Bill Text: TX SB23 | 2011-2012 | 82nd Legislature | Engrossed
Bill Title: Relating to the administration of and efficiency, cost-saving, fraud prevention, and funding measures for certain health and human services and health benefits programs, including the medical assistance and child health plan programs.
Spectrum: Partisan Bill (Republican 4-0)
Status: (Engrossed - Dead) 2011-05-29 - 1 hr. notice-to suspend rules [SB23 Detail]
Download: Texas-2011-SB23-Engrossed.html
By: Nelson, Patrick | S.B. No. 23 | |
Wentworth |
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relating to efficiency, cost-saving, fraud prevention, and funding | ||
measures for certain health and human services and health benefits | ||
programs, including the medical assistance and child health plan | ||
programs. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. SEXUAL ASSAULT PROGRAM FUND; FEE IMPOSED ON | ||
CERTAIN SEXUALLY ORIENTED BUSINESSES. (a) Section 102.054, | ||
Business & Commerce Code, is amended to read as follows: | ||
Sec. 102.054. ALLOCATION OF [ |
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ASSAULT PROGRAMS. The comptroller shall deposit the amount [ |
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program fund. | ||
(b) The comptroller of public accounts shall collect the fee | ||
imposed under Section 102.052, Business & Commerce Code, until a | ||
court, in a final judgment upheld on appeal or no longer subject to | ||
appeal, finds Section 102.052, Business & Commerce Code, or its | ||
predecessor statute, to be unconstitutional. | ||
(c) Section 102.055, Business & Commerce Code, is repealed. | ||
(d) This section prevails over any other Act of the 82nd | ||
Legislature, Regular Session, 2011, regardless of the relative | ||
dates of enactment, that purports to amend or repeal Subchapter B, | ||
Chapter 102, Business & Commerce Code, or any provision of Chapter | ||
1206 (H.B. No. 1751), Acts of the 80th Legislature, Regular | ||
Session, 2007. | ||
SECTION 2. ACCESS TO CERTAIN LONG-TERM CARE SERVICES AND | ||
SUPPORTS UNDER MEDICAID PROGRAM. (a) Subchapter B, Chapter 531, | ||
Government Code, is amended by adding Section 531.02181 to read as | ||
follows: | ||
Sec. 531.02181. PROVISION AND COORDINATION OF CERTAIN | ||
ATTENDANT CARE SERVICES. (a) The commission shall ensure that | ||
recipients who are eligible to receive attendant care services | ||
under the community-based alternatives program are first provided | ||
those services, if available, under a Medicaid state plan program, | ||
including the primary home care and community attendant services | ||
programs. The commission may allow a recipient to receive | ||
attendant care services under the community-based alternatives | ||
program only if: | ||
(1) the recipient requires services beyond those that | ||
are available under a Medicaid state plan program; or | ||
(2) the services are not otherwise provided under a | ||
Medicaid state plan program. | ||
(b) The executive commissioner shall adopt rules and | ||
procedures necessary to implement this section, including: | ||
(1) rules and procedures for the coordination of | ||
services between Medicaid state plan programs and the | ||
community-based alternatives program to ensure that recipients' | ||
needs are being met and to prevent duplication of services; | ||
(2) rules and procedures for an automated | ||
authorization system through which case managers authorize the | ||
provision of attendant care services through the Medicaid state | ||
plan program or the community-based alternatives program, as | ||
appropriate, and register the number of hours authorized through | ||
each program; and | ||
(3) billing procedures for attendant care services | ||
provided through the Medicaid state plan program or the | ||
community-based alternatives program, as appropriate. | ||
(b) Subchapter B, Chapter 531, Government Code, is amended | ||
by adding Section 531.0515 to read as follows: | ||
Sec. 531.0515. RISK MANAGEMENT CRITERIA FOR CERTAIN WAIVER | ||
PROGRAMS. (a) In this section, "legally authorized | ||
representative" has the meaning assigned by Section 531.051. | ||
(b) The commission shall consider developing risk | ||
management criteria under home and community-based services waiver | ||
programs designed to allow individuals eligible to receive services | ||
under the programs to assume greater choice and responsibility over | ||
the services and supports the individuals receive. | ||
(c) The commission shall ensure that any risk management | ||
criteria developed under this section include: | ||
(1) a requirement that if an individual to whom | ||
services and supports are to be provided has a legally authorized | ||
representative, the representative must be involved in determining | ||
which services and supports the individual will receive; and | ||
(2) a requirement that if services or supports are | ||
declined, the decision to decline must be clearly documented. | ||
(c) Section 533.0355, Health and Safety Code, is amended by | ||
adding Subsection (h) to read as follows: | ||
(h) The Department of Aging and Disability Services shall | ||
ensure that local mental retardation authorities are informing and | ||
counseling individuals and their legally authorized | ||
representatives, if applicable, about all program and service | ||
options for which the individuals are eligible in accordance with | ||
Section 533.038(d), including options such as the availability and | ||
types of ICF-MR placements for which an individual may be eligible | ||
while the individual is on a department interest list or other | ||
waiting list for other services. | ||
(d) Subchapter D, Chapter 161, Human Resources Code, is | ||
amended by adding Sections 161.084 and 161.085 to read as follows: | ||
Sec. 161.084. MEDICAID SERVICE OPTIONS PUBLIC EDUCATION | ||
INITIATIVE. (a) In this section, "Section 1915(c) waiver program" | ||
has the meaning assigned by Section 531.001, Government Code. | ||
(b) The department, in cooperation with the commission, | ||
shall educate the public on: | ||
(1) the availability of home and community-based | ||
services under a Medicaid state plan program, including the primary | ||
home care and community attendant services programs, and under a | ||
Section 1915(c) waiver program; and | ||
(2) the various service delivery options available | ||
under the Medicaid program, including the consumer direction models | ||
available to recipients under Section 531.051, Government Code. | ||
(c) The department may coordinate the activities under this | ||
section with any other related activity. | ||
Sec. 161.085. INTEREST LIST REPORTING. The department | ||
