Bill Text: TX SB7 | 2011 | 82nd Legislature 1st Special | Engrossed

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Relating to the administration, quality, and efficiency of health care, health and human services, and health benefits programs in this state; creating an offense; providing penalties.

Sponsorship: Partisan Bill (Republican 10)

Status: (Passed) 2011-07-19 - See remarks for effective date [SB7 Detail]

Download: Texas-2011-SB7-Engrossed.html

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By: Nelson, et al. S.B. No. 7

A BILL TO BE ENTITLED
AN ACT
relating to the administration, quality, efficiency, and funding of
health care, health and human services, and health benefits
programs in this state; providing administrative and civil
penalties.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. ADMINISTRATION OF AND EFFICIENCY, COST-SAVING, FRAUD
PREVENTION, AND FUNDING MEASURES FOR CERTAIN HEALTH AND HUMAN
SERVICES AND HEALTH BENEFITS PROGRAMS
SECTION 1.01. (a) Section 102.054, Business & Commerce
Code, is amended to read as follows:
Sec. 102.054. ALLOCATION OF [CERTAIN] REVENUE FOR SEXUAL
ASSAULT PROGRAMS. The comptroller shall deposit the amount [first
$25 million] received from the fee imposed under this subchapter
[in a state fiscal biennium] to the credit of the sexual assault
program fund.
(b) Section 420.008, Government Code, is amended by
amending Subsection (c) and adding Subsection (d) to read as
follows:
(c) The legislature may appropriate money deposited to the
credit of the fund only to:
(1) the attorney general, for:
(A) sexual violence awareness and prevention
campaigns;
(B) grants to faith-based groups, independent
school districts, and community action organizations for programs
for the prevention of sexual assault and programs for victims of
human trafficking;
(C) grants for equipment for sexual assault nurse
examiner programs, to support the preceptorship of future sexual
assault nurse examiners, and for the continuing education of sexual
assault nurse examiners;
(D) grants to increase the level of sexual
assault services in this state;
(E) grants to support victim assistance
coordinators;
(F) grants to support technology in rape crisis
centers;
(G) grants to and contracts with a statewide
nonprofit organization exempt from federal income taxation under
Section 501(c)(3), Internal Revenue Code of 1986, having as a
primary purpose ending sexual violence in this state, for programs
for the prevention of sexual violence, outreach programs, and
technical assistance to and support of youth and rape crisis
centers working to prevent sexual violence; [and]
(H) grants to regional nonprofit providers of
civil legal services to provide legal assistance for sexual assault
victims;
(I) grants to health science centers and related
nonprofit entities exempt from federal income taxation under
Section 501(a), Internal Revenue Code of 1986, by being listed as an
exempt organization under Section 501(c)(3) of that code, for
research relating to the prevention and mitigation of sexual
assault; and
(J) Internet Crimes Against Children Task Force
locations in this state recognized by the United States Department
of Justice;
(2) the Department of State Health Services, to
measure the prevalence of sexual assault in this state and for
grants to support programs assisting victims of human trafficking;
(3) the Institute on Domestic Violence and Sexual
Assault at The University of Texas at Austin, to conduct research on
all aspects of sexual assault and domestic violence;
(4) Texas State University, for training and technical
assistance to independent school districts for campus safety;
(5) the office of the governor, for grants to support
sexual assault and human trafficking prosecution projects;
(6) the Department of Public Safety, to support sexual
assault training for commissioned officers;
(7) the comptroller's judiciary section, for
increasing the capacity of the sex offender civil commitment
program;
(8) the Texas Department of Criminal Justice:
(A) for pilot projects for monitoring sex
offenders on parole; and
(B) for increasing the number of adult
incarcerated sex offenders receiving treatment;
(9) the Texas Youth Commission, for increasing the
number of incarcerated juvenile sex offenders receiving treatment;
(10) the comptroller, for the administration of the
fee imposed on sexually oriented businesses under Section 102.052,
Business & Commerce Code; [and]
(11) the supreme court, to be transferred to the Texas
Equal Access to Justice Foundation, or a similar entity, to provide
victim-related legal services to sexual assault victims, including
legal assistance with protective orders, relocation-related
matters, victim compensation, and actions to secure privacy
protections available to victims under law; and
(12) the Department of Family and Protective Services
for:
(A) programs related to sexual assault
prevention and intervention; and
(B) research relating to how the department can
effectively address the prevention of sexual assault.
(d) A board, commission, department, office, or other
agency in the executive or judicial branch of state government to
which money is appropriated from the sexual assault program fund
under this section shall, not later than December 1 of each
even-numbered year, provide to the Legislative Budget Board a
report stating, for the preceding fiscal biennium:
(1) the amount appropriated to the entity under this
section;
(2) the purposes for which the money was used; and
(3) any results of a program or research funded under
this section.
(c) The comptroller of public accounts shall collect the fee
imposed under Section 102.052, Business & Commerce Code, until a
court, in a final judgment upheld on appeal or no longer subject to
appeal, finds Section 102.052, Business & Commerce Code, or its
predecessor statute, to be unconstitutional.
(d) Section 102.055, Business & Commerce Code, is repealed.
(e) This section prevails over any other Act of the 82nd
Legislature, 1st Called Session, 2011, regardless of the relative
dates of enactment, that purports to amend or repeal Subchapter B,
Chapter 102, Business & Commerce Code, or any provision of Chapter
1206 (H.B. 1751), Acts of the 80th Legislature, Regular Session,
2007.
SECTION 1.02. (a) Subchapter B, Chapter 531, Government
Code, is amended by adding Sections 531.02417, 531.024171, and
531.024172 to read as follows:
Sec. 531.02417. MEDICAID NURSING SERVICES ASSESSMENTS.
