Bill Text: TX SB57 | 2013-2014 | 83rd Legislature | Introduced


Bill Title: Relating to improving the delivery and quality of certain health and human services, including the delivery and quality of Medicaid acute care services and long-term care services and supports.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2013-01-28 - Referred to Health & Human Services [SB57 Detail]

Download: Texas-2013-SB57-Introduced.html
 
 
  By: Nelson S.B. No. 57
 
 
 
   
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to improving the delivery and quality of certain health
  and human services, including the delivery and quality of Medicaid
  acute care services and long-term care services and supports.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
  ARTICLE 1.  DELIVERY SYSTEM REDESIGN FOR THE PROVISION OF ACUTE CARE
  SERVICES AND LONG-TERM CARE SERVICES AND SUPPORTS TO INDIVIDUALS
  WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
         SECTION 1.01.  Subtitle I, Title 4, Government Code, is
  amended by adding Chapter 534 to read as follows:
  CHAPTER 534.  SYSTEM REDESIGN FOR DELIVERY OF MEDICAID ACUTE CARE
  SERVICES AND LONG-TERM CARE SERVICES AND SUPPORTS TO PERSONS WITH
  INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
  SUBCHAPTER A.  GENERAL PROVISIONS
         Sec. 534.001.  DEFINITIONS. In this chapter:
               (1)  "Capitation" means a method of compensating a
  provider on a monthly basis for providing or coordinating the
  provision of a defined set of services and supports that is based on
  a predetermined payment per services recipient.
               (2)  "Department" means the Department of Aging and
  Disability Services.
               (3)  "ICF-IID" means the Medicaid program serving
  individuals with intellectual and developmental disabilities who
  receive care in intermediate care facilities.
               (4)  "Local intellectual and developmental disability
  authority" means a local mental retardation authority described by
  Section 533.035, Health and Safety Code.
               (5)  "Managed care organization," "managed care plan,"
  and "potentially preventable event" have the meanings assigned
  under Section 536.001.
               (6)  "Medicaid program" means the medical assistance
  program established under Chapter 32, Human Resources Code.
               (7)  "Medicaid waiver program" means only the following
  programs that are authorized under Section 1915(c) of the federal
  Social Security Act (42 U.S.C. Section 1396n(c)) for the provision
  of services to persons with intellectual and developmental
  disabilities:
                     (A)  the community living assistance and support
  services (CLASS) waiver program;
                     (B)  the home and community-based services (HCS)
  waiver program;
                     (C)  the deaf, blind, and multiple disabilities
  (DBMD) waiver program; and
                     (D)  the Texas home living (TxHmL) waiver program.
         Sec. 534.002.  CONFLICT WITH OTHER LAW. To the extent of a
  conflict between a provision of this chapter and another state law,
  the provision of this chapter controls.
  [Sections 534.003-534.050 reserved for expansion]
  SUBCHAPTER B. ACUTE CARE SERVICES AND LONG-TERM CARE SERVICES AND
  SUPPORTS SYSTEM
         Sec. 534.051.  ACUTE CARE SERVICES AND LONG-TERM CARE
  SERVICES AND SUPPORTS SYSTEM FOR INDIVIDUALS WITH INTELLECTUAL AND
  DEVELOPMENTAL DISABILITIES. In accordance with this chapter, the
  commission and the department shall jointly design and implement an
  acute care services and long-term care services and supports system
  for individuals with intellectual and developmental disabilities
  that supports the following goals:
               (1)  provide Medicaid services to more individuals in a
  cost-efficient manner by providing the type and amount of services
  most appropriate to the individuals' needs;
               (2)  improve individuals' access to services by
  ensuring that the individuals receive information about all
  available programs and services and how to apply for the programs
  and services;
               (3)  improve the assessment of individuals' needs and
  available supports;
               (4)  improve the coordination of acute care services
  and long-term care services and supports;
               (5)  improve acute care and long-term care outcomes,
  including reducing potentially preventable events;
               (6)  promote high-quality care; and
               (7)  promote person-centered planning and
  self-direction.
         Sec. 534.052.  IMPLEMENTATION OF SYSTEM. The commission and
  department shall jointly implement the acute care services and
  long-term care services and supports system for individuals with
  intellectual and developmental disabilities in the manner and in
  the stages described in this chapter.
         Sec. 534.053.  ANNUAL REPORT ON IMPLEMENTATION. (a)  Not
  later than September 1 of each year, the commission shall submit a
  report to the legislature regarding:
               (1)  the implementation of the system required by this
  chapter, including appropriate information regarding the provision
  of acute care services and long-term care services and supports to
  individuals with intellectual and developmental disabilities under
  the Medicaid program; and
               (2)  recommendations, including recommendations
  regarding appropriate statutory changes to facilitate the
  implementation.
         (b)  This section expires January 1, 2019.
