Texas 2023 - 88th Regular

Texas House Bill HB3226 Compare Versions

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1	1	88R10277 JG-D
2	2	By: Allison H.B. No. 3226
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 the commission establishes for a
28	28	participant under Section 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 and actively seek employment;
62	62	(F) support participants' overall wellness by
63	63	requiring participants to receive preventative care services and
64	64	maintain relationships with preventative care providers;
65	65	(G) support participants who become ineligible
66	66	to participate in a program health benefit plan in transitioning to
67	67	private health benefit coverage; and
68	68	(H) leverage enhanced federal medical assistance
69	69	percentage funding to minimize or eliminate the need for a program
70	70	enrollment cap; and
71	71	(2) allow for the operation of the program consistent
72	72	with the requirements of this chapter.
73	73	Sec. 537A.0052. FUNDING. Subject to approval of the waiver
74	74	described by Section 537A.0051, the commission shall implement the
75	75	program using enhanced federal medical assistance percentage
76	76	funding available under the Patient Protection and Affordable Care
77	77	Act (Pub. L. No. 111-148) as amended by the Health Care and
78	78	Education Reconciliation Act of 2010 (Pub. L. No. 111-152).
79	79	Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
80	80	(a) This chapter does not establish an entitlement to health
81	81	benefit coverage or health care financial assistance under the
82	82	program for eligible individuals.
83	83	(b) The program terminates at the time federal funding
84	84	terminates under the Patient Protection and Affordable Care Act
85	85	(Pub. L. No. 111-148) as amended by the Health Care and Education
86	86	Reconciliation Act of 2010 (Pub. L. No. 111-152), unless a
87	87	successor program providing federal funding that is at least equal
88	88	to the federal funding under that Act is created.
89	89	SUBCHAPTER C. PROGRAM ADMINISTRATION
90	90	Sec. 537A.0101. PROGRAM OBJECTIVE. The program's principal
91	91	objective is to provide primary and preventative health care
92	92	through high deductible program health benefit plans to eligible
93	93	individuals.
94	94	Sec. 537A.0102. PROGRAM PROMOTION. The commission shall
95	95	promote and provide information about the program to individuals
96	96	who:
97	97	(1) are potentially eligible to participate in the
98	98	program; and
99	99	(2) live in medically underserved areas of this state.
100	100	Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH
101	101	BENEFIT PLAN PROVIDER CONTRACTS. The commission may:
102	102	(1) enter into contracts with health benefit plan
103	103	providers under Section 537A.0107;
104	104	(2) monitor program health benefit plan providers
105	105	through reporting requirements and other means to ensure contract
106	106	performance and quality delivery of services;
107	107	(3) monitor the quality of services delivered to
108	108	participants through outcome measurements; and
109	109	(4) provide payment under the contracts to program
110	110	health benefit plan providers.
111	111	Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO
112	112	ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
113	113	(1) accept applications for health benefit coverage
114	114	under the program and implement program eligibility screening and
115	115	enrollment procedures;
116	116	(2) resolve grievances related to eligibility
117	117	determinations; and
118	118	(3) to the extent possible, coordinate the program
119	119	with Medicaid.
120	120	Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR
121	121	PROGRAM IMPLEMENTATION. (a) In administering the program, the
122	122	commission may contract with a third-party administrator to provide
123	123	enrollment and related services.
124	124	(b) If the commission contracts with a third-party
125	125	administrator under this section, the commission shall:
126	126	(1) monitor the third-party administrator through
127	127	reporting requirements and other means to ensure contract
128	128	performance and quality delivery of services; and
129	129	(2) provide payment under the contract to the
130	130	third-party administrator.
131	131	(c) The executive commissioner shall retain all
132	132	policymaking authority over the program.
133	133	(d) The commission shall procure each contract with a
134	134	third-party administrator, as applicable, through a competitive
135	135	procurement process that complies with all federal and state laws.
136	136	Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a)
137	137	At the commission's request, the Texas Department of Insurance
138	138	shall provide any necessary assistance with the program. The
139	139	department shall monitor the quality of the services provided by
140	140	program health benefit plan providers and resolve grievances
141	141	related to those providers.
142	142	(b) The commission and the Texas Department of Insurance may
143	143	adopt a memorandum of understanding that addresses the
144	144	responsibilities of each agency with respect to the program.
145	145	(c) The Texas Department of Insurance, in consultation with
146	146	the commission, shall adopt rules as necessary to implement this
147	147	section.
148	148	Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS.