shall post on the department's Internet website historical data, | ||
categorized by state fiscal year, on the percentages of individuals | ||
who elect to receive services under a program for which the | ||
department maintains an interest list once their names reach the | ||
top of the list. | ||
(e) As soon as practicable after the effective date of this | ||
Act, the executive commissioner of the Health and Human Services | ||
Commission shall apply for and actively pursue, from the federal | ||
Centers for Medicare and Medicaid Services or any other appropriate | ||
federal agency, amendments to the community living assistance and | ||
support services waiver and the home and community-based services | ||
program waiver granted under Section 1915(c) of the federal Social | ||
Security Act (42 U.S.C. Section 1396n(c)) to authorize the | ||
provision of personal attendant services through the programs | ||
operated under those waivers. | ||
SECTION 3. OBJECTIVE ASSESSMENT PROCESSES FOR CERTAIN | ||
MEDICAID SERVICES. (a) Subchapter B, Chapter 531, Government | ||
Code, is amended by adding Sections 531.02417, 531.024171, and | ||
531.024172 to read as follows: | ||
Sec. 531.02417. MEDICAID NURSING SERVICES ASSESSMENTS. | ||
(a) In this section, "acute nursing services" means home health | ||
skilled nursing services, home health aide services, and private | ||
duty nursing services. | ||
(b) The commission shall develop an objective assessment | ||
process for use in assessing a Medicaid recipient's needs for acute | ||
nursing services. The commission shall require that: | ||
(1) the assessment be conducted: | ||
(A) by a state employee or contractor who is not | ||
the person who will deliver any necessary services to the recipient | ||
and is not affiliated with the person who will deliver those | ||
services; and | ||
(B) in a timely manner so as to protect the health | ||
and safety of the recipient by avoiding unnecessary delays in | ||
service delivery; and | ||
(2) the process include: | ||
(A) an assessment of specified criteria and | ||
documentation of the assessment results on a standard form; | ||
(B) an assessment of whether the recipient should | ||
be referred for additional assessments regarding the recipient's | ||
needs for therapy services, as defined by Section 531.024171, | ||
attendant care services, and durable medical equipment; and | ||
(C) completion by the person conducting the | ||
assessment of any documents related to obtaining prior | ||
authorization for necessary nursing services. | ||
(c) The commission shall: | ||
(1) implement the objective assessment process | ||
developed under Subsection (b) within the Medicaid fee-for-service | ||
model and the primary care case management Medicaid managed care | ||
model; and | ||
(2) take necessary actions, including modifying | ||
contracts with managed care organizations under Chapter 533 to the | ||
extent allowed by law, to implement the process within the STAR and | ||
STAR + PLUS Medicaid managed care programs. | ||
(d) The executive commissioner shall adopt rules providing | ||
for a process by which a provider of acute nursing services who | ||
disagrees with the results of the assessment conducted under | ||
Subsection (b) may request and obtain a review of those results. | ||
Sec. 531.024171. THERAPY SERVICES ASSESSMENTS. (a) In | ||
this section, "therapy services" includes occupational, physical, | ||
and speech therapy services. | ||
(b) After implementing the objective assessment process for | ||
acute nursing services as required by Section 531.02417, the | ||
commission shall consider whether implementing an objective | ||
assessment process for assessing the needs of a Medicaid recipient | ||
for therapy services that is comparable to the process required | ||
under Section 531.02417 for acute nursing services would be | ||
feasible and beneficial. | ||
(c) If the commission determines that implementing a | ||
comparable process with respect to one or more types of therapy | ||
services is feasible and would be beneficial, the commission may | ||
implement the process within: | ||
(1) the Medicaid fee-for-service model; | ||
(2) the primary care case management Medicaid managed | ||
care model; and | ||
(3) the STAR and STAR + PLUS Medicaid managed care | ||
programs. | ||
(d) An objective assessment process implemented under this | ||
section must include a process that allows a provider of therapy | ||
services to request and obtain a review of the results of an | ||
assessment conducted as provided by this section that is comparable | ||
to the process implemented under rules adopted under Section | ||
531.02417(d). | ||
Sec. 531.024172. ELECTRONIC VISIT VERIFICATION SYSTEM. | ||
(a) In this section, "acute nursing services" has the meaning | ||
assigned by Section 531.02417. | ||
(b) If it is cost-effective and feasible, the commission | ||
shall implement an electronic visit verification system to | ||
electronically verify and document, through a telephone or | ||
computer-based system, basic information relating to the delivery | ||
of Medicaid acute nursing services, including: | ||
(1) the provider's name; | ||
(2) the recipient's name; and | ||
(3) the date and time the provider begins and ends each | ||
service delivery visit. | ||
(b) Not later than September 1, 2012, the Health and Human | ||
Services Commission shall implement the electronic visit | ||
verification system required by Section 531.024172, Government | ||
Code, as added by this section, if the commission determines that | ||
implementation of that system is cost-effective and feasible. | ||
SECTION 4. ACCESS TO MEDICALLY NECESSARY PRESCRIPTION DRUGS | ||
UNDER MEDICAID MANAGED CARE PROGRAM. (a) Subsection (a), Section | ||
533.005, Government Code, is amended to read as follows: | ||
(a) A contract between a managed care organization and the | ||
commission for the organization to provide health care services to | ||
recipients must contain: | ||
(1) procedures to ensure accountability to the state | ||
for the provision of health care services, including procedures for | ||
financial reporting, quality assurance, utilization review, and | ||
assurance of contract and subcontract compliance; | ||
(2) capitation rates that ensure the cost-effective | ||
provision of quality health care; | ||
(3) a requirement that the managed care organization | ||
provide ready access to a person who assists recipients in | ||
resolving issues relating to enrollment, plan administration, | ||
education and training, access to services, and grievance | ||
procedures; | ||
(4) a requirement that the managed care organization | ||
provide ready access to a person who assists providers in resolving | ||
