Texas 2023 - 88th 3rd C.S.

Texas Senate Bill SB78 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	By: Johnson S.B. No. 78
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to the development and implementation of the Live Well
7	7	Texas program and the expansion of Medicaid eligibility to provide
8	8	health benefit coverage to certain individuals; imposing
9	9	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 Chapters 537A and 537B 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;
62	62	(F) support participants who become ineligible
63	63	to participate in a program health benefit plan in transitioning to
64	64	private health benefit coverage; and
65	65	(G) leverage enhanced federal medical assistance
66	66	percentage funding to minimize or eliminate the need for a program
67	67	enrollment cap; and
68	68	(2) allow for the operation of the program consistent
69	69	with the requirements of this chapter, except to the extent
70	70	deviation from the requirements is necessary to obtain federal
71	71	authorization of the waiver.
72	72	Sec. 537A.0052. FUNDING. Subject to approval of the waiver
73	73	described by Section 537A.0051, the commission shall implement the
74	74	program using enhanced federal medical assistance percentage
75	75	funding available under the Patient Protection and Affordable Care
76	76	Act (Pub. L. No. 111-148) as amended by the Health Care and
77	77	Education Reconciliation Act of 2010 (Pub. L. No. 111-152).
78	78	Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
79	79	(a) This chapter does not establish an entitlement to health
80	80	benefit coverage or health care financial assistance under the
81	81	program for eligible individuals.
82	82	(b) The program terminates at the time the share of federal
83	83	funding for the program under the Patient Protection and Affordable
84	84	Care Act (Pub. L. No. 111-148) as amended by the Health Care and
85	85	Education Reconciliation Act of 2010 (Pub. L. No. 111-152) is
86	86	reduced below 90 percent.
87	87	SUBCHAPTER C. PROGRAM ADMINISTRATION
88	88	Sec. 537A.0101. PROGRAM OBJECTIVE. The program's principal
89	89	objective is to provide primary and preventative health care
90	90	through high deductible program health benefit plans to eligible
91	91	individuals.
92	92	Sec. 537A.0102. PROGRAM PROMOTION. The commission shall
93	93	promote and provide information about the program to individuals
94	94	who:
95	95	(1) are potentially eligible to participate in the
96	96	program; and
97	97	(2) live in medically underserved areas of this state.
98	98	Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH
99	99	BENEFIT PLAN PROVIDER CONTRACTS. The commission may:
100	100	(1) enter into contracts with health benefit plan
101	101	providers under Section 537A.0107;
102	102	(2) monitor program health benefit plan providers
103	103	through reporting requirements and other means to ensure contract
104	104	performance and quality delivery of services;
105	105	(3) monitor the quality of services delivered to
106	106	participants through outcome measurements; and
107	107	(4) provide payment under the contracts to program
108	108	health benefit plan providers.
109	109	Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO
110	110	ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
111	111	(1) accept applications for health benefit coverage
112	112	under the program and implement program eligibility screening and
113	113	enrollment procedures;
114	114	(2) resolve grievances related to eligibility
115	115	determinations; and
116	116	(3) to the extent possible, coordinate the program
117	117	with Medicaid.
118	118	Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR
119	119	PROGRAM IMPLEMENTATION. (a) In administering the program, the
120	120	commission may contract with a third-party administrator to provide
121	121	enrollment and related services.
122	122	(b) If the commission contracts with a third-party
123	123	administrator under this section, the commission may:
124	124	(1) monitor the third-party administrator through
125	125	reporting requirements and other means to ensure contract
126	126	performance and quality delivery of services; and
127	127	(2) provide payment under the contract to the
128	128	third-party administrator.
129	129	(c) The executive commissioner shall retain all
130	130	policymaking authority over the program.
131	131	(d) The commission shall procure each contract with a
132	132	third-party administrator, as applicable, through a competitive
133	133	procurement process that complies with all federal and state laws.
134	134	Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a)
135	135	At the commission's request, the Texas Department of Insurance
136	136	shall provide any necessary assistance with the program. The
137	137	department shall monitor the quality of the services provided by
138	138	program health benefit plan providers and resolve grievances
139	139	related to those providers.
140	140	(b) The commission and the Texas Department of Insurance may
141	141	adopt a memorandum of understanding that addresses the
142	142	responsibilities of each agency with respect to the program.
143	143	(c) The Texas Department of Insurance, in consultation with
144	144	the commission, shall adopt rules as necessary to implement this
145	145	section.
146	146	Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS.
