By: Klick	H.B. No. 4561

	A BILL TO BE ENTITLED
	AN ACT
	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 and a pilot for certain
	populations with similar functional needs receiving services in
	managed care.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 534.001, Subchapter A, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.001.  DEFINITIONS. In this chapter:
	(3)  ["Department" means the Department of Aging and
	Disability Services.] "Commission" means the Health and Human
	Services Commission or an agency operating part of the state
	Medicaid managed care program, as appropriate.
	(4)  "Comprehensive long term services and supports
	provider" is defined as a provider of long term services and
	supports specified under this chapter that ensures the coordinated,
	seamless provision of the full range of services as approved in
	participants' program plans as described under Section 534.1045
	(b), (b-2),(c), and (d). A comprehensive service provider includes:
	(A)  an ICF/IID program provider who is authorized
	to deliver services in the program defined under Section 534.001
	(8), and
	(B)  a Medicaid waiver program provider who is
	authorized to deliver services in the programs specified under
	Section 534.001 (12) and certified in accordance with 534.301 (b).
	[(4)] (5)  "Functional need" means the measurement of
	an individual's services and supports needs, including the
	individual's intellectual, psychiatric, medical, and physical
	support needs.
	[(5)] (6)  "Habilitation services" includes assistance
	provided to an individual with acquiring, retaining, or improving:
	(A)  skills related to the activities of daily
	living; and
	(B)  the social and adaptive skills necessary to
	enable the individual to live and fully participate in the
	community.
	[(6)] (7)  "ICF-IID" means the program under Medicaid
	serving individuals with an intellectual or developmental
	disability who receive care in intermediate care facilities other
	than a state supported living center.
	[(7)] (8)  "ICF-IID program" means a program under
	Medicaid serving individuals with an intellectual or developmental
	disability who reside in and receive care from:
	(A)  intermediate care facilities licensed under
	Chapter 252, Health and Safety Code; or
	(B)  community-based intermediate care facilities
	operated by local intellectual and developmental disability
	authorities.
	[(8)] (9)  "Local intellectual and developmental
	disability authority" has the meaning assigned by Section 531.002,
	Health and Safety Code.
	[(9)] (11)  "Managed care organization," "managed care
	plan," and "potentially preventable event" have the meanings
	assigned under Section 536.001.
	(10)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 1,
	Sec. 2.287(17), eff. April 2, 2015.
	[(11)] (12)  "Medicaid waiver program" means only the
	following programs that are authorized under Section 1915(c) of the
	federal Social Security Act (42 U.S.C. Section 1396n(c)) for the
	provision of services to persons with an intellectual or
	developmental disability:
	(A)  the community living assistance and support
	services (CLASS) waiver program;
	(B)  the home and community-based services (HCS)
	waiver program;
	(C)  the deaf-blind with multiple disabilities
	(DBMD) waiver program; and
	(D)  the Texas home living (TxHmL) waiver program.
	(13)  "Residential Services" means services provided
	for an individual with intellectual or developmental disability in
	a community-based ICF/IID, a three or four persons home and host
	home/companion service offered through the 1915(c) home and
	community-based waiver services program, or a group home in the
	Deaf Blind Multiple Disabilities program.
	[(12)] (14)  "State supported living center" has the
	meaning assigned by Section 531.002, Health and Safety Code.
	SECTION 2.  Section 534.051, Subchapter B, Chapter 534,
	Government Code, is 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 [and the department] shall [jointly] design and
	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;
	SECTION 3.  Section 534.052, Subchapter B, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.052.  IMPLEMENTATION OF SYSTEM REDESIGN. The
	commission [and department] shall, in consultation and
	collaboration with the advisory committee, [jointly] implement the
	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 4.  Section 534.053, Subchapter B, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.053.  INTELLECTUAL AND DEVELOPMENTAL DISABILITY
	SYSTEM REDESIGN ADVISORY COMMITTEE. (a) The Intellectual and
	Developmental Disability System Redesign Advisory Committee shall
	advise the commission [and the department] on the implementation of
	the acute care services and long-term services and supports system
	redesign under this chapter. Subject to Subsection (b), the
	executive commissioner [and the commissioner of aging and
	disability services] shall [jointly] appoint members of the
	advisory committee who are stakeholders from the intellectual and
	developmental disabilities community, including:
	(b)  To the greatest extent possible, the executive
	commissioner [and the commissioner of aging and disability
	services] shall appoint members of the advisory committee who
	reflect the geographic diversity of the state and include members
	who represent rural Medicaid recipients.
	(e-1)  The advisory committee may establish work groups that
	meet at other times for purposes of studying and making
	recommendations on issues the committee considers appropriate.
	[(g)  On January 1, 2026:
	(1)  the advisory committee is abolished ; and
	(2)  this section expires].
	(g)  On the [one year] two-year anniversary of the date the
	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, Subchapter B, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.054.  ANNUAL REPORT ON IMPLEMENTATION.
	(b)  On the two-year anniversary of the date the commission
	completes implementation of the transition required under Section
	534.202 this [This] section expires [January 1, 2026].
	SECTION 6.  Section 534.101, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.101.  Pilot Program Workgroup [DEFINITIONS]. In
	accordance with Section 534.053 (e-1), for puposes of [In] this
	subchapter the advisory committee shall establish a h Workgroup
	that includes representatives from the advisory committee,
	stakeholders representing individuals with an intellectual and
	developmental disability, individuals with similar functional
	needs, and the STAR+PLUS managed care organizations. [:]
	[(1)     "Capitation" means a method of compensating a
	provider on a monthly basis for providing or coordinating the
	provision of a defined set of services and supports that is based on
	a predetermined payment per services recipient.]
