Bill Text: TX HB4533 | 2019-2020 | 86th Legislature | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to the administration and operation of Medicaid, including Medicaid managed care and the delivery of Medicaid acute care services and long-term services and supports to certain persons.
Spectrum: Slight Partisan Bill (Republican 2-1)
Status: (Passed) 2019-06-14 - Effective on 9/1/19 [HB4533 Detail]
Download: Texas-2019-HB4533-Comm_Sub.html
Bill Title: Relating to the administration and operation of Medicaid, including Medicaid managed care and the delivery of Medicaid acute care services and long-term services and supports to certain persons.
Spectrum: Slight Partisan Bill (Republican 2-1)
Status: (Passed) 2019-06-14 - Effective on 9/1/19 [HB4533 Detail]
Download: Texas-2019-HB4533-Comm_Sub.html
By: Klick, Raymond (Senate Sponsor - Kolkhorst) | H.B. No. 4533 | |
(In the Senate - Received from the House May 13, 2019; | ||
May 13, 2019, read first time and referred to Committee on Health & | ||
Human Services; May 17, 2019, reported favorably by the following | ||
vote: Yeas 9, Nays 0; May 17, 2019, sent to printer.) | ||
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relating to the system redesign for delivery of Medicaid acute care | ||
services and long-term services and supports to persons with an | ||
intellectual or developmental disability or with similar | ||
functional needs. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 534.001, Government Code, is amended by | ||
amending Subdivision (3) and adding Subdivisions (3-a) and (11-a) | ||
to read as follows: | ||
(3) "Comprehensive long-term services and supports | ||
provider" means a provider of long-term services and supports under | ||
this chapter that ensures the coordinated, seamless delivery of the | ||
full range of services in a recipient's program plan. The term | ||
includes: | ||
(A) a provider under the ICF-IID program; and | ||
(B) a provider under a Medicaid waiver program | ||
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(3-a) "Consumer direction model" has the meaning | ||
assigned by Section 531.051. | ||
(11-a) "Residential services" means services provided | ||
to an individual with an intellectual or developmental disability | ||
through a community-based ICF-IID, three- or four-person home or | ||
host home setting under the home and community-based services (HCS) | ||
waiver program, or a group home under the deaf-blind with multiple | ||
disabilities (DBMD) waiver program. | ||
SECTION 2. Sections 534.051 and 534.052, Government Code, | ||
are amended to read as follows: | ||
Sec. 534.051. ACUTE CARE SERVICES AND LONG-TERM SERVICES | ||
AND SUPPORTS SYSTEM FOR INDIVIDUALS WITH AN INTELLECTUAL OR | ||
DEVELOPMENTAL DISABILITY. In accordance with this chapter, the | ||
commission [ |
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implement an acute care services and long-term services and | ||
supports system for individuals with an intellectual or | ||
developmental disability that supports the following goals: | ||
(1) provide Medicaid services to more individuals in a | ||
cost-efficient manner by providing the type and amount of services | ||
most appropriate to the individuals' needs and preferences in the | ||
most integrated and least restrictive setting; | ||
(2) improve individuals' access to services and | ||
supports by ensuring that the individuals receive information about | ||
all available programs and services, including employment and least | ||
restrictive housing assistance, and how to apply for the programs | ||
and services; | ||
(3) improve the assessment of individuals' needs and | ||
available supports, including the assessment of individuals' | ||
functional needs; | ||
(4) promote person-centered planning, self-direction, | ||
self-determination, community inclusion, and customized, | ||
integrated, competitive employment; | ||
(5) promote individualized budgeting based on an | ||
assessment of an individual's needs and person-centered planning; | ||
(6) promote integrated service coordination of acute | ||
care services and long-term services and supports; | ||
(7) improve acute care and long-term services and | ||
supports outcomes, including reducing unnecessary | ||
institutionalization and potentially preventable events; | ||
(8) promote high-quality care; | ||
(9) provide fair hearing and appeals processes in | ||
accordance with applicable federal law; | ||
(10) ensure the availability of a local safety net | ||
provider and local safety net services; | ||
(11) promote independent service coordination and | ||
independent ombudsmen services; and | ||
(12) ensure that individuals with the most significant | ||
needs are appropriately served in the community and that processes | ||
are in place to prevent inappropriate institutionalization of | ||
individuals. | ||
Sec. 534.052. IMPLEMENTATION OF SYSTEM REDESIGN. The | ||
commission [ |
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collaboration with the advisory committee, [ |
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acute care services and long-term services and supports system for | ||
individuals with an intellectual or developmental disability in the | ||
manner and in the stages described in this chapter. | ||
SECTION 3. Sections 534.053(a) and (b), Government Code, | ||
are amended to read as follows: | ||
(a) The Intellectual and Developmental Disability System | ||
Redesign Advisory Committee shall advise the commission [ |
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long-term services and supports system redesign under this | ||
chapter. Subject to Subsection (b), the executive commissioner | ||
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stakeholders from the intellectual and developmental disabilities | ||
community, including: | ||
(1) individuals with an intellectual or developmental | ||
disability who are recipients of services under the Medicaid waiver | ||
programs, individuals with an intellectual or developmental | ||
disability who are recipients of services under the ICF-IID | ||
program, and individuals who are advocates of those recipients, | ||
including at least three representatives from intellectual and | ||
developmental disability advocacy organizations; | ||
(2) representatives of Medicaid managed care and | ||
nonmanaged care health care providers, including: | ||
(A) physicians who are primary care providers and | ||
