Bill Text: TX SB41 | 2021 | 87th Legislature 3rd Special Session | Introduced
Bill Title: Relating to the development and implementation of the Live Well Texas program to provide health benefit coverage to certain individuals; imposing penalties.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Introduced - Dead) 2021-09-27 - Filed [SB41 Detail]
Download: Texas-2021-SB41-Introduced.html
| 87S30235 JG/MM-D | ||
| By: Johnson | S.B. No. 41 | |
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| relating to the development and implementation of the Live Well | ||
| Texas program to provide health benefit coverage to certain | ||
| individuals; imposing penalties. | ||
| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
| SECTION 1. Subtitle I, Title 4, Government Code, is amended | ||
| by adding Chapter 537A to read as follows: | ||
| CHAPTER 537A. LIVE WELL TEXAS PROGRAM | ||
| SUBCHAPTER A. GENERAL PROVISIONS | ||
| Sec. 537A.0001. DEFINITIONS. In this chapter: | ||
| (1) "Basic plan" means the program health benefit plan | ||
| described by Section 537A.0202. | ||
| (2) "Eligible individual" means an individual who is | ||
| eligible to participate in the program. | ||
| (3) "Participant" means an individual who is: | ||
| (A) enrolled in a program health benefit plan; or | ||
| (B) receiving health care financial assistance | ||
| under Subchapter H. | ||
| (4) "Plus plan" means the program health benefit plan | ||
| described by Section 537A.0203. | ||
| (5) "POWER account" means a personal wellness and | ||
| responsibility account established for a participant under Section | ||
| 537A.0251. | ||
| (6) "Program" means the Live Well Texas program | ||
| established under this chapter. | ||
| (7) "Program health benefit plan" includes: | ||
| (A) the basic plan; and | ||
| (B) the plus plan. | ||
| (8) "Program health benefit plan provider" means a | ||
| health benefit plan provider that contracts with the commission | ||
| under Section 537A.0107 to arrange for the provision of health care | ||
| services through a program health benefit plan. | ||
| SUBCHAPTER B. FEDERAL WAIVER FOR LIVE WELL TEXAS PROGRAM | ||
| Sec. 537A.0051. FEDERAL AUTHORIZATION FOR PROGRAM. (a) | ||
| Notwithstanding any other law, the executive commissioner shall | ||
| develop and seek a waiver under Section 1115 of the Social Security | ||
| Act (42 U.S.C. Section 1315) to the state Medicaid plan to implement | ||
| the Live Well Texas program to assist individuals in obtaining | ||
| health benefit coverage through a program health benefit plan or | ||
| health care financial assistance. | ||
| (b) The terms of a waiver the executive commissioner seeks | ||
| under this section must: | ||
| (1) be designed to: | ||
| (A) provide health benefit coverage options for | ||
| eligible individuals; | ||
| (B) produce better health outcomes for | ||
| participants; | ||
| (C) create incentives for participants to | ||
| transition from receiving public assistance benefits to achieving | ||
| stable employment; | ||
| (D) promote personal responsibility and engage | ||
| participants in making decisions regarding health care based on | ||
| cost and quality; | ||
| (E) support participants' self-sufficiency by | ||
| requiring unemployed participants to be referred to work search and | ||
| job training programs; | ||
| (F) support participants who become ineligible | ||
| to participate in a program health benefit plan in transitioning to | ||
| private health benefit coverage; | ||
| (G) leverage enhanced federal medical assistance | ||
| percentage funding to minimize or eliminate the need for a program | ||
| enrollment cap; and | ||
| (H) leverage available federal medical | ||
| assistance percentage funding, including funding available under | ||
| the American Rescue Plan Act of 2021 (Pub. L. No. 117-2); and | ||
| (2) allow for the operation of the program consistent | ||
| with the requirements of this chapter, except to the extent | ||
| deviation from the requirements is necessary to obtain federal | ||
| authorization of the waiver. | ||
| Sec. 537A.0052. FUNDING. Subject to approval of the waiver | ||
| described by Section 537A.0051, the commission shall implement the | ||
| program using federal funding available for that purpose, including | ||
| enhanced federal medical assistance percentage funding available | ||
| under the Patient Protection and Affordable Care Act (Pub. L. | ||
| No. 111-148) as amended by the Health Care and Education | ||
| Reconciliation Act of 2010 (Pub. L. No. 111-152). | ||
| Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM. | ||
| (a) This chapter does not establish an entitlement to health | ||
| benefit coverage or health care financial assistance under the | ||
| program for eligible individuals. | ||
| (b) The program terminates at the time federal funding | ||
| terminates under the Patient Protection and Affordable Care Act | ||
| (Pub. L. No. 111-148) as amended by the Health Care and Education | ||
| Reconciliation Act of 2010 (Pub. L. No. 111-152), unless a | ||
| successor program providing federal funding is created. | ||
| SUBCHAPTER C. PROGRAM ADMINISTRATION | ||
| Sec. 537A.0101. PROGRAM OBJECTIVE. The principal objective | ||
| of the program is to provide primary and preventative health care | ||
| through high deductible program health benefit plans to eligible | ||
| individuals. | ||
| Sec. 537A.0102. PROGRAM PROMOTION. The commission shall | ||
| promote and provide information about the program to individuals | ||
| who: | ||
| (1) are potentially eligible to participate in the | ||
| program; and | ||
| (2) live in medically underserved areas of this state. | ||
| Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH | ||
| BENEFIT PLAN PROVIDER CONTRACTS. The commission may: | ||
| (1) enter into contracts with health benefit plan | ||