issues relating to payment, plan administration, education and | ||
training, and grievance procedures; | ||
(5) a requirement that the managed care organization | ||
provide information and referral about the availability of | ||
educational, social, and other community services that could | ||
benefit a recipient; | ||
(6) procedures for recipient outreach and education; | ||
(7) a requirement that the managed care organization | ||
make payment to a physician or provider for health care services | ||
rendered to a recipient under a managed care plan not later than the | ||
45th day after the date a claim for payment is received with | ||
documentation reasonably necessary for the managed care | ||
organization to process the claim, or within a period, not to exceed | ||
60 days, specified by a written agreement between the physician or | ||
provider and the managed care organization; | ||
(8) a requirement that the commission, on the date of a | ||
recipient's enrollment in a managed care plan issued by the managed | ||
care organization, inform the organization of the recipient's | ||
Medicaid certification date; | ||
(9) a requirement that the managed care organization | ||
comply with Section 533.006 as a condition of contract retention | ||
and renewal; | ||
(10) a requirement that the managed care organization | ||
provide the information required by Section 533.012 and otherwise | ||
comply and cooperate with the commission's office of inspector | ||
general; | ||
(11) a requirement that the managed care | ||
organization's usages of out-of-network providers or groups of | ||
out-of-network providers may not exceed limits for those usages | ||
relating to total inpatient admissions, total outpatient services, | ||
and emergency room admissions determined by the commission; | ||
(12) if the commission finds that a managed care | ||
organization has violated Subdivision (11), a requirement that the | ||
managed care organization reimburse an out-of-network provider for | ||
health care services at a rate that is equal to the allowable rate | ||
for those services, as determined under Sections 32.028 and | ||
32.0281, Human Resources Code; | ||
(13) a requirement that the organization use advanced | ||
practice nurses in addition to physicians as primary care providers | ||
to increase the availability of primary care providers in the | ||
organization's provider network; | ||
(14) a requirement that the managed care organization | ||
reimburse a federally qualified health center or rural health | ||
clinic for health care services provided to a recipient outside of | ||
regular business hours, including on a weekend day or holiday, at a | ||
rate that is equal to the allowable rate for those services as | ||
determined under Section 32.028, Human Resources Code, if the | ||
recipient does not have a referral from the recipient's primary | ||
care physician; [ |
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(15) a requirement that the managed care organization | ||
develop, implement, and maintain a system for tracking and | ||
resolving all provider appeals related to claims payment, including | ||
a process that will require: | ||
(A) a tracking mechanism to document the status | ||
and final disposition of each provider's claims payment appeal; | ||
(B) the contracting with physicians who are not | ||
network providers and who are of the same or related specialty as | ||
the appealing physician to resolve claims disputes related to | ||
denial on the basis of medical necessity that remain unresolved | ||
subsequent to a provider appeal; and | ||
(C) the determination of the physician resolving | ||
the dispute to be binding on the managed care organization and | ||
provider; and | ||
(16) a requirement that the managed care organization | ||
develop, implement, and maintain an outpatient pharmacy benefit | ||
plan for its enrolled recipients that: | ||
(A) exclusively employs the vendor drug program | ||
formulary or a more cost-effective alternative approved by the | ||
commissioner; | ||
(B) complies with the preferred drug list prior | ||
authorization policies and procedures adopted by the commission | ||
under Chapter 531 or a more cost-effective alternative approved by | ||
the commissioner; | ||
(C) includes rebates negotiated by the managed | ||
care organization with a manufacturer or labeler as defined by | ||
Section 531.070, except that a managed care organization may not | ||
negotiate or obtain a rebate with respect to a product for which the | ||
commission has negotiated or obtained a supplemental rebate; and | ||
(D) complies with Section 531.089. | ||
(b) Chapter 533, Government Code, is amended by adding | ||
Subchapter E to read as follows: | ||
SUBCHAPTER E. MEDICAID MANAGED CARE PRESCRIPTION DRUG COVERAGE | ||
Sec. 533.081. DEFINITIONS. In this subchapter, "step | ||
therapy protocol" or "fail first protocol" means a prescription | ||
drug protocol under which coverage will not be provided under a | ||
managed care plan for a particular drug until requirements of the | ||
plan's coverage policy are met. | ||
Sec. 533.082. APPLICABILITY OF SUBCHAPTER. This subchapter | ||
applies to a managed care organization that contracts with the | ||
commission under this chapter to provide a managed care plan under | ||
the Medicaid program, regardless of the Medicaid managed care model | ||
or arrangement through which that plan is provided. | ||
Sec. 533.083. ESTABLISHMENT OF CERTAIN DRUG PROTOCOLS. The | ||
commission may allow a managed care organization to establish for | ||
purposes of the managed care plan offered by the organization a step | ||
therapy protocol or fail first protocol only under the following | ||
conditions: | ||
(1) for a prescription drug restricted by the | ||
protocol, the organization must provide to the prescribing | ||
physician a clear and convenient process for expeditiously | ||
requesting from the organization an override of the restriction; | ||
(2) the organization shall grant an override requested | ||
using the process required by Subdivision (1) not later than 24 | ||
hours after the request is made if the requesting physician can | ||
demonstrate that the treatment required under the protocol: | ||
(A) has previously been ineffective in treating | ||
the enrollee's condition; | ||
(B) is expected to be ineffective based on the | ||
known relevant physical or mental characteristics of the enrollee | ||
and known characteristics of the drug regimen; or | ||
(C) will cause or will likely cause an adverse | ||
reaction or other physical harm to the enrollee; and | ||
(3) the treatment provided in accordance with the | ||