physicians who are specialty care providers; | ||
(B) nonphysician mental health professionals; | ||
and | ||
(C) providers of long-term services and | ||
supports, including direct service workers; | ||
(3) representatives of entities with responsibilities | ||
for the delivery of Medicaid long-term services and supports or | ||
other Medicaid service delivery, including: | ||
(A) representatives of aging and disability | ||
resource centers established under the Aging and Disability | ||
Resource Center initiative funded in part by the federal | ||
Administration on Aging and the Centers for Medicare and Medicaid | ||
Services; | ||
(B) representatives of community mental health | ||
and intellectual disability centers; | ||
(C) representatives of and service coordinators | ||
or case managers from private and public home and community-based | ||
services providers that serve individuals with an intellectual or | ||
developmental disability; and | ||
(D) representatives of private and public | ||
ICF-IID providers; and | ||
(4) representatives of managed care organizations | ||
contracting with the state to provide services to individuals with | ||
an intellectual or developmental disability. | ||
(b) To the greatest extent possible, the executive | ||
commissioner [ |
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reflect the geographic diversity of the state and include members | ||
who represent rural Medicaid recipients. | ||
SECTION 4. Section 534.053(g), Government Code, as amended | ||
by Chapters 837 (S.B. 200), 946 (S.B. 277), and 1117 (H.B. 3523), | ||
Acts of the 84th Legislature, Regular Session, 2015, is reenacted | ||
and amended to read as follows: | ||
(g) On the second [ |
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commission completes implementation of the transition required | ||
under Section 534.202: | ||
(1) the advisory committee is abolished; and | ||
(2) this section expires. | ||
SECTION 5. Section 534.054(b), Government Code, is amended | ||
to read as follows: | ||
(b) This section expires on the second anniversary of the | ||
date the commission completes implementation of the transition | ||
required under Section 534.202 [ |
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SECTION 6. The heading to Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
SUBCHAPTER C. STAGE ONE: PILOT PROGRAM FOR IMPROVING [ |
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SECTION 7. Section 534.101, Government Code, is amended by | ||
amending Subdivision (2) and adding Subdivision (3) to read as | ||
follows: | ||
(2) "Pilot program" means the pilot program | ||
established under this subchapter [ |
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(3) "Pilot program workgroup" means the pilot program | ||
workgroup established under Section 534.1015. | ||
SECTION 8. Subchapter C, Chapter 534, Government Code, is | ||
amended by adding Section 534.1015 to read as follows: | ||
Sec. 534.1015. PILOT PROGRAM WORKGROUP. (a) The executive | ||
commissioner, in consultation with the advisory committee, shall | ||
establish a pilot program workgroup to provide assistance in | ||
developing and advice concerning the operation of the pilot | ||
program. | ||
(b) The pilot program workgroup is composed of: | ||
(1) representatives of the advisory committee; | ||
(2) stakeholders representing individuals with an | ||
intellectual or developmental disability; | ||
(3) stakeholders representing individuals with | ||
similar functional needs as those individuals described by | ||
Subdivision (2); and | ||
(4) representatives of managed care organizations | ||
that contract with the commission to provide services under the | ||
STAR+PLUS Medicaid managed care program. | ||
(c) Chapter 2110 applies to the pilot program workgroup. | ||
SECTION 9. Sections 534.102 and 534.103, Government Code, | ||
are amended to read as follows: | ||
Sec. 534.102. PILOT PROGRAM [ |
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PERSON-CENTERED MANAGED CARE STRATEGIES AND IMPROVEMENTS BASED ON | ||
CAPITATION. The commission, in consultation and collaboration with | ||
the advisory committee and pilot program workgroup, shall [ |
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accordance with this subchapter to test, through the STAR+PLUS | ||
Medicaid managed care program, the delivery of [ |
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Sec. 534.103. STAKEHOLDER INPUT. As part of developing and | ||
implementing the [ |
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commission, in consultation and collaboration with the advisory | ||
committee and pilot program workgroup, [ |
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process to receive and evaluate: | ||
(1) input from statewide stakeholders and | ||
stakeholders from a STAR+PLUS Medicaid managed care service area | ||
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implemented; and | ||
(2) other evaluations and data. | ||
SECTION 10. Subchapter C, Chapter 534, Government Code, is | ||
amended by adding Section 534.1035 to read as follows: | ||
Sec. 534.1035. MANAGED CARE ORGANIZATION SELECTION. (a) | ||
The commission, in consultation and collaboration with the advisory | ||
committee and pilot program workgroup, shall develop criteria | ||
regarding the selection of a managed care organization to | ||
participate in the pilot program. | ||
(b) The commission shall select and contract with not more | ||
than two managed care organizations that contract with the | ||
commission to provide services under the STAR+PLUS Medicaid managed | ||
care program to participate in the pilot program. | ||
SECTION 11. Section 534.104, Government Code, is amended to | ||
read as follows: | ||
Sec. 534.104. [ |
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PROGRAM DESIGN [ |
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must be designed to: | ||
(1) increase access to long-term services and | ||
supports; | ||
(2) improve quality of acute care services and | ||
long-term services and supports; | ||
(3) promote: | ||
(A) informed choice and meaningful outcomes by | ||
using person-centered planning, flexible consumer-directed | ||
services, individualized budgeting, and self-determination;[ |
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(B) [ |
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engagement; | ||
(4) promote integrated service coordination of acute | ||
care services and long-term services and supports; | ||