	[(2)     "Provider" means a person with whom the
	commission contracts for the provision of long-term services and
	supports under Medicaid to a specific population based on
	capitation.]
	SECTION 7.  Section 534.102, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.102.  PILOT PROGRAM [S] TO TEST PERSON-CENTERED
	MANAGED CARE STRATEGIES AND IMPROVEMENTS BASED ON CAPITATION. The
	commission [and the department may] ,in consultation and
	collaboration with the advisory committee and Pilot Program
	Workgroup, shall develop and implement a pilot program[s] in
	accordance with this subchapter to test, through the STAR+PLUS
	Medicaid managed care program, the delivery of [one or more service
	delivery models involving] long term services and supports [a
	managed care strategy based on capitation to deliver long-term
	services and supports under Medicaid] to individuals [with an
	intellectual or developmental disability]specified under Section
	534.1065.
	SECTION 8.  Section 534.103, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.103.  STAKEHOLDER INPUT. As part of developing and
	implementing a pilot program under this subchapter, the
	[department] commission, in consultation and collaboration with
	the advisory committee and Pilot Program Workgroup, shall develop a
	process to receive and evaluate input from statewide stakeholders
	and stakeholders from the STAR+PLUS service area [region] of the
	state in which the pilot program will be implemented and other
	evaluations and data.
	SECTION 9.  Chaoter 534, Government Code is amended to add
	new Section 534.1035, SELECTION OF MANAGED CARE ORGANIZATION
	VENDORS, to read as follows:
	Sec.534.1035.  SELECTON OF MANAGED CARE ORGANIZATION PILOT
	VENDORS. (a) The commission shall select and contract with no more
	than two managed care organizations contracted to provide services
	under the STAR+PLUS Medicaid managed care program to participate in
	the pilot.
	(b)  The commission, in consultation and collaboration with
	the advisory committee and Pilot Program Workgroup, shall develop
	criteria regarding the selection of managed care organizations to
	conduct the pilot program.
	SECTION 10.  Section 534.104, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.104.  PILOT DESIGN [MANAGED CARE STRATEGY
	PROPOSALS; PILOT PROGRAM SERVICE PROVIDERS].
	[(a)     The department, in consultation and collaboration with
	the advisory committee, shall identify private services providers
	or managed care organizations that are good candidates to develop a
	service delivery model involving a managed care strategy based on
	capitation and to test the model in the provision of long-term
	services and supports under Medicaid to individuals with an
	intellectual or developmental disability through a pilot program
	established under this subchapter].
	[(b)     The department shall solicit managed care strategy
	proposals from the private services providers and managed care
	organizations identified under Subsection (a). In addition, the
	department may accept and approve a managed care strategy proposal
	from any qualified entity that is a private services provider or
	managed care organization if the proposal provides for a
	comprehensive array of long-term services and supports, including
	case management and service coordination.]
	[(c)] (a)  [A managed care strategy based on capitation
	developed for implementation through a] The pilot program under
	this subchapter 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 informed choice and meaningful outcomes by
	using person-centered planning, flexible consumer directed
	services, individualized budgeting, and self-determination, and
	promote community inclusion and 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 the individual's needs and preferences;
	(6)  promote [the placement of an individual in]
	housing stability through housing supports and navigation services
	that is the most integrated and least restrictive setting
	appropriate to the individual's needs and preferences;
	(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; and
	(9)  promote sufficient flexibility to achieve the
	goals listed in this section through the pilot program [.] ;
	(10)  promote the use of innovative technology and
	benefits, including telemonitoring and testing of remote
	monitoring for individuals participating in the pilot. The remote
	monitoring and telemonitoring is voluntary and shall ensure an
	individual's privacy and health and welfare and allow access to
	housing in the most integrated and least restrictive environment.
	Innovations may include transportation and other innovations that
	support community integration. If a pilot participant voluntarily
	decides to use telemonitoring or remote monitoring or other
	innovative technologies, the managed care organization providing
	the pilot services shall deliver the telemonitoring, remote
	monitoring and/or innovative technology services in a way that:
	(A)  assesses individual needs and preferences in
	a manner that promotes autonomy, self-determination, consumer
	directed services, privacy and increases personal independence;
	(B)  determines the extent in which remote
	monitoring, telemedicine and other innovative technologies will be
	used, including but not limited to, times of day, where the
	equipment can be used, what types of telemonitoring and/or remote
	monitoring, for what tasks;
	(C)  is identified and agreed to through the
	person centered planning process;
	(D)  ensures the staff overseeing remote
	monitoring, telemedicine and other innovative technologies review
	person-centered plans and implementation plans of each individual
	they are monitoring prior to monitoring that individual and
	demonstrate competency regarding the support needs of each
	individual they are monitoring; and
	(E)  ensures an individual can request to remove
	the remote monitoring and other innovative technology equipment at
	any point during the IDD pilot and the managed care organizations
	must remove the equipment immediately.
	(F)  ensures individuals can choose not to use
	telemedicine at any point during participation in the pilot and
	that the pilot participating managed care organization must arrange
	for services that do not require the use of telemedicine.