(a) In this section, "acute nursing services" means home health
skilled nursing services, home health aide services, and private
duty nursing services.
(b) If cost-effective, the commission shall develop an
objective assessment process for use in assessing a Medicaid
recipient's needs for acute nursing services. If the commission
develops an objective assessment process under this section, the
commission shall require that:
(1) the assessment be conducted:
(A) by a state employee or contractor who is not
the person who will deliver any necessary services to the recipient
and is not affiliated with the person who will deliver those
services; and
(B) in a timely manner so as to protect the health
and safety of the recipient by avoiding unnecessary delays in
service delivery; and
(2) the process include:
(A) an assessment of specified criteria and
documentation of the assessment results on a standard form;
(B) an assessment of whether the recipient should
be referred for additional assessments regarding the recipient's
needs for therapy services, as defined by Section 531.024171,
attendant care services, and durable medical equipment; and
(C) completion by the person conducting the
assessment of any documents related to obtaining prior
authorization for necessary nursing services.
(c) If the commission develops the objective assessment
process under Subsection (b), the commission shall:
(1) implement the process within the Medicaid
fee-for-service model and the primary care case management Medicaid
managed care model; and
(2) take necessary actions, including modifying
contracts with managed care organizations under Chapter 533 to the
extent allowed by law, to implement the process within the STAR and
STAR + PLUS Medicaid managed care programs.
(d) An assessment under Subsection (b)(2)(B) of whether a
recipient should be referred for additional therapy services shall
be waived if the recipient's need for therapy services has been
established by a recommendation from a therapist providing care
prior to discharge of the recipient from a licensed hospital or
nursing home. The assessment may not be waived if the
recommendation is made by a therapist who will deliver any services
to the recipient or is affiliated with a person who will deliver
those services when the recipient is discharged from the licensed
hospital or nursing home.
(e) The executive commissioner shall adopt rules providing
for a process by which a provider of acute nursing services who
disagrees with the results of the assessment conducted under
Subsection (b) may request and obtain a review of those results.
Sec. 531.024171. THERAPY SERVICES ASSESSMENTS. (a) In
this section, "therapy services" includes occupational, physical,
and speech therapy services.
(b) After implementing the objective assessment process for
acute nursing services in accordance with Section 531.02417, the
commission shall consider whether implementing age- and
diagnosis-appropriate objective assessment processes for assessing
the needs of a Medicaid recipient for therapy services would be
feasible and beneficial.
(c) If the commission determines that implementing age- and
diagnosis-appropriate processes with respect to one or more types
of therapy services is feasible and would be beneficial, the
commission may implement the processes within:
(1) the Medicaid fee-for-service model;
(2) the primary care case management Medicaid managed
care model; and
(3) the STAR and STAR + PLUS Medicaid managed care
programs.
(d) An objective assessment process implemented under this
section must include a process that allows a provider of therapy
services to request and obtain a review of the results of an
assessment conducted as provided by this section that is comparable
to the process implemented under rules adopted under Section
531.02417(e).
Sec. 531.024172. ELECTRONIC VISIT VERIFICATION SYSTEM.
(a) In this section, "acute nursing services" has the meaning
assigned by Section 531.02417.
(b) If it is cost-effective and feasible, the commission
shall implement an electronic visit verification system to
electronically verify and document, through a telephone or
computer-based system, basic information relating to the delivery
of Medicaid acute nursing services, including:
(1) the provider's name;
(2) the recipient's name; and
(3) the date and time the provider begins and ends each
service delivery visit.
(b) Not later than September 1, 2012, the Health and Human
Services Commission shall implement the electronic visit
verification system required by Section 531.024172, Government
Code, as added by this section, if the commission determines that
implementation of that system is cost-effective and feasible.
SECTION 1.03. (a) Subsection (e), Section 533.0025,
Government Code, is amended to read as follows:
(e) The commission shall determine the most cost-effective
alignment of managed care service delivery areas. The commissioner
may consider the number of lives impacted, the usual source of
health care services for residents in an area, and other factors
that impact the delivery of health care services in the area
[Notwithstanding Subsection (b)(1), the commission may not provide
medical assistance using a health maintenance organization in
Cameron County, Hidalgo County, or Maverick County].
(b) Subchapter A, Chapter 533, Government Code, is amended
by adding Sections 533.0027, 533.0028, and 533.0029 to read as
follows:
Sec. 533.0027. PROCEDURES TO ENSURE CERTAIN RECIPIENTS ARE
ENROLLED IN SAME MANAGED CARE PLAN. The commission shall ensure
that all recipients who are children and who reside in the same
household may, at the family's election, be enrolled in the same
managed care plan.
Sec. 533.0028. EVALUATION OF CERTAIN STAR + PLUS MEDICAID
MANAGED CARE PROGRAM SERVICES. The external quality review
organization shall periodically conduct studies and surveys to
assess the quality of care and satisfaction with health care
services provided to enrollees in the STAR + PLUS Medicaid managed
care program who are eligible to receive health care benefits under
both the Medicaid and Medicare programs.
Sec. 533.0029. PROMOTION AND PRINCIPLES OF
PATIENT-CENTERED MEDICAL HOMES FOR RECIPIENTS. (a) For purposes
of this section, a "patient-centered medical home" means a medical
relationship:
(1) between a primary care physician and a child or
adult patient in which the physician:
(A) provides comprehensive primary care to the
patient; and
(B) facilitates partnerships between the
physician, the patient, acute care and other care providers, and,
when appropriate, the patient's family; and
(2) that encompasses the following primary
principles:
(A) the patient has an ongoing relationship with
the physician, who is trained to be the first contact for the
patient and to provide continuous and comprehensive care to the
patient;
(B) the physician leads a team of individuals at
the practice level who are collectively responsible for the ongoing
care of the patient;
(C) the physician is responsible for providing
all of the care the patient needs or for coordinating with other
qualified providers to provide care to the patient throughout the
patient's life, including preventive care, acute care, chronic
care, and end-of-life care;
(D) the patient's care is coordinated across
health care facilities and the patient's community and is
facilitated by registries, information technology, and health
information exchange systems to ensure that the patient receives
care when and where the patient wants and needs the care and in a
culturally and linguistically appropriate manner; and
(E) quality and safe care is provided.
