Bill Text: TX HB2658 | 2021-2022 | 87th Legislature | Enrolled
Bill Title: Relating to the Medicaid program, including the administration and operation of the Medicaid managed care program.
Spectrum: Slight Partisan Bill (Republican 2-1)
Status: (Passed) 2021-06-16 - Effective on 9/1/21 [HB2658 Detail]
Download: Texas-2021-HB2658-Enrolled.html
H.B. No. 2658 |
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relating to the Medicaid program, including the administration and | ||
operation of the Medicaid managed care program. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Sections 531.0501 and 531.0512 to read as | ||
follows: | ||
Sec. 531.0501. MEDICAID WAIVER PROGRAMS: INTEREST LIST | ||
MANAGEMENT. (a) The commission, in consultation with the | ||
Intellectual and Developmental Disability System Redesign Advisory | ||
Committee established under Section 534.053, shall study the | ||
feasibility of creating an online portal for individuals to request | ||
to be placed and check the individual's placement on a Medicaid | ||
waiver program interest list. As part of the study, the commission | ||
shall determine the most cost-effective automated method for | ||
determining the level of need of an individual seeking services | ||
through a Medicaid waiver program. | ||
(b) Not later than January 1, 2023, the commission shall | ||
prepare and submit a report to the governor, the lieutenant | ||
governor, the speaker of the house of representatives, and the | ||
standing legislative committees with primary jurisdiction over | ||
health and human services that summarizes the commission's findings | ||
and conclusions from the study. | ||
(c) Subsections (a) and (b) and this subsection expire | ||
September 1, 2023. | ||
(d) The commission shall develop a protocol in the office of | ||
the ombudsman to improve the capture and updating of contact | ||
information for an individual who contacts the office of the | ||
ombudsman regarding Medicaid waiver programs or services. | ||
Sec. 531.0512. NOTIFICATION REGARDING CONSUMER DIRECTION | ||
MODEL. The commission shall: | ||
(1) develop a procedure to: | ||
(A) verify that a Medicaid recipient or the | ||
recipient's parent or legal guardian is informed regarding the | ||
consumer direction model and provided the option to choose to | ||
receive care under that model; and | ||
(B) if the individual declines to receive care | ||
under the consumer direction model, document the declination; and | ||
(2) ensure that each Medicaid managed care | ||
organization implements the procedure. | ||
SECTION 2. Section 533.00251, Government Code, is amended | ||
by adding Subsection (h) to read as follows: | ||
(h) In addition to the minimum performance standards the | ||
commission establishes for nursing facility providers seeking to | ||
participate in the STAR+PLUS Medicaid managed care program, the | ||
executive commissioner shall adopt rules establishing minimum | ||
performance standards applicable to nursing facility providers | ||
that participate in the program. The commission is responsible for | ||
monitoring provider performance in accordance with the standards | ||
and requiring corrective actions, as the commission determines | ||
necessary, from providers that do not meet the standards. The | ||
commission shall share data regarding the requirements of this | ||
subsection with STAR+PLUS Medicaid managed care organizations as | ||
appropriate. | ||
SECTION 3. Section 533.005(a), Government Code, is amended | ||
to read as follows: | ||
(a) A contract between a managed care organization and the | ||
commission for the organization to provide health care services to | ||
recipients must contain: | ||
(1) procedures to ensure accountability to the state | ||
for the provision of health care services, including procedures for | ||
financial reporting, quality assurance, utilization review, and | ||
assurance of contract and subcontract compliance; | ||
(2) capitation rates that: | ||
(A) include acuity and risk adjustment | ||
methodologies that consider the costs of providing acute care | ||
services and long-term services and supports, including private | ||
duty nursing services, provided under the plan; and | ||
(B) ensure the cost-effective provision of | ||
quality health care; | ||
(3) a requirement that the managed care organization | ||
provide ready access to a person who assists recipients in | ||
resolving issues relating to enrollment, plan administration, | ||
education and training, access to services, and grievance | ||
procedures; | ||
(4) a requirement that the managed care organization | ||
provide ready access to a person who assists providers in resolving | ||
issues relating to payment, plan administration, education and | ||
training, and grievance procedures; | ||
(5) a requirement that the managed care organization | ||
provide information and referral about the availability of | ||
educational, social, and other community services that could | ||
benefit a recipient; | ||
(6) procedures for recipient outreach and education; | ||
(7) a requirement that the managed care organization | ||
make payment to a physician or provider for health care services | ||