protocol is required to be provided for not more than 14 days if, on | ||
the expiration of that period, the prescribing physician deems the | ||
treatment under the protocol to be clinically ineffective for the | ||
enrollee. | ||
(c) Subsection (a), Section 32.046, Human Resources Code, | ||
is amended to read as follows: | ||
(a) The department shall adopt rules governing sanctions | ||
and penalties that apply to a provider in the vendor drug program or | ||
enrolled as a network pharmacy provider of a managed care | ||
organization or its subcontractor who submits an improper claim for | ||
reimbursement under the program. | ||
SECTION 5. ABOLISHING STATE KIDS INSURANCE PROGRAM. | ||
(a) Section 62.101, Health and Safety Code, is amended by adding | ||
Subsection (a-1) to read as follows: | ||
(a-1) A child who is the dependent of an employee of an | ||
agency of this state and who meets the requirements of Subsection | ||
(a) may be eligible for health benefits coverage in accordance with | ||
42 U.S.C. Section 1397jj(b)(6) and any other applicable law or | ||
regulations. | ||
(b) Sections 1551.159 and 1551.312, Insurance Code, are | ||
repealed. | ||
(c) The State Kids Insurance Program operated by the | ||
Employees Retirement System of Texas is abolished on the effective | ||
date of this Act. The board of trustees of the system may not | ||
provide dependent child coverage under the program after the first | ||
annual open enrollment period that begins under the employee group | ||
benefits program after the effective date of this Act. | ||
(d) The Health and Human Services Commission, in | ||
cooperation with the Employees Retirement System of Texas, shall | ||
establish a process to ensure the automatic enrollment of eligible | ||
children in the child health plan program established under Chapter | ||
62, Health and Safety Code, on or before the date those children are | ||
scheduled to stop receiving dependent child coverage under the | ||
State Kids Insurance Program, as provided by Subsection (c) of this | ||
section. The commission shall modify any applicable administrative | ||
procedures to ensure that children described by this subsection | ||
maintain continuous health benefits coverage while transitioning | ||
from enrollment in the State Kids Insurance Program to enrollment | ||
in the child health plan program. | ||
SECTION 6. PREVENTION OF CRIMINAL OR FRAUDULENT CONDUCT BY | ||
CERTAIN FACILITIES, PROVIDERS, AND RECIPIENTS. (a) Section | ||
31.0325, Human Resources Code, is amended to read as follows: | ||
Sec. 31.0325. FRAUD PREVENTION [ |
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PROGRAM. [ |
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the department [ |
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prevent welfare fraud by using cost-effective technology to: | ||
(1) confirm the identity [ |
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applicants for and adult and teen parent recipients of financial | ||
assistance under this chapter or supplemental nutrition assistance | ||
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(2) prevent the provision of duplicate benefits to a | ||
person under the financial assistance program or under the | ||
Supplemental Nutrition Assistance Program, as applicable. | ||
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(b) The Health and Human Services Commission shall make | ||
reasonable efforts to ensure the prevention of criminal or | ||
fraudulent conduct by health care facilities and providers, | ||
including facilities and providers under the Medicaid program, and | ||
recipients of benefits under programs administered by the | ||
commission. | ||
SECTION 7. STREAMLINING OF AND UTILIZATION MANAGEMENT IN | ||
MEDICAID LONG-TERM CARE WAIVER PROGRAMS. (a) Section 161.077, | ||
Human Resources Code, as added by Chapter 759 (S.B. 705), Acts of | ||
the 81st Legislature, Regular Session, 2009, is redesignated as | ||
Section 161.081, Human Resources Code, and amended to read as | ||
follows: | ||
Sec. 161.081 [ |
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PROGRAMS: STREAMLINING AND UNIFORMITY. (a) In this section, | ||
"Section 1915(c) waiver program" has the meaning assigned by | ||
Section 531.001, Government Code. | ||
(b) The department, in consultation with the commission, | ||
shall streamline the administration of and delivery of services | ||
through Section 1915(c) waiver programs. In implementing this | ||
subsection, the department, subject to Subsection (c), may consider | ||
implementing the following streamlining initiatives: | ||
(1) reducing the number of forms used in administering | ||
the programs; | ||
(2) revising program provider manuals and training | ||
curricula; | ||
(3) consolidating service authorization systems; | ||
(4) eliminating any physician signature requirements | ||
the department considers unnecessary; | ||
(5) standardizing individual service plan processes | ||
across the programs; [ |
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(6) if feasible: | ||
(A) concurrently conducting program | ||
certification and billing audit and review processes and other | ||
related audit and review processes; | ||
(B) streamlining other billing and auditing | ||
requirements; | ||
(C) eliminating duplicative responsibilities | ||
with respect to the coordination and oversight of individual care | ||
plans for persons receiving waiver services; and | ||
(D) streamlining cost reports and other cost | ||
reporting processes; and | ||
(7) any other initiatives that will increase | ||
efficiencies in the programs. | ||
(c) The department shall ensure that actions taken under | ||
Subsection (b) [ |
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of the commission under Section 531.0218, Government Code. | ||
(d) The department and the commission shall jointly explore | ||
the development of uniform licensing and contracting standards that | ||
would: | ||
(1) apply to all contracts for the delivery of Section | ||
1915(c) waiver program services; | ||
(2) promote competition among providers of those | ||
program services; and | ||
(3) integrate with other department and commission | ||
efforts to streamline and unify the administration and delivery of | ||
the program services, including those required by this section or | ||
Section 531.0218, Government Code. | ||
(b) Subchapter D, Chapter 161, Human Resources Code, is | ||
amended by adding Section 161.082 to read as follows: | ||
Sec. 161.082. LONG-TERM CARE MEDICAID WAIVER PROGRAMS: | ||
UTILIZATION REVIEW. (a) In this section, "Section 1915(c) waiver | ||
program" has the meaning assigned by Section 531.001, Government | ||
Code. | ||