(b) The commission shall, to the extent possible, work to
ensure that managed care organizations:
(1) promote the development of patient-centered
medical homes for recipients; and
(2) provide payment incentives for providers that meet
the requirements of a patient-centered medical home.
(c) Section 533.003, Government Code, is amended to read as
follows:
Sec. 533.003. CONSIDERATIONS IN AWARDING CONTRACTS. (a) In
awarding contracts to managed care organizations, the commission
shall:
(1) give preference to organizations that have
significant participation in the organization's provider network
from each health care provider in the region who has traditionally
provided care to Medicaid and charity care patients;
(2) give extra consideration to organizations that
agree to assure continuity of care for at least three months beyond
the period of Medicaid eligibility for recipients;
(3) consider the need to use different managed care
plans to meet the needs of different populations; [and]
(4) consider the ability of organizations to process
Medicaid claims electronically; and
(5) in the initial implementation of managed care in
the South Texas service region, give extra consideration to an
organization that either:
(A) is locally owned, managed, and operated, if
one exists; or
(B) is in compliance with the requirements of
Section 533.004.
(b) The commission, in considering approval of a
subcontract between a managed care organization and a pharmacy
benefit manager for the provision of prescription drug benefits
under the Medicaid program, shall review and consider whether the
pharmacy benefit manager has been in the preceding three years:
(1) convicted of an offense involving a material
misrepresentation or an act of fraud or of another violation of
state or federal criminal law;
(2) adjudicated to have committed a breach of
contract; or
(3) assessed a penalty or fine in the amount of
$500,000 or more in a state or federal administrative proceeding.
(d) Section 533.005, Government Code, is amended by
amending Subsection (a) and adding Subsection (a-1) to read as
follows:
(a) A contract between a managed care organization and the
commission for the organization to provide health care services to
recipients must contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation rates that ensure the cost-effective
provision of quality health care;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than the
45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to exceed
60 days, specified by a written agreement between the physician or
provider and the managed care organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the managed
care organization, inform the organization of the recipient's
Medicaid certification date;
(9) a requirement that the managed care organization
comply with Section 533.006 as a condition of contract retention
and renewal;
(10) a requirement that the managed care organization
provide the information required by Section 533.012 and otherwise
comply and cooperate with the commission's office of inspector
general and the office of the attorney general;
(11) a requirement that the managed care
organization's usages of out-of-network providers or groups of
out-of-network providers may not exceed limits for those usages
relating to total inpatient admissions, total outpatient services,
and emergency room admissions determined by the commission;
(12) if the commission finds that a managed care
organization has violated Subdivision (11), a requirement that the
managed care organization reimburse an out-of-network provider for
health care services at a rate that is equal to the allowable rate
for those services, as determined under Sections 32.028 and
32.0281, Human Resources Code;
(13) a requirement that the organization use advanced
practice nurses in addition to physicians as primary care providers
to increase the availability of primary care providers in the
organization's provider network;
(14) a requirement that the managed care organization
reimburse a federally qualified health center or rural health
clinic for health care services provided to a recipient outside of
regular business hours, including on a weekend day or holiday, at a
rate that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician; [and]
(15) a requirement that the managed care organization
develop, implement, and maintain a system for tracking and
resolving all provider appeals related to claims payment, including
a process that will require:
(A) a tracking mechanism to document the status
and final disposition of each provider's claims payment appeal;
(B) the contracting with physicians who are not
network providers and who are of the same or related specialty as
the appealing physician to resolve claims disputes related to
denial on the basis of medical necessity that remain unresolved
subsequent to a provider appeal; and
(C) the determination of the physician resolving
the dispute to be binding on the managed care organization and
provider;
(16) a requirement that a medical director who is
authorized to make medical necessity determinations is available to
the region where the managed care organization provides health care
services;
(17) a requirement that the managed care organization
ensure that a medical director and patient care coordinators and
provider and recipient support services personnel are located in
the South Texas service region, if the managed care organization
provides a managed care plan in that region;
(18) a requirement that the managed care organization
provide special programs and materials for recipients with limited
English proficiency or low literacy skills;
(19) a requirement that the managed care organization
develop and establish a process for responding to provider appeals
in the region where the organization provides health care services;
(20) a requirement that the managed care organization
develop and submit to the commission, before the organization
begins to provide health care services to recipients, a
comprehensive plan that describes how the organization's provider
network will provide recipients sufficient access to:
(A) preventive care;
(B) primary care;
(C) specialty care;
(D) after-hours urgent care; and
(E) chronic care;
(21) a requirement that the managed care organization
demonstrate to the commission, before the organization begins to
provide health care services to recipients, that:
(A) the organization's provider network has the
capacity to serve the number of recipients expected to enroll in a
managed care plan offered by the organization;
(B) the organization's provider network
includes:
(i) a sufficient number of primary care
providers;
(ii) a sufficient variety of provider
types; and
(iii) providers located throughout the
region where the organization will provide health care services;
and
(C) health care services will be accessible to
recipients through the organization's provider network to a
comparable extent that health care services would be available to
recipients under a fee-for-service or primary care case management
model of Medicaid managed care;
(22) a requirement that the managed care organization
develop a monitoring program for measuring the quality of the