| providers under Section 537A.0107; | ||
| (2) monitor program health benefit plan providers | ||
| through reporting requirements and other means to ensure contract | ||
| performance and quality delivery of services; | ||
| (3) monitor the quality of services delivered to | ||
| participants through outcome measurements; and | ||
| (4) provide payment under the contracts to program | ||
| health benefit plan providers. | ||
| Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO | ||
| ELIGIBILITY AND MEDICAID COORDINATION. The commission may: | ||
| (1) accept applications for health benefit coverage | ||
| under the program and implement program eligibility screening and | ||
| enrollment procedures; | ||
| (2) resolve grievances related to eligibility | ||
| determinations; and | ||
| (3) to the extent possible, coordinate the program | ||
| with Medicaid. | ||
| Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR | ||
| PROGRAM IMPLEMENTATION. (a) In administering the program, the | ||
| commission may contract with a third-party administrator to provide | ||
| enrollment and related services. | ||
| (b) If the commission contracts with a third-party | ||
| administrator under this section, the commission may: | ||
| (1) monitor the third-party administrator through | ||
| reporting requirements and other means to ensure contract | ||
| performance and quality delivery of services; and | ||
| (2) provide payment under the contract to the | ||
| third-party administrator. | ||
| (c) The executive commissioner shall retain all | ||
| policymaking authority over the program. | ||
| (d) The commission shall procure each contract with a | ||
| third-party administrator, as applicable, through a competitive | ||
| procurement process that complies with all federal and state laws. | ||
| Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a) | ||
| At the commission's request, the Texas Department of Insurance | ||
| shall provide any necessary assistance with the program. The | ||
| department shall monitor the quality of the services provided by | ||
| program health benefit plan providers and resolve grievances | ||
| related to those providers. | ||
| (b) The commission and the Texas Department of Insurance may | ||
| adopt a memorandum of understanding that addresses the | ||
| responsibilities of each agency with respect to the program. | ||
| (c) The Texas Department of Insurance, in consultation with | ||
| the commission, shall adopt rules as necessary to implement this | ||
| section. | ||
| Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS. | ||
| The commission shall select through a competitive procurement | ||
| process that complies with all federal and state laws and contract | ||
| with health benefit plan providers to provide health care services | ||
| under the program. To be eligible for a contract under this section, | ||
| an entity must: | ||
| (1) be a Medicaid managed care organization; | ||
| (2) hold a certificate of authority issued by the | ||
| Texas Department of Insurance that authorizes the entity to provide | ||
| the types of health care services offered under the program; and | ||
| (3) satisfy, except as provided by this chapter, any | ||
| applicable requirement of the Insurance Code or another insurance | ||
| law of this state. | ||
| Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care | ||
| provider who provides health care services under the program must | ||
| meet certification and licensure requirements required by | ||
| commission rules and other law. | ||
| (b) In adopting rules governing the program, the executive | ||
| commissioner shall ensure that a health care provider who provides | ||
| health care services under the program is reimbursed at a rate that | ||
| is at least equal to the rate paid under Medicare for the provision | ||
| of the same or substantially similar services. | ||
| Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTH CARE | ||
| PROVIDERS. The executive commissioner shall adopt rules that | ||
| prohibit a health care provider from providing health care services | ||
| under the program for a reasonable period, as determined by the | ||
| executive commissioner, if the health care provider: | ||
| (1) fails to repay overpayments made under the | ||
| program; or | ||
| (2) owns, controls, manages, or is otherwise | ||
| affiliated with and has financial, managerial, or administrative | ||
| influence over a health care provider who has been suspended or | ||
| prohibited from providing health care services under the program. | ||
| SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE | ||
| Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An | ||
| individual is eligible to enroll in a program health benefit plan | ||
| if: | ||
| (1) the individual is a resident of this state; | ||
| (2) the individual is 19 years of age or older but | ||
| younger than 65 years of age; | ||
| (3) applying the eligibility criteria in effect in | ||
| this state on December 31, 2020, the individual is not eligible for | ||
| Medicaid; and | ||
| (4) federal matching funds are available under the | ||
| Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as | ||
| amended by the Health Care and Education Reconciliation Act of 2010 | ||
| (Pub. L. No. 111-152) or other successor law to provide benefits to | ||
| the individual under the federal medical assistance program | ||
| established under Title XIX, Social Security Act (42 U.S.C. Section | ||
| 1396 et seq.). | ||
| (b) An individual who is a parent or caretaker relative to | ||
| whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a | ||
| program health benefit plan. | ||
| (c) In determining eligibility for the program, the | ||
| commission shall apply the same eligibility criteria regarding | ||
| residency and citizenship in effect for Medicaid in this state on | ||