(b) The department shall perform a utilization review of | ||
services in all Section 1915(c) waiver programs. The utilization | ||
review must include reviewing program recipients' levels of care | ||
and any plans of care for those recipients that exceed service level | ||
thresholds established in the applicable waiver program | ||
guidelines. | ||
SECTION 8. ELECTRONIC VISIT VERIFICATION SYSTEM FOR | ||
MEDICAID PROGRAM. Subchapter D, Chapter 161, Human Resources Code, | ||
is amended by adding Section 161.086 to read as follows: | ||
Sec. 161.086. ELECTRONIC VISIT VERIFICATION SYSTEM. If it | ||
is cost-effective, the department shall implement an electronic | ||
visit verification system under appropriate programs administered | ||
by the department under the Medicaid program that allows providers | ||
to electronically verify and document basic information relating to | ||
the delivery of services, including: | ||
(1) the provider's name; | ||
(2) the recipient's name; | ||
(3) the date and time the provider begins and ends the | ||
delivery of services; and | ||
(4) the location of service delivery. | ||
SECTION 9. REPORT ON LONG-TERM CARE SERVICES. (a) In this | ||
section: | ||
(1) "Long-term care services" has the meaning assigned | ||
by Section 22.0011, Human Resources Code. | ||
(2) "Medical assistance program" means the medical | ||
assistance program administered under Chapter 32, Human Resources | ||
Code. | ||
(3) "Nursing facility" means a convalescent or nursing | ||
home or related institution licensed under Chapter 242, Health and | ||
Safety Code. | ||
(b) The Health and Human Services Commission, in | ||
cooperation with the Department of Aging and Disability Services, | ||
shall prepare a written report regarding individuals who receive | ||
long-term care services in nursing facilities under the medical | ||
assistance program. The report shall use existing data and | ||
information to identify: | ||
(1) the reasons medical assistance recipients of | ||
long-term care services are placed in nursing facilities as opposed | ||
to being provided long-term care services in home or | ||
community-based settings; | ||
(2) the types of medical assistance services | ||
recipients residing in nursing facilities typically receive and | ||
where and from whom those services are typically provided; | ||
(3) the community-based services and supports | ||
available under a Medicaid state plan program, including the | ||
primary home care and community attendant services programs, or | ||
under a medical assistance waiver granted in accordance with | ||
Section 1915(c) of the federal Social Security Act (42 U.S.C. | ||
Section 1396n(c)) for which recipients residing in nursing | ||
facilities may be eligible; and | ||
(4) ways to expedite recipients' access to | ||
community-based services and supports identified under Subdivision | ||
(3) of this subsection for which interest lists or other waiting | ||
lists exist. | ||
(c) Not later than September 1, 2012, the Health and Human | ||
Services Commission shall submit the report described by Subsection | ||
(b) of this section, together with the commission's | ||
recommendations, to the governor, the Legislative Budget Board, the | ||
Senate Committee on Finance, the Senate Committee on Health and | ||
Human Services, the House Appropriations Committee, and the House | ||
Human Services Committee. The recommendations must address options | ||
for expediting access to community-based services and supports by | ||
recipients described by Subdivision (3), Subsection (b) of this | ||
section. | ||
SECTION 10. REGULATION AND OVERSIGHT OF CERTAIN FACILITIES | ||
AND CARE PROVIDERS. (a) In this section, "executive commissioner" | ||
means the executive commissioner of the Health and Human Services | ||
Commission. | ||
(b) The executive commissioner may adopt rules designed to: | ||
(1) enhance the quality of services provided by | ||
certain community-based services agencies through: | ||
(A) the adoption of minimum standards, | ||
additional training requirements, and other similar means; and | ||
(B) the imposition of additional oversight | ||
requirements and limitations on those agencies and home and | ||
community support services agency administrators, and the | ||
prescribing of the duties and responsibilities of those | ||
administrators. | ||
(c) The executive commissioner may adopt rules relating to | ||
nursing institutions regarding application requirements for an | ||
initial or renewal license under Chapter 242, Health and Safety | ||
Code, that are designed to evaluate the applicant's compliance with | ||
applicable laws. | ||
(d) The executive commissioner may adopt rules designed to | ||
prevent criminal or fraudulent conduct by facilities and providers | ||
engaged in the provision of health and human services in this state, | ||
including rules providing for reviewing criminal history | ||
information. | ||
(e) The Department of Aging and Disability Services, | ||
through rules adopted by the executive commissioner, may implement | ||
strategies designed to enhance adult day-care facilities' | ||
compliance with applicable laws and regulations. | ||
SECTION 11. ASSISTED LIVING FACILITY LICENSING EXEMPTIONS. | ||
Section 247.004, Health and Safety Code, is amended to read as | ||
follows: | ||
Sec. 247.004. EXEMPTIONS. This chapter does not apply to: | ||
(1) a boarding home facility as defined by Section | ||
254.001; | ||
(2) an establishment conducted by or for the adherents | ||
of the Church of Christ, Scientist, for the purpose of providing | ||
facilities for the care or treatment of the sick who depend | ||
exclusively on prayer or spiritual means for healing without the | ||
use of any drug or material remedy if the establishment complies | ||
with local safety, sanitary, and quarantine ordinances and | ||
regulations; | ||
(3) a facility conducted by or for the adherents of a | ||
qualified religious society classified as a tax-exempt | ||
organization under an Internal Revenue Service group exemption | ||
ruling for the purpose of providing personal care services without | ||
charge solely for the society's professed members or ministers in | ||
retirement, if the facility complies with local safety, sanitation, | ||
and quarantine ordinances and regulations; or | ||
(4) a facility that provides personal care services | ||
only to persons enrolled in a program that: | ||
(A) is funded in whole or in part by the | ||
department and that is monitored by the department or its | ||
designated local mental retardation authority in accordance with | ||
standards set by the department; or | ||
(B) is funded in whole or in part by the | ||