health care services provided by the organization's provider
network that:
(A) incorporates the National Committee for
Quality Assurance's Healthcare Effectiveness Data and Information
Set (HEDIS) measures;
(B) focuses on measuring outcomes; and
(C) includes the collection and analysis of
clinical data relating to prenatal care, preventive care, mental
health care, and the treatment of acute and chronic health
conditions and substance abuse;
(23) subject to Subsection (a-1), a requirement that
the managed care organization develop, implement, and maintain an
outpatient pharmacy benefit plan for its enrolled recipients:
(A) that exclusively employs the vendor drug
program formulary and preserves the state's ability to reduce
waste, fraud, and abuse under the Medicaid program;
(B) that adheres to the applicable preferred drug
list adopted by the commission under Section 531.072;
(C) that includes the prior authorization
procedures and requirements prescribed by or implemented under
Sections 531.073(b), (c), and (g) for the vendor drug program;
(D) for purposes of which the managed care
organization:
(i) may not negotiate or collect rebates
associated with pharmacy products on the vendor drug program
formulary; and
(ii) may not receive drug rebate or pricing
information that is confidential under Section 531.071;
(E) that complies with the prohibition under
Section 531.089;
(F) under which the managed care organization may
not prohibit, limit, or interfere with a recipient's selection of a
pharmacy or pharmacist of the recipient's choice for the provision
of pharmaceutical services under the plan through the imposition of
different copayments;
(G) that allows the managed care organization or
any subcontracted pharmacy benefit manager to contract with a
pharmacist or pharmacy providers separately for specialty pharmacy
services, except that:
(i) the managed care organization and
pharmacy benefit manager are prohibited from allowing exclusive
contracts with a specialty pharmacy owned wholly or partly by the
pharmacy benefit manager responsible for the administration of the
pharmacy benefit program; and
(ii) the managed care organization and
pharmacy benefit manager must adopt policies and procedures for
reclassifying prescription drugs from retail to specialty drugs,
and those policies and procedures must be consistent with rules
adopted by the executive commissioner and include notice to network
pharmacy providers from the managed care organization;
(H) under which the managed care organization may
not prevent a pharmacy or pharmacist from participating as a
provider if the pharmacy or pharmacist agrees to comply with the
financial terms and conditions of the contract as well as other
reasonable administrative and professional terms and conditions of
the contract;
(I) under which the managed care organization may
include mail-order pharmacies in its networks, but may not require
enrolled recipients to use those pharmacies, and may not charge an
enrolled recipient who opts to use this service a fee, including
postage and handling fees; and
(J) under which the managed care organization or
pharmacy benefit manager must pay claims in accordance with Section
843.339, Insurance Code; and
(24) a requirement that the managed care organization
and any entity with which the managed care organization contracts
for the performance of services under a managed care plan disclose,
at no cost, to the commission and, on request, the office of the
attorney general all discounts, incentives, rebates, fees, free
goods, bundling arrangements, and other agreements affecting the
net cost of goods or services provided under the plan.
(a-1) The requirements imposed by Subsections (a)(23)(A),
(B), and (C) do not apply, and may not be enforced, on and after
August 31, 2013.
(e) Subchapter A, Chapter 533, Government Code, is amended
by adding Section 533.0066 to read as follows:
Sec. 533.0066. PROVIDER INCENTIVES. The commission shall,
to the extent possible, work to ensure that managed care
organizations provide payment incentives to health care providers
in the organizations' networks whose performance in promoting
recipients' use of preventive services exceeds minimum established
standards.
(f) Section 533.0071, Government Code, is amended to read as
follows:
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The commission
shall make every effort to improve the administration of contracts
with managed care organizations. To improve the administration of
these contracts, the commission shall:
(1) ensure that the commission has appropriate
expertise and qualified staff to effectively manage contracts with
managed care organizations under the Medicaid managed care program;
(2) evaluate options for Medicaid payment recovery
from managed care organizations if the enrollee dies or is
incarcerated or if an enrollee is enrolled in more than one state
program or is covered by another liable third party insurer;
(3) maximize Medicaid payment recovery options by
contracting with private vendors to assist in the recovery of
capitation payments, payments from other liable third parties, and
other payments made to managed care organizations with respect to
enrollees who leave the managed care program;
(4) decrease the administrative burdens of managed
care for the state, the managed care organizations, and the
providers under managed care networks to the extent that those
changes are compatible with state law and existing Medicaid managed
care contracts, including decreasing those burdens by:
(A) where possible, decreasing the duplication
of administrative reporting requirements for the managed care
organizations, such as requirements for the submission of encounter
data, quality reports, historically underutilized business
reports, and claims payment summary reports;
(B) allowing managed care organizations to
provide updated address information directly to the commission for
correction in the state system;
(C) promoting consistency and uniformity among
managed care organization policies, including policies relating to
the preauthorization process, lengths of hospital stays, filing
deadlines, levels of care, and case management services; [and]
(D) reviewing the appropriateness of primary
care case management requirements in the admission and clinical
criteria process, such as requirements relating to including a
separate cover sheet for all communications, submitting
handwritten communications instead of electronic or typed review
processes, and admitting patients listed on separate
notifications; and
(E) providing a single portal through which
providers in any managed care organization's provider network may
submit claims; and
(5) reserve the right to amend the managed care
organization's process for resolving provider appeals of denials
based on medical necessity to include an independent review process
established by the commission for final determination of these
disputes.
(g) Subchapter A, Chapter 533, Government Code, is amended
by adding Section 533.0073 to read as follows:
Sec. 533.0073. MEDICAL DIRECTOR QUALIFICATIONS. A person
who serves as a medical director for a managed care plan must be a
physician licensed to practice medicine in this state under
Subtitle B, Title 3, Occupations Code.