(5) promote efficiency and the best use of funding | ||
based on an individual's needs and preferences; | ||
(6) promote through housing supports and navigation | ||
services stability [ |
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is the most integrated and least restrictive based on [ |
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(7) promote employment assistance and customized, | ||
integrated, and competitive employment; | ||
(8) provide fair hearing and appeals processes in | ||
accordance with applicable federal and state law; [ |
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(9) promote sufficient flexibility to achieve the | ||
goals listed in this section through the pilot program; | ||
(10) promote the use of innovative technologies and | ||
benefits, including telemedicine, telemonitoring, the testing of | ||
remote monitoring, transportation services, and other innovations | ||
that support community integration; | ||
(11) ensure an adequate provider network that includes | ||
comprehensive long-term services and supports providers and ensure | ||
that pilot program participants have a choice among those | ||
providers; | ||
(12) ensure the timely initiation and consistent | ||
provision of long-term services and supports in accordance with an | ||
individual's person-centered plan; | ||
(13) ensure that individuals with complex behavioral, | ||
medical, and physical needs are assessed and receive appropriate | ||
services in the most integrated and least restrictive setting based | ||
on the individuals' needs and preferences; | ||
(14) increase access to, expand flexibility of, and | ||
promote the use of the consumer direction model; and | ||
(15) promote independence, self-determination, the | ||
use of the consumer direction model, and decision making by | ||
individuals participating in the pilot program by using | ||
alternatives to guardianship, including a supported | ||
decision-making agreement as defined by Section 1357.002, Estates | ||
Code. | ||
(b) An individual is not required to use an innovative | ||
technology described by Subsection (a)(10). If an individual | ||
chooses to use an innovative technology described by that | ||
subdivision, the commission shall ensure that services associated | ||
with the technology are delivered in a manner that: | ||
(1) ensures the individual's privacy, health, and | ||
well-being; | ||
(2) provides access to housing in the most integrated | ||
and least restrictive environment; | ||
(3) assesses individual needs and preferences to | ||
promote autonomy, self-determination, the use of the consumer | ||
direction model, and privacy; | ||
(4) increases personal independence; | ||
(5) specifies the extent to which the innovative | ||
technology will be used, including: | ||
(A) the times of day during which the technology | ||
will be used; | ||
(B) the place in which the technology may be | ||
used; | ||
(C) the types of telemonitoring or remote | ||
monitoring that will be used; and | ||
(D) for what purposes the technology will be | ||
used; | ||
(6) is consistent with and agreed on during the | ||
person-centered planning process; | ||
(7) ensures that staff overseeing the use of an | ||
innovative technology: | ||
(A) review the person-centered and | ||
implementation plans for each individual before overseeing the use | ||
of the innovative technology; and | ||
(B) demonstrate competency regarding the support | ||
needs of each individual using the innovative technology; | ||
(8) ensures that an individual using an innovative | ||
technology is able to request the removal of equipment relating to | ||
the technology and, on receipt of a request for the removal, the | ||
equipment is immediately removed; and | ||
(9) ensures that an individual is not required to use | ||
telemedicine at any point during the pilot program and, in the event | ||
the individual refuses to use telemedicine, the managed care | ||
organization providing health care services to the individual under | ||
the pilot program arranges for services that do not include | ||
telemedicine. | ||
(c) The pilot program must be designed to test innovative | ||
payment rates and methodologies for the provision of long-term | ||
services and supports to achieve the goals of the pilot program by | ||
using payment methodologies that include: | ||
(1) the payment of a bundled amount without downside | ||
risk to a comprehensive long-term services and supports provider | ||
for some or all services delivered as part of a comprehensive array | ||
of long-term services and supports; | ||
(2) enhanced incentive payments to comprehensive | ||
long-term services and supports providers based on the completion | ||
of predetermined outcomes or quality metrics; and | ||
(3) any other payment models approved by the | ||
commission. | ||
(d) An alternative payment rate or methodology described by | ||
Subsection (c) may be used for a managed care organization and | ||
comprehensive long-term services and supports provider only if the | ||
organization and provider agree in advance and in writing to use the | ||
rate or methodology [ |
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(e) In developing an alternative payment rate or | ||
methodology described by Subsection (c), the commission, managed | ||
care organizations, and comprehensive long-term services and | ||
supports providers shall consider: | ||
(1) the historical costs of long-term services and | ||
supports, including Medicaid fee-for-service rates; | ||
(2) reasonable cost estimates for new services under | ||
the pilot program; and | ||
(3) whether an alternative payment rate or methodology | ||
is sufficient to promote quality outcomes and ensure a provider's | ||
continued participation in the pilot program [ |
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(f) An alternative payment rate or methodology described by | ||
Subsection (c) may not reduce the minimum payment received by a | ||
provider for the delivery of long-term services and supports under | ||
the pilot program below the fee-for-service reimbursement rate | ||
received by the provider for the delivery of those services before | ||
participating in the pilot program. | ||
(g) The pilot program must allow a comprehensive long-term | ||
services and supports provider for individuals with an intellectual | ||
or developmental disability or similar functional needs that | ||