rendered to a recipient under a managed care plan on any claim for | ||
payment that is received with documentation reasonably necessary | ||
for the managed care organization to process the claim: | ||
(A) not later than: | ||
(i) the 10th day after the date the claim is | ||
received if the claim relates to services provided by a nursing | ||
facility, intermediate care facility, or group home; | ||
(ii) the 30th day after the date the claim | ||
is received if the claim relates to the provision of long-term | ||
services and supports not subject to Subparagraph (i); and | ||
(iii) the 45th day after the date the claim | ||
is received if the claim is not subject to Subparagraph (i) or (ii); | ||
or | ||
(B) within a period, not to exceed 60 days, | ||
specified by a written agreement between the physician or provider | ||
and the managed care organization; | ||
(7-a) a requirement that the managed care organization | ||
demonstrate to the commission that the organization pays claims | ||
described by Subdivision (7)(A)(ii) on average not later than the | ||
21st day after the date the claim is received by the organization; | ||
(8) a requirement that the commission, on the date of a | ||
recipient's enrollment in a managed care plan issued by the managed | ||
care organization, inform the organization of the recipient's | ||
Medicaid certification date; | ||
(9) a requirement that the managed care organization | ||
comply with Section 533.006 as a condition of contract retention | ||
and renewal; | ||
(10) a requirement that the managed care organization | ||
provide the information required by Section 533.012 and otherwise | ||
comply and cooperate with the commission's office of inspector | ||
general and the office of the attorney general; | ||
(11) a requirement that the managed care | ||
organization's usages of out-of-network providers or groups of | ||
out-of-network providers may not exceed limits for those usages | ||
relating to total inpatient admissions, total outpatient services, | ||
and emergency room admissions determined by the commission; | ||
(12) if the commission finds that a managed care | ||
organization has violated Subdivision (11), a requirement that the | ||
managed care organization reimburse an out-of-network provider for | ||
health care services at a rate that is equal to the allowable rate | ||
for those services, as determined under Sections 32.028 and | ||
32.0281, Human Resources Code; | ||
(13) a requirement that, notwithstanding any other | ||
law, including Sections 843.312 and 1301.052, Insurance Code, the | ||
organization: | ||
(A) use advanced practice registered nurses and | ||
physician assistants in addition to physicians as primary care | ||
providers to increase the availability of primary care providers in | ||
the organization's provider network; and | ||
(B) treat advanced practice registered nurses | ||
and physician assistants in the same manner as primary care | ||
physicians with regard to: | ||
(i) selection and assignment as primary | ||
care providers; | ||
(ii) inclusion as primary care providers in | ||
the organization's provider network; and | ||
(iii) inclusion as primary care providers | ||
in any provider network directory maintained by the organization; | ||
(14) a requirement that the managed care organization | ||
reimburse a federally qualified health center or rural health | ||
clinic for health care services provided to a recipient outside of | ||
regular business hours, including on a weekend day or holiday, at a | ||
rate that is equal to the allowable rate for those services as | ||
determined under Section 32.028, Human Resources Code, if the | ||
recipient does not have a referral from the recipient's primary | ||
care physician; | ||
(15) a requirement that the managed care organization | ||
develop, implement, and maintain a system for tracking and | ||
resolving all provider appeals related to claims payment, including | ||
a process that will require: | ||
(A) a tracking mechanism to document the status | ||
and final disposition of each provider's claims payment appeal; | ||
(B) the contracting with physicians who are not | ||
network providers and who are of the same or related specialty as | ||
the appealing physician to resolve claims disputes related to | ||
denial on the basis of medical necessity that remain unresolved | ||
subsequent to a provider appeal; | ||
(C) the determination of the physician resolving | ||
the dispute to be binding on the managed care organization and | ||
provider; and | ||
(D) the managed care organization to allow a | ||
provider with a claim that has not been paid before the time | ||
prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that | ||
claim; | ||
(16) a requirement that a medical director who is | ||
authorized to make medical necessity determinations is available to | ||
the region where the managed care organization provides health care | ||
services; | ||
(17) a requirement that the managed care organization | ||
ensure that a medical director and patient care coordinators and | ||
provider and recipient support services personnel are located in | ||