(h) Subsections (a) and (c), Section 533.0076, Government
Code, are amended to read as follows:
(a) Except as provided by Subsections (b) and (c), and to
the extent permitted by federal law, [the commission may prohibit]
a recipient enrolled [from disenrolling] in a managed care plan
under this chapter may not disenroll from that plan and enroll
[enrolling] in another managed care plan during the 12-month period
after the date the recipient initially enrolls in a plan.
(c) The commission shall allow a recipient who is enrolled
in a managed care plan under this chapter to disenroll from [in]
that plan and enroll in another managed care plan:
(1) at any time for cause in accordance with federal
law; and
(2) once for any reason after the periods described by
Subsections (a) and (b).
(i) Subsections (a), (b), (c), and (e), Section 533.012,
Government Code, are amended to read as follows:
(a) Each managed care organization contracting with the
commission under this chapter shall submit the following, at no
cost, to the commission and, on request, the office of the attorney
general:
(1) a description of any financial or other business
relationship between the organization and any subcontractor
providing health care services under the contract;
(2) a copy of each type of contract between the
organization and a subcontractor relating to the delivery of or
payment for health care services;
(3) a description of the fraud control program used by
any subcontractor that delivers health care services; and
(4) a description and breakdown of all funds paid to or
by the managed care organization, including a health maintenance
organization, primary care case management provider, pharmacy
benefit manager, and [an] exclusive provider organization,
necessary for the commission to determine the actual cost of
administering the managed care plan.
(b) The information submitted under this section must be
submitted in the form required by the commission or the office of
the attorney general, as applicable, and be updated as required by
the commission or the office of the attorney general, as
applicable.
(c) The commission's office of investigations and
enforcement or the office of the attorney general, as applicable,
shall review the information submitted under this section as
appropriate in the investigation of fraud in the Medicaid managed
care program.
(e) Information submitted to the commission or the office of
the attorney general, as applicable, under Subsection (a)(1) is
confidential and not subject to disclosure under Chapter 552,
Government Code.
(j) The heading to Section 32.046, Human Resources Code, is
amended to read as follows:
Sec. 32.046. [VENDOR DRUG PROGRAM;] SANCTIONS AND PENALTIES
RELATED TO THE PROVISION OF PHARMACY PRODUCTS.
(k) Subsection (a), Section 32.046, Human Resources Code,
is amended to read as follows:
(a) The executive commissioner of the Health and Human
Services Commission [department] shall adopt rules governing
sanctions and penalties that apply to a provider who participates
in the vendor drug program or is enrolled as a network pharmacy
provider of a managed care organization contracting with the
commission under Chapter 533, Government Code, or its subcontractor
and who submits an improper claim for reimbursement under the
program.
(l) Subsection (d), Section 533.012, Government Code, is
repealed.
(m) Not later than December 1, 2013, the Health and Human
Services Commission shall submit a report to the legislature
regarding the commission's work to ensure that Medicaid managed
care organizations promote the development of patient-centered
medical homes for recipients of medical assistance as required
under Section 533.0029, Government Code, as added by this section.
(n) The Health and Human Services Commission shall, in a
contract between the commission and a managed care organization
under Chapter 533, Government Code, that is entered into or renewed
on or after the effective date of this Act, include the provisions
required by Subsection (a), Section 533.005, Government Code, as
amended by this section.
(o) Section 533.0073, Government Code, as added by this
section, applies only to a person hired or otherwise retained as the
medical director of a Medicaid managed care plan on or after the
effective date of this Act. A person hired or otherwise retained
before the effective date of this Act is governed by the law in
effect immediately before the effective date of this Act, and that
law is continued in effect for that purpose.
(p) Subsections (a) and (c), Section 533.0076, Government
Code, as amended by this section, apply only to a request for
disenrollment from a Medicaid managed care plan under Chapter 533,
Government Code, made by a recipient on or after the effective date
of this Act. A request made by a recipient before that date is
governed by the law in effect on the date the request was made, and
the former law is continued in effect for that purpose.
SECTION 1.04. (a) Section 62.101, Health and Safety Code,
is amended by adding Subsection (a-1) to read as follows:
(a-1) A child who is the dependent of an employee of an
agency of this state and who meets the requirements of Subsection
(a) may be eligible for health benefits coverage in accordance with
42 U.S.C. Section 1397jj(b)(6) and any other applicable law or
regulations.
(b) Sections 1551.159 and 1551.312, Insurance Code, are
repealed.
(c) The State Kids Insurance Program operated by the
Employees Retirement System of Texas is abolished on the effective
date of this Act. The Health and Human Services Commission shall:
(1) establish a process in cooperation with the
Employees Retirement System of Texas to facilitate the enrollment
of eligible children in the child health plan program established
under Chapter 62, Health and Safety Code, on or before the date
those children are scheduled to stop receiving dependent child
coverage under the State Kids Insurance Program; and
(2) modify any applicable administrative procedures
to ensure that children described by this subsection maintain
continuous health benefits coverage while transitioning from
enrollment in the State Kids Insurance Program to enrollment in the
child health plan program.
SECTION 1.05. (a) Subchapter B, Chapter 31, Human
Resources Code, is amended by adding Section 31.0326 to read as
follows:
Sec. 31.0326. VERIFICATION OF IDENTITY AND PREVENTION OF
DUPLICATE PARTICIPATION. The Health and Human Services Commission
shall use appropriate technology to:
(1) confirm the identity of applicants for benefits
under the financial assistance program; and
(2) prevent duplicate participation in the program by
a person.