  [Sections 534.054-534.100 reserved for expansion]
  SUBCHAPTER C.  STAGE ONE:  PROGRAMS TO IMPROVE SERVICE DELIVERY
  MODELS
         Sec. 534.101.  PILOT PROGRAMS TO TEST MANAGED CARE
  STRATEGIES BASED ON CAPITATION. The commission and the department
  may develop and implement pilot programs in accordance with this
  subchapter to test one or more service delivery models involving a
  managed care strategy based on capitation to deliver long-term care
  services and supports under the Medicaid program to individuals
  with intellectual and developmental disabilities.
         Sec. 534.102.  PILOT PROGRAM PROVIDERS. (a)  The department
  shall identify local intellectual and developmental disability
  authorities and private care providers that are good candidates to
  develop a service delivery model involving a managed care strategy
  based on capitation and to test the model in the provision of
  long-term care services and supports under the Medicaid program to
  individuals with intellectual and developmental disabilities
  through a pilot program established under this subchapter.
         (b)  The department shall solicit managed care strategy
  proposals from the local intellectual and developmental disability
  authorities and private care providers identified under Subsection
  (a).
         (c)  A managed care strategy based on capitation developed
  for implementation through a pilot program under this subchapter
  must be designed to:
               (1)  increase access to long-term care services and
  supports;
               (2)  improve quality and service coordination;
               (3)  promote person-centered planning and
  self-direction; and
               (4)  promote efficiency and the best use of funding.
         (d)  The department shall evaluate each submitted managed
  care strategy proposal and determine whether:
               (1)  the proposed strategy satisfies the requirements
  of this section; and
               (2)  the local intellectual and developmental
  disability authority or private care provider that submitted the
  proposal is likely able to provide the long-term care services and
  supports appropriate to the individuals who will receive care
  through the program.
         (e)  Based on the evaluation performed by the department
  under Subsection (d), the department may select as pilot program
  service providers not more than two local intellectual and
  developmental disability authorities and not more than two private
  care providers.
         (f)  For each pilot program service provider, the department
  shall develop and implement a pilot program. Under a pilot program,
  the pilot program service provider shall provide long-term care
  services and supports under the Medicaid program to persons with
  intellectual and developmental disabilities to test its managed
  care strategy based on capitation.
         Sec. 534.103.  PILOT PROGRAM GOALS. (a)  The department
  shall identify measurable goals to be achieved by each pilot
  program implemented under this subchapter.
         (b)  The department shall propose specific strategies for
  achieving the identified goals. A proposed strategy may be
  evidence-based if there is an evidence-based strategy available for
  meeting the pilot program's goals.
         Sec. 534.104.  IMPLEMENTATION, LOCATION, AND DURATION.
  (a)  The commission and department shall implement any pilot
  programs established under this subchapter not later than September
  1, 2014.
         (b)  A pilot program established under this subchapter must
  operate for not less than 24 months.
         (c)  A pilot program established under this subchapter shall
  be conducted in one or more regions selected by the department.
         Sec. 534.105.  COORDINATING SERVICES. In providing
  long-term care services and supports under the Medicaid program to
  an individual with intellectual or developmental disabilities, a
  pilot program service provider shall:
               (1)  coordinate through the pilot program
  institutional and community-based services available to the
  individual, including services provided through:
                     (A)  a facility licensed under Chapter 252, Health
  and Safety Code;
                     (B)  a Medicaid waiver program; or
                     (C)  a community-based ICF-IID operated by local
  authorities; and
               (2)  coordinate with managed care organizations to
  improve the coordination of acute care services and long-term care
  services and supports.
         Sec. 534.106.  PILOT PROGRAM INFORMATION. (a)  The
  commission and the department shall collect and compute the
  following information with respect to each pilot program
  established under this subchapter to the extent it is available:
               (1)  the difference between the average monthly cost
  per person for all services received by individuals participating
  in the pilot program while the program is operating, including
  services provided through the pilot program and other services with
  which pilot program services are coordinated as described by
  Section 534.105, and the average cost per person for all services
  received by the individuals before the operation of the pilot
  program;
               (2)  the percentage of individuals receiving services
  through the pilot program who begin receiving services in a
  non-residential setting instead of from a facility licensed under
  Chapter 252, Health and Safety Code, or any other residential
  setting;
               (3)  the difference between the percentage of
  individuals receiving services through the pilot program who live
  in non-provider-owned housing during the operation of the pilot
  program and the percentage of individuals receiving services
  through the pilot program who lived in non-provider-owned housing
  before the operation of the pilot program;
               (4)  the difference between the average total Medicaid
  cost by level of care for individuals in various residential
  settings receiving services through the pilot program during the
  operation of the program and the average total Medicaid cost by
  level of care for those individuals before the operation of the
  program;
               (5)  the difference between the percentage of
  individuals receiving services through the pilot program who obtain
  and maintain employment in meaningful, integrated settings during
  the operation of the program and the percentage of individuals
  receiving services through the program who obtained and maintained
  employment in meaningful, integrated settings before the operation
  of the program; and
               (6)  the difference between the percentage of
  individuals receiving services through the pilot program whose
  behavioral outcomes have improved since the beginning of the
  program and the percentage of individuals receiving services
  through the program whose behavioral outcomes improved before the
  operation of the program, as measured over a comparable period.