contracts with the commission to provide services under Medicaid | ||
before the implementation date of the pilot program to voluntarily | ||
participate in the pilot program. A provider's choice not to | ||
participate in the pilot program does not affect the provider's | ||
status as a significant traditional provider. | ||
(h) [ |
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and supports under Medicaid to persons with an intellectual or | ||
developmental disability and persons with similar functional needs | ||
to test its managed care strategy based on capitation. | ||
(i) [ |
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collaboration with the advisory committee and pilot program | ||
workgroup, shall analyze information provided by the managed care | ||
organizations participating in the pilot program [ |
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for purposes of making a recommendation about a system of programs | ||
and services for implementation through future state legislation or | ||
rules. | ||
(j) [ |
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include an assessment of the effect of the managed care strategies | ||
implemented in the pilot program [ |
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by this section [ |
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(k) Before implementing the pilot program, the commission, | ||
in consultation and collaboration with the advisory committee and | ||
pilot program workgroup, shall develop and implement a process to | ||
ensure pilot program participants remain eligible for Medicaid | ||
benefits for 12 consecutive months during the pilot program. | ||
SECTION 12. Subchapter C, Chapter 534, Government Code, is | ||
amended by adding Section 534.1045 to read as follows: | ||
Sec. 534.1045. PILOT PROGRAM BENEFITS AND PROVIDER | ||
QUALIFICATIONS. (a) Subject to Subsection (b), the commission | ||
shall ensure that a managed care organization participating in the | ||
pilot program provides: | ||
(1) all Medicaid state plan acute care benefits | ||
available under the STAR+PLUS Medicaid managed care program; | ||
(2) long-term services and supports under the Medicaid | ||
state plan, including: | ||
(A) Community First Choice services; | ||
(B) personal assistance services; | ||
(C) day activity health services; and | ||
(D) habilitation services; | ||
(3) long-term services and supports under the | ||
STAR+PLUS home and community-based services (HCBS) waiver program, | ||
including: | ||
(A) assisted living services; | ||
(B) personal assistance services; | ||
(C) employment assistance; | ||
(D) supported employment; | ||
(E) adult foster care; | ||
(F) dental care; | ||
(G) nursing care; | ||
(H) respite care; | ||
(I) home-delivered meals; | ||
(J) cognitive rehabilitative therapy; | ||
(K) physical therapy; | ||
(L) occupational therapy; | ||
(M) speech-language pathology; | ||
(N) medical supplies; | ||
(O) minor home modifications; and | ||
(P) adaptive aids; | ||
(4) the following long-term services and supports | ||
under a Medicaid waiver program: | ||
(A) enhanced behavioral health services; | ||
(B) behavioral supports; | ||
(C) day habilitation; and | ||
(D) community support transportation; | ||
(5) the following additional long-term services and | ||
supports: | ||
(A) housing supports; | ||
(B) behavioral health crisis intervention | ||
services; and | ||
(C) high medical needs services; and | ||
(6) other nonresidential long-term services and | ||
supports that the commission, in consultation and collaboration | ||
with the advisory committee and pilot program workgroup, determines | ||
are appropriate and consistent with applicable requirements | ||
governing the Medicaid waiver programs, person-centered | ||
approaches, home and community-based setting requirements, and | ||
achieving the most integrated and least restrictive setting based | ||
on an individual's needs and preferences. | ||
(b) A comprehensive long-term services and supports | ||
provider may deliver services listed under the following provisions | ||
only if the provider also delivers the services under a Medicaid | ||
waiver program: | ||
(1) Subsections (a)(2)(A) and (D); | ||
(2) Subsections (a)(3)(B), (C), (D), (G), (H), (J), | ||
(K), (L), and (M); and | ||
(3) Subsection (a)(4). | ||
(c) A comprehensive long-term services and supports | ||
provider may deliver services listed under Subsections (a)(5) and | ||
(6) only if the managed care organization in the network of which | ||
the provider participates agrees to, in a contract with the | ||
provider, the provision of those services. | ||
(d) Day habilitation services listed under Subsection | ||
(a)(4)(C) may be delivered by a provider who contracts or | ||
subcontracts with the commission to provide day habilitation | ||
services under the home and community-based services (HCS) waiver | ||
program or the ICF-IID program. | ||
(e) A comprehensive long-term services and supports | ||
provider participating in the pilot program shall work in | ||
coordination with the care coordinators of a managed care | ||
organization participating in the pilot program to ensure the | ||
seamless delivery of acute care and long-term services and supports | ||
on a daily basis in accordance with an individual's plan of care. A | ||
comprehensive long-term services and supports provider may be | ||
reimbursed by a managed care organization for coordinating with | ||
care coordinators under this subsection. | ||
(f) Before implementing the pilot program, the commission, | ||
in consultation and collaboration with the advisory committee and | ||
pilot program workgroup, shall: | ||
(1) for purposes of the pilot program only, develop | ||
recommendations to modify adult foster care and supported | ||
employment and employment assistance benefits to increase access to | ||
and availability of those services; and | ||
(2) as necessary, define services listed under | ||
Subsections (a)(4) and (5) and any other services determined to be | ||
appropriate under Subsection (a)(6). | ||
SECTION 13. Sections 534.105, 534.106, 534.1065, 534.107, | ||
534.108, and 534.109, Government Code, are amended to read as | ||
follows: | ||
Sec. 534.105. PILOT PROGRAM: MEASURABLE GOALS. (a) The | ||
commission [ |
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the advisory committee and pilot program workgroup and using | ||
national core indicators, the National Quality Forum long-term | ||