149	149	The commission shall select through a competitive procurement
150	150	process that complies with all federal and state laws and contract
151	151	with health benefit plan providers to provide health care services
152	152	under the program. To be eligible for a contract under this section,
153	153	an entity must:
154	154	(1) be a Medicaid managed care organization;
155	155	(2) hold a certificate of authority issued by the
156	156	Texas Department of Insurance that authorizes the entity to provide
157	157	the types of health care services offered under the program; and
158	158	(3) satisfy, except as provided by this chapter, any
159	159	applicable requirement of the Insurance Code or another insurance
160	160	law of this state.
161	161	Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care
162	162	provider who provides health care services under the program must
163	163	meet certification and licensure requirements required by
164	164	commission rules and other law.
165	165	(b) In adopting rules governing the program, the executive
166	166	commissioner shall ensure that a health care provider who provides
167	167	health care services under the program is reimbursed at a rate that
168	168	is at least equal to the rate paid under Medicare for the provision
169	169	of the same or substantially similar services.
170	170	Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTH CARE
171	171	PROVIDERS. The executive commissioner shall adopt rules that
172	172	prohibit a health care provider from providing program health care
173	173	services for a reasonable period, as determined by the executive
174	174	commissioner, if the health care provider:
175	175	(1) fails to repay program overpayments; or
176	176	(2) owns, controls, manages, or is otherwise
177	177	affiliated with and has financial, managerial, or administrative
178	178	influence over a health care provider who has been suspended or
179	179	prohibited from providing program health care services.
180	180	SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE
181	181	Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An
182	182	individual is eligible to enroll in a program health benefit plan
183	183	if:
184	184	(1) the individual is:
185	185	(A) a citizen or permanent resident of the United
186	186	States; and
187	187	(B) 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, 2022, 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) to provide benefits to the individual under
197	197	the federal medical assistance program established under Title XIX,
198	198	Social Security Act (42 U.S.C. Section 1396 et seq.).
199	199	(b) An individual who is a parent or caretaker relative to
200	200	whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a
201	201	program health benefit plan.
202	202	(c) In determining eligibility for the program, the
203	203	commission shall apply the same eligibility criteria regarding
204	204	residency and citizenship in effect for Medicaid in this state on
205	205	December 31, 2022.
206	206	Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall
207	207	ensure that an individual who is initially determined or
208	208	redetermined to be eligible to participate in the program and
209	209	enroll in a program health benefit plan will remain eligible for
210	210	coverage under the plan for a period of 12 months beginning on the
211	211	first day of the month following the date eligibility was
212	212	determined or redetermined, subject to Section 537A.0252(f).
213	213	Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The
214	214	executive commissioner shall adopt an application form and
215	215	application procedures for the program. The form and procedures
216	216	must be coordinated with forms and procedures under Medicaid to
217	217	ensure that there is a single consolidated application process to
218	218	seek health benefit coverage under the program or Medicaid.
219	219	(b) To the extent possible, the commission shall make the
220	220	application form available in languages other than English.
221	221	(c) The executive commissioner may permit an individual to
222	222	apply by mail, over the telephone, or through the Internet.
223	223	Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
224	224	The executive commissioner shall adopt eligibility screening and
225	225	enrollment procedures or use the Texas Integrated Enrollment
226	226	Services eligibility determination system or a compatible system to
227	227	screen individuals and enroll eligible individuals in the program.
228	228	(b) The eligibility screening and enrollment procedures
229	229	must ensure that an individual applying for the program who appears
230	230	eligible for Medicaid is identified and assisted with obtaining
231	231	Medicaid coverage. If the individual is denied Medicaid coverage
232	232	but is determined eligible to enroll in a program health benefit
233	233	plan, the commission shall enroll the individual in a program
234	234	health benefit plan of the individual's choosing and for which the
235	235	individual is eligible without further application or
236	236	qualification.
237	237	(c) Not later than the 30th day after the date an individual
238	238	submits a complete application form and unless the individual is
239	239	identified and assisted with obtaining Medicaid coverage under
240	240	Subsection (b), the commission shall ensure that the individual's
241	241	eligibility to participate in the program is determined and that
242	242	the individual is provided with information on program health
243	243	benefit plans and program health benefit plan providers. The
244	244	commission shall enroll the individual in the program health
245	245	benefit plan and with the program health benefit plan provider of
246	246	the individual's choosing in a timely manner, as determined by the
247	247	commission.
248	248	(d) The executive commissioner may establish enrollment
249	249	periods for the program.
250	250	Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS;
251	251	DISENROLLMENT. (a) Not later than the 90th day before a
252	252	participant's coverage period expires, the commission shall notify
253	253	the participant regarding the eligibility redetermination process
254	254	and request documentation necessary to redetermine the
255	255	participant's eligibility.