         (b)  The pilot program service provider shall collect any
  information described by Subsection (a) that is available to the
  provider and provide the information to the department and the
  commission not later than the 30th day before the date the program's
  operation concludes.
         Sec. 534.107.  PERSON-CENTERED PLANNING. The commission, in
  cooperation with the department, shall ensure that each individual
  with intellectual or developmental disabilities who receives
  services and supports under the Medicaid program through a pilot
  program established under this subchapter has choice, direction,
  and control over Medicaid benefits should the individual choose the
  consumer direction model, as defined by Section 531.051.
         Sec. 534.108.  CONCLUSION OF PILOT PROGRAMS; EXPIRATION. On
  September 1, 2018:
               (1)  each pilot program established under this
  subchapter that is still in operation must conclude; and
               (2)  this subchapter expires.
  [Sections 534.109-534.150 reserved for expansion]
  SUBCHAPTER D. STAGE ONE:  PROVISION OF ACUTE CARE AND
  CERTAIN OTHER SERVICES
         Sec. 534.151.  DELIVERY OF ACUTE CARE SERVICES FOR
  INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES. The
  commission shall provide Medicaid program benefits for acute care
  services to individuals with intellectual and developmental
  disabilities through:
               (1)  the STAR Medicaid managed care program, or the
  most appropriate capitated managed care program delivery model, if
  the individual receives long-term care Medicaid waiver program
  services or ICF-IID services not integrated into the STAR + PLUS
  Medicaid managed care delivery model or other managed care delivery
  model under Section 534.201 or 534.202; and
               (2)  the STAR + PLUS Medicaid managed care program or
  the most appropriate integrated capitated managed care program
  delivery model, if the individual is eligible to receive medical
  assistance for acute care services and is not receiving medical
  assistance under a Medicaid waiver program.
         Sec. 534.152.  DELIVERY OF CERTAIN OTHER SERVICES UNDER STAR
  + PLUS MEDICAID MANAGED CARE PROGRAM. The commission shall
  implement the most cost-effective option for the delivery of basic
  attendant and habilitation services for individuals with
  intellectual and developmental disabilities under the STAR + PLUS
  Medicaid managed care program that maximizes federal funding for
  the delivery of services across that and other similar programs.
  [Sections 534.153-534.200 reserved for expansion]
  SUBCHAPTER E.  STAGE TWO: TRANSITION OF LONG-TERM CARE MEDICAID
  WAIVER PROGRAM RECIPIENTS TO INTEGRATED MANAGED CARE SYSTEM
         Sec. 534.201.  TRANSITION OF RECIPIENTS UNDER TEXAS HOME
  LIVING (TxHmL) WAIVER PROGRAM TO MANAGED CARE PROGRAM. (a)  This
  section applies to individuals with intellectual and developmental
  disabilities who meet the eligibility criteria required to receive
  long-term care services and supports under the Texas home living
  (TxHmL) waiver program on the date the commission implements the
  transition described by Subsection (b).
         (b)  Not later than September 1, 2016, the commission shall
  transition the provision of Medicaid program benefits to
  individuals to whom this section applies to the STAR + PLUS Medicaid
  managed care program delivery model or the most appropriate
  integrated capitated managed care program delivery model, as
  determined by the commission based on the cost effectiveness and
  the success of the STAR + PLUS Medicaid managed care program in
  providing basic attendant and habilitation services and the pilot
  programs established under Subchapter C, subject to Subsection
  (c)(1).
         (c)  At the time of the transition described by Subsection
  (b), the commission shall determine whether to:
               (1)  continue operation of the Texas home living
  (TxHmL) waiver program for purposes of providing supplemental
  long-term care services and supports not available under the
  managed care program delivery model selected by the commission; or
               (2)  cease operation of the Texas home living (TxHmL)
  waiver program and expand all or a portion of the long-term care
  services and supports previously available under the waiver program
  to the managed care program delivery model selected by the
  commission.
         Sec. 534.202.  TRANSITION OF ICF-IID RECIPIENTS AND CERTAIN
  OTHER MEDICAID WAIVER PROGRAM RECIPIENTS TO MANAGED CARE PROGRAM.
  (a)  This section applies to individuals with intellectual and
  developmental disabilities who, on the date the commission
  implements the transition described by Subsection (b):
               (1)  meet the eligibility criteria required to receive
  long-term care services and supports under a Medicaid waiver
  program other than the Texas home living (TxHmL) waiver program; or
               (2)  reside in an ICF-IID.
