89R11869 JG-F
By: Manuel H.B. No. 5244
A BILL TO BE ENTITLED
AN ACT
relating to the development and implementation of the Texas Plan
demonstration program to fund the purchase by and provision to
certain eligible individuals of health care services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle I, Title 4, Government Code, is amended
by adding Chapter 532A to read as follows:
CHAPTER 532A. TEXAS PLAN DEMONSTRATION PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 532A.0001. DEFINITIONS. In this chapter:
(1) "Board" means the board of directors of the
med-pool.
(2) "Eligible individual" means an individual who is
eligible to participate in the program.
(3) "Health benefit account" means a health benefit
account the comptroller establishes for a participant under
Subchapter E.
(4) "Health care provider" means:
(A) a primary care provider;
(B) a specialty and major medical care provider;
and
(C) an integrated health care organization.
(5) "Integrated health care organization" means a
health care organization that provides all of a participant's
health care needs, including primary care and specialty and major
medical care services, using a capitated payment model.
(6) "Med-pool" means the risk pool established under
Subchapter F to provide specialty and major medical care services
to participants.
(7) "Nondiscriminatory price" means a fixed,
transparent, nonnegotiable price for a health care service that a
health care provider charges each individual for the service
regardless of the payment model used to pay for the service.
(8) "Participant" means an individual who is enrolled
in the program.
(9) "Primary care provider" means a provider of
primary care services.
(10) "Primary care services" includes whole-person,
integrated, and accessible health care provided by
interprofessional teams that are engaged to address the majority of
an individual's health and wellness needs across different health
care settings through sustained relationships with patients,
families, and communities in order to achieve better health
outcomes, better care, and lower health care prices.
(11) "Program" means the Texas Plan demonstration
program established under this chapter.
(12) "Specialty and major medical care provider" means
a provider of specialty and major medical care services.
(13) "Specialty and major medical care services" means
health care services other than primary care services. The term
includes:
(A) emergency care;
(B) urgent care;
(C) hospital care;
(D) allergy and immunology;
(E) anesthesiology;
(F) cardiology;
(G) dermatology;
(H) diagnostic radiology;
(I) medical genetics;
(J) nephrology;
(K) neurology;
(L) nuclear medicine;
(M) obstetrics and gynecology;
(N) oncology;
(O) ophthalmology;
(P) orthopedics;
(Q) pathology;
(R) pediatrics;
(S) physical medicine and rehabilitation;
(T) psychiatry;
(U) radiation oncology;
(V) surgery; and
(W) urology.
Sec. 532A.0002. FEDERAL AUTHORIZATION FOR PROGRAM. (a)
The executive commissioner shall develop and seek a waiver under
Section 1115 of the Social Security Act (42 U.S.C. Section 1315) or,
if available, a block grant or comparable funding system that may be
used for this purpose to obtain any federal money available for
implementing the Texas Plan demonstration program to assist
eligible individuals in obtaining health care services.
(b) The terms of the waiver the executive commissioner seeks
must:
(1) be designed to:
(A) make high value health care services more
accessible to eligible individuals;
(B) provide money to cover the costs of a
participant's primary care services, specialty and major medical
care services, dental health services, prescription drugs, and
other eligible out-of-pocket health care expenses;
(C) for the purpose of shifting costs from
hospital care to prevention, emphasize the provision of capitated,
whole-person, person-centered primary care, including case
management, mental health services, and health system navigation,
as a core component of the program's overall health goals;
(D) improve health outcomes of participants
based on the value of care the program offers, including by:
(i) when diagnosing and treating a
participant, considering nonmedical factors that impact the
participant's health, including nutrition, transportation,
housing, and employment; and
(ii) to the extent possible, coordinating
with community health organizations and other local resources
available to address the nonmedical factors;
(E) emphasize and encourage price and quality
transparency by program health care providers to enable:
(i) a participant to make informed
decisions regarding health care price and quality; and
(ii) the commission and board to collect
accurate and current pricing information for each provider,
including nondiscriminatory price information;
(F) provide a framework for the commission and
board to use existing data sources or develop new data sources to
obtain and publish information on high-value care that:
(i) identifies health care providers who
provide low health care prices and high quality of care, including
health care centers of excellence; and
(ii) facilitates a participant's ability to
navigate between health care providers to obtain high-value care;
and
(G) subject to Section 532A.0104, provide
continuous coverage for participants for the duration of the
program;
(2) because some participants may have limited primary
care options, recognize a broad range of primary care arrangements
and providers under the program, including:
(A) direct primary care, advanced primary care,
and similar primary care service arrangements provided virtually or
on-site;
(B) federally qualified health centers, as
defined by 42 U.S.C. Section 1396d(l)(2)(B); and
(C) commercial retailers that provide primary
care services at a published, nondiscriminatory price for each
offered service;
(3) allow health care services to be provided remotely
as telehealth services or telemedicine medical services; and
(4) allow for the operation of the program consistent
with the requirements of this chapter for a period of five years,
except to the extent deviation from the requirements is necessary
to obtain the waiver.