| December 31, 2020. | ||
| Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall | ||
| ensure that an individual who is initially determined or | ||
| redetermined to be eligible to participate in the program and | ||
| enroll in a program health benefit plan will remain eligible for | ||
| coverage under the plan for a period of 12 months beginning on the | ||
| first day of the month following the date eligibility was | ||
| determined or redetermined, subject to Section 537A.0252(f). | ||
| Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The | ||
| executive commissioner shall adopt an application form and | ||
| application procedures for the program. The form and procedures | ||
| must be coordinated with forms and procedures under Medicaid to | ||
| ensure that there is a single consolidated application process to | ||
| seek health benefit coverage under the program or Medicaid. | ||
| (b) To the extent possible, the commission shall make the | ||
| application form available in languages other than English. | ||
| (c) The executive commissioner may permit an individual to | ||
| apply by mail, over the telephone, or through the Internet. | ||
| Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a) | ||
| The executive commissioner shall adopt eligibility screening and | ||
| enrollment procedures or use the Texas Integrated Enrollment | ||
| Services eligibility determination system or a compatible system to | ||
| screen individuals and enroll eligible individuals in the program. | ||
| (b) The eligibility screening and enrollment procedures | ||
| must ensure that an individual applying for the program who appears | ||
| eligible for Medicaid is identified and assisted with obtaining | ||
| Medicaid coverage. If the individual is denied Medicaid coverage | ||
| but is determined eligible to enroll in a program health benefit | ||
| plan, the commission shall enroll the individual in a program | ||
| health benefit plan of the individual's choosing and for which the | ||
| individual is eligible without further application or | ||
| qualification. | ||
| (c) Not later than the 30th day after the date an individual | ||
| submits a complete application form and unless the individual is | ||
| identified and assisted with obtaining Medicaid coverage under | ||
| Subsection (b), the commission shall ensure that the individual's | ||
| eligibility to participate in the program is determined and that | ||
| the individual is provided with information on program health | ||
| benefit plans and program health benefit plan providers. The | ||
| commission shall enroll the individual in the program health | ||
| benefit plan and with the program health benefit plan provider of | ||
| the individual's choosing in a timely manner, as determined by the | ||
| commission. | ||
| (d) The executive commissioner may establish enrollment | ||
| periods for the program. | ||
| Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS; | ||
| DISENROLLMENT. (a) Not later than the 90th day before the | ||
| expiration of a participant's coverage period, the commission shall | ||
| notify the participant regarding the eligibility redetermination | ||
| process and request documentation necessary to redetermine the | ||
| participant's eligibility. | ||
| (b) The commission shall provide written notice of | ||
| termination of eligibility to a participant not later than the 30th | ||
| day before the date the participant's eligibility will terminate. | ||
| The commission shall disenroll the participant from the program if: | ||
| (1) the participant does not submit the requested | ||
| eligibility redetermination documentation before the last day of | ||
| the participant's coverage period; or | ||
| (2) the commission, based on the submitted | ||
| documentation, determines the participant is no longer eligible for | ||
| the program, subject to Subchapter H. | ||
| (c) An individual may submit the requested eligibility | ||
| redetermination documentation not later than the 90th day after the | ||
| date the individual is disenrolled from the program. If the | ||
| commission determines that the individual continues to meet program | ||
| eligibility requirements, the commission shall reenroll the | ||
| individual in the program without any additional application | ||
| requirements. | ||
| (d) An individual who does not complete the eligibility | ||
| redetermination process in accordance with this section and who is | ||
| disenrolled from the program may not participate in the program for | ||
| a period of 180 days beginning on the date of disenrollment. This | ||
| subsection does not apply to an individual described by Section | ||
| 537A.0206 or 537A.0208 or an individual who is pregnant or is | ||
| younger than 21 years of age. | ||
| (e) At the time a participant is disenrolled from the | ||
| program under this section, the commission shall provide to the | ||
| participant: | ||
| (1) notice that the participant may be eligible to | ||
| receive health care financial assistance under Subchapter H in | ||
| transitioning to private health benefit coverage; and | ||
| (2) information on and the eligibility requirements | ||
| for that financial assistance. | ||
| SUBCHAPTER E. BASIC AND PLUS PLANS | ||
| Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY. | ||
| (a) The basic and plus plans offered under the program must: | ||
| (1) comply with this subchapter and coverage | ||
| requirements prescribed by other law; and | ||
| (2) at a minimum, provide coverage for essential | ||
| health benefits required under 42 U.S.C. Section 18022(b). | ||
| (b) In modifying covered health benefits under the basic and | ||
| plus plans, the executive commissioner shall consider the health | ||
| care needs of healthy individuals and individuals with special | ||