the South Texas service region, if the managed care organization | ||
provides a managed care plan in that region; | ||
(18) a requirement that the managed care organization | ||
provide special programs and materials for recipients with limited | ||
English proficiency or low literacy skills; | ||
(19) a requirement that the managed care organization | ||
develop and establish a process for responding to provider appeals | ||
in the region where the organization provides health care services; | ||
(20) a requirement that the managed care organization: | ||
(A) develop and submit to the commission, before | ||
the organization begins to provide health care services to | ||
recipients, a comprehensive plan that describes how the | ||
organization's provider network complies with the provider access | ||
standards established under Section 533.0061; | ||
(B) as a condition of contract retention and | ||
renewal: | ||
(i) continue to comply with the provider | ||
access standards established under Section 533.0061; and | ||
(ii) make substantial efforts, as | ||
determined by the commission, to mitigate or remedy any | ||
noncompliance with the provider access standards established under | ||
Section 533.0061; | ||
(C) pay liquidated damages for each failure, as | ||
determined by the commission, to comply with the provider access | ||
standards established under Section 533.0061 in amounts that are | ||
reasonably related to the noncompliance; and | ||
(D) regularly, as determined by the commission, | ||
submit to the commission and make available to the public a report | ||
containing data on the sufficiency of the organization's provider | ||
network with regard to providing the care and services described | ||
under Section 533.0061(a) and specific data with respect to access | ||
to primary care, specialty care, long-term services and supports, | ||
nursing services, and therapy services on the average length of | ||
time between: | ||
(i) the date a provider requests prior | ||
authorization for the care or service and the date the organization | ||
approves or denies the request; and | ||
(ii) the date the organization approves a | ||
request for prior authorization for the care or service and the date | ||
the care or service is initiated; | ||
(21) a requirement that the managed care organization | ||
demonstrate to the commission, before the organization begins to | ||
provide health care services to recipients, that, subject to the | ||
provider access standards established under Section 533.0061: | ||
(A) the organization's provider network has the | ||
capacity to serve the number of recipients expected to enroll in a | ||
managed care plan offered by the organization; | ||
(B) the organization's provider network | ||
includes: | ||
(i) a sufficient number of primary care | ||
providers; | ||
(ii) a sufficient variety of provider | ||
types; | ||
(iii) a sufficient number of providers of | ||
long-term services and supports and specialty pediatric care | ||
providers of home and community-based services; and | ||
(iv) providers located throughout the | ||
region where the organization will provide health care services; | ||
and | ||
(C) health care services will be accessible to | ||
recipients through the organization's provider network to a | ||
comparable extent that health care services would be available to | ||
recipients under a fee-for-service or primary care case management | ||
model of Medicaid managed care; | ||
(22) a requirement that the managed care organization | ||
develop a monitoring program for measuring the quality of the | ||
health care services provided by the organization's provider | ||
network that: | ||
(A) incorporates the National Committee for | ||
Quality Assurance's Healthcare Effectiveness Data and Information | ||
Set (HEDIS) measures or, as applicable, the national core | ||
indicators adult consumer survey and the national core indicators | ||
child family survey for individuals with an intellectual or | ||
developmental disability; | ||
(B) focuses on measuring outcomes; and | ||
(C) includes the collection and analysis of | ||
clinical data relating to prenatal care, preventive care, mental | ||
health care, and the treatment of acute and chronic health | ||
conditions and substance abuse; | ||
(23) subject to Subsection (a-1), a requirement that | ||
the managed care organization develop, implement, and maintain an | ||
outpatient pharmacy benefit plan for its enrolled recipients: | ||
(A) that, except as provided by Paragraph | ||
(L)(ii), exclusively employs the vendor drug program formulary and | ||
preserves the state's ability to reduce waste, fraud, and abuse | ||
under Medicaid; | ||
(B) that adheres to the applicable preferred drug | ||
list adopted by the commission under Section 531.072; | ||
(C) that, except as provided by Paragraph (L)(i), | ||
includes the prior authorization procedures and requirements | ||
prescribed by or implemented under Sections 531.073(b), (c), and | ||
(g) for the vendor drug program; | ||
(C-1) that does not require a clinical, | ||
nonpreferred, or other prior authorization for any antiretroviral | ||
drug, as defined by Section 531.073, or a step therapy or other | ||
