Bill Text: TX HB2603 | 2021-2022 | 87th Legislature | Introduced
Bill Title: Relating to a direct primary care model pilot program for Medicaid.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2021-03-17 - Referred to Human Services [HB2603 Detail]
Download: Texas-2021-HB2603-Introduced.html
87R6749 KFF-D | ||
By: Shaheen | H.B. No. 2603 |
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relating to a direct primary care model pilot program for Medicaid. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Section 531.024151 to read as follows: | ||
Sec. 531.024151. DIRECT PRIMARY CARE MODEL PILOT PROGRAM | ||
FOR MEDICAID. (a) In this section: | ||
(1) "Direct fee" means a fee charged by a physician to | ||
a patient or a patient's designee for primary medical care services | ||
provided by, or to be provided by, the physician to the | ||
patient. The term includes a fee in any form, including a: | ||
(A) retainer; | ||
(B) membership fee; | ||
(C) subscription fee; or | ||
(D) fee paid under a medical service agreement. | ||
(2) "Direct primary care," "medical service | ||
agreement," "physician," and "primary medical care service" have | ||
the meanings assigned by Section 162.251, Occupations Code. | ||
(3) "Participating physician" means a physician | ||
participating in the pilot program. | ||
(4) "Participating recipient" means a Medicaid | ||
recipient participating in the pilot program. | ||
(5) "Pilot program" means the direct primary care | ||
model pilot program established under this section. | ||
(b) The commission shall develop a pilot program to | ||
implement a direct primary care model in Medicaid through which a | ||
Medicaid recipient enters into a medical service agreement with a | ||
physician for the provision of primary medical care services in | ||
exchange for a direct fee that is paid on a monthly basis. | ||
(c) The commission shall implement the pilot program | ||
statewide. | ||
(d) Under the pilot program, a participating physician: | ||
(1) is not required to enroll as a Medicaid provider; | ||
and | ||
(2) notwithstanding Subdivision (1), has the | ||
authority of ordering, referring, and prescribing Medicaid | ||
providers for purposes of the pilot program. | ||
(e) To be eligible to participate in the pilot program, a | ||
physician must be practicing under a direct primary care model that | ||
does not accept payment or otherwise seek reimbursement for primary | ||
medical care services from a third-party insurer or managed care | ||
organization. | ||
(f) A Medicaid recipient must be younger than 65 years of | ||
age to be eligible to participate in the pilot program. The | ||
recipient or the recipient's parent or legally authorized | ||
representative on behalf of the recipient must enter into a medical | ||
service agreement with a physician eligible to participate in the | ||
pilot program. After the commission verifies that the recipient or | ||
the recipient's parent or legally authorized representative has | ||
entered into the agreement, the commission shall pay the lesser of: | ||
(1) the amount of the direct fee required under the | ||
agreement; or | ||
(2) $40 per month for a recipient who is 18 years of | ||
age or younger, or $70 per month for a recipient who is at least 19 | ||
years of age but younger than 65 years of age. | ||
(g) A participating recipient shall pay the amount of the | ||
direct fee required under the medical service agreement that | ||
exceeds the maximum fee amount the commission pays under Subsection | ||
(f). | ||
(h) The commission may pay the amount of the direct fee | ||
under a medical service agreement directly to the participating | ||
recipient, who is then responsible for paying the participating | ||
physician under the agreement, or may establish a system under | ||
which the commission pays the fee directly to the physician, either | ||
by depositing the fee into an account established for the physician | ||
for that purpose or by another means the commission determines most | ||
appropriate. If cost-effective, the commission may issue an | ||
electronic benefits transfer card to a participating recipient who | ||
shall use the card to pay the amount of the direct fee under an | ||
agreement. | ||
(i) To the extent permitted by the contract entered into | ||
between the commission and a Medicaid managed care organization, | ||
the commission shall fund the direct fee required under a medical | ||
service agreement by making an appropriate reduction in the | ||
capitation rate paid to the organization that issued the managed | ||
care plan in which the participating recipient is enrolled. | ||
(j) A participating recipient shall immediately notify the | ||
commission when a medical service agreement terminates. | ||
(k) Not later than December 31, 2024, the commission shall | ||
prepare and submit a report to the legislature that includes: | ||
(1) a summary of the commission's evaluation of the | ||
effect of the pilot program on the provision of primary medical care | ||
services and Medicaid costs; and | ||
(2) a recommendation as to whether the pilot program | ||
should be continued or terminated. | ||
(l) The executive commissioner shall adopt rules as | ||
necessary to implement this section. | ||
(m) The pilot program terminates and this section expires | ||
September 1, 2025. | ||
SECTION 2. If before implementing any provision of this Act | ||
a state agency determines that a waiver or authorization 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 3. This Act takes effect September 1, 2021. |