         (b)  After implementing the transition required by Section
  534.201 but not later than September 1, 2018, the commission shall
  transition the provision of Medicaid program benefits to
  individuals to whom this section applies to the STAR + PLUS Medicaid
  managed care program delivery model or the most appropriate
  integrated capitated managed care program delivery model, as
  determined by the commission based on cost-effectiveness and an
  evaluation of the success of the transition of Texas home living
  (TxHmL) waiver program recipients to a managed care program
  delivery model under Section 534.201, subject to Subsection (c)(1).
         (c)  At the time of the transition described by Subsection
  (b), the commission shall determine whether to:
               (1)  continue operation of the Medicaid waiver programs
  for purposes of providing supplemental long-term care services and
  supports not available under the managed care program delivery
  model selected by the commission; or
               (2)  cease operation of the Medicaid waiver programs
  and expand all or a portion of the long-term care services and
  supports previously available under the waiver programs to the
  managed care program delivery model selected by the commission.
         SECTION 1.02.  The Health and Human Services Commission
  shall submit:
               (1)  the initial report on the implementation of the
  acute care services and long-term care services and supports system
  for individuals with intellectual and developmental disabilities
  as required by Section 534.053, Government Code, as added by this
  Act, not later than September 1, 2014; and
               (2)  the final report under that section not later than
  September 1, 2018.
         SECTION 1.03.  The Health and Human Services Commission and
  Department of Aging and Disability Services shall implement any
  pilot program to be established under Subchapter C, Chapter 534,
  Government Code, as added by this Act, as soon as practicable after
  the effective date of this Act.
  ARTICLE 2. MEDICAID MANAGED CARE EXPANSION
         SECTION 2.01.  Sections 533.0025(a) and (b), Government
  Code, are amended to read as follows:
         (a)  In this section and Sections 533.00251 and 533.00252,
  "medical assistance" has the meaning assigned by Section 32.003,
  Human Resources Code.
         (b)  Notwithstanding [Except as otherwise provided by this
  section and notwithstanding] any other law, the commission shall
  provide medical assistance for acute care services through the most
  cost-effective model of Medicaid capitated managed care as
  determined by the commission. The [If the] commission shall
  require mandatory participation in a Medicaid capitated managed
  care program for all persons eligible for acute care [determines
  that it is more cost-effective, the commission may provide] medical
  assistance benefits [for acute care in a certain part of this state
  or to a certain population of recipients using:
               [(1)     a health maintenance organization model,
  including the acute care portion of Medicaid Star + Plus pilot
  programs;
               [(2)  a primary care case management model;
               [(3)  a prepaid health plan model;
               [(4)  an exclusive provider organization model; or
               [(5)     another Medicaid managed care model or
  arrangement].
         SECTION 2.02.  Subchapter A, Chapter 533, Government Code,
  is amended by adding Sections 533.00251 and 533.00252 to read as
  follows:
         Sec. 533.00251.  DELIVERY OF SERVICES THROUGH STAR + PLUS
  MEDICAID MANAGED CARE PROGRAM.  (a)  In this section:
               (1)  "Nursing facility" has the meaning assigned by
  Section 531.912.
               (2)  "Potentially preventable event" has the meaning
  assigned by Section 536.001.
         (b)  The commission shall expand the STAR + PLUS Medicaid
  managed care program to all areas of this state to serve individuals
  eligible for acute care services and long-term care services and
  supports under the medical assistance program.
         (c)  Notwithstanding any other law, the commission shall
  provide benefits under the medical assistance program to recipients
  who reside in nursing facilities through the STAR + PLUS Medicaid
  managed care program. In implementing this subsection, the
  commission shall ensure:
               (1)  that the commission is responsible for setting the
  reimbursement rate paid to a nursing facility under the managed
  care program;
               (2)  that a nursing facility is paid not later than the
  10th day after the date the facility submits a proper claim;
               (3)  the appropriate utilization of services;
               (4)  a reduction in the incidence of potentially
  preventable events; and
               (5)  that a managed care organization providing
  services under the managed care program provides payment incentives
  to nursing facility providers that reward reductions in preventable
  acute care costs and encourage transformative efforts in the
  delivery of nursing facility services.
         Sec. 533.00252.  STAR KIDS MEDICAID MANAGED CARE PROGRAM.
  (a)  In this section:
               (1)  "Health home" means a primary care provider
  practice or, if appropriate, a specialty care provider practice,
  incorporating several features, including comprehensive care
  coordination, family-centered care, and data management, that are
  focused on improving outcome-based quality of care and increasing
  patient and provider satisfaction under the medical assistance
  program.
               (2)  "Potentially preventable event" has the meaning
  assigned by Section 536.001.