256	256	(b) The commission shall provide written notice of
257	257	termination of eligibility to a participant not later than the 30th
258	258	day before the date the participant's eligibility will terminate.
259	259	The commission shall disenroll the participant from the program if:
260	260	(1) the participant does not submit the requested
261	261	eligibility redetermination documentation before the last day of
262	262	the participant's coverage period; or
263	263	(2) the commission, based on the submitted
264	264	documentation, determines the participant is no longer eligible for
265	265	the program, subject to Subchapter H.
266	266	(c) An individual may submit the requested eligibility
267	267	redetermination documentation not later than the 90th day after the
268	268	date the commission disenrolls the individual from the program. If
269	269	the commission determines that the individual continues to meet
270	270	program eligibility requirements, the commission shall reenroll
271	271	the individual in the program without any additional application
272	272	requirements.
273	273	(d) An individual who does not complete the eligibility
274	274	redetermination process in accordance with this section and who the
275	275	commission disenrolls from the program may not participate in the
276	276	program for a period of 180 days beginning on the date of
277	277	disenrollment. This subsection does not apply to an individual:
278	278	(1) described by Section 537A.0206 or 537A.0208; or
279	279	(2) who is:
280	280	(A) pregnant; or
281	281	(B) younger than 21 years of age.
282	282	(e) At the time the commission disenrolls a participant from
283	283	the program, the commission shall provide to the 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	participant's age, gender, and preexisting conditions. 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 sixth 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 the participant's program health benefit plan
529	529	requires. The commission shall issue to each participant an
530	530	electronic payment card that allows the participant to use the card
531	531	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 the program health benefit plan provider offers may earn money
538	538	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 the executive commissioner adopts in
556	556	accordance with that subsection. If a program health benefit plan
557	557	provider chooses to contribute money under this subsection, the
558	558	program health benefit plan provider shall determine the amount of
559	559	money to be contributed 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 the executive commissioner establishes under
564	564	Section 537A.0252.
565	565	(e) Contributions a program health benefit plan provider
566	566	makes under a rewards program that result in a participant's POWER
567	567	account balance exceeding the participant's required annual POWER
568	568	account contribution may be rolled over into the next coverage
569	569	period in accordance with Section 537A.0256.
570	570	(f) During the first coverage period of a participant who
571	571	uses one or more tobacco products, a program health benefit plan
572	572	provider shall actively attempt to engage the participant in and
573	573	provide educational materials to the participant on:
574	574	(1) smoking cessation activities for which the
575	575	participant may receive a monetary contribution under this section;
576	576	and
577	577	(2) other smoking cessation programs or resources
578	578	available to the participant.
579	579	Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall
580	580	distribute to each participant with a POWER account a monthly
581	581	statement that includes information on:
582	582	(1) the participant's POWER account activity during
583	583	the preceding month, including information on the cost of health
584	584	care services delivered to the participant during that month;
585	585	(2) the balance of money available in the POWER
586	586	account at the time the statement is issued; and
587	587	(3) the amount of any contributions due from the
588	588	participant.
589	589	Sec. 537A.0256. POWER ACCOUNT ROLL OVER. (a) The executive
590	590	commissioner by rule shall establish a process in accordance with
591	591	this section to roll over money in a participant's POWER account to
592	592	the succeeding coverage period. The commission shall calculate the
593	593	amount to be rolled over at the time the participant's program
594	594	eligibility is redetermined.
595	595	(b) For a participant enrolled in the basic plan, the
596	596	commission shall calculate the amount to be rolled over to a
597	597	subsequent coverage period POWER account from the participant's
598	598	current coverage period POWER account based on the amount of money
599	599	remaining in the participant's POWER account from the current
600	600	coverage period.
601	601	(c) For a participant enrolled in the plus plan who, as
602	602	determined by the commission, timely makes POWER account
603	603	contributions in accordance with this subchapter, the commission
604	604	shall calculate the amount to be rolled over to a subsequent
605	605	coverage period POWER account from the participant's current
606	606	coverage period POWER account based on:
607	607	(1) the amount of money remaining in the participant's
608	608	POWER account from the current coverage period; and
609	609	(2) the total amount of money the participant
610	610	contributed to the participant's POWER account during the current
611	611	coverage period.
612	612	(d) Except as provided by Subsection (e), a participant may
613	613	use money rolled over into the participant's POWER account for the
614	614	succeeding coverage period to offset required annual POWER account
615	615	contributions, as applicable, during that coverage period.