	(11)  ensure an adequate provider network that includes
	comprehensive long term services and supports providers as
	described in Section 534.001 (4) and Section 534.107 (a)(2) and
	choice from among these providers;
	(12)  ensure timely initiation and consistent
	provision of long term services and supports in accordance with an
	individual's person centered care plan;
	(13)  ensure individuals with complex behavioral,
	medical and physical needs receive services based on assessed needs
	and in the most integrated, least restrictive setting according to
	the each individual's needs and preferences;
	(14)  increase, expand flexibility and promote use of
	the consumer directed services model ; and
	(15)  promote independence, self-determination,
	consumer directed services and decision making by using
	alternatives to guardianship, including supported decision-making
	agreements under Chapter 1357, Estates Code.
	(b)  The pilot program shall be designed to test innovations
	and payment models for the provision of long-term services and
	supports to achieve the goals outlined in subsection (a) utilizing
	methods such as:
	(1)  payment of a bundled amount without downside risk
	to a 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 providers of long
	term services and supports based on meeting pre-determined outcome
	or quality metrics; and
	(3)  any other payment models approved by the
	commission.
	(c)  The alternative payment rates or methodologies tested
	under subsection (b) must be agreed to in writing by the managed
	care organization and participating long term services and supports
	provider. In developing the alternative payment rates or
	methodologies, the parties must utilize:
	(1)  the historical costs of long term services and
	supports, including Medicaid fee-for-service rates; and
	(2)  reasonable cost estimates for new pilot program
	services; and
	(3)  whether alternative payment rates or
	methodologies are sufficient to ensure the provider's continued
	participation in the pilot program and promote quality outcomes.
	(d)  For long term services and supports delivered under the
	pilot, the alternative payment models tested under subsection (b)
	shall not reduce the minimum payment to providers below the current
	fee for service reimbursement rates.
	(e)  The pilot program must allow existing providers of
	long-term services and supports for persons with intellectual and
	developmental disabilities, as defined in Section 534.001 (4), and
	providers of long term services and supports for persons with
	similar functional needs to voluntarily participate in one or more
	pilot projects. Failure to participate in a pilot project does not
	affect the contracting status of any provider as a significant
	traditional provider.
	[(d)     The department, in consultation and collaboration with
	the advisory committee, shall evaluate each submitted managed care
	strategy proposal and determine whether:
	(1)     the proposed strategy satisfies the requirements
	of this section; and
	(2)     the private services provider or managed care
	organization that submitted the proposal has a demonstrated ability
	to provide the long-term services and supports appropriate to the
	individuals who will receive services through the pilot program
	based on the proposed strategy, if implemented.]
	[(e)     Based on the evaluation performed under Subsection
	(d), the department may select as pilot program service providers
	one or more private services providers or managed care
	organizations with whom the commission will contract.]
	(f)  [For each pilot program service provider, the
	department__shall develop and implement a pilot program.] Under a
	pilot program, the [pilot program service provider] the
	participating managed care organizations shall provide long-term
	services and supports under Medicaid to persons with an
	intellectual or developmental disability, and other individuals
	with disabilities with similar functional needs, to test its
	managed care strategy based on capitation.
	(g)  The [department] commission, in consultation and
	collaboration with the advisory committee and Pilot Program
	Workgroup, shall analyze information provided by the [pilot program
	service providers] participating managed care organizations and
	any information collected by the [department] commission during the
	operation of the pilot program[s] for purposes of making a
	recommendation about a system of programs and services for
	implementation through future state legislation or rules.
	(h)  The analysis under Subsection (g) must include an
	assessment of the effect of the managed care strategies implemented
	in the pilot program[s] on the goals specified under Subsections
	(a), (b), (c) and (d). [:]
	[(1)  access to long-term services and supports;
	(2)     the quality of acute care services and long-term
	services and supports;
	(3)     meaningful outcomes using person-centered
	planning, individualized budgeting, and self-determination,
	including a person's inclusion in the community;
	(4)     the integration of service coordination of acute
	care services and long-term services and supports;
	(5)  the efficiency and use of funding;
	(6)     the placement of individuals in housing that is
	the least restrictive setting appropriate to an individual's needs;
	(7)     employment assistance and customized, integrated,
	competitive employment options; and
	(8)     the number and types of fair hearing and appeals
	processes in accordance with applicable federal law.]
	(i)  Prior to implementation of the pilot program, the
	commission, in consultation and collaboration with the advisory
	committee and Pilot Program Workgroup, shall develop a process to
	ensure 12 months continuous Medicaid eligibility for pilot
	participants.
	SECTION 11.  Chapter 534, Government Code is amended to add
	new section 534.1045, PILOT BENEFITS AND PROVIDER QUALIFICATIONS as
	follows:
	Sec. 534.1045.  PILOT BENEFITS AND PROVIDER QUALIFICATIONS.
	(a) The pilot program must ensure that participating managed care
	organizations provide:
	(1)  all Medicaid state plan acute care benefits
	available under the STAR+PLUS program;
	(2)  long term services and supports in the Medicaid
	state plan, including:
	(A)  Community First Choice services;
	(B)  Personal Assistant services;
	(C)  Day Activity Health Services;
	(D)  Habilitation services defined under Section
	534/001 (6);
	(3)  long term services and supports in the STAR+PLUS
	home and community-based services waiver, including:
	(A)  assisted living
	(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)  cogniticve rehabilitative therapy;
	(K)  physical therapy;
	(L)  occupational therapy;
	(M)  speech-language pathology;
	(N)  medical supplies;
	(O)  minor home modifcations;
	(P)  adaptive aids;
	(4)  long term services and supports available in the
	Medicaid waiver programs defined in Section 534.001 (12),
	including:
	(A)  enhanced behavioral health services;
	(B)  behavioral supports;
	(C)  day habilitation;
	(D)  community support transporation;
	(5)  additional long term services and supports,
	including:
	(A)  housing supports;
	(B)  behavioral health crisis intervention;
	(C)  high medical needs services; and
	(6)  Other non-residential long term services and
	supports the commission, in consultation and coordination with the
	advisory committee and Pilot Program Workgroup, determines
	appropriate and consistent with the regulations governing the 1915
	(c) waiver programs defined in Section 534.001 (12),
	person-centered approaches, home and community-based settings
	requirements, and the most integrated and least restrictive setting
	according to an individual's needs and preferences.