         (b)  The commission shall establish a mandatory STAR Kids
  capitated managed care program tailored to provide medical
  assistance benefits to children with disabilities who are not
  otherwise enrolled in the STAR + PLUS Medicaid managed care
  program.  The managed care program developed under this section
  must:
               (1)  provide medical assistance benefits that are
  customized to meet the health care needs of recipients under the
  program through a defined system of care;
               (2)  better coordinate care of recipients under the
  program;
               (3)  improve the health outcomes of recipients;
               (4)  improve recipients' access to health care
  services;
               (5)  achieve cost containment and cost efficiency;
               (6)  reduce the administrative complexity of
  delivering medical assistance benefits;
               (7)  reduce the incidence of potentially preventable
  events by ensuring the availability of appropriate services and
  care management;
               (8)  require a health home; and
               (9)  coordinate and collaborate with long-term care
  service providers and long-term care management providers, if
  recipients are receiving long-term care services outside of the
  managed care organization.
         (c)  The commission shall provide medical assistance
  benefits through the STAR Kids managed care program established
  under this section to children who meet the eligibility criteria
  required to receive benefits under the medically dependent children
  (MDCP) waiver program. The commission shall ensure that the STAR
  Kids managed care program provides all or a portion of the benefits
  provided under the medically dependent children (MDCP) waiver
  program to the extent necessary to implement this subsection.
         SECTION 2.03.  Section 32.0212, Human Resources Code, is
  amended to read as follows:
         Sec. 32.0212.  DELIVERY OF MEDICAL ASSISTANCE.
  Notwithstanding any other law [and subject to Section 533.0025,
  Government Code], the department shall provide medical assistance
  for acute care services through the Medicaid managed care system
  implemented under Chapter 533, Government Code, or another Medicaid
  capitated managed care program.
         SECTION 2.04.  Sections 533.0025(c) and (d), Government
  Code, and Subchapter D, Chapter 533, Government Code, are repealed.
  ARTICLE 3.  OTHER PROVISIONS RELATING TO INDIVIDUALS WITH
  INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
         SECTION 3.01.  Subchapter B, Chapter 533, Health and Safety
  Code, is amended by adding Section 533.0335 to read as follows:
         Sec. 533.0335.  COMPREHENSIVE ASSESSMENT AND RESOURCE
  ALLOCATION PROCESS. (a)  In this section:
               (1)  "Department" means the Department of Aging and
  Disability Services.
               (2)  "Medicaid waiver program" has the meaning assigned
  by Section 534.001, Government Code.
         (b)  The department shall develop and implement a
  comprehensive assessment instrument and a resource allocation
  process. The assessment instrument and resource allocation process
  must be designed to recommend for each individual with intellectual
  and developmental disabilities enrolled in a Medicaid waiver
  program the type, intensity, and range of services that are both
  appropriate and available, based on the functional needs of that
  individual.
         (c)  The department may satisfy the requirement to implement
  the comprehensive assessment instrument and the resource
  allocation process developed under Subsection (b) by implementing
  the instrument and process only for purposes of pilot programs
  established under Subchapter C, Chapter 534, Government Code. This
  subsection expires on the date Subchapter C, Chapter 534,
  Government Code, expires.
         (d)  The department shall establish a prior authorization
  process for requests for placement of an individual with
  intellectual and developmental disabilities in a group home. The
  process must ensure that placement in a group home is available only
  to individuals for whom a more independent setting is not
  appropriate or available.
         SECTION 3.02.  Subchapter B, Chapter 533, Health and Safety
  Code, is amended by adding Sections 533.03551 and 533.03552 to read
  as follows:
         Sec. 533.03551.  FLEXIBLE, LOW-COST RESIDENTIAL OPTIONS.
  (a)  To the extent permitted under federal law and regulations, the
  executive commissioner shall adopt or amend rules as necessary to
  allow for the development of additional housing supports for
  individuals with intellectual and developmental disabilities in
  urban and rural areas, including:
               (1)  congregate living arrangements, such as houses,
  condominiums, or rental properties that may be in close proximity
  to each other;
               (2)  non-provider-owned residential settings;
               (3)  assistance with living more independently; and
               (4)  rental properties with on-site supports.
         (b)  The Department of Aging and Disability Services, in
  cooperation with the Texas Department of Housing and Community
  Affairs, shall coordinate with federal, state, and local public
  housing entities as necessary to expand opportunities for
  accessible, affordable, and integrated housing to meet the complex
  needs of individuals with intellectual and developmental
  disabilities.
         Sec. 533.03552.  BEHAVIORAL SUPPORTS FOR INDIVIDUALS WITH
  INTELLECTUAL AND DEVELOPMENTAL DISABILITIES AT RISK OF
  INSTITUTIONALIZATION; INTERVENTION TEAMS. (a)  In this section,
  "department" means the Department of Aging and Disability Services.