616	616	(e) A participant enrolled in the basic plan who rolls over
617	617	money into the participant's POWER account for the succeeding
618	618	coverage period and who chooses to enroll in the plus plan for that
619	619	coverage period may use the money rolled over to offset a maximum of
620	620	50 percent of the required annual POWER account contributions for
621	621	that coverage period.
622	622	Sec. 537A.0257. REFUND. If at the end of a participant's
623	623	coverage period the participant chooses to cease participating in a
624	624	program health benefit plan or is no longer eligible to participate
625	625	in a program health benefit plan, or if the commission disenrolls a
626	626	participant from the program health benefit plan under Section
627	627	537A.0258 for failure to pay required contributions, the commission
628	628	shall refund to the participant any money the participant
629	629	contributed that remains in the participant's POWER account at the
630	630	end of the coverage period or on the disenrollment date.
631	631	Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE POWER ACCOUNT
632	632	CONTRIBUTIONS. (a) For a participant whose annual household
633	633	income exceeds 100 percent of the federal poverty level and who
634	634	fails to make a contribution in accordance with Section 537A.0252,
635	635	the commission shall provide a 60-day grace period during which the
636	636	participant may make the contribution without penalty. If the
637	637	participant fails to make the contribution during the grace period,
638	638	the commission shall disenroll the participant from the program
639	639	health benefit plan in which the participant is enrolled and the
640	640	participant may not reenroll in a program health benefit plan
641	641	until:
642	642	(1) the 181st day after the disenrollment date; and
643	643	(2) the participant pays any debt accrued due to the
644	644	participant's failure to make the contribution.
645	645	(b) For a participant enrolled in the plus plan whose annual
646	646	household income is equal to or less than 100 percent of the federal
647	647	poverty level and who fails to make a contribution in accordance
648	648	with Section 537A.0252, the commission shall disenroll the
649	649	participant from the plus plan and enroll the participant in the
650	650	basic plan. A participant enrolled in the basic plan under this
651	651	subsection may not change enrollment to the plus plan until the
652	652	participant's program eligibility is redetermined.
653	653	SUBCHAPTER G. EMPLOYMENT AND WELLNESS INITIATIVES
654	654	Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The
655	655	commission shall develop and implement a gateway to work program
656	656	to:
657	657	(1) integrate existing job training and job search
658	658	programs available in this state through the Texas Workforce
659	659	Commission or other appropriate state agencies with the program;
660	660	and
661	661	(2) provide each participant with general information
662	662	on the job training and job search programs.
663	663	(b) Under the gateway to work program, the commission shall
664	664	refer each participant who is unemployed or working less than 20
665	665	hours a week to available job search and job training programs.
666	666	(c) Under the gateway to work program, the executive
667	667	commissioner by rule shall require as a condition to remain in the
668	668	program that each participant who is able to work demonstrate to the
669	669	commission's satisfaction a reasonable effort to secure and
670	670	maintain employment.
671	671	(d) The commission shall disenroll a participant from the
672	672	program if at the end of the participant's coverage period the
673	673	participant is unable to demonstrate a reasonable effort to secure
674	674	and maintain employment. A participant who is disenrolled from the
675	675	program under this section is ineligible to participate in the
676	676	program for a period of 12 months from the date of disenrollment.
677	677	Sec. 537A.0302. GATEWAY TO WELLNESS PROGRAM. (a) The
678	678	commission shall develop and implement a gateway to wellness
679	679	program to:
680	680	(1) integrate existing health care assistance
681	681	programs available in this state through the Texas Medical
682	682	Association, the Texas Department of Insurance, and other
683	683	appropriate state agencies with the program to ensure access to
684	684	preventative care services and providers under the program; and
685	685	(2) provide each participant with information on
686	686	available preventative care services and providers under the
687	687	program.
688	688	(b) Under the gateway to wellness program, the executive
689	689	commissioner by rule shall require as a condition to remain in the
690	690	program that each participant receive preventative care services
691	691	during a coverage period.
692	692	(c) The commission shall disenroll a participant from the
693	693	program if at the end of the participant's coverage period the
694	694	participant did not receive preventative care services required
695	695	under Subsection (b). A participant who is disenrolled from the
696	696	program under this section is ineligible to participate in the
697	697	program for a period of 12 months from the date of disenrollment.