| health care needs. | ||
| (c) The basic and plus plans must allow a participant with a | ||
| chronic, disabling, or life-threatening illness to select an | ||
| appropriate specialist as the participant's primary care | ||
| physician. | ||
| Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME | ||
| ELIGIBILITY. (a) The program must include a basic plan that is | ||
| sufficient to meet the basic health care needs of individuals who | ||
| enroll in the plan. | ||
| (b) The covered health benefits under the basic plan must | ||
| include: | ||
| (1) primary care physician services; | ||
| (2) prenatal and postpartum care; | ||
| (3) specialty care physician visits; | ||
| (4) home health services, not to exceed 100 visits per | ||
| year; | ||
| (5) outpatient surgery; | ||
| (6) allergy testing; | ||
| (7) chemotherapy; | ||
| (8) intravenous infusion services; | ||
| (9) radiation therapy; | ||
| (10) dialysis; | ||
| (11) emergency care hospital services; | ||
| (12) emergency transportation, including ambulance | ||
| and air ambulance; | ||
| (13) urgent care clinic services; | ||
| (14) hospitalization, including for: | ||
| (A) general inpatient hospital care; | ||
| (B) inpatient physician services; | ||
| (C) inpatient surgical services; | ||
| (D) non-cosmetic reconstructive surgery; | ||
| (E) a transplant; | ||
| (F) treatment for a congenital abnormality; | ||
| (G) anesthesia; | ||
| (H) hospice care; and | ||
| (I) care in a skilled nursing facility for a | ||
| period not to exceed 100 days per occurrence; | ||
| (15) inpatient and outpatient behavioral health | ||
| services; | ||
| (16) inpatient, outpatient, and residential substance | ||
| use treatment; | ||
| (17) prescription drugs, including tobacco cessation | ||
| drugs; | ||
| (18) inpatient and outpatient rehabilitative and | ||
| habilitative care, including physical, occupational, and speech | ||
| therapy, not to exceed 60 combined visits per year; | ||
| (19) medical equipment, appliances, and assistive | ||
| technology, including prosthetics and hearing aids, and the repair, | ||
| technical support, and customization needed for individual use; | ||
| (20) laboratory and pathology tests and services; | ||
| (21) diagnostic imaging, including x-rays, magnetic | ||
| resonance imaging, computed tomography, and positron emission | ||
| tomography; | ||
| (22) preventative care services as described by | ||
| Section 537A.0204; and | ||
| (23) services under the early and periodic screening, | ||
| diagnostic, and treatment program for participants who are younger | ||
| than 21 years of age. | ||
| (c) To be eligible for health care benefits under the basic | ||
| plan, an individual who is eligible for the program must have an | ||
| annual household income that is equal to or less than 100 percent of | ||
| the federal poverty level. | ||
| Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY. | ||
| (a) The program must include a plus plan that includes the covered | ||
| health benefits listed in Section 537A.0202 and the following | ||
| additional enhanced health benefits: | ||
| (1) services related to the treatment of conditions | ||
| affecting the temporomandibular joint; | ||
| (2) dental care; | ||
| (3) vision care; | ||
| (4) notwithstanding Section 537A.0202(b)(18), | ||
| inpatient and outpatient rehabilitative and habilitative care, | ||
| including physical, occupational, and speech therapy, not to exceed | ||
| 75 combined visits per year; | ||
| (5) bariatric surgery; and | ||
| (6) other services the commission considers | ||
| appropriate. | ||
| (b) An individual who is eligible for the program and whose | ||
| annual household income exceeds 100 percent of the federal poverty | ||
| level will automatically be enrolled in and receive health benefits | ||
| under the plus plan. An individual who is eligible for the program | ||
| and whose annual household income is equal to or less than 100 | ||
| percent of the federal poverty level may choose to enroll in the | ||
| plus plan. | ||
| (c) A participant enrolled in the plus plan is required to | ||
| make POWER account contributions in accordance with Section | ||
| 537A.0252. | ||
| Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The | ||
| commission shall provide to each participant a list of health care | ||
| services that qualify as preventative care services based on the | ||
| age, gender, and preexisting conditions of the participant. In | ||
| developing the list, the commission shall consult with the federal | ||
| Centers for Disease Control and Prevention. | ||
| (b) A program health benefit plan shall, at no cost to the | ||
| participant, provide coverage for: | ||
| (1) preventative care services described by 42 U.S.C. | ||
| Section 300gg-13; and | ||
| (2) a maximum of $500 per year of preventative care | ||
| services other than those described by Subdivision (1). | ||
| (c) A participant who receives preventative care services | ||
| not described by Subsection (b) that are covered under the | ||
| participant's program health benefit plan is subject to deductible | ||
| and copayment requirements for the services in accordance with the | ||
| terms of the plan. | ||
| Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in | ||
| the basic plan shall pay a copayment for each covered health benefit | ||
| except for a preventative care or family planning service. The | ||
| executive commissioner by rule shall adopt a copayment schedule for | ||
| basic plan services, subject to Subsection (c). | ||
| (b) Except as provided by Subsection (c), a participant | ||
| enrolled in the plus plan may not be required to pay a copayment for | ||
| a covered service. | ||
| (c) A participant enrolled in the basic or plus plan shall | ||
| pay a copayment in an amount set by commission rule not to exceed | ||