147	147	The commission shall select through a competitive procurement
148	148	process that complies with all federal and state laws and contract
149	149	with health benefit plan providers to provide health care services
150	150	under the program. To be eligible for a contract under this section,
151	151	an entity must:
152	152	(1) be a Medicaid managed care organization;
153	153	(2) hold a certificate of authority issued by the
154	154	Texas Department of Insurance that authorizes the entity to provide
155	155	the types of health care services offered under the program; and
156	156	(3) satisfy, except as provided by this chapter, any
157	157	applicable requirement of the Insurance Code or another insurance
158	158	law of this state.
159	159	Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care
160	160	provider who provides health care services under the program must
161	161	meet certification and licensure requirements required by
162	162	commission rules and other law.
163	163	(b) In adopting rules governing the program, the executive
164	164	commissioner shall ensure that a health care provider who provides
165	165	health care services under the program is reimbursed at a rate that
166	166	is at least equal to the rate paid under Medicare for the provision
167	167	of the same or substantially similar services.
168	168	Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTHCARE
169	169	PROVIDERS. The executive commissioner shall adopt rules that
170	170	prohibit a health care provider from providing program health care
171	171	services for a reasonable period, as determined by the executive
172	172	commissioner, if the health care provider:
173	173	(1) fails to repay program overpayments; or
174	174	(2) owns, controls, manages, or is otherwise
175	175	affiliated with and has financial, managerial, or administrative
176	176	influence over a health care provider who has been suspended or
177	177	prohibited from providing program health care services.
178	178	SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE
179	179	Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An
180	180	individual is eligible to enroll in a program health benefit plan
181	181	if:
182	182	(1) the individual is a resident of this state;
183	183	(2) the individual is 19 years of age or older but
184	184	younger than 65 years of age;
185	185	(3) applying the eligibility criteria in effect in
186	186	this state on December 31, 2022, the individual is not eligible for
187	187	Medicaid; and
188	188	(4) federal matching funds are available under the
189	189	Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as
190	190	amended by the Health Care and Education Reconciliation Act of 2010
191	191	(Pub. L. No. 111-152) to provide benefits to the individual under
192	192	the federal medical assistance program established under Title XIX,
193	193	Social Security Act (42 U.S.C. Section 1396 et seq.).
194	194	(b) An individual who is a parent or caretaker relative to
195	195	whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a
196	196	program health benefit plan.
197	197	(c) In determining eligibility for the program, the
198	198	commission shall apply the same eligibility criteria regarding
199	199	residency and citizenship in effect for Medicaid in this state on
200	200	December 31, 2022.
201	201	Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall
202	202	ensure that an individual who is initially determined or
203	203	redetermined to be eligible to participate in the program and
204	204	enroll in a program health benefit plan will remain eligible for
205	205	coverage under the plan for a period of 12 months beginning on the
206	206	first day of the month following the date eligibility was
207	207	determined or redetermined, subject to Section 537A.0252(f).
208	208	Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The
209	209	executive commissioner shall adopt an application form and
210	210	application procedures for the program. The form and procedures
211	211	must be coordinated with forms and procedures under Medicaid to
212	212	ensure that there is a single consolidated application process to
213	213	seek health benefit coverage under the program or Medicaid.
214	214	(b) To the extent possible, the commission shall make the
215	215	application form available in languages other than English.
216	216	(c) The executive commissioner may permit an individual to
217	217	apply by mail, over the telephone, or through the Internet.
218	218	Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
219	219	The executive commissioner shall adopt eligibility screening and
220	220	enrollment procedures or use the Texas Integrated Enrollment
221	221	Services eligibility determination system or a compatible system to
222	222	screen individuals and enroll eligible individuals in the program.
223	223	(b) The eligibility screening and enrollment procedures
224	224	must ensure that an individual applying for the program who appears
225	225	eligible for Medicaid is identified and assisted with obtaining
226	226	Medicaid coverage. If the individual is denied Medicaid coverage
227	227	but is determined eligible to enroll in a program health benefit
228	228	plan, the commission shall enroll the individual in a program
229	229	health benefit plan of the individual's choosing and for which the
230	230	individual is eligible without further application or
231	231	qualification.
232	232	(c) Not later than the 30th day after the date an individual
233	233	submits a complete application form and unless the individual is
234	234	identified and assisted with obtaining Medicaid coverage under
235	235	Subsection (b), the commission shall ensure that the individual's
236	236	eligibility to participate in the program is determined and that
237	237	the individual, if eligible, is provided with information on
238	238	program health benefit plans and program health benefit plan
239	239	providers. The commission shall enroll the individual in the
240	240	program health benefit plan and with the program health benefit
241	241	plan provider of the individual's choosing in a timely manner, as
242	242	determined by the commission.