services and supports measures, and other appropriate Consumer | ||
Assessment of Healthcare Providers and Systems measures, shall | ||
identify measurable goals to be achieved by the [ |
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program [ |
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(b) The commission [ |
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collaboration with the advisory committee and pilot program | ||
workgroup, shall develop [ |
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performance measures for achieving the identified goals. A | ||
proposed strategy may be evidence-based if there is an | ||
evidence-based strategy available for meeting the pilot program's | ||
goals. | ||
(c) The commission, in consultation and collaboration with | ||
the advisory committee and pilot program workgroup, shall ensure | ||
that mechanisms to report, track, and assess specific strategies | ||
and performance measures for achieving the identified goals are | ||
established before implementing the pilot program. | ||
Sec. 534.106. IMPLEMENTATION, LOCATION, AND DURATION. (a) | ||
The commission [ |
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program on [ |
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(b) The [ |
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(c) The [ |
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service area [ |
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Sec. 534.1065. RECIPIENT ENROLLMENT, PARTICIPATION, AND | ||
ELIGIBILITY [ |
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eligible for the pilot program will be enrolled automatically | ||
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services and supports under the pilot [ |
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legally authorized representative. | ||
(b) To ensure prospective pilot program participants are | ||
able to make an informed decision on whether to participate in the | ||
pilot program, the commission, in consultation and collaboration | ||
with the advisory committee and pilot program workgroup, shall | ||
develop and distribute informational materials on the pilot program | ||
that describe the pilot program's benefits, the pilot program's | ||
impact on current services, and other related information. The | ||
commission shall establish a timeline and process for the | ||
development and distribution of the materials and shall ensure: | ||
(1) the materials are developed and distributed to | ||
individuals eligible to participate in the pilot program with | ||
sufficient time to educate the individuals, their families, and | ||
other persons actively involved in their lives regarding the pilot | ||
program; | ||
(2) individuals eligible to participate in the pilot | ||
program, including individuals enrolled in the STAR+PLUS Medicaid | ||
managed care program, their families, and other persons actively | ||
involved in their lives, receive the materials and oral information | ||
on the pilot program; | ||
(3) the materials contain clear, simple language | ||
presented in a manner that is easy to understand; and | ||
(4) the materials explain, at a minimum, that: | ||
(A) on conclusion of the pilot program, pilot | ||
program participants will be asked to provide feedback on their | ||
experience, including feedback on whether the pilot program was | ||
able to meet their unique support needs; | ||
(B) participation in the pilot program does not | ||
remove individuals from any Medicaid waiver program interest list; | ||
(C) individuals who choose to participate in the | ||
pilot program and who, during the pilot program's operation, are | ||
offered enrollment in a Medicaid waiver program may accept the | ||
enrollment, transition, or diversion offer; and | ||
(D) pilot program participants have a choice | ||
among acute care and comprehensive long-term services and supports | ||
providers and service delivery options, including the consumer | ||
direction model and comprehensive services model. | ||
(c) The commission, in consultation and collaboration with | ||
the advisory committee and pilot program workgroup, shall develop | ||
pilot program participant eligibility criteria. The criteria must | ||
ensure pilot program participants: | ||
(1) include individuals with an intellectual or | ||
developmental disability or a cognitive disability, including: | ||
(A) individuals with autism; | ||
(B) individuals with significant complex | ||
behavioral, medical, and physical needs who are receiving home and | ||
community-based services through the STAR+PLUS Medicaid managed | ||
care program; | ||
(C) individuals enrolled in the STAR+PLUS | ||
Medicaid managed care program who: | ||
(i) are on a Medicaid waiver program | ||
interest list; | ||
(ii) meet the criteria for an intellectual | ||
or developmental disability; or | ||
(iii) have a traumatic brain injury that | ||
occurred after the age of 21; and | ||
(D) other individuals with disabilities who have | ||
similar functional needs without regard to the age of onset or | ||
diagnosis; and | ||
(2) do not include individuals who are receiving only | ||
acute care services under the STAR+PLUS Medicaid managed care | ||
program and are enrolled in the community-based ICF-IID program or | ||
another Medicaid waiver program. | ||
Sec. 534.107. COMMISSION RESPONSIBILITIES [ |
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require that a managed care organization participating in the pilot | ||
program: | ||
(1) ensures that individuals participating in the | ||
pilot program have a choice among acute care and comprehensive | ||
long-term services and supports providers and service delivery | ||
options, including the consumer direction model [ |
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(2) demonstrates to the commission's satisfaction that | ||
the organization's network of acute care, long-term services and | ||
supports, and comprehensive long-term services and supports | ||
providers have experience and expertise in providing services for | ||
individuals with an intellectual or developmental disability and | ||
individuals with similar functional needs [ |
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(3) has [ |
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institutionalizations of individuals; and | ||
(4) ensures the timely initiation and consistent | ||
provision of services in accordance with an individual's | ||