(b) Chapter 33, Human Resources Code, is amended by adding
Section 33.0231 to read as follows:
Sec. 33.0231. VERIFICATION OF IDENTITY AND PREVENTION OF
DUPLICATE PARTICIPATION IN SNAP. The department shall use
appropriate technology to:
(1) confirm the identity of applicants for benefits
under the supplemental nutrition assistance program; and
(2) prevent duplicate participation in the program by
a person.
(c) Section 531.109, Government Code, is amended by adding
Subsection (d) to read as follows:
(d) Absent an allegation of fraud, waste, or abuse, the
commission may conduct an annual review of claims under this
section only after the commission has completed the prior year's
annual review of claims.
(d) Section 31.0325, Human Resources Code, is repealed.
SECTION 1.06. (a) Section 242.033, Health and Safety Code,
is amended by amending Subsection (d) and adding Subsection (g) to
read as follows:
(d) Except as provided by Subsection (f), a license is
renewable every three [two] years after:
(1) an inspection, unless an inspection is not
required as provided by Section 242.047;
(2) payment of the license fee; and
(3) department approval of the report filed every
three [two] years by the licensee.
(g) The executive commissioner by rule shall adopt a system
under which an appropriate number of licenses issued by the
department under this chapter expire on staggered dates occurring
in each three-year period. If the expiration date of a license
changes as a result of this subsection, the department shall
prorate the licensing fee relating to that license as appropriate.
(b) Subsection (e-1), Section 242.159, Health and Safety
Code, is amended to read as follows:
(e-1) An institution is not required to comply with
Subsections (a) and (e) until September 1, 2014 [2012]. This
subsection expires January 1, 2015 [2013].
(c) The executive commissioner of the Health and Human
Services Commission shall adopt the rules required under Subsection
(g), Section 242.033, Health and Safety Code, as added by this
section, as soon as practicable after the effective date of this
Act, but not later than December 1, 2012.
SECTION 1.07. (a) Section 161.077, Human Resources Code,
as added by Chapter 759 (S.B. 705), Acts of the 81st Legislature,
Regular Session, 2009, is redesignated as Section 161.081, Human
Resources Code, and amended to read as follows:
Sec. 161.081 [161.077]. LONG-TERM CARE MEDICAID WAIVER
PROGRAMS: STREAMLINING AND UNIFORMITY. (a) In this section,
"Section 1915(c) waiver program" has the meaning assigned by
Section 531.001, Government Code.
(b) The department, in consultation with the commission,
shall streamline the administration of and delivery of services
through Section 1915(c) waiver programs. In implementing this
subsection, the department, subject to Subsection (c), may consider
implementing the following streamlining initiatives:
(1) reducing the number of forms used in administering
the programs;
(2) revising program provider manuals and training
curricula;
(3) consolidating service authorization systems;
(4) eliminating any physician signature requirements
the department considers unnecessary;
(5) standardizing individual service plan processes
across the programs; [and]
(6) if feasible:
(A) concurrently conducting program
certification and billing audit and review processes and other
related audit and review processes;
(B) streamlining other billing and auditing
requirements;
(C) eliminating duplicative responsibilities
with respect to the coordination and oversight of individual care
plans for persons receiving waiver services; and
(D) streamlining cost reports and other cost
reporting processes; and
(7) any other initiatives that will increase
efficiencies in the programs.
(c) The department shall ensure that actions taken under
Subsection (b) [this section] do not conflict with any requirements
of the commission under Section 531.0218, Government Code.
(d) The department and the commission shall jointly explore
the development of uniform licensing and contracting standards that
would:
(1) apply to all contracts for the delivery of Section
1915(c) waiver program services;
(2) promote competition among providers of those
program services; and
(3) integrate with other department and commission
efforts to streamline and unify the administration and delivery of
the program services, including those required by this section or
Section 531.0218, Government Code.
(b) Subchapter D, Chapter 161, Human Resources Code, is
amended by adding Section 161.082 to read as follows:
Sec. 161.082. LONG-TERM CARE MEDICAID WAIVER PROGRAMS:
UTILIZATION REVIEW. (a) In this section, "Section 1915(c) waiver
program" has the meaning assigned by Section 531.001, Government
Code.
(b) The department shall perform a utilization review of
services in all Section 1915(c) waiver programs. The utilization
review must include, at a minimum, reviewing program recipients'
levels of care and any plans of care for those recipients that
exceed service level thresholds established in the applicable
waiver program guidelines.
SECTION 1.08. Subchapter D, Chapter 161, Human Resources
Code, is amended by adding Section 161.086 to read as follows:
Sec. 161.086. ELECTRONIC VISIT VERIFICATION SYSTEM. If it
is cost-effective, the department shall implement an electronic
visit verification system under appropriate programs administered
by the department under the Medicaid program that allows providers
to electronically verify and document basic information relating to
the delivery of services, including:
(1) the provider's name;
(2) the recipient's name;
(3) the date and time the provider begins and ends the
delivery of services; and
(4) the location of service delivery.
SECTION 1.09. (a) Subdivision (1), Section 247.002, Health
and Safety Code, is amended to read as follows:
(1) "Assisted living facility" means an establishment
that:
(A) furnishes, in one or more facilities, food
and shelter to four or more persons who are unrelated to the
proprietor of the establishment;
(B) provides:
(i) personal care services; or
(ii) administration of medication by a
person licensed or otherwise authorized in this state to administer
the medication; [and]
(C) may provide assistance with or supervision of
the administration of medication; and
(D) may provide skilled nursing services for a
limited duration or to facilitate the provision of hospice
services.