         (b)  Subject to the availability of federal funding, the
  department shall develop and implement specialized training for
  providers, family members, caregivers, and first responders
  providing direct services and supports to individuals with
  intellectual and developmental disabilities and behavioral health
  needs.
         (c)  The department shall establish one or more behavioral
  health intervention teams to provide services and supports to
  individuals with intellectual and developmental disabilities and
  behavioral health needs. An intervention team may include one or
  more professionals such as a:
               (1)  psychiatrist or psychologist;
               (2)  physician;
               (3)  registered nurse;
               (4)  behavior analyst;
               (5)  social worker; or
               (6)  crisis coordinator.
         (d)  In providing services and supports, a behavioral health
  intervention team established by the department shall:
               (1)  use the team's best efforts to ensure an individual
  remains in the community and avoids institutionalization;
               (2)  focus on stabilizing the individual and assessing
  the individual for medical, psychiatric, psychological, and other
  needs;
               (3)  provide support to the individual's family members
  and other caregivers;
               (4)  provide intensive behavioral assessment and
  training to assist the individual in establishing positive
  behaviors and continuing to live in the community; and
               (5)  provide clinical and other referrals.
  ARTICLE 4. QUALITY-BASED OUTCOMES AND PAYMENTS PROVISIONS
         SECTION 4.01.  Subchapter A, Chapter 533, Government Code,
  is amended by adding Section 533.00511 to read as follows:
         Sec. 533.00511.  QUALITY-BASED ENROLLMENT INCENTIVE PROGRAM
  FOR MANAGED CARE ORGANIZATIONS.  (a)  In this section, "potentially
  preventable admission," "potentially preventable ancillary
  service," "potentially preventable complication," "potentially
  preventable emergency room visit," "potentially preventable
  readmission," and "potentially preventable event" have the
  meanings assigned by Section 536.001.
         (b)  The commission shall create an incentive program that
  automatically enrolls a greater percentage of recipients, who did
  not actively choose their managed care plan, to a managed care plan,
  based on:
               (1)  the quality of care provided through the managed
  care organization offering that managed care plan;
               (2)  the organization's ability to efficiently and
  effectively provide services, taking into consideration the acuity
  of populations primarily served by the organization; and
               (3)  the organization's performance with respect to
  exceeding, or failing to achieve, appropriate outcome and process
  measures developed by the commission, including measures based on
  all potentially preventable events.
         SECTION 4.02.  Section 536.003, Government Code, is amended
  by amending Subsections (a) and (b) and adding Subsection (a-1) to
  read as follows:
         (a)  The commission, in consultation with the advisory
  committee, shall develop quality-based outcome and process
  measures that promote the provision of efficient, quality health
  care and that can be used in the child health plan and Medicaid
  programs to implement quality-based payments for acute and
  long-term care services across all delivery models and payment
  systems, including fee-for-service and managed care payment
  systems. Subject to Subsection (a-1), the [The] commission, in
  developing outcome and process measures under this section, must
  include measures based on all [consider measures addressing]
  potentially preventable events.
         (a-1)  The outcome measures based on potentially preventable
  events must be risk-adjusted and allow for rate-based performance
  among health care providers.
         (b)  To the extent feasible, the commission shall develop
  outcome and process measures:
               (1)  consistently across all child health plan and
  Medicaid program delivery models and payment systems;
               (2)  in a manner that takes into account appropriate
  patient risk factors, including the burden of chronic illness on a
  patient and the severity of a patient's illness;
               (3)  that will have the greatest effect on improving
  quality of care and the efficient use of services, including acute
  and long-term care services; [and]
               (4)  that are similar to outcome and process measures
  used in the private sector, as appropriate;
               (5)  that reflect effective coordination of acute and
  long-term care services;
               (6)  that can be tied to expenditures; and
               (7)  that reduce preventable health care utilization
  and costs.
         SECTION 4.03.  Section 536.004(a), Government Code, is
  amended to read as follows:
         (a)  Using quality-based outcome and process measures
  developed under Section 536.003 and subject to this section, the
  commission, after consulting with the advisory committee, shall
  develop quality-based payment systems, and require managed care
  organizations to develop quality-based payment systems, for
  compensating a physician or other health care provider
  participating in the child health plan or Medicaid program that:
               (1)  align payment incentives with high-quality,
  cost-effective health care;
               (2)  reward the use of evidence-based best practices;
               (3)  promote the coordination of health care;
               (4)  encourage appropriate physician and other health
  care provider collaboration;
               (5)  promote effective health care delivery models; and
               (6)  take into account the specific needs of the child
  health plan program enrollee and Medicaid recipient populations.