protocol, that could restrict or delay the dispensing of the drug | ||
except to minimize fraud, waste, or abuse; | ||
(D) for purposes of which the managed care | ||
organization: | ||
(i) may not negotiate or collect rebates | ||
associated with pharmacy products on the vendor drug program | ||
formulary; and | ||
(ii) may not receive drug rebate or pricing | ||
information that is confidential under Section 531.071; | ||
(E) that complies with the prohibition under | ||
Section 531.089; | ||
(F) under which the managed care organization may | ||
not prohibit, limit, or interfere with a recipient's selection of a | ||
pharmacy or pharmacist of the recipient's choice for the provision | ||
of pharmaceutical services under the plan through the imposition of | ||
different copayments; | ||
(G) that allows the managed care organization or | ||
any subcontracted pharmacy benefit manager to contract with a | ||
pharmacist or pharmacy providers separately for specialty pharmacy | ||
services, except that: | ||
(i) the managed care organization and | ||
pharmacy benefit manager are prohibited from allowing exclusive | ||
contracts with a specialty pharmacy owned wholly or partly by the | ||
pharmacy benefit manager responsible for the administration of the | ||
pharmacy benefit program; and | ||
(ii) the managed care organization and | ||
pharmacy benefit manager must adopt policies and procedures for | ||
reclassifying prescription drugs from retail to specialty drugs, | ||
and those policies and procedures must be consistent with rules | ||
adopted by the executive commissioner and include notice to network | ||
pharmacy providers from the managed care organization; | ||
(H) under which the managed care organization may | ||
not prevent a pharmacy or pharmacist from participating as a | ||
provider if the pharmacy or pharmacist agrees to comply with the | ||
financial terms and conditions of the contract as well as other | ||
reasonable administrative and professional terms and conditions of | ||
the contract; | ||
(I) under which the managed care organization may | ||
include mail-order pharmacies in its networks, but may not require | ||
enrolled recipients to use those pharmacies, and may not charge an | ||
enrolled recipient who opts to use this service a fee, including | ||
postage and handling fees; | ||
(J) under which the managed care organization or | ||
pharmacy benefit manager, as applicable, must pay claims in | ||
accordance with Section 843.339, Insurance Code; | ||
(K) under which the managed care organization or | ||
pharmacy benefit manager, as applicable: | ||
(i) to place a drug on a maximum allowable | ||
cost list, must ensure that: | ||
(a) the drug is listed as "A" or "B" | ||
rated in the most recent version of the United States Food and Drug | ||
Administration's Approved Drug Products with Therapeutic | ||
Equivalence Evaluations, also known as the Orange Book, has an "NR" | ||
or "NA" rating or a similar rating by a nationally recognized | ||
reference; and | ||
(b) the drug is generally available | ||
for purchase by pharmacies in the state from national or regional | ||
wholesalers and is not obsolete; | ||
(ii) must provide to a network pharmacy | ||
provider, at the time a contract is entered into or renewed with the | ||
network pharmacy provider, the sources used to determine the | ||
maximum allowable cost pricing for the maximum allowable cost list | ||
specific to that provider; | ||
(iii) must review and update maximum | ||
allowable cost price information at least once every seven days to | ||
reflect any modification of maximum allowable cost pricing; | ||
(iv) must, in formulating the maximum | ||
allowable cost price for a drug, use only the price of the drug and | ||
drugs listed as therapeutically equivalent in the most recent | ||
version of the United States Food and Drug Administration's | ||
Approved Drug Products with Therapeutic Equivalence Evaluations, | ||
also known as the Orange Book; | ||
(v) must establish a process for | ||
eliminating products from the maximum allowable cost list or | ||
modifying maximum allowable cost prices in a timely manner to | ||
remain consistent with pricing changes and product availability in | ||
the marketplace; | ||
(vi) must: | ||
(a) provide a procedure under which a | ||
network pharmacy provider may challenge a listed maximum allowable | ||
cost price for a drug; | ||
(b) respond to a challenge not later | ||
than the 15th day after the date the challenge is made; | ||
(c) if the challenge is successful, | ||
make an adjustment in the drug price effective on the date the | ||
challenge is resolved and make the adjustment applicable to all | ||
similarly situated network pharmacy providers, as determined by the | ||
managed care organization or pharmacy benefit manager, as | ||
appropriate; | ||
(d) if the challenge is denied, | ||
provide the reason for the denial; and | ||
(e) report to the commission every 90 | ||
days the total number of challenges that were made and denied in the | ||
preceding 90-day period for each maximum allowable cost list drug | ||
for which a challenge was denied during the period; | ||
