88R4080 MM-D
By: Oliverson H.B. No. 4541
A BILL TO BE ENTITLED
AN ACT
relating to the establishment of a pilot program to provide
comprehensive whole child care for children with complex medical
needs.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 531, Government Code, is
amended by adding Section 531.06051 to read as follows:
Sec. 531.06051. PILOT PROGRAM FOR COMPREHENSIVE WHOLE CHILD
CARE FOR CHILDREN WITH COMPLEX MEDICAL NEEDS. (a) In this section:
(1) "Child with complex medical needs" means a child
who has:
(A) one or more chronic health conditions that:
(i) affect three or more organ systems; and
(ii) result in severe functional
limitations, high health care needs or utilization, or the need for
or use of medical technology; or
(B) one life-limiting illness or rare pediatric
disease as defined in Section 529(a)(3) of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C. 360ff(a)(3)).
(2) "Pilot program" means the comprehensive whole
child care for children with complex medical needs pilot program
established under this section.
(3) "Recipient" means a recipient of Medicaid.
(4) "Specialty provider" means a person who provides
health-related goods or services to a recipient, including a
provider of medication, therapy services, or durable medical
equipment or other equipment.
(b) The commission shall enter into an agreement with the
Dell Medical School at The University of Texas at Austin to develop
and implement in one or more areas of this state a phased pilot
program to establish an alternative model of care using existing
capitated rates outside the managed care model to provide
transformative, comprehensive multidisciplinary whole child care
and fully integrated health homes for children with complex medical
needs.
(c) The pilot program shall be designed to:
(1) develop, improve, and increase access to service
delivery innovations and comprehensive care centers of excellence
throughout this state for children with complex medical needs;
(2) incorporate and develop increased capacity
through a phased approach for children to receive:
(A) intermediate and post-acute care services;
(B) pediatric palliative and hospice care; and
(C) transition services and continuity of care;
(3) improve delivery and access in rural communities;
(4) continue to build and improve capacity to provide
health care services using telecommunications and information
technology;
(5) use existing electronic medical records systems to
integrate and streamline technology to improve access to care and
health outcomes for children participating in the program, track
the use of funding and best practices for maximizing money spent
under the pilot program, and better coordinate care, including with
respect to:
(A) diagnoses and cohesive care plans;
(B) treatment plans;
(C) telemedicine medical services and telehealth
services; and
(D) coordinated access and integration with home
health providers;
(6) develop and align targeted incentives to induce
integration and true value-based care that will result in:
(A) cohesive, coordinated multidisciplinary care
with improved health outcomes for children participating in the
program and long-term cost effectiveness;
(B) continuity of care for children
participating in the program; and
(C) reduced emergency room visits and
hospitalizations;
(7) identify shared needs to improve health outcomes,
including behavioral, social, and familial needs;
(8) use and incentivize appropriate and meaningful
quality outcome measures customized and tailored for children with
complex medical needs, including:
(A) improving coordination of care and access to
services;
(B) developing a shared plan of care;
(C) reducing unscheduled hospitalizations;
(D) reducing unmet needs; and
(E) encouraging families to be shared decision
makers;
(9) allow physicians or the medical team of a child
with complex medical needs to determine medical necessity of the
services recommended or provided for the child;
(10) allow the parent or guardian of a child with
complex medical needs to opt the child out of receiving benefits
through the STAR Kids managed care program and instead have the
child receive benefits under the pilot program; and
(11) be administered by a neutral board established by
the Dell Medical School at The University of Texas at Austin.