243	243	(d) The executive commissioner may establish enrollment
244	244	periods for the program.
245	245	Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS;
246	246	DISENROLLMENT. (a) Not later than the 90th day before a
247	247	participant's coverage period expires, the commission shall notify
248	248	the participant regarding the eligibility redetermination process
249	249	and request documentation necessary to redetermine the
250	250	participant's eligibility.
251	251	(b) The commission shall provide written notice of
252	252	termination of eligibility to a participant not later than the 30th
253	253	day before the date the participant's eligibility will terminate.
254	254	The commission shall disenroll the participant from the program if:
255	255	(1) the participant does not submit the requested
256	256	eligibility redetermination documentation before the last day of
257	257	the participant's coverage period; or
258	258	(2) the commission, based on the submitted
259	259	documentation, determines the participant is no longer eligible for
260	260	the program, subject to Subchapter H.
261	261	(c) An individual may submit the requested eligibility
262	262	redetermination documentation not later than the 90th day after the
263	263	date the commission disenrolls the individual from the program. If
264	264	the commission determines that the individual continues to meet
265	265	program eligibility requirements, the commission shall reenroll
266	266	the individual in the program without any additional application
267	267	requirements.
268	268	(d) An individual who does not complete the eligibility
269	269	redetermination process in accordance with this section and who the
270	270	commission disenrolls from the program may not participate in the
271	271	program for a period of 180 days beginning on the date of
272	272	disenrollment. This subsection does not apply to an individual:
273	273	(1) described by Section 537A.0206 or 537A.0208; or
274	274	(2) who is:
275	275	(A) pregnant; or
276	276	(B) younger than 21 years of age.
277	277	(e) At the time the commission disenrolls a participant from
278	278	the program, the commission shall provide to the participant:
279	279	(1) notice that the participant may be eligible to
280	280	receive health care financial assistance under Subchapter H in
281	281	transitioning to private health benefit coverage; and
282	282	(2) information on and the eligibility requirements
283	283	for that financial assistance.
284	284	SUBCHAPTER E. BASIC AND PLUS PLANS
285	285	Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY.
286	286	(a) The basic and plus plans offered under the program must:
287	287	(1) comply with this subchapter and coverage
288	288	requirements prescribed by other law; and
289	289	(2) at a minimum, provide coverage for essential
290	290	health benefits required under 42 U.S.C. Section 18022(b).
291	291	(b) In modifying covered health benefits under the basic and
292	292	plus plans, the executive commissioner shall consider the health
293	293	care needs of healthy individuals and individuals with special
294	294	health care needs.
295	295	(c) The basic and plus plans must allow a participant with a
296	296	chronic, disabling, or life-threatening illness to select an
297	297	appropriate specialist as the participant's primary care
298	298	physician.
299	299	Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME
300	300	ELIGIBILITY. (a) The program must include a basic plan that is
301	301	sufficient to meet the basic health care needs of individuals who
302	302	enroll in the plan.
303	303	(b) The covered health benefits under the basic plan must
304	304	include:
305	305	(1) primary care physician services;
306	306	(2) prenatal and postpartum care;
307	307	(3) specialty care physician visits;
308	308	(4) home health services, not to exceed 100 visits per
309	309	year;
310	310	(5) outpatient surgery;
311	311	(6) allergy testing;
312	312	(7) chemotherapy;
313	313	(8) intravenous infusion services;
314	314	(9) radiation therapy;
315	315	(10) dialysis;
316	316	(11) emergency care hospital services;
317	317	(12) emergency transportation, including ambulance
318	318	and air ambulance;
319	319	(13) urgent care clinic services;
320	320	(14) hospitalization, including for:
321	321	(A) general inpatient hospital care;
322	322	(B) inpatient physician services;
323	323	(C) inpatient surgical services;
324	324	(D) non-cosmetic reconstructive surgery;
325	325	(E) a transplant;
326	326	(F) treatment for a congenital abnormality;
327	327	(G) anesthesia;
328	328	(H) hospice care; and
329	329	(I) care in a skilled nursing facility for a
330	330	period not to exceed 100 days per occurrence;
331	331	(15) inpatient and outpatient behavioral health
332	332	services;
333	333	(16) inpatient, outpatient, and residential substance
334	334	use treatment;
335	335	(17) prescription drugs, including tobacco cessation
336	336	drugs;
337	337	(18) inpatient and outpatient rehabilitative and
338	338	habilitative care, including physical, occupational, and speech
339	339	therapy, not to exceed 60 combined visits per year;
340	340	(19) medical equipment, appliances, and assistive
341	341	technology, including prosthetics and hearing aids, and the repair,
342	342	technical support, and customization needed for individual use;
343	343	(20) laboratory and pathology tests and services;
344	344	(21) diagnostic imaging, including x-rays, magnetic
345	345	resonance imaging, computed tomography, and positron emission
346	346	tomography;
347	347	(22) preventative care services as described by
348	348	Section 537A.0204; and
349	349	(23) services under the early and periodic screening,
350	350	diagnostic, and treatment program for participants who are younger
351	351	than 21 years of age.