	(b)  A comprehensive long term services and supports
	provider is authorized to deliver services listed under under
	subsections (a)(2)(A), (a)(2)(D), (a)(3)(B), (a)(3)(C), (a)(3)(D),
	(a)(3)(G), (a)(3)(H), (a)(3)(J), (a)(3)(K), (a)(3)(L), (a)(3)(M),
	and (a)(3)(4),if they also deliver the service in a Medicaid waiver
	defined under Section 534.001 (12).
	(b-2)  A comprehensive long term services and supports
	provider may deliver services under subsections (a)(5) and (a)(6)
	if agreed to under contract with the pilot participating managed
	care organization.
	(c)  Day habilitation services under (a)(4)(c) may be
	delivered by a provider who is contracted or subcontracted under a
	1915 (c) Medicaid waiver as defined under Section 534.001 (12) or an
	ICF/IID program as defined under Section 534.001 (8).
	(d)  A comprehensive long term services and supports
	provider works in consultation with the pilot participating managed
	care organization's care coordinators to ensure the seamless
	delivery of acute care and long term services and supports on a
	day-to-day basis in accordance with an individual's plan of care
	and may be reimbursed by the managed care organization for this
	coordination.
	(e)  Prior to implementation of the pilot program, the
	commission, in consultation and collaboration with the advisory
	committee and Pilot Program Workgroup, shall:
	(1)  develop recommendations to modify, for the pilot
	program only, the Adult Foster Care, Supported Employment and
	Employment Assistance benefits to ensure increased access to and
	availability of this service, and
	(2)  as needed, definitions for services described
	under subsection (a)(4) and (5), and any services added under
	subsection (6).
	SECTION 12.  Section 534.105, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.105.  PILOT PROGRAM: MEASURABLE GOALS. (a) The
	[department] commission, in consultation and collaboration with
	the advisory committee and Pilot Program Workgroup, shall identify
	measurable goals using National Core Indicators, National Quality
	Forum LTSS measures and other appropriate CAHPS measures to be
	achieved by [each] the pilot program implemented under this
	subchapter. [The identified goals must:
	(1)     align with information that will be collected
	under Section 534.108(a); and
	(2)     be designed to improve the quality of outcomes for
	individuals receiving services through the pilot program.]
	(b)  The [department] commission, in consultation and
	collaboration with the advisory committee and Pilot Program
	Workgroup, shall [propose] develop specific strategies and
	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 the mechanisms to report, track and assess the specific
	strategies and performance measures for achieving the identified
	goals are established prior to implementation of the pilot program.
	SECTION 13.  Section 534.106, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.106.  IMPLEMENTATION, LOCATION, AND DURATION. (a)
	The commission [and the department] shall implement [any] the pilot
	program[s] established under this subchapter [not later than] on
	September 1, [2017] 2023.
	(b)  A pilot program established under this subchapter [may]
	shall operate for at least [up to] 24 months. [A pilot program may
	cease operation if the pilot program service provider terminates
	the contract with the commission before the agreed-to termination
	date.]
	(c)  A pilot program established under this subchapter shall
	be conducted in [one or more] the STAR+PLUS service area [regions]
	selected by the [department] commission.
	SECTION 14.  Section 534.1065, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.1065.  RECIPIENT ENROLLMENT, PARTICIPATION AND
	ELIGIBILITY [IN PROGRAM VOLUNTARY]. (a) Enrollment
	[Participation]in a pilot program established under this
	subchapter by an individual [with an intellectual or developmental
	disability] shall occur using an opt-out process [is voluntary,
	and] with the decision whether to participate in a program and
	receive long-term services and supports from a provider through
	that program [may] to be made only by the individual or the
	individual's legally authorized representative.
	(1)  The commission, in consultation and collaboration
	with the advisory committee and Pilot Program Workgroup, shall
	develop a timeline and process for and informational materials
	related to educating pilot participants about the pilot including
	its benefits, impact on current services and other related
	information to ensure prospective pilot participants are able to
	make an informed decision regarding participation. The process must
	ensure:
	(A)  the timeline for development and
	distribution of the pilot informational materials allows for
	sufficient advance notification to and education of individuals
	eligible for pilot participation, their families and other
	individuals actively involved in their lives;
	(B)  individuals eligible for pilot
	participation, including new and current STAR+PLUS enrollees and
	other individuals specified in subsection (a) (1) (A), receive oral
	and written information about the pilot prior to participation,
	(C)  the information provided is written in clear,
	simple language and presented in a manner individuals are able to
	understand and, at a minimum, explains that:
	(i)  upon conclusion of the pilot,
	individuals will be requested to provide input on their pilot
	participation experience, including whether the pilot was able to
	meet their unique support needs;
	(ii)  participation in the pilot does not
	remove individuals from any Interest List or, in accordance with
	Section 534.1065 (c), the right to select an enrollment, transition
	or diversion offer; and
	(iii)  individuals have choice among acute
	care and long term services providers, including the consumer
	directed services model and the comprehensive services model.