person-centered plan [ |
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(b) For the duration of the pilot program, the commission | ||
shall ensure that comprehensive long-term services and supports | ||
providers are considered significant traditional providers and | ||
included in the provider network of a managed care organization | ||
participating in the pilot program. | ||
Sec. 534.108. PILOT PROGRAM INFORMATION. (a) The | ||
commission, in consultation and collaboration with the advisory | ||
committee and pilot program workgroup, [ |
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determine which information will be collected from a managed care | ||
organization participating in the pilot program to use in | ||
conducting the evaluation and preparing the report under Section | ||
534.112 [ |
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(b) For the duration of the pilot program, a managed care | ||
organization participating in the pilot program shall submit to the | ||
commission and the advisory committee quarterly reports on the | ||
services provided to each pilot program participant that include | ||
information on: | ||
(1) the level of each requested service and the | ||
authorization and utilization rates for those services; | ||
(2) timelines of: | ||
(A) the delivery of each requested service; | ||
(B) authorization of each requested service; | ||
(C) the initiation of each requested service; and | ||
(D) each unplanned break in the delivery of | ||
requested services and the duration of the break; | ||
(3) the number of pilot program participants using | ||
employment assistance and supported employment services; | ||
(4) the number of service denials and fair hearings | ||
and the dispositions of fair hearings; | ||
(5) the number of complaints and inquiries received by | ||
the managed care organization and the outcome of each complaint; | ||
and | ||
(6) the number of pilot program participants who | ||
choose the consumer direction model and the reasons why other | ||
participants did not choose the consumer direction model [ |
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(c) The commission shall ensure that the mechanisms to | ||
report and track the information and data required by this section | ||
are established before implementing the pilot program [ |
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Sec. 534.109. PERSON-CENTERED PLANNING. The commission, in | ||
consultation and collaboration [ |
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committee and pilot program workgroup [ |
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that each individual [ |
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through the [ |
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or the individual's legally authorized representative, has access | ||
to a comprehensive, facilitated, person-centered plan that | ||
identifies outcomes for the individual and drives the development | ||
of the individualized budget. The consumer direction model must be | ||
an available option for individuals to achieve self-determination, | ||
choice, and control[ |
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SECTION 14. Section 534.110, Government Code, is amended to | ||
read as follows: | ||
Sec. 534.110. TRANSITION BETWEEN PROGRAMS; CONTINUITY OF | ||
SERVICES. (a) During the evaluation of the pilot program required | ||
under Section 534.112, the [ |
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program to ensure continuity of care for pilot program | ||
participants. If the commission does not continue the pilot | ||
program following the evaluation, the commission shall ensure that | ||
there is a comprehensive plan for transitioning the provision of | ||
Medicaid benefits for pilot program participants to the benefits | ||
provided before participating in the pilot program [ |
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(b) A [ |
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developed in consultation and collaboration with the advisory | ||
committee and pilot program workgroup and with stakeholder input as | ||
described by Section 534.103. | ||
SECTION 15. Section 534.111, Government Code, is amended to | ||
read as follows: | ||
Sec. 534.111. CONCLUSION OF PILOT PROGRAM [ |
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concluded unless the commission continues the pilot program under | ||
Section 534.110 [ |
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(b) If the commission continues the pilot program under | ||
Section 534.110, the commission shall publish notice of the pilot | ||
program's continuance in the Texas Register not later than | ||
September 1, 2025. | ||
SECTION 16. Subchapter C, Chapter 534, Government Code, is | ||
amended by adding Section 534.112 to read as follows: | ||
Sec. 534.112. PILOT PROGRAM EVALUATIONS AND REPORTS. (a) | ||
The commission, in consultation and collaboration with the advisory | ||
committee and pilot program workgroup, shall review and evaluate | ||
the progress and outcomes of the pilot program and submit, as part | ||
of the annual report required under Section 534.054, a report on the | ||
pilot program's status that includes recommendations for improving | ||
the program. | ||
(b) Not later than September 1, 2026, the commission, in | ||
consultation and collaboration with the advisory committee and | ||
pilot program workgroup, shall prepare and submit to the | ||
legislature a written report that evaluates the pilot program based | ||
on a comprehensive analysis. The analysis must: | ||
(1) assess the effect of the pilot program on: | ||
(A) access to and quality of long-term services | ||
and supports; | ||
(B) informed choice and meaningful outcomes | ||
using person-centered planning, flexible consumer-directed | ||
services, individualized budgeting, and self-determination, | ||
including a pilot program participant's inclusion in the community; | ||
(C) the integration of service coordination of | ||
acute care services and long-term services and supports; | ||
(D) employment assistance and customized, | ||
integrated, competitive employment options; | ||
(E) the number, types, and dispositions of fair | ||
hearings and appeals in accordance with applicable federal and | ||
state law; | ||
(F) increasing the use and flexibility of the | ||
consumer direction model; | ||
(G) increasing the use of alternatives to | ||
