) A participant to which this section applies is subject
428	428	to the cost-sharing requirements, including copayment and POWER
429	429	account contribution requirements, of the program health benefit
430	430	plan in which the participant is enrolled.
431	431	(c) The commission shall develop screening measures to
432	432	identify participants to which this section applies.
433	433	Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant
434	434	who becomes pregnant while enrolled in the program and who meets the
435	435	eligibility requirements for Medicaid may choose to remain in the
436	436	program or enroll in Medicaid.
437	437	(b) A pregnant participant described by Subsection (a) who
438	438	is enrolled in the basic or plus plan and who remains in the program
439	439	is:
440	440	(1) notwithstanding Section 537A.0205, not subject to
441	441	any cost-sharing requirements, including copayment and POWER
442	442	account contribution requirements, of the program health benefit
443	443	plan in which the participant is enrolled until the expiration of
444	444	the second month following the month in which the pregnancy ends;
445	445	(2) entitled to receive as a Medicaid wrap-around
446	446	benefit all Medicaid services a pregnant woman enrolled in Medicaid
447	447	is entitled to receive, including a pharmacy benefit, when the
448	448	participant exceeds coverage limits under the participant's
449	449	program health benefit plan or if a service is not covered by the
450	450	plan; and
451	451	(3) eligible for additional vision and dental care
452	452	benefits.
453	453	Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A
454	454	parent or caretaker relative to whom 42 C.F.R. Section 435.110
455	455	applies is entitled to receive as a Medicaid wrap-around benefit
456	456	all Medicaid services to which the individual would be entitled
457	457	under the state Medicaid plan that are not covered under the
458	458	individual's program health benefit plan or exceed the plan's
459	459	coverage limits.
460	460	(b) An individual described by Subsection (a) who chooses to
461	461	participate in the program is subject to the cost-sharing
462	462	requirements, including copayment and POWER account contribution
463	463	requirements, of the program health benefit plan in which the
464	464	individual is enrolled.
465	465	SUBCHAPTER F. PERSONAL WELLNESS AND RESPONSIBILITY (POWER)
466	466	ACCOUNTS
467	467	Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF POWER
468	468	ACCOUNTS. (a) The commission shall establish a personal wellness
469	469	and responsibility (POWER) account for each participant who is
470	470	enrolled in a program health benefit plan that is funded with money
471	471	contributed in accordance with this subchapter.
472	472	(b) The commission shall enable each participant to access
473	473	and manage money in and information regarding the participant's
474	474	POWER account through an electronic system. The commission may
475	475	contract with an entity that has appropriate experience and
476	476	expertise to establish, implement, or administer the electronic
477	477	system.
478	478	(c) Except as otherwise provided by Section 537A.0252, the
479	479	commission shall require each participant to contribute to the
480	480	participant's POWER account in amounts described by that section.
481	481	Sec. 537A.0252. POWER ACCOUNT CONTRIBUTIONS; DEDUCTIBLE.
482	482	(a) The executive commissioner by rule shall establish an annual
483	483	universal deductible for each participant enrolled in the basic or
484	484	plus plan.
485	485	(b) To ensure each participant's POWER account contains a
486	486	sufficient amount of money at the beginning of a coverage period,
487	487	the commission shall, before the beginning of that period, fund
488	488	each account with the following amounts:
489	489	(1) for a participant enrolled in the basic plan, the
490	490	annual universal deductible amount; and
491	491	(2) for a participant enrolled in the plus plan, the
492	492	difference between the annual universal deductible amount and the
493	493	participant's required annual contribution as determined by the
494	494	schedule established under Subsection (c).
495	495	(c) The executive commissioner by rule shall establish a
496	496	graduated annual POWER account contribution schedule for
497	497	participants enrolled in the plus plan that:
498	498	(1) is based on a participant's annual household
499	499	income, with participants whose annual household incomes are less
500	500	than the federal poverty level paying progressively less and
501	501	participants whose annual household incomes are equal to or greater
502	502	than the federal poverty level paying progressively more; and
503	503	(2) may not require a participant to contribute more
504	504	than a total of five percent of the participant's annual household
505	505	income to the participant's POWER account.
506	506	(d) A participant's employer may contribute on behalf of the
507	507	participant any amount of the participant's annual POWER account
508	508	contribution. A nonprofit organization may contribute on behalf of
509	509	a participant any amount of the participant's annual POWER account
510	510	contribution.
511	511	(e) Subject to the contribution cap described by Subsection
512	512	(c)(2) and not before the expiration of the participant's first
513	513	coverage period, the commission shall require a participant who
514	514	uses one or more tobacco products to contribute to the
515	515	participant's POWER account an annual POWER account contribution
516	516	amount that is one percent more than the participant would
517	517	otherwise be required to contribute under the schedule established
518	518	under Subsection (c).