	(b)  The commission, in consultation and coordination with
	the advisory committee and Pilot Program Workgroup, shall develop
	pilot program participant eligibility criteria. The criteria must
	ensure pilot participants include:
	(1)  individuals with an intellectual and
	developmental disability including autism and individuals with
	significant complex behavioral, medical and physical needs
	receiving home and community-based services through STAR+PLUS or a
	STAR+PLUS member who is also on a Medicaid Waiver Interest List or
	is a STAR+PLUS member meeting criteria for intellectual
	disabilities. It does not include individuals who are receiving
	only acute care services under STAR+PLUS and enrolled in the
	community-based ICF/IID program or one of the Medicaid waiver
	programs defined under Section 534.001 (12).
	(2)  individuals receiving services under the
	STAR+PLUS Medicaid managed care program who have a traumatic brain
	injury that occurred after the age of 22; and
	(3)  other individuals with disabilities who have
	similar functional needs independent of age of onset or diagnosis.
	(c)  Individuals participating in the pilot who, during the
	pilot's implementation, are offered enrollment in one of the 1915
	(c) Medicaid waiver programs defined under Section 534.001 (12)
	shall be eligible to accept the enrollment, transition or diversion
	offer.
	SECTION 15.  Section 534.107, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.107.  [COORDINATING SERVICES] COMMISSION
	RESPONSIBILTIES. (a) [In providing long-term services and supports
	under Medicaid to individuals with an intellectual or developmental
	disability,] The commission [a pilot program service provider]
	shall require managed care organizations participating in the pilot
	program to:
	(1)  ensure individuals participating in the pilot have
	choice among acute care and comprehensive long term services and
	supports providers and service delivery options including the
	consumer directed services model as specified under Section
	534.109. [coordinate through the pilot program institutional and
	community-based services available to the individuals, including
	services provided through:
	(A)     a facility licensed under Chapter 252, Health
	and Safety Code;
	(B)  a Medicaid waiver program; or
	(C)     a community-based ICF-IID operated by local
	authorities] ;
	(2)  demonstrate to the satisfaction of the commission
	that their network of acute care, long term services and supports
	and comprehensive service providers have experience and expertise
	providing services for individuals with an intellectual or
	developmental disability and individuals with similar functional
	needs;
	[collaborate with managed care organizations to provide
	integrated coordination of acute care services and long-term
	services and supports, including discharge planning from acute care
	services to community-based long-term services and supports];
	(3)  have a process for preventing inappropriate
	institutionalizations of individuals; and
	(4)  ensure timely initiation and consistent provision
	of services in accordance with an individual's person-centered plan
	[accept the risk of inappropriate institutionalizations of
	individuals previously residing in community settings].
	(b)  For the duration of the pilot the commission must ensure
	that comprehensive long term services and supports providers as
	defined under Section 534.001(4) are deemed significant
	traditional providers and included in the provider network of the
	managed care organizations participating in the pilot.
	SECTION 16.  Section 534.108, Subchapter C., Chapter 534,
	Government Code, is amended to read as follows:
	Section 534.108.  Pilot Program Information. (a) The
	commission [and the department, in consultation and coordination
	with the advisory committee and Pilot Program Workgroup, shall
	determine the information to be collected from each managed care
	organization participating in the pilot for use in the evaluation
	and reports required under Section 534.121. [collect and compute
	the following information with respect to each pilot program
	implemented under this subchapter to the extent it is available:]
	(b)  For the duration of the pilot each managed care
	organization participating in the pilot shall submit to the
	commission and the advisory committee a quarterly report on the
	services provided to each pilot participant that includes the
	following information:
	(A)  the level of services requested, and the
	authorization and utilization rates of services for each pilot
	service;
	(B)  timeliness of services requested,
	authorized, initiated, and number and duration of unplanned service
	breaks;
	(C)  number of pilot participants using
	employment assistance and supported employment services;
	(D)  number of service denials and fair hearings,
	and disposition of fair hearings;
	(E)  number of complaints and inquiries received
	by the commission and managed care organizations participating in
	the pilot and the outcome of the complaints; and
	(F)  number of participants who select the
	consumer directed services model and reasons participants did not
	select the service model.
	(c)  The commission shall ensure that the mechanisms to
	report and track the information and data required in subsections
	(a) and (b) are established prior to implementation of the pilot
	program.
	[(1)     the difference between the average monthly cost
	per person for all acute care services and long-term services and
	supports received by individuals participating in the pilot program
	while the program is operating, including services provided through
	the pilot program and other services with which pilot program
	services are coordinated as described by Section 534.107, and the
	average monthly cost per person for all services received by the
	individuals before the operation of the pilot program;
	(2)     the percentage of individuals receiving services
	through the pilot program who begin receiving services in a
	nonresidential setting instead of from a facility licensed under
	Chapter 252, Health and Safety Code, or any other residential
	setting;
	(3)     the difference between the percentage of
	individuals receiving services through the pilot program who live
	in non-provider-owned housing during the operation of the pilot
	program and the percentage of individuals receiving services
	through the pilot program who lived in non-provider-owned housing
	before the operation of the pilot program;
	(4)     the difference between the average total Medicaid
	cost, by level of need, for individuals in various residential
	settings receiving services through the pilot program during the
	operation of the program and the average total Medicaid cost, by
	level of need, for those individuals before the operation of the
	program;
	(5)     the difference between the percentage of
	individuals receiving services through the pilot program who obtain
	and maintain employment in meaningful, integrated settings during
	the operation of the program and the percentage of individuals
	receiving services through the program who obtained and maintained
	employment in meaningful, integrated settings before the operation
	of the program;
	(6)     the difference between the percentage of
	individuals receiving services through the pilot program whose
	behavioral, medical, life-activity, and other personal outcomes
	have improved since the beginning of the program and the percentage
	of individuals receiving services through the program whose
	behavioral, medical, life-activity, and other personal outcomes
	improved before the operation of the program, as measured over a
	comparable period; and
	(7)     a comparison of the overall client satisfaction
	with services received through the pilot program, including for
	individuals who leave the program after a determination is made in
	the individuals' cases at hearings or on appeal, and the overall
	client satisfaction with services received before the individuals
	entered the pilot program.