| $25 for nonemergency use of hospital emergency department services | ||
| unless: | ||
| (1) the participant has met the cost-sharing maximum | ||
| for the calendar quarter, as prescribed by commission rule; | ||
| (2) the participant is referred to the hospital | ||
| emergency department by a health care provider; | ||
| (3) the visit is a true emergency, as defined by | ||
| commission rule; or | ||
| (4) the participant is pregnant. | ||
| Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE | ||
| MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R. | ||
| Section 440.315 who is enrolled in the basic or plus plan is | ||
| entitled to receive under the program all health benefits that | ||
| would be available under the state Medicaid plan. | ||
| (b) A participant to which this section applies is subject | ||
| to the cost-sharing requirements, including copayment and POWER | ||
| account contribution requirements, of the program health benefit | ||
| plan in which the participant is enrolled. | ||
| (c) The commission shall develop screening measures to | ||
| identify participants to which this section applies. | ||
| Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant | ||
| who becomes pregnant while enrolled in the program and who meets the | ||
| eligibility requirements for Medicaid may choose to remain in the | ||
| program or enroll in Medicaid. | ||
| (b) A pregnant participant described by Subsection (a) who | ||
| is enrolled in the basic or plus plan and who remains in the program | ||
| is: | ||
| (1) notwithstanding Section 537A.0205, not subject to | ||
| any cost-sharing requirements, including copayment and POWER | ||
| account contribution requirements, of the program health benefit | ||
| plan in which the participant is enrolled until the expiration of | ||
| the second month following the month in which the pregnancy ends; | ||
| (2) entitled to receive as a Medicaid wrap-around | ||
| benefit all Medicaid services a pregnant woman enrolled in Medicaid | ||
| is entitled to receive, including a pharmacy benefit, when the | ||
| participant exceeds coverage limits under the participant's | ||
| program health benefit plan or if a service is not covered by the | ||
| plan; and | ||
| (3) eligible for additional vision and dental care | ||
| benefits. | ||
| Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A | ||
| parent or caretaker relative to whom 42 C.F.R. Section 435.110 | ||
| applies is entitled to receive as a Medicaid wrap-around benefit | ||
| all Medicaid services to which the individual would be entitled | ||
| under the state Medicaid plan that are not covered under the | ||
| individual's program health benefit plan or exceed the plan's | ||
| coverage limits. | ||
| (b) An individual described by Subsection (a) who chooses to | ||
| participate in the program is subject to the cost-sharing | ||
| requirements, including copayment and POWER account contribution | ||
| requirements, of the program health benefit plan in which the | ||
| individual is enrolled. | ||
| SUBCHAPTER F. PERSONAL WELLNESS AND RESPONSIBILITY (POWER) | ||
| ACCOUNTS | ||
| Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF POWER | ||
| ACCOUNTS. (a) The commission shall establish a personal wellness | ||
| and responsibility (POWER) account for each participant who is | ||
| enrolled in a program health benefit plan that is funded with money | ||
| contributed in accordance with this subchapter. | ||
| (b) The commission shall enable each participant to access | ||
| and manage money in and information regarding the participant's | ||
| POWER account through an electronic system. The commission may | ||
| contract with an entity that has appropriate experience and | ||
| expertise to establish, implement, or administer the electronic | ||
| system. | ||
| (c) Except as otherwise provided by Section 537A.0252, the | ||
| commission shall require each participant to contribute to the | ||
| participant's POWER account in amounts described by that section. | ||
| Sec. 537A.0252. POWER ACCOUNT CONTRIBUTIONS; DEDUCTIBLE. | ||
| (a) The executive commissioner by rule shall establish an annual | ||
| universal deductible for each participant enrolled in the basic or | ||
| plus plan. | ||
| (b) To ensure each participant's POWER account contains a | ||
| sufficient amount of money at the beginning of a coverage period, | ||
| the commission shall, before the beginning of that period, fund | ||
| each account with the following amounts: | ||
| (1) for a participant enrolled in the basic plan, the | ||
| annual universal deductible amount; and | ||
| (2) for a participant enrolled in the plus plan, the | ||
| difference between the annual universal deductible amount and the | ||
| participant's required annual contribution as determined by the | ||
| schedule established under Subsection (c). | ||
| (c) The executive commissioner by rule shall establish a | ||
| graduated annual POWER account contribution schedule for | ||
| participants enrolled in the plus plan that: | ||
| (1) is based on a participant's annual household | ||
| income, with participants whose annual household incomes are less | ||
| than the federal poverty level paying progressively less and | ||
| participants whose annual household incomes are equal to or greater | ||
| than the federal poverty level paying progressively more; and | ||
| (2) may not require a participant to contribute more | ||
| than a total of five percent of the participant's annual household | ||
| income to the participant's POWER account. | ||
| (d) A participant's employer may contribute on behalf of the | ||
| participant any amount of the participant's annual POWER account | ||
| contribution. A nonprofit organization may contribute on behalf of | ||
| a participant any amount of the participant's annual POWER account | ||
| contribution. | ||