(d) Under the pilot program, the commission may take any
measures permitted under federal law that are necessary to:
(1) supersede and rework existing systemic and
regulatory barriers to care and integration for children with
complex medical needs under Medicaid;
(2) reduce administrative burdens inherent in the
current Medicaid system while maintaining high accountability
standards;
(3) adopt a specific procedure or other billing code
under Medicaid for a health care provider to diagnose or treat
conditions specific to children with complex medical needs,
including for:
(A) a value-based whole child visit to include a
bundled payment for multidisciplinary whole child complex care;
(B) care coordination;
(C) family support;
(D) intermediate and post-acute care;
(E) transition services;
(F) mid-tier caregiver workforce providers,
including certified nursing assistant care; and
(G) parents as paid caregivers; and
(4) allow a third-party payor to act in the capacity of
a preferred provider organization operating under Chapter 1301,
Insurance Code.
(e) The commission, in coordination with the Dell Medical
School at The University of Texas at Austin, shall develop a
statewide, neutral third-party de-identified data collection
registry to:
(1) improve access to care and recipient outcomes
under the pilot program;
(2) track funding and cost effectiveness,
utilization, clinical practices, safety and effectiveness, and the
allocation of resources under the pilot program; and
(3) identify best practices for the provision of care
to children with complex medical needs.
(e-1) The registry developed under Subsection (e) must be
integrated and coordinated with the all payor claims database
established under Subchapter I, Chapter 38, Insurance Code.
(f) For purposes of funding the pilot program, the
commission may:
(1) establish a Medicaid directed provider payment
program for children with complex medical needs who are enrolled in
the STAR Kids managed care program and make a portion of the
directed provider payment program funds available for the pilot
program based on the recipient's anticipated or actual
participation in the pilot program;
(2) obtain additional federal money under the
Advancing Care for Exceptional (ACE) Kids Act of 2019 enacted as
part of the Medicaid Services Investment and Accountability Act of
2019 (Pub. L. No. 116-16);
(3) leverage enhanced federal medical assistance
percentage funding related to establishing health homes available
under the Patient Protection and Affordable Care Act (Pub. L.
No. 111-148) as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. No. 111-152); and
(4) make funds available from a portion of STAR Kids
managed care program experience rebates.
(g) Not later than March 1, 2025, the commission, in
coordination with the Dell Medical School at The University of
Texas at Austin, shall prepare and submit to the governor,
lieutenant governor, and speaker of the house of representatives a
written report that includes:
(1) a summary of the pilot program's progress;
(2) an assessment of the impact of providing
transformative, comprehensive multidisciplinary whole child care
and fully integrated health homes for children with complex medical
needs;
(3) an update on any waiver or amendment request
necessary to modify the state Medicaid plan to provide the level of
care and health homes for children with complex medical needs
necessary under the pilot program;
(4) a description of the level of care and status of
health homes being provided to children with complex medical needs
at the time the report is prepared;
(5) an analysis of the effectiveness of providing the
level of care and health homes for children with complex medical
needs at the level at which those services are provided at the time
the report is prepared;
(6) estimates of the costs and potential savings of
expanding health programs administered by the commission to meet
the needs of children with complex medical needs;
(7) proposed modification to eligibility criteria for
providing the level of care and health homes for children with
complex medical needs under the pilot program; and
(8) any legislative recommendations.
(h) Not later than September 1, 2028, the commission shall
prepare and submit to the governor, lieutenant governor, and
speaker of the house of representatives a final written report on
the pilot program that includes:
(1) a summary of the results of the pilot program;
(2) a statement on the pilot program's success in
providing transformative, comprehensive multidisciplinary whole
child care and fully integrated health homes for children with
complex medical needs;
(3) a recommendation as to whether the pilot program
should be continued as a pilot program or permanent program; and
(4) any legislative recommendations.
(i) The pilot program established under this section
concludes September 1, 2028.
(j) This section expires September 1, 2029.
SECTION 2. Section 531.0605, Government Code, is repealed.
SECTION 3. If before implementing any provision of this Act
a state agency determines that a waiver or authorization, including
a state plan amendment, from a federal agency is necessary for
implementation of that provision, the agency affected by the
provision shall request the waiver or authorization and may delay
implementing that provision until the waiver or authorization is
granted.
SECTION 4. This Act takes effect September 1, 2023.