519	519	(f) An annual POWER account contribution must be paid by or
520	520	on behalf of a participant monthly in installments that are at least
521	521	equal to one-twelfth of the total required contribution. The
522	522	coverage period for a participant whose annual household income
523	523	exceeds 100 percent of the federal poverty level may not begin until
524	524	the first day of the first month following the month in which the
525	525	first monthly installment is received.
526	526	Sec. 537A.0253. USE OF POWER ACCOUNT MONEY. A participant
527	527	may use money in the participant's POWER account to pay copayments
528	528	and deductible costs required under the participant's program
529	529	health benefit plan. The commission shall issue to each
530	530	participant an electronic payment card that allows the participant
531	531	to use the card to pay the program health benefit plan costs.
532	532	Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER
533	533	REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS;
534	534	SMOKING CESSATION INITIATIVE. (a) A program health benefit plan
535	535	provider shall establish a rewards program through which a
536	536	participant receiving health care through a program health benefit
537	537	plan offered by the program health benefit plan provider may earn
538	538	money to be contributed to the participant's POWER account.
539	539	(b) Under a rewards program, a program health benefit plan
540	540	provider shall contribute money to a participant's POWER account if
541	541	the participant engages in certain healthy behaviors. The
542	542	executive commissioner by rule shall determine:
543	543	(1) the behaviors in which a participant must engage
544	544	to receive a contribution, which must include behaviors related to:
545	545	(A) completion of a health risk assessment;
546	546	(B) smoking cessation; and
547	547	(C) as applicable, chronic disease management;
548	548	and
549	549	(2) the amount of money a program health benefit plan
550	550	provider shall contribute for each behavior described by
551	551	Subdivision (1).
552	552	(c) Subsection (b) does not prevent a program health benefit
553	553	plan provider from contributing money to a participant's POWER
554	554	account if the participant engages in a behavior not specified by
555	555	that subsection or a rule adopted in accordance with that
556	556	subsection. If a program health benefit plan provider chooses to
557	557	contribute money under this subsection, the program health benefit
558	558	plan provider shall determine the amount of money to be contributed
559	559	for the behavior.
560	560	(d) A participant may use contributions a program health
561	561	benefit plan provider makes under a rewards program to offset a
562	562	maximum of 50 percent of the participant's required annual POWER
563	563	account contribution established under Section 537A.0252.
564	564	(e) Contributions a program health benefit plan provider
565	565	makes under a rewards program that result in a participant's POWER
566	566	account balance exceeding the participant's required annual POWER
567	567	account contribution may be rolled over into the next coverage
568	568	period in accordance with Section 537A.0256.
569	569	(f) During the first coverage period of a participant who
570	570	uses one or more tobacco products, a program health benefit plan
571	571	provider shall actively attempt to engage the participant in and
572	572	provide educational materials to the participant on:
573	573	(1) smoking cessation activities for which the
574	574	participant may receive a monetary contribution under this section;
575	575	and
576	576	(2) other smoking cessation programs or resources
577	577	available to the participant.
578	578	Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall
579	579	distribute to each participant with a POWER account a monthly
580	580	statement that includes information on:
581	581	(1) the participant's POWER account activity during
582	582	the preceding month, including information on the cost of health
583	583	care services delivered to the participant during that month;
584	584	(2) the balance of money available in the POWER
585	585	account at the time the statement is issued; and
586	586	(3) the amount of any contributions due from the
587	587	participant.
588	588	Sec. 537A.0256. POWER ACCOUNT ROLLOVER. (a) The executive
589	589	commissioner by rule shall establish a process in accordance with
590	590	this section to roll over money in a participant's POWER account to
591	591	the succeeding coverage period. The commission shall calculate the
592	592	amount to be rolled over at the time the participant's program
593	593	eligibility is redetermined.
594	594	(b) For a participant enrolled in the basic plan, the
595	595	commission shall calculate the amount to be rolled over to a
596	596	subsequent coverage period POWER account from the participant's
597	597	current coverage period POWER account based on:
598	598	(1) the amount of money remaining in the participant's
599	599	POWER account from the current coverage period; and
600	600	(2) whether the participant received recommended
601	601	preventative care services during the current coverage period.
602	602	(c) For a participant enrolled in the plus plan who, as
603	603	determined by the commission, timely makes POWER account
604	604	contributions in accordance with this subchapter, the commission
605	605	shall calculate the amount to be rolled over to a subsequent
606	606	coverage period POWER account from the participant's current
607	607	coverage period POWER account based on:
608	608	(1) the amount of money remaining in the participant's
609	609	POWER account from the current coverage period;
610	610	(2) the total amount of money the participant
611	611	contributed to the participant's POWER account during the current
612	612	coverage period; and
613	613	(3) whether the participant received recommended
614	614	preventative care services during the current coverage period.