(vii) must notify the commission not later | ||
than the 21st day after implementing a practice of using a maximum | ||
allowable cost list for drugs dispensed at retail but not by mail; | ||
and | ||
(viii) must provide a process for each of | ||
its network pharmacy providers to readily access the maximum | ||
allowable cost list specific to that provider; and | ||
(L) under which the managed care organization or | ||
pharmacy benefit manager, as applicable: | ||
(i) may not require a prior authorization, | ||
other than a clinical prior authorization or a prior authorization | ||
imposed by the commission to minimize the opportunity for waste, | ||
fraud, or abuse, for or impose any other barriers to a drug that is | ||
prescribed to a child enrolled in the STAR Kids managed care program | ||
for a particular disease or treatment and that is on the vendor drug | ||
program formulary or require additional prior authorization for a | ||
drug included in the preferred drug list adopted under Section | ||
531.072; | ||
(ii) must provide for continued access to a | ||
drug prescribed to a child enrolled in the STAR Kids managed care | ||
program, regardless of whether the drug is on the vendor drug | ||
program formulary or, if applicable on or after August 31, 2023, the | ||
managed care organization's formulary; | ||
(iii) may not use a protocol that requires a | ||
child enrolled in the STAR Kids managed care program to use a | ||
prescription drug or sequence of prescription drugs other than the | ||
drug that the child's physician recommends for the child's | ||
treatment before the managed care organization provides coverage | ||
for the recommended drug; and | ||
(iv) must pay liquidated damages to the | ||
commission for each failure, as determined by the commission, to | ||
comply with this paragraph in an amount that is a reasonable | ||
forecast of the damages caused by the noncompliance; | ||
(24) a requirement that the managed care organization | ||
and any entity with which the managed care organization contracts | ||
for the performance of services under a managed care plan disclose, | ||
at no cost, to the commission and, on request, the office of the | ||
attorney general all discounts, incentives, rebates, fees, free | ||
goods, bundling arrangements, and other agreements affecting the | ||
net cost of goods or services provided under the plan; | ||
(25) a requirement that the managed care organization | ||
not implement significant, nonnegotiated, across-the-board | ||
provider reimbursement rate reductions unless: | ||
(A) subject to Subsection (a-3), the | ||
organization has the prior approval of the commission to make the | ||
reductions; or | ||
(B) the rate reductions are based on changes to | ||
the Medicaid fee schedule or cost containment initiatives | ||
implemented by the commission; and | ||
(26) a requirement that the managed care organization | ||
make initial and subsequent primary care provider assignments and | ||
changes. | ||
SECTION 4. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.00515 to read as follows: | ||
Sec. 533.00515. MEDICATION THERAPY MANAGEMENT. The | ||
executive commissioner shall collaborate with Medicaid managed | ||
care organizations to implement medication therapy management | ||
services to lower costs and improve quality outcomes for recipients | ||
by reducing adverse drug events. | ||
SECTION 5. Section 533.009(c), Government Code, is amended | ||
to read as follows: | ||
(c) The executive commissioner, by rule, shall prescribe | ||
the minimum requirements that a managed care organization, in | ||
providing a disease management program, must meet to be eligible to | ||
receive a contract under this section. The managed care | ||
organization must, at a minimum, be required to: | ||
(1) provide disease management services that have | ||
performance measures for particular diseases that are comparable to | ||
the relevant performance measures applicable to a provider of | ||
disease management services under Section 32.057, Human Resources | ||
Code; [ |
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(2) show evidence of ability to manage complex | ||
diseases in the Medicaid population; and | ||
(3) if a disease management program provided by the | ||
organization has low active participation rates, identify the | ||
reason for the low rates and develop an approach to increase active | ||
participation in disease management programs for high-risk | ||
recipients. | ||
SECTION 6. Section 32.054, Human Resources Code, is amended | ||
by adding Subsection (f) to read as follows: | ||
(f) To prevent serious medical conditions and reduce | ||
emergency room visits necessitated by complications resulting from | ||
a lack of access to dental care, the commission shall provide | ||
medical assistance reimbursement for preventive dental services, | ||
including reimbursement for one preventive dental care visit per | ||
year, for an adult recipient with a disability who is enrolled in | ||
the STAR+PLUS Medicaid managed care program. This subsection does | ||
not apply to an adult recipient who is enrolled in the STAR+PLUS | ||
home and community-based services (HCBS) waiver program. This | ||