| (e) Subject to the contribution cap described by Subsection | ||
| (c)(2) and not before the expiration of the participant's first | ||
| coverage period, the commission shall require a participant who | ||
| uses one or more tobacco products to contribute to the | ||
| participant's POWER account an annual POWER account contribution | ||
| amount that is one percent more than the participant would | ||
| otherwise be required to contribute under the schedule established | ||
| under Subsection (c). | ||
| (f) An annual POWER account contribution must be paid by or | ||
| on behalf of a participant monthly in installments that are at least | ||
| equal to one-twelfth of the total required contribution. The | ||
| coverage period for a participant whose annual household income | ||
| exceeds 100 percent of the federal poverty level may not begin until | ||
| the first day of the first month following the month in which the | ||
| first monthly installment is received. | ||
| Sec. 537A.0253. USE OF POWER ACCOUNT MONEY. A participant | ||
| may use money in the participant's POWER account to pay copayments | ||
| and deductible costs required under the participant's program | ||
| health benefit plan. The commission shall issue to each | ||
| participant an electronic payment card that allows the participant | ||
| to use the card to pay the program health benefit plan costs. | ||
| Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER | ||
| REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS; | ||
| SMOKING CESSATION INITIATIVE. (a) A program health benefit plan | ||
| provider shall establish a rewards program through which a | ||
| participant receiving health care through a program health benefit | ||
| plan offered by the program health benefit plan provider may earn | ||
| money to be contributed to the participant's POWER account. | ||
| (b) Under a rewards program, a program health benefit plan | ||
| provider shall contribute money to a participant's POWER account if | ||
| the participant engages in certain healthy behaviors. The | ||
| executive commissioner by rule shall determine: | ||
| (1) the behaviors in which a participant must engage | ||
| to receive a contribution, which must include behaviors related to: | ||
| (A) completion of a health risk assessment; | ||
| (B) smoking cessation; and | ||
| (C) as applicable, chronic disease management; | ||
| and | ||
| (2) the amount of money a program health benefit plan | ||
| provider shall contribute for each behavior described by | ||
| Subdivision (1). | ||
| (c) Subsection (b) does not prevent a program health benefit | ||
| plan provider from contributing money to a participant's POWER | ||
| account if the participant engages in a behavior not specified by | ||
| that subsection or a rule adopted in accordance with that | ||
| subsection. If a program health benefit plan provider chooses to | ||
| contribute money under this subsection, the program health benefit | ||
| plan provider shall determine the amount of money to be contributed | ||
| for the behavior. | ||
| (d) A participant may use contributions a program health | ||
| benefit plan provider makes under a rewards program to offset a | ||
| maximum of 50 percent of the participant's required annual POWER | ||
| account contribution established under Section 537A.0252. | ||
| (e) Contributions a program health benefit plan provider | ||
| makes under a rewards program that result in a participant's POWER | ||
| account balance exceeding the participant's required annual POWER | ||
| account contribution may be rolled over into the next coverage | ||
| period in accordance with Section 537A.0256. | ||
| (f) During the first coverage period of a participant who | ||
| uses one or more tobacco products, a program health benefit plan | ||
| provider shall actively attempt to engage the participant in and | ||
| provide educational materials to the participant on: | ||
| (1) smoking cessation activities for which the | ||
| participant may receive a monetary contribution under this section; | ||
| and | ||
| (2) other smoking cessation programs or resources | ||
| available to the participant. | ||
| Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall | ||
| distribute to each participant with a POWER account a monthly | ||
| statement that includes information on: | ||
| (1) the participant's POWER account activity during | ||
| the preceding month, including information on the cost of health | ||
| care services delivered to the participant during that month; | ||
| (2) the balance of money available in the POWER | ||
| account at the time the statement is issued; and | ||
| (3) the amount of any contributions due from the | ||
| participant. | ||
| Sec. 537A.0256. POWER ACCOUNT ROLLOVER. (a) The executive | ||
| commissioner by rule shall establish a process in accordance with | ||
| this section to roll over money in a participant's POWER account to | ||
| the succeeding coverage period. The commission shall calculate the | ||
| amount to be rolled over at the time the participant's program | ||
| eligibility is redetermined. | ||
| (b) For a participant enrolled in the basic plan, the | ||
| commission shall calculate the amount to be rolled over to a | ||
| subsequent coverage period POWER account from the participant's | ||
| current coverage period POWER account based on: | ||
| (1) the amount of money remaining in the participant's | ||
| POWER account from the current coverage period; and | ||
| (2) whether the participant received recommended | ||
| preventative care services during the current coverage period. | ||
| (c) For a participant enrolled in the plus plan who, as | ||
| determined by the commission, timely makes POWER account | ||
| contributions in accordance with this subchapter, the commission | ||