Department of State Health Services and that is monitored by the | ||
Department of State Health Services or its designated local mental | ||
health authority in accordance with standards set by the Department | ||
of State Health Services. | ||
SECTION 12. ACCOUNTABILITY AND STANDARDS UNDER MEDICAID | ||
MANAGED CARE PROGRAM. (a) Section 533.002, Government Code, is | ||
amended to read as follows: | ||
Sec. 533.002. PURPOSE. The commission shall implement the | ||
Medicaid managed care program as part of the health care delivery | ||
system developed under former Chapter 532 as it existed on August | ||
31, 2001, by contracting with managed care organizations in a | ||
manner that, to the extent possible: | ||
(1) improves the health of Texans by: | ||
(A) emphasizing prevention; | ||
(B) promoting continuity of care; and | ||
(C) providing a medical home for recipients; | ||
(2) ensures that each recipient receives high quality, | ||
comprehensive health care services in the recipient's local | ||
community; | ||
(3) encourages the training of and access to primary | ||
care physicians and providers; | ||
(4) maximizes cooperation with existing public health | ||
entities, including local departments of health; | ||
(5) provides incentives to managed care organizations | ||
to improve the quality of health care services for recipients by | ||
providing value-added services; and | ||
(6) reduces administrative and other nonfinancial | ||
barriers for recipients in obtaining health care services. | ||
(b) Section 533.0025, Government Code, is amended by | ||
amending Subsection (e) and adding Subsection (f) to read as | ||
follows: | ||
(e) In the expansion of the health maintenance organization | ||
model of Medicaid managed care into South Texas, the executive | ||
commissioner shall determine the most effective alignment of | ||
managed care service delivery areas for each model of managed care | ||
in Duval, Hidalgo, Jim Hogg, Cameron, Maverick, McMullen, Starr, | ||
Webb, Willacy, and Zapata Counties. In developing the service | ||
delivery areas for each managed care model, the executive | ||
commissioner shall consider the number of lives impacted, the usual | ||
source of health care services for residents of these counties, and | ||
other factors that impact the delivery of health care services in | ||
this 10-county area [ |
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(f) Managed care organizations that operate within the | ||
10-county South Texas service delivery area must maintain a medical | ||
director within the service delivery area. The medical director | ||
may be a managed care organization employee or under contract with | ||
the managed care organization. The duties of the medical director | ||
in the service delivery area must include oversight and management | ||
of the managed care organization medical necessity determination | ||
process. The managed care organization medical director must be | ||
available for peer-to-peer discussions about managed care | ||
organization medical necessity determinations and other managed | ||
care organization clinical policies. The managed care organization | ||
medical director may not be affiliated with any hospital, clinic, | ||
or other health care related institution or business that operates | ||
within the service delivery area. | ||
(c) Subchapter A, Chapter 533, Government Code, is amended | ||
by adding Sections 533.0027, 533.0028, and 533.0029 to read as | ||
follows: | ||
Sec. 533.0027. PROCEDURES TO ALLOW CERTAIN CHILDREN TO | ||
CHANGE MANAGED CARE PLANS. The commission shall ensure that all | ||
children who reside in the same household may, at the family's | ||
election, be enrolled in the same health plan. | ||
Sec. 533.0028. EVALUATION OF CERTAIN MEDICAID STAR + PLUS | ||
MANAGED CARE PROGRAM SERVICES. The external quality review | ||
organization shall periodically conduct studies and surveys to | ||
assess the quality of care and satisfaction with health care | ||
services provided to enrollees in the Medicaid Star + Plus managed | ||
care program who are eligible to receive health care benefits under | ||
both the Medicaid and Medicare programs. | ||
Sec. 533.0029. PROMOTION AND PRINCIPLES OF | ||
PATIENT-CENTERED MEDICAL HOMES FOR RECIPIENTS. (a) For purposes | ||
of this section, a "patient-centered medical home" means a medical | ||
relationship: | ||
(1) between a primary care physician and a child or | ||
adult patient in which the physician: | ||
(A) provides comprehensive primary care to the | ||
patient; and | ||
(B) facilitates partnerships between the | ||
physician, the patient, acute care and other care providers, and, | ||
when appropriate, the patient's family; and | ||
(2) that encompasses the following primary | ||
principles: | ||
(A) the patient has an ongoing relationship with | ||
the physician, who is trained to be the first contact for the | ||
patient and to provide continuous and comprehensive care to the | ||
patient; | ||
(B) the physician leads a team of individuals at | ||
the practice level who are collectively responsible for the ongoing | ||
care of the patient; | ||
(C) the physician is responsible for providing | ||
all of the care the patient needs or for coordinating with other | ||
qualified providers to provide care to the patient throughout the | ||
patient's life, including preventive care, acute care, chronic | ||
care, and end-of-life care; | ||
(D) the patient's care is coordinated across | ||
health care facilities and the patient's community and is | ||
facilitated by registries, information technology, and health | ||
information exchange systems to ensure that the patient receives | ||
care when and where the patient wants and needs the care and in a | ||
culturally and linguistically appropriate manner; and | ||
(E) quality and safe care is provided. | ||
(b) The commission shall, to the extent possible, work to | ||
ensure that managed care organizations: | ||
(1) promote the development of patient-centered | ||
medical homes for recipients; and | ||
(2) provide payment incentives for providers that meet | ||
the requirements of a patient-centered medical home. | ||
(d) Section 533.003, Government Code, is amended to read as | ||
follows: | ||
Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. | ||
(a) In awarding contracts to managed care organizations, the | ||
commission shall: | ||
(1) give preference to organizations that have | ||
significant participation in the organization's provider network | ||
from each health care provider in the region who has traditionally | ||
provided care to Medicaid and charity care patients; | ||
(2) give extra consideration to organizations that | ||