(b) Section 247.004, Health and Safety Code, is amended to
read as follows:
Sec. 247.004. EXEMPTIONS. This chapter does not apply to:
(1) a boarding home facility as defined by Section
254.001, as added by Chapter 1106 (H.B. 216), Acts of the 81st
Legislature, Regular Session, 2009;
(2) an establishment conducted by or for the adherents
of the Church of Christ, Scientist, for the purpose of providing
facilities for the care or treatment of the sick who depend
exclusively on prayer or spiritual means for healing without the
use of any drug or material remedy if the establishment complies
with local safety, sanitary, and quarantine ordinances and
regulations;
(3) a facility conducted by or for the adherents of a
qualified religious society classified as a tax-exempt
organization under an Internal Revenue Service group exemption
ruling for the purpose of providing personal care services without
charge solely for the society's professed members or ministers in
retirement, if the facility complies with local safety, sanitation,
and quarantine ordinances and regulations; or
(4) a facility that provides personal care services
only to persons enrolled in a program that:
(A) is funded in whole or in part by the
department and that is monitored by the department or its
designated local mental retardation authority in accordance with
standards set by the department; or
(B) is funded in whole or in part by the
Department of State Health Services and that is monitored by that
department, or by its designated local mental health authority in
accordance with standards set by the department.
(c) Subsection (b), Section 247.067, Health and Safety
Code, is amended to read as follows:
(b) Unless otherwise prohibited by law, a [A] health care
professional may be employed by an assisted living facility to
provide at the facility to the facility's residents services that
are authorized by this chapter and that are within the
professional's scope of practice [to a resident of an assisted
living facility at the facility]. This subsection does not
authorize a facility to provide ongoing services comparable to the
services available in an institution licensed under Chapter 242. A
health care professional providing services under this subsection
shall maintain medical records of those services in accordance with
the licensing, certification, or other regulatory standards
applicable to the health care professional under law.
SECTION 1.10. (a) Subchapter B, Chapter 531, Government
Code, is amended by adding Sections 531.086 and 531.0861 to read as
follows:
Sec. 531.086. STUDY REGARDING PHYSICIAN INCENTIVE PROGRAMS
TO REDUCE HOSPITAL EMERGENCY ROOM USE FOR NON-EMERGENT CONDITIONS.
(a) The commission shall conduct a study to evaluate physician
incentive programs that attempt to reduce hospital emergency room
use for non-emergent conditions by recipients under the medical
assistance program. Each physician incentive program evaluated in
the study must:
(1) be administered by a health maintenance
organization participating in the STAR or STAR + PLUS Medicaid
managed care program; and
(2) provide incentives to primary care providers who
attempt to reduce emergency room use for non-emergent conditions by
recipients.
(b) The study conducted under Subsection (a) must evaluate:
(1) the cost-effectiveness of each component included
in a physician incentive program; and
(2) any change in statute required to implement each
component within the Medicaid fee-for-service payment model.
(c) Not later than August 31, 2013, the executive
commissioner shall submit to the governor and the Legislative
Budget Board a report summarizing the findings of the study
required by this section.
(d) This section expires September 1, 2014.
Sec. 531.0861. PHYSICIAN INCENTIVE PROGRAM TO REDUCE
HOSPITAL EMERGENCY ROOM USE FOR NON-EMERGENT CONDITIONS. (a) If
cost-effective, the executive commissioner by rule shall establish
a physician incentive program designed to reduce the use of
hospital emergency room services for non-emergent conditions by
recipients under the medical assistance program.
(b) In establishing the physician incentive program under
Subsection (a), the executive commissioner may include only the
program components identified as cost-effective in the study
conducted under Section 531.086.
(c) If the physician incentive program includes the payment
of an enhanced reimbursement rate for routine after-hours
appointments, the executive commissioner shall implement controls
to ensure that the after-hours services billed are actually being
provided outside of normal business hours.
(b) Section 32.0641, Human Resources Code, is amended to
read as follows:
Sec. 32.0641. RECIPIENT ACCOUNTABILITY PROVISIONS;
COST-SHARING REQUIREMENT TO IMPROVE APPROPRIATE UTILIZATION OF
[COST SHARING FOR CERTAIN HIGH-COST MEDICAL] SERVICES. (a) To [If
the department determines that it is feasible and cost-effective,
and 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, after
consulting with the Medicaid and CHIP Quality-Based Payment
Advisory Committee established under Section 536.002, Government
Code, cost-sharing provisions that encourage personal
accountability and appropriate utilization of health care
services, including a cost-sharing provision applicable to
[require] a recipient who chooses to receive a nonemergency [a
high-cost] medical service [provided] through a hospital emergency
room [to pay a copayment, premium payment, or other cost-sharing
payment for the high-cost medical service if:
[(1) the hospital from which the recipient seeks
service:
[(A) performs an appropriate medical screening
and determines that the recipient does not have a condition
requiring emergency medical services;
[(B) informs the recipient:
[(i) that the recipient does not have a
condition requiring emergency medical services;
[(ii) that, if the hospital provides the
nonemergency service, the hospital may require payment of a
copayment, premium payment, or other cost-sharing payment by the
recipient in advance; and
[(iii) of the name and address of a
nonemergency Medicaid provider who can provide the appropriate
medical service without imposing a cost-sharing payment; and
[(C) offers to provide the recipient with a
referral to the nonemergency provider to facilitate scheduling of
the service; and
[(2) after receiving the information and assistance
described by Subdivision (1) from the hospital, the recipient
chooses to obtain emergency medical services despite having access
to medically acceptable, lower-cost medical services].
(b) The department may not seek a federal waiver or other
authorization under this section [Subsection (a)] that would:
(1) prevent a Medicaid recipient who has a condition
requiring emergency medical services from receiving care through a
hospital emergency room; or
(2) waive any provision under Section 1867, Social
Security Act (42 U.S.C. Section 1395dd).