352	352	(c) To be eligible for health care benefits under the basic
353	353	plan, an individual who is eligible for the program must have an
354	354	annual household income that is equal to or less than 100 percent of
355	355	the federal poverty level.
356	356	Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY.
357	357	(a) The program must include a plus plan that includes the covered
358	358	health benefits listed in Section 537A.0202 and the following
359	359	additional enhanced health benefits:
360	360	(1) services related to the treatment of conditions
361	361	affecting the temporomandibular joint;
362	362	(2) dental care;
363	363	(3) vision care;
364	364	(4) notwithstanding Section 537A.0202(b)(18),
365	365	inpatient and outpatient rehabilitative and habilitative care,
366	366	including physical, occupational, and speech therapy, not to exceed
367	367	75 combined visits per year;
368	368	(5) bariatric surgery; and
369	369	(6) other services the commission considers
370	370	appropriate.
371	371	(b) An individual who is eligible for the program and whose
372	372	annual household income exceeds 100 percent of the federal poverty
373	373	level will automatically be enrolled in and receive health benefits
374	374	under the plus plan. An individual who is eligible for the program
375	375	and whose annual household income is equal to or less than 100
376	376	percent of the federal poverty level may choose to enroll in the
377	377	plus plan.
378	378	(c) A participant enrolled in the plus plan is required to
379	379	make POWER account contributions in accordance with Section
380	380	537A.0252.
381	381	Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The
382	382	commission shall provide to each participant a list of health care
383	383	services that qualify as preventative care services based on the
384	384	participant's age, gender, and preexisting conditions. In
385	385	developing the list, the commission shall consult with the federal
386	386	Centers for Disease Control and Prevention.
387	387	(b) A program health benefit plan shall, at no cost to the
388	388	participant, provide coverage for:
389	389	(1) preventative care services described by 42 U.S.C.
390	390	Section 300gg-13; and
391	391	(2) a maximum of $500 per year of preventative care
392	392	services other than those described by Subdivision (1).
393	393	(c) A participant who receives preventative care services
394	394	not described by Subsection (b) that are covered under the
395	395	participant's program health benefit plan is subject to deductible
396	396	and copayment requirements for the services in accordance with the
397	397	terms of the plan.
398	398	Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in
399	399	the basic plan shall pay a copayment for each covered health benefit
400	400	except for a preventative care or family planning service. The
401	401	executive commissioner by rule shall adopt a copayment schedule for
402	402	basic plan services, subject to Subsection (c).
403	403	(b) Except as provided by Subsection (c), a participant
404	404	enrolled in the plus plan may not be required to pay a copayment for
405	405	a covered service.
406	406	(c) A participant enrolled in the basic or plus plan shall
407	407	pay a copayment in an amount set by commission rule not to exceed
408	408	$25 for nonemergency use of hospital emergency department services
409	409	unless:
410	410	(1) the participant has met the cost-sharing maximum
411	411	for the calendar quarter, as prescribed by commission rule;
412	412	(2) the participant is referred to the hospital
413	413	emergency department by a health care provider;
414	414	(3) the visit is a true emergency, as defined by
415	415	commission rule; or
416	416	(4) the participant is pregnant.
417	417	Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE
418	418	MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R.
419	419	Section 440.315 who is enrolled in the basic or plus plan is
420	420	entitled to receive under the program all health benefits that
421	421	would be available under the state Medicaid plan.
422	422	(b) A participant to which this section applies is subject
423	423	to the cost-sharing requirements, including copayment and POWER
424	424	account contribution requirements, of the program health benefit
425	425	plan in which the participant is enrolled.
426	426	(c) The commission shall develop screening measures to
427	427	identify participants to which this section applies.
428	428	Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant
429	429	who becomes pregnant while enrolled in the program and who meets the
430	430	eligibility requirements for Medicaid may choose to remain in the
431	431	program or enroll in Medicaid.