subsection may not be construed to reduce dental services available | ||
to persons with disabilities that are otherwise reimbursable under | ||
the medical assistance program. | ||
SECTION 7. Subchapter B, Chapter 32, Human Resources Code, | ||
is amended by adding Section 32.0317 to read as follows: | ||
Sec. 32.0317. REIMBURSEMENT FOR SERVICES PROVIDED UNDER | ||
SCHOOL HEALTH AND RELATED SERVICES PROGRAM. The executive | ||
commissioner shall adopt rules requiring parental consent for | ||
services provided under the school health and related services | ||
program in order for a school district to receive reimbursement for | ||
the services. The rules must allow a school district to seek a | ||
waiver to receive reimbursement for services provided to a student | ||
who does not have a parent or legal guardian who can provide | ||
consent. | ||
SECTION 8. Section 32.0261, Human Resources Code, is | ||
amended to read as follows: | ||
Sec. 32.0261. CONTINUOUS ELIGIBILITY. (a) This section | ||
applies only to a child younger than 19 years of age who is | ||
determined eligible for medical assistance under this chapter. | ||
(b) The executive commissioner shall adopt rules in | ||
accordance with 42 U.S.C. Section 1396a(e)(12), as amended, to | ||
provide for two consecutive periods of [ |
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eligibility for a child between each certification and | ||
recertification of the child's eligibility, subject to Subsections | ||
(f) and (h) [ |
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(c) The first of the two consecutive periods of eligibility | ||
described by Subsection (b) must be continuous in accordance with | ||
Subsection (d). The second of the two consecutive periods of | ||
eligibility is not continuous and may be affected by changes in a | ||
child's household income, regardless of whether those changes | ||
occurred or whether the commission became aware of the changes | ||
during the first or second of the two consecutive periods of | ||
eligibility. | ||
(d) A [ |
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eligible for medical assistance during the first of the two | ||
consecutive periods of eligibility, without additional review by | ||
the commission and regardless of changes in the child's household | ||
[ |
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[ |
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date on which the child's eligibility was determined, except as | ||
provided by Subsections (f)(1) and (h) [ |
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[ |
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(e) During the sixth month following the date on which a | ||
child's eligibility for medical assistance is certified or | ||
recertified, the commission shall, in a manner that complies with | ||
federal law, including verification plan requirements under 42 | ||
C.F.R. Section 435.945(j), review the child's household income | ||
using electronic income data available to the commission. The | ||
commission may conduct this review only once during the child's two | ||
consecutive periods of eligibility. Based on the review: | ||
(1) the commission shall, if the review indicates that | ||
the child's household income does not exceed the maximum income for | ||
eligibility for the medical assistance program, provide for a | ||
second consecutive period of eligibility for the child until the | ||
child's required annual recertification, except as provided by | ||
Subsection (h) and subject to Subsection (c); or | ||
(2) the commission may, if the review indicates that | ||
the child's household income exceeds the maximum income for | ||
eligibility for the medical assistance program, request additional | ||
documentation to verify the child's household income in a manner | ||
that complies with federal law. | ||
(f) If, after reviewing a child's household income under | ||
Subsection (e), the commission determines that the household income | ||
exceeds the maximum income for eligibility for the medical | ||
assistance program, the commission shall continue to provide | ||
medical assistance to the child until: | ||
(1) the commission provides the child's parent or | ||
guardian with a period of not less than 30 days to provide | ||
documentation demonstrating that the child's household income does | ||
not exceed the maximum income for eligibility; and | ||
(2) the child's parent or guardian fails to provide the | ||
documentation during the period described by Subdivision (1). | ||
(g) If a child's parent or guardian provides to the | ||
commission within the period described by Subsection (f) | ||
documentation demonstrating that the child's household income does | ||
not exceed the maximum income for eligibility for the medical | ||
assistance program, the commission shall provide for a second | ||
consecutive period of eligibility for the child until the child's | ||
required annual recertification, except as provided by Subsection | ||
(h) and subject to Subsection (c). | ||
(h) Notwithstanding any other period prescribed by this | ||
section, a child's eligibility for medical assistance ends on the | ||