698	698	SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN
699	699	PARTICIPANTS
700	700	Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR
701	701	CONTINUITY OF CARE. (a) The commission shall ensure continuity of
702	702	care by providing health care financial assistance in accordance
703	703	with and in the manner described by this subchapter for a
704	704	participant who:
705	705	(1) the commission disenrolls from a program health
706	706	benefit plan in accordance with Section 537A.0155 because the
707	707	participant's annual household income exceeds the income
708	708	eligibility requirements for enrollment in a program health benefit
709	709	plan; and
710	710	(2) seeks and obtains private health benefit coverage
711	711	within 12 months following the date of disenrollment.
712	712	(b) To receive health care financial assistance under this
713	713	subchapter, a participant must provide to the commission, in the
714	714	form and manner the commission requires, documentation showing the
715	715	participant has obtained or is actively seeking private health
716	716	benefit coverage.
717	717	(c) The commission may not impose an upper income
718	718	eligibility limit on a participant to receive health care financial
719	719	assistance under this subchapter.
720	720	Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE
721	721	FINANCIAL ASSISTANCE. (a) A participant described by Section
722	722	537A.0351 may receive health care financial assistance under this
723	723	subchapter until the first anniversary of the date the commission
724	724	disenrolled the participant from a program health benefit plan.
725	725	(b) Health care financial assistance the commission makes
726	726	available to a participant under this subchapter:
727	727	(1) may not exceed the amount described by Section
728	728	537A.0353; and
729	729	(2) may be used only to pay for eligible services
730	730	described by Section 537A.0354.
731	731	Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The
732	732	commission shall establish a bridge account for each participant
733	733	eligible to receive health care financial assistance under Section
734	734	537A.0351. The account is funded with money the commission
735	735	contributes in accordance with this section.
736	736	(b) The commission shall enable each participant for whom
737	737	the commission establishes a bridge account to access and manage
738	738	money in and information regarding the participant's account
739	739	through an electronic system. The commission may contract with the
740	740	same entity described by Section 537A.0251(b) or another entity
741	741	with appropriate experience and expertise to establish, implement,
742	742	or administer the electronic system.
743	743	(c) The commission shall fund each bridge account in an
744	744	amount equal to $1,000 using money the commission retains or
745	745	recoups:
746	746	(1) during the roll over process described by Section
747	747	537A.0256;
748	748	(2) following the issuance of a refund as described by
749	749	Section 537A.0257; or
750	750	(3) under Subsection (e).
751	751	(d) The commission may not require a participant to
752	752	contribute money to the participant's bridge account.
753	753	(e) The commission shall retain or recoup any unexpended
754	754	money in a participant's bridge account at the end of the period for
755	755	which the participant is eligible to receive health care financial
756	756	assistance under this subchapter for the purpose of funding another
757	757	participant's POWER account under Subchapter F or bridge account
758	758	under this subchapter.
759	759	Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The
760	760	commission shall issue to each participant for whom the commission
761	761	establishes a bridge account an electronic payment card that allows
762	762	the participant to use the card to pay costs for eligible services
763	763	described by Subsection (b).
764	764	(b) A participant may use money in the participant's bridge
765	765	account to pay:
766	766	(1) premium costs incurred during the private health
767	767	benefit coverage enrollment process and coverage period; and
768	768	(2) copayments, deductible costs, and coinsurance
769	769	associated with the private health benefit coverage the participant
770	770	obtains for health care services that would otherwise be
771	771	reimbursable under Medicaid.
772	772	(c) Costs described by Subsection (b)(2) associated with
773	773	eligible services delivered to a participant may be paid by:
774	774	(1) a participant using the electronic payment card
775	775	issued under Subsection (a); or
776	776	(2) a health care provider directly charging and
777	777	receiving payment from the participant's bridge account.
778	778	Sec. 537A.0355. ENROLLMENT COUNSELING. The commission
779	779	shall provide enrollment counseling to an individual who is seeking
780	780	private health benefit coverage and who is otherwise eligible to
781	781	receive health care financial assistance under this subchapter.
782	782	SECTION 2. As soon as practicable after the effective date
783	783	of this Act, the executive commissioner of the Health and Human
784	784	Services Commission shall apply for and actively pursue from the
785	785	federal Centers for Medicare and Medicaid Services or another
786	786	appropriate federal agency the waiver as required by Section
787	787	537A.0051, Government Code, as added by this Act. The commission
788	788	may delay implementing other provisions of this Act until the
789	789	waiver applied for under that section is granted.
790	790	SECTION 3. This Act takes effect immediately if it receives
791	791	a vote of two-thirds of all the members elected to each house, as
792	792	provided by Section 39, Article III, Texas Constitution. If this
793	793	Act does not receive the vote necessary for immediate effect, this
794	794	Act takes effect September 1, 2023.