432	432	(b) A pregnant participant described by Subsection (a) who
433	433	is enrolled in the basic or plus plan and who remains in the program
434	434	is:
435	435	(1) notwithstanding Section 537A.0205, not subject to
436	436	any cost-sharing requirements, including copayment and POWER
437	437	account contribution requirements, of the program health benefit
438	438	plan in which the participant is enrolled until the expiration of
439	439	the second month following the month in which the pregnancy ends;
440	440	(2) entitled to receive as a Medicaid wrap-around
441	441	benefit all Medicaid services a pregnant woman enrolled in Medicaid
442	442	is entitled to receive, including a pharmacy benefit, when the
443	443	participant exceeds coverage limits under the participant's
444	444	program health benefit plan or if a service is not covered by the
445	445	plan; and
446	446	(3) eligible for additional vision and dental care
447	447	benefits.
448	448	Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A
449	449	parent or caretaker relative to whom 42 C.F.R. Section 435.110
450	450	applies is entitled to receive as a Medicaid wrap-around benefit
451	451	all Medicaid services to which the individual would be entitled
452	452	under the state Medicaid plan that are not covered under the
453	453	individual's program health benefit plan or exceed the plan's
454	454	coverage limits.
455	455	(b) An individual described by Subsection (a) who chooses to
456	456	participate in the program is subject to the cost-sharing
457	457	requirements, including copayment and POWER account contribution
458	458	requirements, of the program health benefit plan in which the
459	459	individual is enrolled.
460	460	SUBCHAPTER F. PERSONAL WELLNESS AND RESPONSIBILITY (POWER)
461	461	ACCOUNTS
462	462	Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF POWER
463	463	ACCOUNTS. (a) The commission shall establish a personal wellness
464	464	and responsibility (POWER) account for each participant who is
465	465	enrolled in a program health benefit plan that is funded with money
466	466	contributed in accordance with this subchapter.
467	467	(b) The commission shall enable each participant to access
468	468	and manage money in and information regarding the participant's
469	469	POWER account through an electronic system. The commission may
470	470	contract with an entity that has appropriate experience and
471	471	expertise to establish, implement, or administer the electronic
472	472	system.
473	473	(c) Except as otherwise provided by Section 537A.0252, the
474	474	commission shall require each participant to contribute to the
475	475	participant's POWER account in amounts described by that section.
476	476	Sec. 537A.0252. POWER ACCOUNT CONTRIBUTIONS; DEDUCTIBLE.
477	477	(a) The executive commissioner by rule shall establish an annual
478	478	universal deductible for each participant enrolled in the basic or
479	479	plus plan.
480	480	(b) To ensure each participant's POWER account contains a
481	481	sufficient amount of money at the beginning of a coverage period,
482	482	the commission shall, before the beginning of that period, fund
483	483	each account with the following amounts:
484	484	(1) for a participant enrolled in the basic plan, the
485	485	annual universal deductible amount; and
486	486	(2) for a participant enrolled in the plus plan, the
487	487	difference between the annual universal deductible amount and the
488	488	participant's required annual contribution as determined by the
489	489	schedule established under Subsection (c).
490	490	(c) The executive commissioner by rule shall establish a
491	491	graduated annual POWER account contribution schedule for
492	492	participants enrolled in the plus plan that:
493	493	(1) is based on a participant's annual household
494	494	income, with participants whose annual household incomes are less
495	495	than the federal poverty level paying progressively less and
496	496	participants whose annual household incomes are equal to or greater
497	497	than the federal poverty level paying progressively more; and
498	498	(2) may not require a participant to contribute more
499	499	than a total of five percent of the participant's annual household
500	500	income to the participant's POWER account.
501	501	(d) A participant's employer may contribute on behalf of the
502	502	participant any amount of the participant's annual POWER account
503	503	contribution. A nonprofit organization may contribute on behalf of
504	504	a participant any amount of the participant's annual POWER account
505	505	contribution.
506	506	(e) Subject to the contribution cap described by Subsection
507	507	(c)(2) and not before the expiration of the participant's first
508	508	coverage period, the commission shall require a participant who
509	509	uses one or more tobacco products to contribute to the
510	510	participant's POWER account an annual POWER account contribution
511	511	amount that is one percent more than the participant would
512	512	otherwise be required to contribute under the schedule established
513	513	under Subsection (c).
514	514	(f) An annual POWER account contribution must be paid by or
515	515	on behalf of a participant monthly in installments that are at least
516	516	equal to one-twelfth of the total required contribution. The
517	517	coverage period for a participant whose annual household income
518	518	exceeds 100 percent of the federal poverty level may not begin until
519	519	the first day of the first month following the month in which the
520	520	first monthly installment is received.