child's 19th birthday. | ||
(i) The commission may not recertify a child's eligibility | ||
for medical assistance more frequently than every 12 months as | ||
required by federal law. | ||
(j) If a child's parent or guardian fails to provide to the | ||
commission within the period described by Subsection (f) | ||
documentation demonstrating that the child's household income does | ||
not exceed the maximum income for eligibility for the medical | ||
assistance program, the commission shall provide the child's parent | ||
or guardian with written notice of termination following that | ||
period. The notice must include a statement that the child may be | ||
eligible for enrollment in the child health plan under Chapter 62, | ||
Health and Safety Code. | ||
(k) In developing the notice, the commission shall consult | ||
with health care providers, children's health care advocates, | ||
family members of children enrolled in the medical assistance | ||
program, and other stakeholders to determine the most user-friendly | ||
method to provide the notice to a child's parent or guardian. | ||
(l) The executive commissioner may adopt rules as necessary | ||
to implement this section. | ||
SECTION 9. (a) In this section, "commission," "executive | ||
commissioner," and "Medicaid" have the meanings assigned by Section | ||
531.001, Government Code. | ||
(b) Using existing resources, the commission shall: | ||
(1) review the commission's staff rate enhancement | ||
programs to: | ||
(A) identify and evaluate methods for improving | ||
administration of those programs to reduce administrative barriers | ||
that prevent an increase in direct care staffing and direct care | ||
wages and benefits in nursing homes; and | ||
(B) develop recommendations for increasing | ||
participation in the programs; | ||
(2) revise the commission's policies regarding the | ||
quality incentive payment program (QIPP) to require improvements to | ||
staff-to-patient ratios in nursing facilities participating in the | ||
program by January 1, 2025; and | ||
(3) identify factors influencing active participation | ||
by Medicaid recipients in disease management programs by examining | ||
variations in: | ||
(A) eligibility criteria for the programs; and | ||
(B) participation rates by health plan, disease | ||
management program, and year. | ||
(c) The executive commissioner may approve a capitation | ||
payment system that provides for reimbursement for physicians under | ||
a primary care capitation model or total care capitation model. | ||
SECTION 10. (a) In this section, "commission" and | ||
"Medicaid" have the meanings assigned by Section 531.001, | ||
Government Code. | ||
(b) As soon as practicable after the effective date of this | ||
Act, the commission shall conduct a study to determine the | ||
cost-effectiveness and feasibility of providing to Medicaid | ||
recipients who have been diagnosed with diabetes, including Type 1 | ||
diabetes, Type 2 diabetes, and gestational diabetes: | ||
(1) diabetes self-management education and support | ||
services that follow the National Standards for Diabetes | ||
Self-Management Education and Support and that may be delivered by | ||
a certified diabetes educator; and | ||
(2) medical nutrition therapy services. | ||
(c) If the commission determines that providing one or both | ||
of the types of services described by Subsection (b) of this section | ||
would improve health outcomes for Medicaid recipients and lower | ||
Medicaid costs, the commission shall, notwithstanding Section | ||
32.057, Human Resources Code, or Section 533.009, Government Code, | ||
and to the extent allowed by federal law develop a program to | ||
provide the benefits and seek prior approval from the Legislative | ||
Budget Board before implementing the program. | ||
SECTION 11. (a) In this section, "commission" and | ||
"Medicaid" have the meanings assigned by Section 531.001, | ||
Government Code. | ||
(b) As soon as practicable after the effective date of this | ||
Act, the commission shall conduct a study to: | ||
(1) identify benefits and services provided under | ||
Medicaid that are not provided in this state under the Medicaid | ||
managed care model; and | ||
(2) evaluate the feasibility, cost-effectiveness, and | ||
impact on Medicaid recipients of providing the benefits and | ||
services identified under Subdivision (1) of this subsection | ||
through the Medicaid managed care model. | ||
(c) Not later than December 1, 2022, the commission shall | ||
prepare and submit a report to the legislature that includes: | ||
(1) a summary of the commission's evaluation under | ||
Subsection (b)(2) of this section; and | ||
(2) a recommendation as to whether the commission | ||
should implement providing benefits and services identified under | ||
Subsection (b)(1) of this section through the Medicaid managed care | ||
model. | ||
SECTION 12. (a) In this section: | ||
(1) "Commission," "Medicaid," and "Medicaid managed | ||
care organization" have the meanings assigned by Section 531.001, | ||
Government Code. | ||
(2) "Dually eligible individual" has the meaning | ||
assigned by Section 531.0392, Government Code. | ||