agree to assure continuity of care for at least three months beyond | ||
the period of Medicaid eligibility for recipients; | ||
(3) consider the need to use different managed care | ||
plans to meet the needs of different populations; [ |
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(4) consider the ability of organizations to process | ||
Medicaid claims electronically; and | ||
(5) give extra consideration in each service delivery | ||
area to an organization that: | ||
(A) is locally owned, managed, and operated, if | ||
one exists; and | ||
(B) notwithstanding Section 533.004 or any other | ||
law, is not owned or operated by and does not have a contract, | ||
agreement, or other arrangement with a hospital district in the | ||
region. | ||
(b) For purposes of this section, a managed care | ||
organization is considered to be locally owned if the organization | ||
is formed under the laws of this state and is headquartered in and | ||
operates in, and the majority of whose staff resides in, the region | ||
where the organization provides health care services. | ||
(e) Subsection (a), Section 533.005, Government Code, is | ||
amended to read as follows: | ||
(a) A contract between a managed care organization and the | ||
commission for the organization to provide health care services to | ||
recipients must contain: | ||
(1) procedures to ensure accountability to the state | ||
for the provision of health care services, including procedures for | ||
financial reporting, quality assurance, utilization review, and | ||
assurance of contract and subcontract compliance; | ||
(2) capitation rates that ensure the cost-effective | ||
provision of quality health care; | ||
(3) a requirement that the managed care organization | ||
provide ready access to a person who assists recipients in | ||
resolving issues relating to enrollment, plan administration, | ||
education and training, access to services, and grievance | ||
procedures; | ||
(4) subject to Subdivision (17), a requirement that | ||
the managed care organization provide ready access to a person who | ||
assists providers in resolving issues relating to payment, plan | ||
administration, education and training, and grievance procedures; | ||
(5) a requirement that the managed care organization | ||
provide information and referral about the availability of | ||
educational, social, and other community services that could | ||
benefit a recipient; | ||
(6) procedures for recipient outreach and education; | ||
(7) a requirement that the managed care organization | ||
make payment to a physician or provider for health care services | ||
rendered to a recipient under a managed care plan not later than the | ||
45th day after the date a claim for payment is received with | ||
documentation reasonably necessary for the managed care | ||
organization to process the claim, or within a period, not to exceed | ||
60 days, specified by a written agreement between the physician or | ||
provider and the managed care organization; | ||
(8) a requirement that the commission, on the date of a | ||
recipient's enrollment in a managed care plan issued by the managed | ||
care organization, inform the organization of the recipient's | ||
Medicaid certification date; | ||
(9) a requirement that the managed care organization | ||
comply with Section 533.006 as a condition of contract retention | ||
and renewal; | ||
(10) a requirement that the managed care organization | ||
provide the information required by Section 533.012 and otherwise | ||
comply and cooperate with the commission's office of inspector | ||
general; | ||
(11) a requirement that the managed care | ||
organization's usages of out-of-network providers or groups of | ||
out-of-network providers may not exceed limits for those usages | ||
relating to total inpatient admissions, total outpatient services, | ||
and emergency room admissions determined by the commission; | ||
(12) if the commission finds that a managed care | ||
organization has violated Subdivision (11), a requirement that the | ||
managed care organization reimburse an out-of-network provider for | ||
health care services at a rate that is equal to the allowable rate | ||
for those services, as determined under Sections 32.028 and | ||
32.0281, Human Resources Code; | ||
(13) a requirement that the organization use advanced | ||
practice nurses in addition to physicians as primary care providers | ||
to increase the availability of primary care providers in the | ||
organization's provider network; | ||
(14) a requirement that the managed care organization | ||
reimburse a federally qualified health center or rural health | ||
clinic for health care services provided to a recipient outside of | ||
regular business hours, including on a weekend day or holiday, at a | ||
rate that is equal to the allowable rate for those services as | ||
determined under Section 32.028, Human Resources Code, if the | ||
recipient does not have a referral from the recipient's primary | ||
care physician; [ |
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(15) subject to Subdivision (17), a requirement that | ||
the managed care organization develop, implement, and maintain a | ||
system for tracking and resolving all provider appeals related to | ||
claims payment, including a process that will require: | ||
(A) a tracking mechanism to document the status | ||
and final disposition of each provider's claims payment appeal; | ||
(B) the contracting with physicians who are not | ||
network providers and who are of the same or related specialty as | ||
the appealing physician to resolve claims disputes related to | ||
denial on the basis of medical necessity that remain unresolved | ||
subsequent to a provider appeal; and | ||
(C) the determination of the physician resolving | ||
the dispute to be binding on the managed care organization and | ||
provider; | ||
(16) a requirement that the managed care organization | ||
ensure that employees of the organization who hold management | ||
positions, including patient-care coordinators and provider and | ||
recipient support services personnel, are located in the region | ||
where the organization provides health care services; | ||
(17) a requirement that a medical director who is | ||
authorized to make medical necessity determinations is available in | ||
the region where the organization provides health care services; | ||
(18) a requirement that the managed care organization | ||
develop and establish a process for responding to provider appeals | ||
in the region where the organization provides health care services; | ||
(19) a requirement that the managed care organization | ||