guardianship, including supported decision-making agreements as | ||
defined by Section 1357.002, Estates Code; | ||
(H) achieving the best and most cost-effective | ||
use of funding based on a pilot program participant's needs and | ||
preferences; and | ||
(I) attendant recruitment and retention; | ||
(2) analyze the experiences and outcomes of the | ||
following systems changes: | ||
(A) the comprehensive assessment instrument | ||
described by Section 533A.0335, Health and Safety Code; | ||
(B) the 21st Century Cures Act (Pub. L. No. | ||
114-255); | ||
(C) implementation of the federal rule adopted by | ||
the Centers for Medicare and Medicaid Services and published at 79 | ||
Fed. Reg. 2948 (January 16, 2014) related to the provision of | ||
long-term services and supports through a home and community-based | ||
services (HCS) waiver program under Section 1915(c), 1915(i), or | ||
1915(k) of the federal Social Security Act (42 U.S.C. Section | ||
1396n(c), (i), or (k)); | ||
(D) the provision of basic attendant and | ||
habilitation services under Section 534.152; and | ||
(E) the benefits of providing STAR+PLUS Medicaid | ||
managed care services to persons based on functional needs; | ||
(3) include feedback on the pilot program based on the | ||
personal experiences of: | ||
(A) individuals with an intellectual or | ||
developmental disability and individuals with similar functional | ||
needs who participated in the pilot program; | ||
(B) families of and other persons actively | ||
involved in the lives of individuals described by Paragraph (A); | ||
and | ||
(C) comprehensive long-term services and | ||
supports providers who delivered services under the pilot program; | ||
(4) be incorporated in the annual report required | ||
under Section 534.054; and | ||
(5) include recommendations on: | ||
(A) a system of programs and services for | ||
consideration by the legislature; | ||
(B) necessary statutory changes; and | ||
(C) whether to implement the pilot program | ||
statewide under the STAR+PLUS Medicaid managed care program for | ||
eligible individuals. | ||
SECTION 17. The heading to Subchapter E, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
SUBCHAPTER E. STAGE TWO: TRANSITION OF ICF-IID PROGRAM RECIPIENTS | ||
AND LONG-TERM CARE MEDICAID WAIVER PROGRAM RECIPIENTS TO INTEGRATED | ||
MANAGED CARE SYSTEM | ||
SECTION 18. The heading to Section 534.202, Government | ||
Code, is amended to read as follows: | ||
Sec. 534.202. DETERMINATION TO TRANSITION [ |
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PROGRAM RECIPIENTS AND CERTAIN OTHER MEDICAID WAIVER PROGRAM | ||
RECIPIENTS TO MANAGED CARE PROGRAM. | ||
SECTION 19. Sections 534.202(a), (b), (c), (e), and (i), | ||
Government Code, are amended to read as follows: | ||
(a) This section applies to individuals with an | ||
intellectual or developmental disability who[ |
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are receiving long-term services and supports under: | ||
(1) a Medicaid waiver program [ |
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(2) an ICF-IID program. | ||
(b) Subject to Subsection (g), after [ |
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the pilot program under Subchapter C and completing the evaluation | ||
under Section 534.112 [ |
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collaboration with the advisory committee, shall develop a plan for | ||
the transition of all or a portion of the services provided through | ||
an ICF-IID program or a Medicaid waiver program to a Medicaid | ||
managed care model. The plan must include: | ||
(1) a process for transitioning the services in phases | ||
as follows: | ||
(A) beginning September 1, 2027, the Texas home | ||
living (TxHmL) waiver program services; | ||
(B) beginning September 1, 2029, the community | ||
living assistance and support services (CLASS) waiver program | ||
services; | ||
(C) beginning September 1, 2031, nonresidential | ||
services provided under the home and community-based services (HCS) | ||
waiver program and the deaf-blind with multiple disabilities (DBMD) | ||
waiver program; and | ||
(D) subject to Subdivision (2), the residential | ||
services provided under an ICF-IID program, the home and | ||
community-based services (HCS) waiver program, and the deaf-blind | ||
with multiple disabilities (DBMD) waiver program; and | ||
(2) a process for evaluating and determining the | ||
feasibility and cost efficiency of transitioning residential | ||
services described by Subdivision (1)(D) to a Medicaid managed care | ||
model that is based on an evaluation of a separate pilot program | ||
conducted by the commission, in consultation and collaboration with | ||
the advisory committee, that operates after the transition process | ||
described by Subdivision (1) [ |
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(c) Before implementing the [ |
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described by Subsection (b), the commission shall, subject to | ||
Subsection (g), determine whether to: | ||
(1) continue operation of the Medicaid waiver programs | ||
or ICF-IID program only for purposes of providing, if applicable: | ||
(A) supplemental long-term services and supports | ||
not available under the managed care program delivery model | ||
selected by the commission; or | ||
(B) long-term services and supports to Medicaid | ||
waiver program recipients who choose to continue receiving benefits | ||
under the waiver programs [ |
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or | ||
(2) [ |
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portion of the long-term services and supports previously available | ||
under the Medicaid waiver programs or ICF-IID program through the | ||
managed care program delivery model selected by the commission. | ||
(e) The commission shall ensure that there is a | ||
comprehensive plan for transitioning the provision of Medicaid | ||
benefits under this section that protects the continuity of care | ||
provided to individuals to whom this section applies and ensures | ||
individuals have a choice among acute care and comprehensive | ||
long-term services and supports providers and service delivery | ||
options, including the consumer direction model. | ||
(i) In addition to the requirements of Section 533.005, a | ||
contract between a managed care organization and the commission for | ||
the organization to provide Medicaid benefits under this section | ||