(b) The commission shall conduct a study regarding dually | ||
eligible individuals who are enrolled in the Medicaid managed care | ||
program. The study must include an evaluation of: | ||
(1) Medicare cost-sharing requirements for those | ||
individuals; | ||
(2) the cost-effectiveness for a Medicaid managed care | ||
organization to provide all Medicaid-eligible services not covered | ||
under Medicare and require cost-sharing for those services; and | ||
(3) the impact on dually eligible individuals and | ||
Medicaid providers that would result from the implementation of | ||
Subdivision (2) of this subsection. | ||
(c) Not later than September 1, 2022, the commission shall | ||
prepare and submit a report to the legislature that includes: | ||
(1) a summary of the commission's findings from the | ||
study conducted under Subsection (b) of this section; and | ||
(2) a recommendation as to whether the commission | ||
should implement Subsection (b)(2) of this section. | ||
SECTION 13. (a) Using existing resources, the Health and | ||
Human Services Commission shall conduct a study to assess the | ||
impact of revising the capitation rate setting strategy used to | ||
cover long-term care services and supports provided to recipients | ||
under the STAR+PLUS Medicaid managed care program from a strategy | ||
based on the setting in which services are provided to a strategy | ||
based on a blended rate. The study must: | ||
(1) assess the potential impact using a blended | ||
capitation rate would have on recipients' choice of setting; | ||
(2) include an actuarial analysis of the impact using | ||
a blended capitation rate would have on program spending; and | ||
(3) consider the experience of other states that use a | ||
blended capitation rate to reimburse managed care organizations for | ||
the provision of long-term care services and supports under | ||
Medicaid. | ||
(b) Not later than September 1, 2022, the Health and Human | ||
Services Commission shall prepare and submit a report that | ||
summarizes the findings of the study conducted under Subsection (a) | ||
of this section to the governor, the lieutenant governor, the | ||
speaker of the house of representatives, the House Human Services | ||
Committee, and the Senate Health and Human Services Committee. | ||
SECTION 14. Notwithstanding Section 2, Chapter 1117 (H.B. | ||
3523), Acts of the 84th Legislature, Regular Session, 2015, Section | ||
533.00251(c), Government Code, as amended by Section 2 of that Act, | ||
takes effect September 1, 2023. | ||
SECTION 15. (a) Section 533.005(a), Government Code, as | ||
amended by this Act, applies only to a contract between the Health | ||
and Human Services Commission and a managed care organization that | ||
is entered into or renewed on or after the effective date of this | ||
Act. | ||
(b) To the extent permitted by the terms of the contract, | ||
the Health and Human Services Commission shall seek to amend a | ||
contract entered into before the effective date of this Act with a | ||
managed care organization to comply with Section 533.005(a), | ||
Government Code, as amended by this Act. | ||
SECTION 16. As soon as practicable after the effective date | ||
of this Act, the Health and Human Services Commission shall conduct | ||
the study and make the determination required by Section | ||
531.0501(a), Government Code, as added by this Act. | ||
SECTION 17. 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 18. The Health and Human Services Commission is | ||
required to implement this Act only if the legislature appropriates | ||
money specifically for that purpose. If the legislature does not | ||
appropriate money specifically for that purpose, the commission | ||
may, but is not required to, implement this Act using other | ||
appropriations available for the purpose. | ||
SECTION 19. This Act takes effect September 1, 2021. | ||
______________________________ | ______________________________ | |
President of the Senate | Speaker of the House | |
I certify that H.B. No. 2658 was passed by the House on April | ||
21, 2021, by the following vote: Yeas 147, Nays 0, 2 present, not | ||
voting; that the House refused to concur in Senate amendments to | ||
H.B. No. 2658 on May 27, 2021, and requested the appointment of a | ||
conference committee to consider the differences between the two | ||
houses; and that the House adopted the conference committee report | ||
on H.B. No. 2658 on May 30, 2021, by the following vote: Yeas 135, | ||
Nays 0, 2 present, not voting. | ||
______________________________ | ||
Chief Clerk of the House | ||
I certify that H.B. No. 2658 was passed by the Senate, with | ||
amendments, on May 22, 2021, by the following vote: Yeas 31, Nays | ||
0; at the request of the House, the Senate appointed a conference | ||
committee to consider the differences between the two houses; and | ||
that the Senate adopted the conference committee report on H.B. No. | ||
2658 on May 30, 2021, by the following vote: Yeas 31, Nays 0. | ||
______________________________ | ||
Secretary of the Senate | ||
APPROVED: __________________ | ||
Date | ||
__________________ | ||
Governor |