	(b)     The pilot program service provider shall collect any
	information described by Subsection (a) that is available to the
	provider and provide the information to the department and the
	commission not later than the 30th day before the date the program's
	operation concludes.
	(c)     In addition to the information described by Subsection
	(a), the pilot program service provider shall collect any
	information specified by the department for use by the department
	in making an evaluation under Section 534.104(g).
	(d)     The commission and the department, in consultation and
	collaboration with the advisory committee, shall review and
	evaluate the progress and outcomes of each pilot program
	implemented under this subchapter and submit, as part of the annual
	report to the legislature required by Section 534.054, a report to
	the legislature during the operation of the pilot programs. Each
	report must include recommendations for program improvement and
	continued implementation.]
	SECTION 17.  Section 534.109, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.109.  PERSON-CENTERED PLANNING. The commission, in
	consultation and collaboration [cooperation] with the [department]
	advisory committee and Pilot Program Workgroup, shall ensure that
	each individual[with an intellectual or developmental disability]
	who receives services and supports under Medicaid through a pilot
	program established under this subchapter, 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 directed services[direction] model, as defined by
	Section 531.051, [may be an outcome of the plan] must be an
	available option for individuals to achieve self-determination,
	choice and control.
	SECTION 18.  Section 534.110, Subchapter C., Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.110.  TRANSITION BETWEEN PROGRAMS; CONTINUITY OF
	SERVICES. (a) During the evaluation of the pilot required under
	Section 534.121,[The] the commission may continue the pilot to
	protect continuity of care. If the commission determines not to
	continue the pilot during the evaluation, the commission, in
	consultation and collaboration with the advisory committee and
	Pilot Program Workgroup, shall ensure that there is a comprehensive
	plan for transitioning the provision of Medicaid benefits provided
	to pilot participants to the services provided before the pilot.
	[between a Medicaid waiver program or an ICF-IID program and a pilot
	program under this subchapter to protect continuity of care.]
	(b)  The transition plan shall be developed in consultation
	and collaboration with the advisory committee and with stakeholder
	input as described by Section 534.103.
	SECTION 19.  Section 534.111, Subchapter C, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.111.  CONCLUSION OF PILOT PROGRAM[S]; EXPIRATION.
	Contingent on the decision made under Section 534.110, [On] on
	September 1, [2019] 2025:
	(1)  [each] the pilot program established under this
	subchapter [that is still in operation] either continues or must
	conclude. [; and
	(2)  this subchapter expires.]
	SECTION 21.  Chapter 534, Government Code,is amended to add
	new Subchapter C-1 to read as follows: SUBCHAPTER C-1. PILOT
	EVALUATION AND REPORT
	Section 534.121.  EVALUATION OF AND REPORT ON PILOT PROGRAM.
	(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 implemented
	under Subchapter C of this Chapter and submit, as part of the annual
	report required by Section 534.054, a report on the status of the
	pilot program. The report must include recommendations for program
	improvement.
	(b)  Upon conclusion of the pilot program required under
	Subchapter C, the commission, in consultation and collaboration
	with the advisory committee and Pilot Program Workgroup, shall
	evaluate the pilot program and prepare and submit a report to the
	legislature based on a comprehensive analysis of the pilot.
	(c)  The comprehensive analysis must:
	(1)  include an assessment of the effect of the pilot
	on:
	(A)  access to and improved 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 person'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
	hearing and appeals processes in accordance with applicable federal
	and state law;
	(F)  increasing use and flexibility of the
	consumer directed service model;
	(G)  increasing use of alternatives to
	guardianship, including supported decision-making agreements under
	Chapter 1357, Estates Code;
	(H)  achieving cost effectiveness and best use of
	funding based on individuals' needs and preferences; and
	(I)  attendant recruitment and retention;
	(2)  provide an analysis of the experience and outcome
	of the following systems changes:
	(A)  the IDD assessment tool required under
	Chapter 533, Subchapter B, Section 533.0335, Health and Safety
	Code;
	(B)  the 21st Century Cures Act;
	(C)  implementation of the federal HCBS Settings
	regulations; and
	(D)  the provision of basic attendant and
	habilitation services required under Section 534.152 of this
	Chapter, and
	(E)  the benefits of providing STAR+PLUS services
	to persons based on functional needs;
	(3)  include input from the individuals with
	intellectual and developmental disabilities and participants of
	similar functional needs, families and other individuals actively
	involved in the lives of the individuals; and providers of long term
	services and supports programs defined under Section 534.001 (8)
	and (12) who participated in the pilot about their experiences;
	(4)  be incorporated into the annual report to the
	legislature required under Section 534.054; and
	(5)  include recommendations about a system of programs
	and services for consideration by the legislature, including
	recommendations for needed statutory changes and whether to
	transition the pilot to a statewide program under the STAR+PLUS
	program for individuals who meet the eligibility criteria specified
	in Section 534.1065.