615	615	(d) Except as provided by Subsection (e), a participant may
616	616	use money rolled over into the participant's POWER account for the
617	617	succeeding coverage period to offset required annual POWER account
618	618	contributions, as applicable, during that coverage period.
619	619	(e) A participant enrolled in the basic plan who rolls over
620	620	money into the participant's POWER account for the succeeding
621	621	coverage period and who chooses to enroll in the plus plan for that
622	622	coverage period may use the money rolled over to offset a maximum of
623	623	50 percent of the required annual POWER account contributions for
624	624	that coverage period.
625	625	Sec. 537A.0257. REFUND. If at the end of a participant's
626	626	coverage period the participant chooses to cease participating in a
627	627	program health benefit plan or is no longer eligible to participate
628	628	in a program health benefit plan, or if a participant is terminated
629	629	from the program health benefit plan under Section 537A.0258 for
630	630	failure to pay required contributions, the commission shall refund
631	631	to the participant any money the participant contributed that
632	632	remains in the participant's POWER account at the end of the
633	633	coverage period or on the termination date.
634	634	Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE POWER ACCOUNT
635	635	CONTRIBUTIONS. (a) For a participant whose annual household
636	636	income exceeds 100 percent of the federal poverty level and who
637	637	fails to make a contribution in accordance with Section 537A.0252,
638	638	the commission shall provide a 60-day grace period during which the
639	639	participant may make the contribution without penalty. If the
640	640	participant fails to make the contribution during the grace period,
641	641	the participant will be disenrolled from the program health benefit
642	642	plan in which the participant is enrolled and may not reenroll in a
643	643	program health benefit plan until:
644	644	(1) the 181st day after the date the participant is
645	645	disenrolled; and
646	646	(2) the participant pays any debt accrued due to the
647	647	participant's failure to make the contribution.
648	648	(b) For a participant enrolled in the plus plan whose annual
649	649	household income is equal to or less than 100 percent of the federal
650	650	poverty level and who fails to make a contribution in accordance
651	651	with Section 537A.0252, the commission shall disenroll the
652	652	participant from the plus plan and enroll the participant in the
653	653	basic plan. A participant enrolled in the basic plan under this
654	654	subsection may not change enrollment to the plus plan until the
655	655	participant's program eligibility is redetermined.
656	656	SUBCHAPTER G. EMPLOYMENT INITIATIVE
657	657	Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The
658	658	commission shall develop and implement a gateway to work program
659	659	to:
660	660	(1) integrate existing job training and job search
661	661	programs available in this state through the Texas Workforce
662	662	Commission or other appropriate state agencies with the Live Well
663	663	Texas program; and
664	664	(2) provide each participant with general information
665	665	on the job training and job search programs.
666	666	(b) Under the gateway to work program, the commission shall
667	667	refer each participant who is unemployed or working less than 20
668	668	hours a week to available job search and job training programs.
669	669	SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN
670	670	PARTICIPANTS
671	671	Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR
672	672	CONTINUITY OF CARE. (a) The commission shall ensure continuity of
673	673	care by providing health care financial assistance in accordance
674	674	with and in the manner described by this subchapter for a
675	675	participant who:
676	676	(1) is disenrolled from a program health benefit plan
677	677	in accordance with Section 537A.0155 because the participant's
678	678	annual household income exceeds the income eligibility
679	679	requirements for enrollment in a program health benefit plan; and
680	680	(2) seeks and obtains private health benefit coverage
681	681	within 12 months following the date of disenrollment.
682	682	(b) To receive health care financial assistance under this
683	683	subchapter, a participant must provide to the commission, in the
684	684	form and manner required by the commission, documentation showing
685	685	the participant has obtained or is actively seeking private health
686	686	benefit coverage.
687	687	(c) The commission may not impose an upper income
688	688	eligibility limit on a participant to receive health care financial
689	689	assistance under this subchapter.
690	690	Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE
691	691	FINANCIAL ASSISTANCE. (a) A participant described by Section
692	692	537A.0351 may receive health care financial assistance under this
693	693	subchapter until the first anniversary of the date the participant
694	694	was disenrolled from a program health benefit plan.
695	695	(b) Health care financial assistance made available to a
696	696	participant under this subchapter:
697	697	(1) may not exceed the amount described by Section
698	698	537A.0353; and
699	699	(2) is limited to payment for eligible services
700	700	described by Section 537A.0354.
701	701	Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The
702	702	commission shall establish a bridge account for each participant
703	703	eligible to receive health care financial assistance under Section
704	704	537A.0351. The account is funded with money the commission
705	705	contributes in accordance with this section.
