Bill Text: TX SB1190 | 2021-2022 | 87th Legislature | Introduced
Bill Title: Relating to a direct primary care model pilot program for Medicaid.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2021-03-18 - Referred to Health & Human Services [SB1190 Detail]
Download: Texas-2021-SB1190-Introduced.html
| 87R941 KFF-D | ||
| By: Buckingham | S.B. No. 1190 | |
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| relating to a direct primary care model pilot program for Medicaid. | ||
| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
| SECTION 1. Subchapter B, Chapter 531, Government Code, is | ||
| amended by adding Section 531.024151 to read as follows: | ||
| Sec. 531.024151. DIRECT PRIMARY CARE MODEL PILOT PROGRAM | ||
| FOR MEDICAID. (a) In this section: | ||
| (1) "Direct fee" means a fee charged by a physician to | ||
| a patient or a patient's designee for primary medical care services | ||
| provided by, or to be provided by, the physician to the | ||
| patient. The term includes a fee in any form, including a: | ||
| (A) retainer; | ||
| (B) membership fee; | ||
| (C) subscription fee; or | ||
| (D) fee paid under a medical service agreement. | ||
| (2) "Direct primary care," "medical service | ||
| agreement," "physician," and "primary medical care service" have | ||
| the meanings assigned by Section 162.251, Occupations Code. | ||
| (3) "Participating physician" means a physician | ||
| participating in the pilot program. | ||
| (4) "Participating recipient" means a Medicaid | ||
| recipient participating in the pilot program. | ||
| (5) "Pilot program" means the direct primary care | ||
| model pilot program established under this section. | ||
| (b) The commission shall develop a pilot program to | ||
| implement a direct primary care model in Medicaid through which a | ||
| Medicaid recipient enters into a medical service agreement with a | ||
| physician for the provision of primary medical care services in | ||
| exchange for a direct fee that is paid on a monthly basis. | ||
| (c) The commission shall implement the pilot program | ||
| statewide. | ||
| (d) Under the pilot program, a participating physician: | ||
| (1) is not required to enroll as a Medicaid provider; | ||
| and | ||
| (2) notwithstanding Subdivision (1), has the | ||
| authority of ordering, referring, and prescribing Medicaid | ||
| providers for purposes of the pilot program. | ||
| (e) To be eligible to participate in the pilot program, a | ||
| physician must be practicing under a direct primary care model that | ||
| does not accept payment or otherwise seek reimbursement for primary | ||
| medical care services from a third-party insurer or managed care | ||
| organization. | ||
| (f) A Medicaid recipient must be younger than 65 years of | ||
| age to be eligible to participate in the pilot program. The | ||
| recipient or the recipient's parent or legally authorized | ||
| representative on behalf of the recipient must enter into a medical | ||
| service agreement with a physician eligible to participate in the | ||
| pilot program. After the commission verifies that the recipient or | ||
| the recipient's parent or legally authorized representative has | ||
| entered into the agreement, the commission shall pay the lesser of: | ||
| (1) the amount of the direct fee required under the | ||
| agreement; or | ||
| (2) $40 per month for a recipient who is 18 years of | ||
| age or younger, or $70 per month for a recipient who is at least 19 | ||
| years of age but younger than 65 years of age. | ||
| (g) A participating recipient shall pay the amount of the | ||
| direct fee required under the medical service agreement that | ||
| exceeds the maximum fee amount the commission pays under Subsection | ||
| (f). | ||
| (h) The commission may pay the amount of the direct fee | ||
| under a medical service agreement directly to the participating | ||
| recipient, who is then responsible for paying the participating | ||
| physician under the agreement, or may establish a system under | ||
| which the commission pays the fee directly to the physician, either | ||
| by depositing the fee into an account established for the physician | ||
| for that purpose or by another means the commission determines most | ||
| appropriate. If cost-effective, the commission may issue an | ||
| electronic benefits transfer card to a participating recipient who | ||
| shall use the card to pay the amount of the direct fee under an | ||
| agreement. | ||
| (i) A participating recipient shall immediately notify the | ||
| commission when a medical service agreement terminates. | ||
| (j) Not later than December 31, 2024, the commission shall | ||
| prepare and submit a report to the legislature that includes: | ||
| (1) a summary of the commission's evaluation of the | ||
| effect of the pilot program on the provision of primary medical care | ||
| services and Medicaid costs; and | ||
| (2) a recommendation as to whether the pilot program | ||
| should be continued or terminated. | ||
| (k) The executive commissioner shall adopt rules as | ||
| necessary to implement this section. | ||
| (l) The pilot program terminates and this section expires | ||
| September 1, 2025. | ||
| SECTION 2. If before implementing any provision of this Act | ||
| a state agency determines that a waiver or authorization from a | ||
| federal agency is necessary for implementation of that provision, | ||
| the agency affected by the provision shall request the waiver or | ||
| authorization and may delay implementing that provision until the | ||
| waiver or authorization is granted. | ||
| SECTION 3. This Act takes effect September 1, 2021. | ||