Sec. 532A.0003. FUNDING. (a) Subject to approval of the
waiver described by Section 532A.0002, the commission shall
implement the program using federal money obtained and state money
available for that purpose.
(b) The commission shall implement the program in
accordance with the following spending requirements:
(1) except as provided by Subdivision (2), the
commission shall use state money appropriated for the program to
cover:
(A) the administrative costs of implementing and
operating the program; and
(B) the costs of med-pool health care claims and
excess loss coverage to protect the med-pool against financial
losses that may place the med-pool's solvency in financial
jeopardy; and
(2) except as provided by Subsection (c), the
commission shall use federal money received for the program and an
amount of state money appropriated for the program that the
commission determines necessary to cover the costs of providing
health care services to program participants by distributing the
money among each participant on a per capita basis in the following
proportions and manner:
(A) 25 percent of allocated money must be:
(i) used to cover the costs of providing a
participant's primary care services, including dental health and
prescription drug costs related to those services; and
(ii) deposited into the participant's
health benefit account in accordance with Subchapter E; and
(B) 75 percent of allocated money must be:
(i) used to cover the costs of providing a
participant's specialty and major medical care services, including
prescription drug costs related to those services; and
(ii) disbursed to the med-pool.
(c) For a participant who receives all of the participant's
health care needs from an integrated health care organization, the
commission shall:
(1) disburse 96 percent of the per capita amount
described by Subsection (b)(2) to the organization to cover the
costs of providing the participant's health care services; and
(2) deposit the remaining four percent into the
participant's health benefit account in accordance with Subchapter
E to cover the costs of eligible out-of-pocket health care
expenses.
Sec. 532A.0004. EXPIRATION. The program concludes and this
chapter expires September 1, 2031.
SUBCHAPTER B. PROGRAM ADMINISTRATION
Sec. 532A.0051. PROGRAM OBJECTIVE. The program's objective
is to enable eligible individuals to obtain, and to provide money to
participants to cover the costs of, health care services, including
dental health services, and prescription drugs in a manner that:
(1) offers convenient access to high-value care;
(2) prioritizes whole-person, person-centered,
coordinated primary care services; and
(3) lowers the overall costs for providing health care
services to participants over the course of the program.
Sec. 532A.0052. PROGRAM PROMOTION. The commission shall
promote and provide information on the program to individuals who
are potentially eligible to participate in the program. The
commission shall ensure the program's promotion is designed in a
manner to reach as many eligible individuals as possible.
Sec. 532A.0053. COMMISSION'S AUTHORITY RELATED TO
ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
(1) accept applications for program participation and
implement program eligibility screening and enrollment procedures;
(2) resolve grievances related to eligibility
determinations; and
(3) to the extent possible, coordinate the program
with Medicaid and any exchange offering a health benefit plan 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).