         SECTION 4.04.  Section 536.005, Government Code, is amended
  by adding Subsection (c) to read as follows:
         (c)  Notwithstanding Subsection (a) and to the extent
  possible, the commission shall convert outpatient hospital
  reimbursement systems under the child health plan and Medicaid
  programs to an appropriate prospective payment system that will
  allow the commission to:
               (1)  more accurately classify the full range of
  outpatient service episodes;
               (2)  more accurately account for the intensity of
  services provided; and
               (3)  motivate outpatient service providers to increase
  efficiency and effectiveness.
         SECTION 4.05.  Section 536.008, Government Code, is amended
  to read as follows:
         Sec. 536.008.  ANNUAL REPORT. (a)  The commission shall
  submit to the legislature and make available to the public an annual
  report [to the legislature] regarding:
               (1)  the quality-based outcome and process measures
  developed under Section 536.003, including measures based on each
  potentially preventable event; and
               (2)  the progress of the implementation of
  quality-based payment systems and other payment initiatives
  implemented under this chapter.
         (b)  As appropriate, the [The] commission shall report
  outcome and process measures under Subsection (a)(1) by:
               (1)  geographic location, which may require reporting
  by county, health care service region, or other appropriately
  defined geographic area;
               (2)  recipient population or eligibility group served;
               (3)  type of health care provider, such as acute care or
  long-term care provider;
               (4)  quality-based payment system; and
               (5)  service delivery model.
         (c)  The report required under this section may not identify
  specific health care providers.
         SECTION 4.06.  Section 536.051(a), Government Code, is
  amended to read as follows:
         (a)  Subject to Section 1903(m)(2)(A), Social Security Act
  (42 U.S.C. Section 1396b(m)(2)(A)), and other applicable federal
  law, the commission shall base a percentage of the premiums paid to
  a managed care organization participating in the child health plan
  or Medicaid program on the organization's performance with respect
  to outcome and process measures developed under Section 536.003
  that address all[, including outcome measures addressing]
  potentially preventable events.
         SECTION 4.07.  Section 536.052(a), Government Code, is
  amended to read as follows:
         (a)  The commission may allow a managed care organization
  participating in the child health plan or Medicaid program
  increased flexibility to implement quality initiatives in a managed
  care plan offered by the organization, including flexibility with
  respect to financial arrangements, in order to:
               (1)  achieve high-quality, cost-effective health care;
               (2)  increase the use of high-quality, cost-effective
  delivery models; [and]
               (3)  reduce potentially preventable events; and
               (4)  increase the use of alternative payment systems.
         SECTION 4.08.  Section 536.151, Government Code, is amended
  by amending Subsections (a) and (b) and adding Subsection (a-1) to
  read as follows:
         (a)  The executive commissioner shall adopt rules for
  identifying:
               (1)  potentially preventable admissions and
  readmissions of child health plan program enrollees and Medicaid
  recipients;
               (2)  potentially preventable ancillary services
  provided to or ordered for child health plan program enrollees and
  Medicaid recipients;
               (3)  potentially preventable emergency room visits by
  child health plan program enrollees and Medicaid recipients; and
               (4)  potentially preventable complications experienced
  by child health plan program enrollees and Medicaid recipients.
         (a-1)  The commission shall collect data from hospitals on
  present-on-admission indicators for purposes of this section.
         (b)  The commission shall establish a program to provide a
  confidential report to each hospital in this state that
  participates in the child health plan or Medicaid program regarding
  the hospital's performance with respect to each potentially
  preventable event described under Subsection (a) [readmissions and
  potentially preventable complications]. To the extent possible, a
  report provided under this section should include all potentially
  preventable events [readmissions and potentially preventable
  complications information] across all child health plan and
  Medicaid program payment systems. A hospital shall distribute the
  information contained in the report to physicians and other health
  care providers providing services at the hospital.
         SECTION 4.09.  Section 536.152(a), Government Code, is
  amended to read as follows:
         (a)  Subject to Subsection (b), using the data collected
  under Section 536.151 and the diagnosis-related groups (DRG)
  methodology implemented under Section 536.005, if applicable, the
  commission, after consulting with the advisory committee, shall to
  the extent feasible adjust child health plan and Medicaid
  reimbursements to hospitals, including payments made under the
  disproportionate share hospitals and upper payment limit
  supplemental payment programs, [in a manner that may reward or
  penalize a hospital] based on the hospital's performance with
  respect to exceeding, or failing to achieve, outcome and process
  measures developed under Section 536.003 that address the rates of
  potentially preventable readmissions and potentially preventable
  complications.
         SECTION 4.10.  Section 536.202(a), Government Code, is
  amended to read as follows:
         (a)  The commission shall, after consulting with the
  advisory committee, establish payment initiatives to test the
  effectiveness of quality-based payment systems, alternative
  payment methodologies, and high-quality, cost-effective health
  care delivery models that provide incentives to physicians and
  other health care providers to develop health care interventions
  for child health plan program enrollees or Medicaid recipients, or
  both, that will:
               (1)  improve the quality of health care provided to the
  enrollees or recipients;
               (2)  reduce potentially preventable events;
               (3)  promote prevention and wellness;
               (4)  increase the use of evidence-based best practices;
               (5)  increase appropriate physician and other health
  care provider collaboration; [and]
               (6)  contain costs; and
               (7)  improve integration of acute care services and
  long-term care services and supports.