| shall calculate the amount to be rolled over to a subsequent | ||
| coverage period POWER account from the participant's current | ||
| coverage period POWER account based on: | ||
| (1) the amount of money remaining in the participant's | ||
| POWER account from the current coverage period; | ||
| (2) the total amount of money the participant | ||
| contributed to the participant's POWER account during the current | ||
| coverage period; and | ||
| (3) whether the participant received recommended | ||
| preventative care services during the current coverage period. | ||
| (d) Except as provided by Subsection (e), a participant may | ||
| use money rolled over into the participant's POWER account for the | ||
| succeeding coverage period to offset required annual POWER account | ||
| contributions, as applicable, during that coverage period. | ||
| (e) A participant enrolled in the basic plan who rolls over | ||
| money into the participant's POWER account for the succeeding | ||
| coverage period and who chooses to enroll in the plus plan for that | ||
| coverage period may use the money rolled over to offset a maximum of | ||
| 50 percent of the required annual POWER account contributions for | ||
| that coverage period. | ||
| Sec. 537A.0257. REFUND. If at the end of a participant's | ||
| coverage period the participant chooses to cease participating in a | ||
| program health benefit plan or is no longer eligible to participate | ||
| in a program health benefit plan, or if a participant is terminated | ||
| from the program health benefit plan under Section 537A.0258 for | ||
| failure to pay required contributions, the commission shall refund | ||
| to the participant any money the participant contributed that | ||
| remains in the participant's POWER account at the end of the | ||
| coverage period or on the termination date. | ||
| Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE POWER ACCOUNT | ||
| CONTRIBUTIONS. (a) For a participant whose annual household | ||
| income exceeds 100 percent of the federal poverty level and who | ||
| fails to make a contribution in accordance with Section 537A.0252, | ||
| the commission shall provide a 60-day grace period during which the | ||
| participant may make the contribution without penalty. If the | ||
| participant fails to make the contribution during the grace period, | ||
| the participant will be disenrolled from the program health benefit | ||
| plan in which the participant is enrolled and may not reenroll in a | ||
| program health benefit plan until: | ||
| (1) the 181st day after the date the participant is | ||
| disenrolled; and | ||
| (2) the participant pays any debt accrued due to the | ||
| participant's failure to make the contribution. | ||
| (b) For a participant enrolled in the plus plan whose annual | ||
| household income is equal to or less than 100 percent of the federal | ||
| poverty level and who fails to make a contribution in accordance | ||
| with Section 537A.0252, the commission shall disenroll the | ||
| participant from the plus plan and enroll the participant in the | ||
| basic plan. A participant enrolled in the basic plan under this | ||
| subsection may not change enrollment to the plus plan until the | ||
| participant's program eligibility is redetermined. | ||
| SUBCHAPTER G. EMPLOYMENT INITIATIVE | ||
| Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The | ||
| commission shall develop and implement a gateway to work program | ||
| to: | ||
| (1) integrate existing job training and job search | ||
| programs available in this state through the Texas Workforce | ||
| Commission or other appropriate state agencies with the Live Well | ||
| Texas program; and | ||
| (2) provide each participant with general information | ||
| on the job training and job search programs. | ||
| (b) Under the gateway to work program, the commission shall | ||
| refer each participant who is unemployed or working less than 20 | ||
| hours a week to available job search and job training programs. | ||
| SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN | ||
| PARTICIPANTS | ||
| Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR | ||
| CONTINUITY OF CARE. (a) The commission shall ensure continuity of | ||
| care by providing health care financial assistance in accordance | ||
| with and in the manner described by this subchapter for a | ||
| participant who: | ||
| (1) is disenrolled from a program health benefit plan | ||
| in accordance with Section 537A.0155 because the participant's | ||
| annual household income exceeds the income eligibility | ||
| requirements for enrollment in a program health benefit plan; and | ||
| (2) seeks and obtains private health benefit coverage | ||
| within 12 months following the date of disenrollment. | ||
| (b) To receive health care financial assistance under this | ||
| subchapter, a participant must provide to the commission, in the | ||
| form and manner required by the commission, documentation showing | ||
| the participant has obtained or is actively seeking private health | ||
| benefit coverage. | ||
| (c) The commission may not impose an upper income | ||
| eligibility limit on a participant to receive health care financial | ||
| assistance under this subchapter. | ||
| Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE | ||
| FINANCIAL ASSISTANCE. (a) A participant described by Section | ||
| 537A.0351 may receive health care financial assistance under this | ||
| subchapter until the first anniversary of the date the participant | ||
| was disenrolled from a program health benefit plan. | ||
| (b) Health care financial assistance made available to a | ||
| participant under this subchapter: | ||
| (1) may not exceed the amount described by Section | ||
| 537A.0353; and | ||
| (2) is limited to payment for eligible services | ||
| described by Section 537A.0354. | ||
| Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The | ||
| commission shall establish a bridge account for each participant | ||
| eligible to receive health care financial assistance under Section | ||
| 537A.0351. The account is funded with money the commission | ||
| contributes in accordance with this section. | ||
| (b) The commission shall enable each participant for whom a | ||
| bridge account is established to access and manage money in and | ||
| information regarding the participant's account through an | ||
| electronic system. The commission may contract with the same | ||
| entity described by Section 537A.0251(b) or another entity with | ||
| appropriate experience and expertise to establish, implement, or | ||
| administer the electronic system. | ||
| (c) The commission shall fund each bridge account in an | ||
| amount equal to $1,000 using money the commission retains or | ||
| recoups during the rollover process described by Section 537A.0256 | ||
| or following the issuance of a refund as described by Section | ||
| 537A.0257. | ||
| (d) The commission may not require a participant to | ||
| contribute money to the participant's bridge account. | ||
| (e) The commission shall retain or recoup any unexpended | ||
| money in a participant's bridge account at the end of the period for | ||
| which the participant is eligible to receive health care financial | ||
| assistance under this subchapter for the purpose of funding another | ||
| participant's POWER account under Subchapter F or bridge account | ||
| under this subchapter. | ||
| Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The | ||
| commission shall issue to each participant for whom a bridge | ||
| account is established an electronic payment card that allows the | ||
| participant to use the card to pay costs for eligible services | ||
| described by Subsection (b). | ||
| (b) A participant may use money in the participant's bridge | ||
| account to pay: | ||
| (1) premium costs incurred during the private health | ||
| benefit coverage enrollment process and coverage period; and | ||
| (2) copayments, deductible costs, and coinsurance | ||
| associated with the private health benefit coverage obtained by the | ||
| participant for health care services that would otherwise be | ||
| reimbursable under Medicaid. | ||
| (c) Costs described by Subsection (b)(2) associated with | ||
| eligible services delivered to a participant may be paid by: | ||
| (1) a participant using the electronic payment card | ||
| issued under Subsection (a); or | ||
| (2) a health care provider directly charging and | ||
| receiving payment from the participant's bridge account. | ||
| Sec. 537A.0355. ENROLLMENT COUNSELING. The commission | ||
| shall provide enrollment counseling to an individual who is seeking | ||
| private health benefit coverage and who is otherwise eligible to | ||
| receive health care financial assistance under this subchapter. | ||
| SECTION 2. (a) The Health and Human Services Commission | ||
| shall conduct a study on the development and implementation of the | ||
| Live Well Texas program under Chapter 537A, Government Code, as | ||
| added by this Act, including potential sources of funding for the | ||
| state's share of costs associated with implementing the program. | ||
| The study must: | ||
| (1) consider the feasibility of using funding from the | ||
| following sources to fund the program: | ||
| (A) rebates collected under the Medicaid vendor | ||
| drug program; and | ||
| (B) managed care state premium tax revenue; | ||
| (2) evaluate the anticipated savings to this state | ||
| resulting from the reduction or elimination of: | ||
| (A) health care-related benefits that a program | ||
| participant would otherwise be eligible to receive under other | ||
| programs administered by the commission or another health and human | ||
| services agency, including: | ||
| (i) the kidney health care program; | ||
| (ii) the Healthy Texas Women program; and | ||
| (iii) other programs that provide benefits: | ||
| (a) to pregnant women; | ||
| (b) for treating breast and cervical | ||
| cancer; | ||
| (c) to support community health | ||
| treatment; | ||
| (d) for substance use treatment; and | ||
| (e) for treatment of HIV infection; | ||
| and | ||
| (B) health care expenses incurred by the Texas | ||
| Department of Criminal Justice for inpatient hospital stays of more | ||
| than 24 hours in a freestanding hospital; and | ||
| (3) based on the evaluation under Subdivision (2) of | ||
| this subsection, determine the extent to which savings offset or | ||
| eliminate the state's share of costs associated with implementing | ||
| the program. | ||
| (b) Not later than November 30, 2022, the Health and Human | ||
| Services Commission shall prepare and submit to the legislature a | ||
| written report that: | ||
| (1) summarizes the results of the study conducted | ||
| under Subsection (a) of this section; and | ||
| (2) includes legislative recommendations, as | ||
| applicable. | ||
| SECTION 3. 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 another | ||
| appropriate federal agency the waiver as required by Section | ||
| 537A.0051, Government Code, as added by this Act. The commission | ||
| may delay implementing this Act until the waiver applied for under | ||
| that section is granted. | ||
| SECTION 4. This Act takes effect January 1, 2023, but only | ||
| if the constitutional amendment proposed by the 87th Legislature, | ||
| 3rd Called Session, 2021, requiring the state to develop and seek | ||
| appropriate authorization under the federal Medicaid program to | ||
| implement the Live Well Texas program to provide health benefit | ||
| coverage to certain individuals is approved by the voters. If that | ||
| amendment is not approved by the voters, this Act has no effect. | ||