	SECTION 22.  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 23.  Section 534.201, Subchapter E, Chapter 534,
	Government Code, is repealed:
	[Sec. 534.201. TRANSITION OF RECIPIENTS UNDER TEXAS HOME
	LIVING (TxHmL) WAIVER PROGRAM TO MANAGED CARE PROGRAM.] [(a)[This
	section applies to individuals with an intellectual or
	developmental disability who are receiving long-term services and
	supports under the Texas home living (TxHmL) waiver program on the
	date the commission implements the transition described by
	Subsection (b).]
	[(b)     On September 1, 2020, the commission shall transition
	the provision of Medicaid benefits to individuals to whom this
	section applies to the STAR + PLUS Medicaid managed care program
	delivery model or the most appropriate integrated capitated managed
	care program delivery model, as determined by the commission based
	on cost-effectiveness and the experience of the STAR + PLUS
	Medicaid managed care program in providing basic attendant and
	habilitation services and of the pilot programs established under
	Subchapter C, subject to Subsection (c)(1).]
	[(c)     At the time of the transition described by Subsection
	(b), the commission shall determine whether to:
	(1)     continue operation of the Texas home living
	(TxHmL) waiver program for purposes of providing supplemental
	long-term services and supports not available under the managed
	care program delivery model selected by the commission; or
	(2)     provide all or a portion of the long-term services
	and supports previously available under the Texas home living
	(TxHmL) waiver program through the managed care program delivery
	model selected by the commission.]
	[(d)     In implementing the transition described by Subsection
	(b), the commission, in consultation and collaboration with the
	advisory committee, shall develop a process to receive and evaluate
	input from interested statewide stakeholders.]
	[(e)     The commission, in consultation and collaboration with
	the advisory committee, 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.]
	[(f)     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 of
	providers;
	(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].
	[(g)]     [The commission, in consultation and collaboration
	with the advisory committee, shall analyze the outcomes of the
	transition of the long-term services and supports under the Texas
	home living (TxHmL) Medicaid waiver program to a managed care
	program delivery model.]  [The analysis must:]
	[(1)     include an assessment of the effect of the
	transition on:]
	[(A)  access to long-term services and supports;]
	[(B)     meaningful outcomes using person-centered
	planning, individualized budgeting, and self-determination,
	including a person'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; and]
	[(E)     the number and types of fair hearing and
	appeals processes in accordance with applicable federal law;]
	[(2)     be incorporated into the annual report to the
	legislature required under Section 534.054; and]
	(3)     include recommendations for improvements to the
	transition implementation for consideration by the legislature,
	including recommendations for needed statutory changes.]
	SECTION 24.  Section 534.202, Subchapter E, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.202.  DETERMINATION TO TRANSITION [OF] ICF-IID
	PROGRAM RECIPIENTS AND CERTAIN [OTHER] MEDICAID WAIVER PROGRAM
	RECIPIENTS TO MANAGED CARE PROGRAM. (a) This section applies to
	individuals with an intellectual or developmental disability who
	[ , on the date the commission implements the transition
	described by Subsection (b), ] are receiving long-term services and
	supports under:
	(1)  a Medicaid waiver program as defined under Section
	534.001 (12) [other than the Texas home living (TxHmL) waiver
	program]; or
	(2)  an ICF-IID program.
	(b)  After implementing the pilot [transition] required by
	Subchapter C of this Chapter, completing the evaluation required
	under Section 534.121, and subject to subsection (g)[on September
	1, 2021], the commission, in consultation and collaboration with
	the advisory committee, shall develop a plan for the transition of
	all or a portion of the services provided through the programs
	defined in Sections 534.001 (8) and (12) which were not included in
	the pilot under Subchapter C. The plan must include:
	(1)  The process for transitioning the services in the
	programs defined in Sections 534.001 (8) and (12) in a phased-in
	manner as follows:
	(A)  Texas Home Living;
	(B)  CLASS;
	(C)  non-residential services provided through
	the 1915 (c) Home and Community-based Services and DBMD waivers;
	and
	(D)  subject to subsection (b) (3), the
	residential services offered through the ICF/IID program and the
	HCS and DBMD waiver programs.
	(2)  With the exception of the residential services
	provided through the programs specified in subsection (b) (1)(D),
	the schedule for transitioning the services and individuals into
	managed care must occur in the order specified under subsection
	(b)(1)beginning with TxHmL on September 1, 2027; CLASS on September
	1, 2029,; and the non-residential services provided through the
	Home and Community-based services and DBMD waivers on September 1,
	2031.
	(3)  The process for evaluating the feasibility and
	cost efficiency of transitioning the residential services offered
	through the ICF/IID program and the HCS and DBMD waiver programs,
	and, as appropriate, transitioning to the managed care program.
	(A)  The process for determining the transition of
	the residential services must be based on an evaluation of a two
	year pilot.
	[transition the provision of Medicaid benefits to individuals to
	whom this section applies to the STAR + PLUS Medicaid managed care
	program delivery model or the most appropriate integrated capitated
	managed care program delivery model, as determined by the
	commission based on cost-effectiveness and the experience of the
	transition of Texas home living (TxHmL) waiver program recipients
	to a managed care program delivery model under Section 534.201
	subject to Subsections (c)(1) and (g).]