706	706	(b) The commission shall enable each participant for whom a
707	707	bridge account is established to access and manage money in and
708	708	information regarding the participant's account through an
709	709	electronic system. The commission may contract with the same
710	710	entity described by Section 537A.0251(b) or another entity with
711	711	appropriate experience and expertise to establish, implement, or
712	712	administer the electronic system.
713	713	(c) The commission shall fund each bridge account in an
714	714	amount equal to $1,000 using money the commission retains or
715	715	recoups during the rollover process described by Section 537A.0256
716	716	or following the issuance of a refund as described by Section
717	717	537A.0257.
718	718	(d) The commission may not require a participant to
719	719	contribute money to the participant's bridge account.
720	720	(e) The commission shall retain or recoup any unexpended
721	721	money in a participant's bridge account at the end of the period for
722	722	which the participant is eligible to receive health care financial
723	723	assistance under this subchapter for the purpose of funding another
724	724	participant's POWER account under Subchapter F or bridge account
725	725	under this subchapter.
726	726	Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The
727	727	commission shall issue to each participant for whom a bridge
728	728	account is established an electronic payment card that allows the
729	729	participant to use the card to pay costs for eligible services
730	730	described by Subsection (b).
731	731	(b) A participant may use money in the participant's bridge
732	732	account to pay:
733	733	(1) premium costs incurred during the private health
734	734	benefit coverage enrollment process and coverage period; and
735	735	(2) copayments, deductible costs, and coinsurance
736	736	associated with the private health benefit coverage obtained by the
737	737	participant for health care services that would otherwise be
738	738	reimbursable under Medicaid.
739	739	(c) Costs described by Subsection (b)(2) associated with
740	740	eligible services delivered to a participant may be paid by:
741	741	(1) a participant using the electronic payment card
742	742	issued under Subsection (a); or
743	743	(2) a health care provider directly charging and
744	744	receiving payment from the participant's bridge account.
745	745	Sec. 537A.0355. ENROLLMENT COUNSELING. The commission
746	746	shall provide enrollment counseling to an individual who is seeking
747	747	private health benefit coverage and who is otherwise eligible to
748	748	receive health care financial assistance under this subchapter.
749	749	SECTION 2. (a) The Health and Human Services Commission
750	750	shall conduct a study on the development and implementation of the
751	751	Live Well Texas program under Chapter 537A, Government Code, as
752	752	added by this Act, including potential sources of funding for the
753	753	state's share of costs associated with implementing the program.
754	754	The study must:
755	755	(1) consider the feasibility of using funding from the
756	756	following sources to fund the program:
757	757	(A) rebates collected under the Medicaid vendor
758	758	drug program; and
759	759	(B) managed care state premium tax revenue;
760	760	(2) evaluate the anticipated savings to this state
761	761	resulting from the reduction or elimination of:
762	762	(A) health care-related benefits that a program
763	763	participant would otherwise be eligible to receive under other
764	764	programs administered by the commission or another health and human
765	765	services agency, including:
766	766	(i) the kidney health care program;
767	767	(ii) the Healthy Texas Women program; and
768	768	(iii) other programs that provide benefits:
769	769	(a) to pregnant women;
770	770	(b) for treating breast and cervical
771	771	cancer;
772	772	(c) to support community health
773	773	treatment;
774	774	(d) for substance use treatment; and
775	775	(e) for treatment of HIV infection;
776	776	and
777	777	(B) health care expenses incurred by the Texas
778	778	Department of Criminal Justice for inpatient hospital stays of more
779	779	than 24 hours in a freestanding hospital; and
780	780	(3) based on the evaluation under Subdivision (2) of
781	781	this subsection, determine the extent to which savings offset or
782	782	eliminate the state's share of costs associated with implementing
783	783	the program.
784	784	(b) Not later than November 30, 2022, the Health and Human
785	785	Services Commission shall prepare and submit to the legislature a
786	786	written report that:
787	787	(1) summarizes the results of the study conducted
788	788	under Subsection (a) of this section; and
789	789	(2) includes legislative recommendations, as
790	790	applicable.
791	791	SECTION 3. As soon as practicable after the effective date
792	792	of this Act, the executive commissioner of the Health and Human
793	793	Services Commission shall apply for and actively pursue from the
794	794	federal Centers for Medicare and Medicaid Services or another
795	795	appropriate federal agency the waiver as required by Section
796	796	537A.0051, Government Code, as added by this Act. The commission
797	797	may delay implementing this Act until the waiver applied for under
798	798	that section is granted.
799	799	SECTION 4. This Act takes effect January 1, 2023, but only
800	800	if the constitutional amendment proposed by the 87th Legislature,
801	801	3rd Called Session, 2021, requiring the state to develop and seek
802	802	appropriate authorization under the federal Medicaid program to
803	803	implement the Live Well Texas program to provide health benefit
804	804	coverage to certain individuals is approved by the voters. If that
805	805	amendment is not approved by the voters, this Act has no effect.