provide special programs and materials for recipients with limited | ||
English proficiency or low literacy skills; | ||
(20) a requirement that the managed care organization | ||
develop and submit to the commission, before the organization | ||
begins to provide health care services to recipients, a | ||
comprehensive plan that describes how the organization's provider | ||
network will provide recipients sufficient access to: | ||
(A) preventive care; | ||
(B) primary care; | ||
(C) specialty care; | ||
(D) after-hours urgent care; and | ||
(E) chronic care; | ||
(21) a requirement that the managed care organization | ||
demonstrate to the commission, before the organization begins to | ||
provide health care services to recipients, that: | ||
(A) the organization's provider network has the | ||
capacity to serve the number of recipients expected to enroll in a | ||
managed care plan offered by the organization; | ||
(B) the organization's provider network | ||
includes: | ||
(i) a sufficient number of primary care | ||
providers; | ||
(ii) a sufficient variety of provider | ||
types; and | ||
(iii) providers located throughout the | ||
region where the organization will provide health care services; | ||
and | ||
(C) health care services will be accessible to | ||
recipients through the organization's provider network to the same | ||
extent that health care services would be available to recipients | ||
under a fee-for-service or primary care case management model of | ||
Medicaid managed care; and | ||
(22) a requirement that the managed care organization | ||
develop a monitoring program for measuring the quality of the | ||
health care services provided by the organization's provider | ||
network that: | ||
(A) incorporates the National Committee for | ||
Quality Assurance's Healthcare Effectiveness Data and Information | ||
Set (HEDIS) measures; | ||
(B) focuses on measuring outcomes; and | ||
(C) includes the collection and analysis of | ||
clinical data relating to prenatal care, preventive care, mental | ||
health care, and the treatment of acute and chronic health | ||
conditions and substance abuse. | ||
(f) Subchapter A, Chapter 533, Government Code, is amended | ||
by adding Section 533.0066 to read as follows: | ||
Sec. 533.0066. PROVIDER INCENTIVES. The commission shall, | ||
to the extent possible, work to ensure that managed care | ||
organizations provide payment incentives to health care providers | ||
in the organizations' networks whose performance in promoting | ||
recipients' use of preventive services exceeds minimum established | ||
standards. | ||
(g) Section 533.0071, Government Code, is amended to read as | ||
follows: | ||
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission | ||
shall make every effort to improve the administration of contracts | ||
with managed care organizations. To improve the administration of | ||
these contracts, the commission shall: | ||
(1) ensure that the commission has appropriate | ||
expertise and qualified staff to effectively manage contracts with | ||
managed care organizations under the Medicaid managed care program; | ||
(2) evaluate options for Medicaid payment recovery | ||
from managed care organizations if the enrollee dies or is | ||
incarcerated or if an enrollee is enrolled in more than one state | ||
program or is covered by another liable third party insurer; | ||
(3) maximize Medicaid payment recovery options by | ||
contracting with private vendors to assist in the recovery of | ||
capitation payments, payments from other liable third parties, and | ||
other payments made to managed care organizations with respect to | ||
enrollees who leave the managed care program; | ||
(4) decrease the administrative burdens of managed | ||
care for the state, the managed care organizations, and the | ||
providers under managed care networks to the extent that those | ||
changes are compatible with state law and existing Medicaid managed | ||
care contracts, including decreasing those burdens by: | ||
(A) where possible, decreasing the duplication | ||
of administrative reporting requirements for the managed care | ||
organizations, such as requirements for the submission of encounter | ||
data, quality reports, historically underutilized business | ||
reports, and claims payment summary reports; | ||
(B) allowing managed care organizations to | ||
provide updated address information directly to the commission for | ||
correction in the state system; | ||
(C) promoting consistency and uniformity among | ||
managed care organization policies, including policies relating to | ||
the preauthorization process, lengths of hospital stays, filing | ||
deadlines, levels of care, and case management services; [ |
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(D) reviewing the appropriateness of primary | ||
care case management requirements in the admission and clinical | ||
criteria process, such as requirements relating to including a | ||
separate cover sheet for all communications, submitting | ||
handwritten communications instead of electronic or typed review | ||
processes, and admitting patients listed on separate | ||
notifications; and | ||
(E) providing a single portal through which | ||
providers in any managed care organization's provider network may | ||
submit claims and prior authorization requests and obtain | ||
information; and | ||
(5) reserve the right to amend the managed care | ||
organization's process for resolving provider appeals of denials | ||
based on medical necessity to include an independent review process | ||
established by the commission for final determination of these | ||
disputes. | ||
SECTION 13. FEDERAL AUTHORIZATION. Subject to the | ||
requirements of Subsection (e), Section 2 of this Act, 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 14. REPORT TO LEGISLATURE. Not later than December | ||
1, 2013, the Health and Human Services Commission shall submit a | ||
report to the legislature regarding the commission's work to ensure | ||
that Medicaid managed care organizations promote the development of | ||
patient-centered medical homes for recipients of medical | ||
assistance as required under Section 533.0029, Government Code, as | ||
added by this Act. | ||
SECTION 15. CONTRACTING REQUIREMENTS. The Health and Human | ||
Services Commission shall, in a contract between the commission and | ||
a managed care organization under Chapter 533, Government Code, | ||
that is entered into or renewed on or after the effective date of | ||
this Act, include the provisions required by Subsection (a), | ||
Section 533.005, Government Code, as amended by this Act. | ||
SECTION 16. EFFECTIVE DATE. This Act takes effect | ||
September 1, 2011. |