521	521	Sec. 537A.0253. USE OF POWER ACCOUNT MONEY. A participant
522	522	may use money in the participant's POWER account to pay copayments
523	523	and deductible costs the participant's program health benefit plan
524	524	requires. The commission shall issue to each participant an
525	525	electronic payment card that allows the participant to use the card
526	526	to pay the program health benefit plan costs.
527	527	Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER
528	528	REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS;
529	529	SMOKING CESSATION INITIATIVE. (a) A program health benefit plan
530	530	provider shall establish a rewards program through which a
531	531	participant receiving health care through a program health benefit
532	532	plan the program health benefit plan provider offers may earn money
533	533	to be contributed to the participant's POWER account.
534	534	(b) Under a rewards program, a program health benefit plan
535	535	provider shall contribute money to a participant's POWER account if
536	536	the participant engages in certain healthy behaviors. The executive
537	537	commissioner by rule shall determine:
538	538	(1) the behaviors in which a participant must engage
539	539	to receive a contribution, which must include behaviors related to:
540	540	(A) completion of a health risk assessment;
541	541	(B) smoking cessation; and
542	542	(C) as applicable, chronic disease management;
543	543	and
544	544	(2) the amount of money a program health benefit plan
545	545	provider shall contribute for each behavior described by
546	546	Subdivision (1).
547	547	(c) Subsection (b) does not prevent a program health benefit
548	548	plan provider from contributing money to a participant's POWER
549	549	account if the participant engages in a behavior not specified by
550	550	that subsection or a rule the executive commissioner adopts in
551	551	accordance with that subsection. If a program health benefit plan
552	552	provider chooses to contribute money under this subsection, the
553	553	program health benefit plan provider shall determine the amount of
554	554	money to be contributed for the behavior.
555	555	(d) A participant may use contributions a program health
556	556	benefit plan provider makes under a rewards program to offset a
557	557	maximum of 50 percent of the participant's required annual POWER
558	558	account contribution the executive commissioner establishes under
559	559	Section 537A.0252.
560	560	(e) Contributions a program health benefit plan provider
561	561	makes under a rewards program that result in a participant's POWER
562	562	account balance exceeding the participant's required annual POWER
563	563	account contribution may be rolled over into the next coverage
564	564	period in accordance with Section 537A.0256.
565	565	(f) During the first coverage period of a participant who
566	566	uses one or more tobacco products, a program health benefit plan
567	567	provider shall actively attempt to engage the participant in and
568	568	provide educational materials to the participant on:
569	569	(1) smoking cessation activities for which the
570	570	participant may receive a monetary contribution under this section;
571	571	and
572	572	(2) other smoking cessation programs or resources
573	573	available to the participant.
574	574	Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall
575	575	distribute to each participant with a POWER account a monthly
576	576	statement that includes information on:
577	577	(1) the participant's POWER account activity during
578	578	the preceding month, including information on the cost of health
579	579	care services delivered to the participant during that month;
580	580	(2) the balance of money available in the POWER
581	581	account at the time the statement is issued; and
582	582	(3) the amount of any contributions due from the
583	583	participant.
584	584	Sec. 537A.0256. POWER ACCOUNT ROLL OVER. (a) The executive
585	585	commissioner by rule shall establish a process in accordance with
586	586	this section to roll over money in a participant's POWER account to
587	587	the succeeding coverage period. The commission shall calculate the
588	588	amount to be rolled over at the time the participant's program
589	589	eligibility is redetermined.
590	590	(b) For a participant enrolled in the basic plan, the
591	591	commission shall calculate the amount to be rolled over to a
592	592	subsequent coverage period POWER account from the participant's
593	593	current coverage period POWER account based on:
594	594	(1) the amount of money remaining in the participant's
595	595	POWER account from the current coverage period; and
596	596	(2) whether the participant received recommended
597	597	preventative care services during the current coverage period.
598	598	(c) For a participant enrolled in the plus plan who, as
599	599	determined by the commission, timely makes POWER account
600	600	contributions in accordance with this subchapter, the commission
601	601	shall calculate the amount to be rolled over to a subsequent
602	602	coverage period POWER account from the participant's current
603	603	coverage period POWER account based on:
604	604	(1) the amount of money remaining in the participant's
605	605	POWER account from the current coverage period;
606	606	(2) the total amount of money the participant
607	607	contributed to the participant's POWER account during the current
608	608	coverage period; and
609	609	(3) whether the participant received recommended
610	610	preventative care services during the current coverage period.
611	611	(d) Except as provided by Subsection (e), a participant may
612	612	use money rolled over into the participant's POWER account for the
613	613	succeeding coverage period to offset required annual POWER account
614	614	contributions, as applicable, during that coverage period.