must contain a requirement that the organization implement a | ||
process for individuals with an intellectual or developmental | ||
disability that: | ||
(1) ensures that the individuals have a choice among | ||
acute care and comprehensive long-term services and supports | ||
providers and service delivery options, including the consumer | ||
direction model; | ||
(2) to the greatest extent possible, protects those | ||
individuals' continuity of care with respect to access to primary | ||
care providers, including the use of single-case agreements with | ||
out-of-network providers; and | ||
(3) provides access to a member services phone line | ||
for individuals or their legally authorized representatives to | ||
obtain information on and assistance with accessing services | ||
through network providers, including providers of primary, | ||
specialty, and other long-term services and supports. | ||
SECTION 20. Section 534.203, Government Code, is amended to | ||
read as follows: | ||
Sec. 534.203. RESPONSIBILITIES OF COMMISSION UNDER | ||
SUBCHAPTER. In administering this subchapter, the commission shall | ||
ensure, on making a determination to transition services under | ||
Section 534.202: | ||
(1) that the commission is responsible for setting the | ||
minimum reimbursement rate paid to a provider of ICF-IID services | ||
or a group home provider under the integrated managed care system, | ||
including the staff rate enhancement paid to a provider of ICF-IID | ||
services or a group home provider; | ||
(2) that an ICF-IID service provider or a group home | ||
provider is paid not later than the 10th day after the date the | ||
provider submits a clean claim in accordance with the criteria used | ||
by the commission [ |
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service providers or a group home provider, as applicable; [ |
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(3) the establishment of an electronic portal through | ||
which a provider of ICF-IID services or a group home provider | ||
participating in the STAR+PLUS [ |
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program delivery model or the most appropriate integrated capitated | ||
managed care program delivery model, as appropriate, may submit | ||
long-term services and supports claims to any participating managed | ||
care organization; and | ||
(4) that the consumer direction model is an available | ||
option for each individual with an intellectual or developmental | ||
disability who receives Medicaid benefits in accordance with this | ||
subchapter to achieve self-determination, choice, and control, and | ||
that the individual or the individual's legally authorized | ||
representative has access to a comprehensive, facilitated, | ||
person-centered plan that identifies outcomes for the individual. | ||
SECTION 21. Chapter 534, Government Code, is amended by | ||
adding Subchapter F to read as follows: | ||
SUBCHAPTER F. OTHER IMPLEMENTATION REQUIREMENTS AND | ||
RESPONSIBILITIES | ||
Sec. 534.251. DELAYED IMPLEMENTATION AUTHORIZED. | ||
Notwithstanding any other law, the commission may delay | ||
implementation of a provision of this chapter without further | ||
investigation, adjustments, or legislative action if the | ||
commission determines the provision adversely affects the system of | ||
services and supports to persons and programs to which this chapter | ||
applies. | ||
Sec. 534.252. REQUIREMENTS REGARDING TRANSITION OF | ||
SERVICES. (a) For purposes of implementing the pilot program under | ||
Subchapter C and transitioning the provision of services provided | ||
to recipients under certain Medicaid waiver programs to a Medicaid | ||
managed care delivery model following completion of the pilot | ||
program, the commission shall: | ||
(1) implement and maintain a certification process for | ||
and maintain regulatory oversight over providers under the Texas | ||
home living (TxHmL) and home and community-based services (HCS) | ||
waiver programs; and | ||
(2) require managed care organizations to include in | ||
the organizations' provider networks providers who are certified in | ||
accordance with the certification process described by Subdivision | ||
(1). | ||
(b) For purposes of implementing the pilot program under | ||
Subchapter C and transitioning the provision of services described | ||
by Section 534.202 to the STAR+PLUS Medicaid managed care program, | ||
a comprehensive long-term services and supports provider: | ||
(1) must report to the managed care organization in | ||
the network of which the provider participates each encounter of | ||
any directly contracted service; | ||
(2) must provide to the managed care organization | ||
quarterly reports on: | ||
(A) coordinated services and time frames for the | ||
delivery of those services; and | ||
(B) the goals and objectives outlined in an | ||
individual's person-centered plan and progress made toward meeting | ||
those goals and objectives; and | ||
(3) may not be held accountable for the provision of | ||
services specified in an individual's service plan that are not | ||
authorized or subsequently denied by the managed care organization. | ||
(c) On transitioning services under a Medicaid waiver | ||
program to a Medicaid managed care delivery model, the commission | ||
shall ensure that individuals do not lose benefits they receive | ||
under the Medicaid waiver program. | ||
SECTION 22. Section 534.201, Government Code, is repealed. | ||
SECTION 23. Not later than September 1, 2020, and only if | ||
the Health and Human Services Commission determines it would be | ||
cost effective, the executive commissioner of the Health and Human | ||
Services Commission shall seek a waiver or authorization from the | ||
appropriate federal agency to provide Medicaid benefits to | ||
medically fragile individuals: | ||
(1) who are 21 years of age or older; and | ||
(2) whose health care costs exceed cost limits under | ||
appropriate Medicaid waiver programs, as defined by Section | ||
534.001, Government Code. | ||
SECTION 24. As soon as practicable after the effective date | ||
of this Act, the executive commissioner of the Health and Human | ||
Services Commission shall adopt rules as necessary to implement the | ||
changes in law made by this Act. | ||
SECTION 25. 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 26. This Act takes effect September 1, 2019. | ||
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