SUBCHAPTER C. PROGRAM ELIGIBILITY
Sec. 532A.0101. ELIGIBILITY REQUIREMENTS. An individual is
eligible to participate in the program if:
(1) the individual is a:
(A) citizen or permanent resident of the United
States; and
(B) resident of this state;
(2) the individual is 19 years of age or older but
younger than 65 years of age;
(3) applying the eligibility criteria in effect in
this state on December 31, 2024, the individual is not eligible for
Medicaid; and
(4) federal money is available to provide benefits to
the individual under the program.
Sec. 532A.0102. APPLICATION FORM AND PROCEDURES. (a) The
executive commissioner shall adopt an application form and
application procedures for the program. The form and procedures
may be coordinated with Medicaid forms and procedures to ensure
there is a single consolidated application process to seek health
care services under the program or Medicaid.
(b) To the extent possible, the commission shall make the
application form available in languages other than English.
(c) The executive commissioner may permit an individual to
apply by mail, over the telephone, or through the Internet.
Sec. 532A.0103. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
The executive commissioner shall adopt eligibility screening and
enrollment procedures or use the Texas Integrated Enrollment
Services eligibility determination system or a compatible or
successor system to screen individuals and enroll eligible
individuals in the program.
(b) The eligibility screening and enrollment procedures
must ensure that an individual applying for the program who appears
eligible for Medicaid is identified and assisted with obtaining
Medicaid coverage. If the individual is denied Medicaid coverage
but is otherwise determined eligible to participate in the program,
the commission shall enroll the individual in the program without
additional application or qualification.
(c) Not later than the 30th day after the date an individual
submits a complete application form and unless the individual is
identified and assisted with obtaining Medicaid coverage under
Subsection (b), the commission shall ensure that the individual's
eligibility to participate in the program is determined and that
the individual is enrolled in the program.
(d) At the time an eligible individual is enrolled in the
program and using the database the commission establishes under
Section 532A.0152, the commission shall assist the individual in
selecting an accessible, high-value primary care provider under the
program. A participant may:
(1) change the participant's primary care provider at
any time; and
(2) contact the commission for assistance in selecting
a new primary care provider.
Sec. 532A.0104. CONTINUOUS COVERAGE; ELIGIBILITY
REDETERMINATION AND DISENROLLMENT. (a) If authorized by the terms
of the waiver the executive commissioner seeks under Section
532A.0002, the commission shall ensure that an individual who is
initially determined to be eligible to participate in the program
remains enrolled in the program until the program concludes.
(b) If the terms of the waiver the executive commissioner
seeks under Section 532A.0002 do not authorize continuous coverage
described by Subsection (a), the commission shall:
(1) redetermine a participant's eligibility to
participate in the program during the later of the 12th month
following the date the participant is initially enrolled in the
program or was most recently redetermined eligible for the program;
(2) to the extent possible, conduct an eligibility
redetermination automatically without requiring information from
the participant using information from verifiable electronic data
sources or that is otherwise available to the commission;
(3) not later than the 60th day before the expiration
of a participant's coverage period, take all reasonable steps to
notify the participant regarding the eligibility redetermination
process and request documentation necessary to redetermine the
participant's eligibility;
(4) disenroll a participant from the program if:
(A) the participant does not submit the requested
eligibility redetermination documentation on or before the last day
of the participant's coverage period; or
(B) the commission, based on the submitted
documentation, determines the participant is no longer eligible to
participate in the program; and
(5) ensure the eligibility redetermination process is
as seamless and contains as little administrative burden for the
participant as possible to facilitate the participant's successful
eligibility redetermination.
SUBCHAPTER D. HEALTH CARE PROVIDERS AND PROVISION OF HEALTH CARE
UNDER PROGRAM
Sec. 532A.0151. HEALTH CARE PROVIDER REGISTRATION AND
PRICING INFORMATION. (a) The commission shall establish a
streamlined registration process through which a health care
provider may register to participate in the program.