615	615	(e) A participant enrolled in the basic plan who rolls over
616	616	money into the participant's POWER account for the succeeding
617	617	coverage period and who chooses to enroll in the plus plan for that
618	618	coverage period may use the money rolled over to offset a maximum of
619	619	50 percent of the required annual POWER account contributions for
620	620	that coverage period.
621	621	Sec. 537A.0257. REFUND. If at the end of a participant's
622	622	coverage period the participant chooses to cease participating in a
623	623	program health benefit plan or is no longer eligible to participate
624	624	in a program health benefit plan, or if the commission disenrolls a
625	625	participant from the program health benefit plan under Section
626	626	537A.0258 for failure to pay required contributions, the commission
627	627	shall refund to the participant any money the participant
628	628	contributed that remains in the participant's POWER account at the
629	629	end of the coverage period or on the disenrollment date.
630	630	Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE POWER ACCOUNT
631	631	CONTRIBUTIONS. (a) For a participant whose annual household
632	632	income exceeds 100 percent of the federal poverty level and who
633	633	fails to make a contribution in accordance with Section 537A.0252,
634	634	the commission shall provide a 60-day grace period during which the
635	635	participant may make the contribution without penalty. If the
636	636	participant fails to make the contribution during the grace period,
637	637	the commission shall disenroll the participant from the program
638	638	health benefit plan in which the participant is enrolled and the
639	639	participant may not reenroll in a program health benefit plan
640	640	until:
641	641	(1) the 181st day after the disenrollment date; and
642	642	(2) the participant pays any debt accrued due to the
643	643	participant's failure to make the contribution.
644	644	(b) For a participant enrolled in the plus plan whose annual
645	645	household income is equal to or less than 100 percent of the federal
646	646	poverty level and who fails to make a contribution in accordance
647	647	with Section 537A.0252, the commission shall disenroll the
648	648	participant from the plus plan and enroll the participant in the
649	649	basic plan. A participant enrolled in the basic plan under this
650	650	subsection may not change enrollment to the plus plan until the
651	651	participant's program eligibility is redetermined.
652	652	SUBCHAPTER G. EMPLOYMENT INITIATIVE
653	653	Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The
654	654	commission shall develop and implement a gateway to work program
655	655	to:
656	656	(1) integrate existing job training and job search
657	657	programs available in this state through the Texas Workforce
658	658	Commission or other appropriate state agencies with the Live Well
659	659	Texas program; and
660	660	(2) provide each participant with general information
661	661	on the job training and job search programs.
662	662	(b) Under the gateway to work program, the commission shall
663	663	refer each participant who is unemployed or working less than 20
664	664	hours a week to available job search and job training programs.
665	665	SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN
666	666	PARTICIPANTS
667	667	Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR
668	668	CONTINUITY OF CARE. (a) The commission shall ensure continuity of
669	669	care by providing health care financial assistance in accordance
670	670	with and in the manner described by this subchapter for a
671	671	participant who:
672	672	(1) the commission disenrolls from a program health
673	673	benefit plan in accordance with Section 537A.0155 because the
674	674	participant's annual household income exceeds the income
675	675	eligibility requirements for enrollment in a program health benefit
676	676	plan; and
677	677	(2) seeks and obtains private health benefit coverage
678	678	within 12 months following the date of disenrollment.
679	679	(b) To receive health care financial assistance under this
680	680	subchapter, a participant must provide to the commission, in the
681	681	form and manner the commission requires, documentation showing the
682	682	participant has obtained or is actively seeking private health
683	683	benefit coverage.
684	684	(c) The commission may not impose an upper income
685	685	eligibility limit on a participant to receive health care financial
686	686	assistance under this subchapter.
687	687	Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE
688	688	FINANCIAL ASSISTANCE. (a) A participant described by Section
689	689	537A.0351 may receive health care financial assistance under this
690	690	subchapter until the first anniversary of the date the commission
691	691	disenrolled the participant from a program health benefit plan.
692	692	(b) Health care financial assistance the commission makes
693	693	available to a participant under this subchapter:
694	694	(1) may not exceed the amount described by Section
695	695	537A.0353; and
696	696	(2) may be used only to pay for eligible services
697	697	described by Section 537A.0354.
698	698	Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The
699	699	commission shall establish a bridge account for each participant
700	700	eligible to receive health care financial assistance under Section
701	701	537A.0351. The account is funded with money the commission
702	702	contributes in accordance with this section.