         SECTION 4.11.  Chapter 536, Government Code, is amended by
  adding Subchapter F to read as follows:
  SUBCHAPTER F. QUALITY-BASED LONG-TERM CARE PAYMENT SYSTEMS
         Sec. 536.251.  QUALITY-BASED LONG-TERM CARE PAYMENTS.
  (a)  Subject to this subchapter, the commission, after consulting
  with the advisory committee, may develop and implement
  quality-based payment systems for Medicaid long-term care services
  and supports providers designed to improve quality of care and
  reduce the provision of unnecessary services. A quality-based
  payment system developed under this section must base payments to
  providers on quality and efficiency measures that may include
  measurable wellness and prevention criteria and use of
  evidence-based best practices, sharing a portion of any realized
  cost savings achieved by the provider, and ensuring quality of care
  outcomes, including a reduction in potentially preventable events.
         (b)  The commission may develop a quality-based payment
  system for Medicaid long-term care services and supports providers
  under this subchapter only if implementing the system would be
  feasible and cost-effective.
         Sec. 536.252.  EVALUATION OF DATA SETS. To ensure that the
  commission is using the best data to inform the development and
  implementation of quality-based payment systems under Section
  536.251, the commission shall evaluate the reliability, validity,
  and functionality of post-acute and long-term care services and
  supports data sets. The commission's evaluation under this section
  should assess:
               (1)  to what degree data sets relied on by the
  commission meet a standard:
                     (A)  for integrating care;
                     (B)  for developing coordinated care plans; and
                     (C)  that would allow for the meaningful
  development of risk adjustment techniques; and
               (2)  whether the data sets will provide value for
  outcome or performance measures and cost containment.
         Sec. 536.253.  COLLECTION AND REPORTING OF CERTAIN
  INFORMATION. (a)  The executive commissioner shall adopt rules for
  identifying the incidence of potentially preventable admissions,
  potentially preventable readmissions, and potentially preventable
  emergency room visits by Medicaid long-term care services and
  supports recipients.
         (b)  The commission shall establish a program to provide a
  confidential report to each Medicaid long-term care services and
  supports provider in this state regarding the provider's
  performance with respect to potentially preventable admissions,
  potentially preventable readmissions, and potentially preventable
  emergency room visits. To the extent possible, a report provided
  under this section should include applicable potentially
  preventable events information across all Medicaid program payment
  systems.
         (c)  A report provided to a provider under this section is
  confidential and is not subject to Chapter 552.
         SECTION 4.12.  Not later than September 1, 2013, the Health
  and Human Services Commission shall convert outpatient hospital
  reimbursement systems as required by Section 536.005(c),
  Government Code, as added by this Act.
  ARTICLE 5. SPECIFIC PROVISIONS RELATING TO PREMIUMS UNDER THE
  MEDICAL ASSISTANCE PROGRAM
         SECTION 5.01.  Subchapter A, Chapter 533, Government Code,
  is amended by adding Section 533.0133 to read as follows:
         Sec. 533.0133.  INCLUSION OF RETROACTIVE FEE-FOR-SERVICE
  PAYMENTS IN PREMIUMS PAID. If the commission determines that it is
  cost-effective, the commission shall include all or a portion of
  any retroactive fee-for-service payments payable under the medical
  assistance program in the premium paid to a managed care
  organization under a managed care plan, including retroactive
  fee-for-service payments owed for services provided to a recipient
  before the recipient's enrollment in the medical assistance program
  or the managed care program, as applicable.
         SECTION 5.02.  Subchapter B, Chapter 32, Human Resources
  Code, is amended by adding Section 32.0642 to read as follows:
         Sec. 32.0642.  PREMIUM REQUIREMENT FOR RECEIPT OF CERTAIN
  SERVICES. To the extent permitted under and in a manner that is
  consistent with Title XIX, Social Security Act (42 U.S.C. Section
  1396 et seq.), and any other applicable law or regulation or under a
  federal waiver or other authorization, the executive commissioner
  of the Health and Human Services Commission shall adopt and
  implement in the most cost-effective manner a premium for long-term
  care services provided to a child under the medical assistance
  program to be paid by the child's parent or other legal guardian.
  ARTICLE 6. FEDERAL AUTHORIZATION, FUNDING, AND EFFECTIVE DATE
         SECTION 6.01.  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 6.02.  The Health and Human Services Commission may
  use any available revenue, including legislative appropriations
  and available federal funds, for purposes of implementing any
  provision of this Act.
         SECTION 6.03.  This Act takes effect September 1, 2013.
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