(b) As part of the registration process, a health care
provider may submit to the commission:
(1) information on:
(A) the provider's office location; and
(B) specific pricing information the provider
charges for a health care service, including pricing information
on, as applicable:
(i) capitated arrangements;
(ii) bundled services;
(iii) fee-for-service prices; and
(iv) health care services for which the
provider charges a nondiscriminatory price; and
(2) other information or data the provider determines
relevant to allow the commission and board to assess the provider's
value of care based on metrics that include:
(A) patient-reported health outcomes for
patients the provider serves; and
(B) the provider's quality of care provided based
on objective clinical metrics.
(c) The commission shall ensure a health care provider is
able to easily and timely update any information the provider
submits.
(d) A primary care provider charging a monthly or annual
capitated rate may not charge a participant for a health care
service, regardless of the payment model used to pay for the
service, in an amount that is greater than the amount specified for
that service in the pricing information submitted under this
section but may charge participants different amounts in accordance
with price categories the provider establishes based on age or
gender only if the provider charges the same price for all
participants in those price categories.
(e) The commission, in collaboration with the board, may
develop processes to ensure information on a health care provider's
pricing and quality of care is accurate and up-to-date to enable the
commission and board to adequately and meaningfully measure and
assess the provider's value of services for the purpose of
compiling and processing data under Section 532A.0152.
Sec. 532A.0152. VALUE OF CARE METRICS AND DATA; PROVIDER
DATABASE. (a) The commission may develop and use metrics to
measure and assess the value of care provided by program health care
providers who submit to the commission the information described by
Section 532A.0151. The metrics may:
(1) include measurements that demonstrate
improvements in an individual's objective and subjective health
outcomes relative to the cost of achieving those improvements; and
(2) be designed to measure as broad a range of health
care services as is practicable, including:
(A) primary care services; and
(B) specialty and major medical care services.
(b) The commission may compile and process data on a health
care provider's value of care based on the measurements and
assessments submitted to the commission by the provider or based on
information independently obtained by the commission or board. The
commission shall ensure the data is sufficient to enable a
participant to make informed decisions in selecting, including at
the time the participant is initially enrolled in the program,
health care providers that:
(1) are accessible to the participant; and
(2) provide high-value care.
(c) The commission may develop and maintain a public
machine-readable database of high-value program health care
providers as the commission and board determine in accordance with
this section.
(d) The commission shall collaborate with the board in
implementing this section.
Sec. 532A.0153. SPECIALTY AND MAJOR MEDICAL CARE. (a) The
med-pool or integrated health care organization with which a
participant enrolls shall pay the costs for providing the
participant's specialty and major medical care services, including
prescription drug costs related to those services.
(b) The board and commission shall develop and implement
procedures for a participant to seek and obtain payment for
specialty and major medical care costs the participant incurs.
Sec. 532A.0154. EMERGENCY CARE PRICING. Unless the board
determines otherwise or contracts for a lesser rate, emergency care
services provided to a participant through the med-pool or an
integrated health care organization will be reimbursed at the same
rate at which those services are reimbursed under the Medicare
program.
SUBCHAPTER E. HEALTH BENEFIT ACCOUNTS
Sec. 532A.0201. ESTABLISHMENT OF HEALTH BENEFIT ACCOUNTS.
(a) The comptroller, in collaboration with the commission and
board, shall establish and maintain for each participant a health
benefit account that is funded in accordance with this subchapter.
The comptroller may contract with a qualified entity to perform the
comptroller's duties under this subchapter.
(b) The comptroller shall establish an electronic portal or
similar system through which a participant may electronically
access and manage money in and information regarding the
participant's health benefit account.
Sec. 532A.0202. HEALTH BENEFIT ACCOUNT FUNDING. Subject to
Section 532A.0003, the comptroller shall fund each participant's
health benefit account with federal and state money in accordance
with Section 532A.0003(b). The amount deposited must be:
(1) equal for each participant based on the program's
total funding and the spending requirements prescribed in Section
532A.0003; and
(2) in excess of money remaining in a participant's
health benefit account from a preceding coverage period, as
applicable.