703	703	(b) The commission shall enable each participant for whom
704	704	the commission establishes a bridge account to access and manage
705	705	money in and information regarding the participant's account
706	706	through an electronic system. The commission may contract with the
707	707	same entity described by Section 537A.0251(b) or another entity
708	708	with appropriate experience and expertise to establish, implement,
709	709	or administer the electronic system.
710	710	(c) The commission shall fund each bridge account in an
711	711	amount equal to $1,000 using money the commission retains or
712	712	recoups:
713	713	(1) during the roll over process described by Section
714	714	537A.0256;
715	715	(2) following the issuance of a refund as described by
716	716	Section 537A.0257; or
717	717	(3) under Subsection (e).
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 the commission
728	728	establishes a bridge account an electronic payment card that allows
729	729	the 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 the participant
737	737	obtains 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	CHAPTER 537B. EXPANDED MEDICAID ELIGIBILITY FOR CERTAIN
750	750	INDIVIDUALS
751	751	Sec. 537B.0001. APPLICABILITY. This chapter applies only
752	752	to an individual who would be eligible to participate in the Live
753	753	Well Texas program under Chapter 537A based on the eligibility
754	754	requirements described by Section 537A.0151, if the commission were
755	755	to establish the program.
756	756	Sec. 537B.0002. EXPANDED MEDICAID ELIGIBILITY UNDER
757	757	PATIENT PROTECTION AND AFFORDABLE CARE ACT. (a) Except as provided
758	758	by Subsection (b) and notwithstanding any other law, the commission
759	759	shall provide Medicaid benefits to all individuals who apply for
760	760	those benefits and to whom this chapter applies.
761	761	(b) After the waiver described by Section 537A.0051 is
762	762	approved and the commission implements the Live Well Texas program
763	763	under Chapter 537A, the commission shall:
764	764	(1) provide health benefit coverage through that
765	765	program in accordance with Chapter 537A to individuals to whom this
766	766	chapter applies; and
767	767	(2) cease providing Medicaid benefits to those
768	768	individuals, except as provided by Chapter 537A.
769	769	(c) The commission shall:
770	770	(1) continue to provide Medicaid benefits to
771	771	individuals described by Subsection (a) if the waiver described by
772	772	Section 537A.0051 is not approved; and
773	773	(2) resume providing Medicaid benefits to individuals
774	774	described by Subsection (a) if the Live Well Texas program
775	775	implemented under Chapter 537A terminates in accordance with
776	776	Section 537A.0053(b).
777	777	(d) The executive commissioner shall adopt rules regarding
778	778	the provision of Medicaid benefits as required by this section,
779	779	including, as applicable, rules on transitioning individuals from
780	780	receiving Medicaid benefits under this section to receiving health
781	781	benefit coverage under the Live Well Texas program implemented
782	782	under Chapter 537A.
783	783	SECTION 2. As soon as practicable after the effective date
784	784	of this Act, the executive commissioner of the Health and Human
785	785	Services Commission shall apply for and actively pursue from the
786	786	federal Centers for Medicare and Medicaid Services or another
787	787	appropriate federal agency the waiver as required by Section
788	788	537A.0051, Government Code, as added by this Act. The commission
789	789	may delay implementing other provisions of Chapter 537A, Government
790	790	Code, as added by this Act, until the waiver applied for under that
791	791	section is granted.
792	792	SECTION 3. (a) Chapter 537B, Government Code, as added by
793	793	this Act, applies only to an initial determination or
794	794	recertification of an individual's Medicaid eligibility under
795	795	Chapter 32, Human Resources Code, made on or after the
796	796	implementation of Chapter 537B, regardless of the date the
797	797	individual applied for Medicaid.
798	798	(b) As soon as practicable after the effective date of this
799	799	Act, the executive commissioner of the Health and Human Services
800	800	Commission shall take all necessary actions to expand Medicaid
801	801	eligibility in accordance with Chapter 537B, Government Code, as
802	802	added by this Act, including notifying appropriate federal agencies
803	803	of that expanded eligibility. If before implementing Chapter 537B a
804	804	state agency determines that any other waiver or authorization from
805	805	a federal agency is necessary for implementation of that chapter,
806	806	the agency affected by the chapter shall request the waiver or
807	807	authorization and may delay implementing that chapter until the
808	808	waiver or authorization is granted.
809	809	SECTION 4. This Act takes effect immediately if it receives
810	810	a vote of two-thirds of all the members elected to each house, as
811	811	provided by Section 39, Article III, Texas Constitution. If this
812	812	Act does not receive the vote necessary for immediate effect, this
813	813	Act takes effect on the 91st day after the last day of the
814	814	legislative session.