	(c)  [At the time of] Prior to the transition [described by]
	dates specified under Subsection (b) (2) and subject to subsection
	(g), the commission shall determine whether to:
	(1)  continue operation of the Medicaid waiver programs
	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 who choose to continue receiving benefits
	under the waiver program as provided by Subsection (g); or
	(2)  subject to Subsection (g), provide all or a
	portion of the long-term services and supports previously available
	under the Medicaid waiver programs through the managed care program
	delivery model selected by the commission.
	(d)  In implementing the transition described by Subsection
	(b)(2), the commission shall develop a process to receive and
	evaluate input from interested statewide stakeholders that is in
	addition to the input provided by the advisory committee.
	(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 directed services model as specified under
	Subsection (i).
	(f)  Before transitioning the provision of Medicaid benefits
	for children under this section, a managed care organization
	providing services under the managed care program delivery model
	selected by the commission must demonstrate to the satisfaction of
	the commission that the organization's network of providers has
	experience and expertise in the provision of services to children
	with an intellectual or developmental disability. Before
	transitioning the provision of Medicaid benefits for adults with an
	intellectual or developmental disability under this section, a
	managed care organization providing services under the managed care
	program delivery model selected by the commission must demonstrate
	to the satisfaction of the commission that the organization's
	network of providers has experience and expertise in the provision
	of services to adults with an intellectual or developmental
	disability.
	(g)  If the commission determines that all or a portion of
	the long-term services and supports previously available under the
	Medicaid waiver programs should be provided through a managed care
	program delivery model under Subsection (c)(1), the commission
	shall, at the time of the transition, allow each recipient
	receiving long-term services and supports under a Medicaid waiver
	program the option of:
	(1)  continuing to receive the services and supports
	under the Medicaid waiver program; or
	(2)  receiving the services and supports through the
	managed care program delivery model selected by the commission.
	(h)  A recipient who chooses to receive long-term services
	and supports through a managed care program delivery model under
	Subsection (g) may not, at a later time, choose to receive the
	services and supports under a Medicaid waiver program.
	(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
	directed services 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 25.  Section 534.203, Subchapter E, Chapter 534,
	Government Code, is amended to read as follows:
	Sec. 534.203.  RESPONSIBILITIES OF COMMISSION UNDER
	SUBCHAPTER. In administering this subchapter, the commission shall
	ensure that upon a determination to transition services in the
	programs defined under Sections 534.001 (8) and (12):
	(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 department for the reimbursement of ICF-IID service
	providers or a group home provider, as applicable; and
	(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 Medicaid managed care 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 each individual with an intellectual or
	developmental disability and the individual's legally authorized
	representative has access to a comprehensive facilitated,
	person-centered plan that identifies outcomes for the individual.
	The consumer directed services model must be promoted as an
	available option for individuals to achieve self-determination,
	choice and control.
	SECTION 26.  Chapter 534, Government Code, is amended to add
	Subchapter F. to read as follows:
	SUBCHAPTER F. OTHER IMPLEMENTATION REQUIREMENTS AND
	RESPONSIBILITIES UNDER THIS CHAPTER
	Sec. 534.301.  IMPLEMENTATION AND RESPONSIBILITIES UNDER
	THIS CHAPTER. (a) The commission is authorized to delay
	implementation of this Chapter or its subchapters without further
	investigation or adjustments or legislative intervention, if it
	determines any provision under the Chapter or other related mandate
	or initiative integral to implementation adversely affects the
	system of services and supports to persons and programs to which the
	Chapter applies.
	(b)  For purpose of the pilot under Subchpater C. of this
	Chapter and any subsequent transition of recipients receiving
	services under certain Medicaid waiver programs defined under
	Section 534.001 (12) to a managed care program as specified under
	Section 534.202 (c), the commission must:
	(1)  maintain a certification process and regulatory
	oversight of Texas Home Living and Home and Community-based
	Services providers; and
	(2)  require managed care organizations include in
	their network of qualified long term services and supports
	providers certified Texas Home Living and Home and Community-based
	Services providers that specialize in services for persons with
	intellectual disabilities.
	(c)  Subject to Section 534.202 (b) and (c), upon a decision
	to transition the long term services and supports under a Medicaid
	waiver program defined under Section 534.001 (12), the commission
	shall ensure individuals do not lose the benefits they are
	receiving through these Medicaid waiver programs.
	(d)  For purposes of the pilot under Subchapter C. and any
	future transition of services specified under Section 534.202 into
	the STAR+PLUS program, the comprehensive long term services and
	supports provider defined in Section 534.001 (4):
	(1)  must report encounters of any directly contracted
	services to the managed care organization; provide quarterly
	reporting of coordinated services and timeframes to the managed
	care organization, and provide quarterly progress on goals and
	objectives set by an individual's person centered plan; and
	(2)  will not be held accountable for the provision of
	services on an individual's service plan for which a managed care
	organization denies or does not authorize access to in a timely
	manner.
	SECTION 27.  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 28.  If the Health and Human Services Commission
	determines that it is cost effective, the commission shall apply
	for and actively seek a waiver or authorization from the
	appropriate federal agency to allow the state to provide medical
	assistance under the waiver or authorization to medically fragile
	individuals;
	(1)  Who are at least 21 years of age; and
	(2)  Whose costs to receive care exceed cost limits
	under existing Medicaid waiver programs.
	SECTION 29.  This act takes effect September 1, 2019.