Sec. 532A.0203. USE OF HEALTH BENEFIT ACCOUNT MONEY. (a) A
participant may use money in the participant's health benefit
account to pay primary care costs, including dental health costs,
prescription drug costs related to primary care services, and other
eligible out-of-pocket health care expenses. The comptroller shall
issue to the participant an electronic payment card that allows the
participant to use the card to pay costs described by this section.
(b) For purposes of this section, "eligible out-of-pocket
health care expense" means a health care-related expense not
covered by the primary care capitation rate, including copayments
for blood draws and other primary care services, over-the-counter
medications, vision care, and copayments that may be required for
specialty and major medical care services.
Sec. 532A.0204. CLOSING OF HEALTH BENEFIT ACCOUNT. If at
the end of a participant's coverage period the participant chooses
to cease participating in the program or is no longer eligible to
participate in the program, the comptroller shall close the
participant's health benefit account and the commission shall:
(1) recoup any money remaining in the account at the
time it is closed; and
(2) use the recouped money to continue to fund the
program in accordance with the spending requirements prescribed by
Section 532A.0003.
SUBCHAPTER F. MED-POOL
Sec. 532A.0251. ESTABLISHMENT. The med-pool is established
to provide specialty and major medical care services to
participants.
Sec. 532A.0252. BOARD OF DIRECTORS. (a) The med-pool is
governed by a board of directors. The board is composed of the
following seven members appointed by the executive commissioner:
(1) two members with appropriate expertise in health
insurance, risk pools, and the evaluation of risk within risk
pools;
(2) one member who is a licensed physician;
(3) one member with appropriate expertise in health
care technology;
(4) one member who is a representative of a federally
qualified health center;
(5) one member who is a representative of a community
health organization; and
(6) one public member.
(b) In making appointments under Subsection (a), the
executive commissioner shall make an effort to select board members
who reflect the ethnic and geographic diversity of this state.
(c) The board shall select from among the board members a
presiding officer.
Sec. 532A.0253. EXCESS LOSS COVERAGE AUTHORIZED. The board
may purchase excess loss coverage for the med-pool to the extent
available state money is insufficient to protect the med-pool
against actuarially projected financial losses the board
determines may place the med-pool's solvency in financial jeopardy.
Sec. 532A.0254. INVESTMENTS. (a) The board shall invest
med-pool money in accordance with Subchapter A, Chapter 2256,
Government Code, to the extent that law can be made applicable.
(b) In addition to investments authorized under Subchapter
A, Chapter 2256, Government Code, the board may invest med-pool
money in any investment authorized under Subtitle B, Title 9,
Property Code.
Sec. 532A.0255. AUDITS. (a) The board shall have the
med-pool's fiscal accounts and records audited annually by an
independent auditor. The audit must cover the med-pool's fiscal
year.
(b) The independent auditor must be a certified public
accountant or public accountant licensed by the Texas State Board
of Public Accountancy.
(c) The board shall file annually with the commission a copy
of the audit report. The commission shall make copies of the audit
reports available to the public on the commission's Internet
website.
Sec. 532A.0256. APPLICATION OF CERTAIN LAWS. The med-pool
is not:
(1) insurance or an insurer under the Insurance Code
and other laws of this state; or
(2) subject to regulation by the commissioner of
insurance or the Texas Department of Insurance.
Sec. 532A.0257. LOW-VALUE PROVIDER COPAYMENT. The med-pool
may require that a participant pay a copayment for services
received from a provider that the commission has designated as a
low-value provider unless a high-value provider is not available to
the participant. The participant may use money in the participant's
health benefit account to pay this expense.
SECTION 2. (a) The executive commissioner of the Health and
Human Services Commission shall:
(1) apply for and actively pursue from the Centers for
Medicare and Medicaid Services or another appropriate federal
agency the waiver as required by Section 532A.0002, Government
Code, as added by this Act, as soon as practicable after the
effective date of this Act; and
(2) begin operating the Texas Plan demonstration
program under Chapter 532A, Government Code, as added by this Act,
not later than September 1, 2026.
(b) The Health and Human Services Commission may delay
implementing this Act until the waiver described by Subsection
(a)(1) of this section is granted.
SECTION 3. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2025.