[(c) If the executive commissioner of the Health and Human
Services Commission adopts a copayment or other cost-sharing
payment under Subsection (a), the commission may not reduce
hospital payments to reflect the potential receipt of a copayment
or other payment from a recipient receiving medical services
provided through a hospital emergency room.]
SECTION 1.11. Subchapter B, Chapter 531, Government Code,
is amended by adding Section 531.024131 to read as follows:
Sec. 531.024131. EXPANSION OF BILLING COORDINATION AND
INFORMATION COLLECTION ACTIVITIES. (a) If cost-effective, the
commission may:
(1) contract to expand all or part of the billing
coordination system established under Section 531.02413 to process
claims for services provided through other benefits programs
administered by the commission or a health and human services
agency;
(2) expand any other billing coordination tools and
resources used to process claims for health care services provided
through the Medicaid program to process claims for services
provided through other benefits programs administered by the
commission or a health and human services agency; and
(3) expand the scope of persons about whom information
is collected under Section 32.042, Human Resources Code, to include
recipients of services provided through other benefits programs
administered by the commission or a health and human services
agency.
(b) Notwithstanding any other state law, each health and
human services agency shall provide the commission with any
information necessary to allow the commission or the commission's
designee to perform the billing coordination and information
collection activities authorized by this section.
SECTION 1.12. (a) Subsections (b), (c), and (d), Section
531.502, Government Code, are amended to read as follows:
(b) The executive commissioner may include the following
federal money in the waiver:
(1) [all] money provided under the disproportionate
share hospitals or [and] upper payment limit supplemental payment
program, or both [programs];
(2) money provided by the federal government in lieu
of some or all of the payments under one or both of those programs;
(3) any combination of funds authorized to be pooled
by Subdivisions (1) and (2); and
(4) any other money available for that purpose,
including:
(A) federal money and money identified under
Subsection (c);
(B) gifts, grants, or donations for that purpose;
(C) local funds received by this state through
intergovernmental transfers; and
(D) if approved in the waiver, federal money
obtained through the use of certified public expenditures.
(c) The commission shall seek to optimize federal funding
by:
(1) identifying health care related state and local
funds and program expenditures that, before September 1, 2011
[2007], are not being matched with federal money; and
(2) exploring the feasibility of:
(A) certifying or otherwise using those funds and
expenditures as state expenditures for which this state may receive
federal matching money; and
(B) depositing federal matching money received
as provided by Paragraph (A) with other federal money deposited as
provided by Section 531.504, or substituting that federal matching
money for federal money that otherwise would be received under the
disproportionate share hospitals and upper payment limit
supplemental payment programs as a match for local funds received
by this state through intergovernmental transfers.
(d) The terms of a waiver approved under this section must:
(1) include safeguards to ensure that the total amount
of federal money provided under the disproportionate share
hospitals or [and] upper payment limit supplemental payment program
[programs] that is deposited as provided by Section 531.504 is, for
a particular state fiscal year, at least equal to the greater of the
annualized amount provided to this state under those supplemental
payment programs during state fiscal year 2011 [2007], excluding
amounts provided during that state fiscal year that are retroactive
payments, or the state fiscal years during which the waiver is in
effect; and
(2) allow for the development by this state of a
methodology for allocating money in the fund to:
(A) be used to supplement Medicaid hospital
reimbursements under a waiver that includes terms that are
consistent with, or that produce revenues consistent with,
disproportionate share hospital and upper payment limit principles
[offset, in part, the uncompensated health care costs incurred by
hospitals];
(B) reduce the number of persons in this state
who do not have health benefits coverage; and
(C) maintain and enhance the community public
health infrastructure provided by hospitals.
(b) Section 531.504, Government Code, is amended to read as
follows:
Sec. 531.504. DEPOSITS TO FUND. (a) The comptroller shall
deposit in the fund:
(1) [all] federal money provided to this state under
the disproportionate share hospitals supplemental payment program
or [and] the hospital upper payment limit supplemental payment
program, or both, other than money provided under those programs to
state-owned and operated hospitals, and all other non-supplemental
payment program federal money provided to this state that is
included in the waiver authorized by Section 531.502; and
(2) state money appropriated to the fund.
(b) The commission and comptroller may accept gifts,
grants, and donations from any source, and receive
intergovernmental transfers, for purposes consistent with this
subchapter and the terms of the waiver. The comptroller shall
deposit a gift, grant, or donation made for those purposes in the
fund. Any intergovernmental transfer received, including
associated federal matching funds, shall be used, if feasible, for
the purposes intended by the transferring entity and in accordance
with the terms of the waiver.
(c) Section 531.508, Government Code, is amended by adding
Subsection (d) to read as follows:
(d) Money from the fund may not be used to finance the
construction, improvement, or renovation of a building or land
unless the construction, improvement, or renovation is approved by
the commission, according to rules adopted by the executive
commissioner for that purpose.
(d) Subsection (g), Section 531.502, Government Code, is
repealed.
SECTION 1.13. (a) Subtitle I, Title 4, Government Code, is
amended by adding Chapter 536, and Section 531.913, Government
Code, is transferred to Subchapter D, Chapter 536, Government Code,
redesignated as Section 536.151, Government Code, and amended to
read as follows:
CHAPTER 536. MEDICAID AND CHILD HEALTH PLAN PROGRAMS:
QUALITY-BASED OUTCOMES AND PAYMENTS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 536.001. DEFINITIONS. In this chapter:
(1) "Advisory committee" means the Medicaid and CHIP
Quality-Based Payment Advisory Committee established under Section
536.002.
(2) "Alternative payment system" includes:
(A) a global payment system;
(B) an episode-based bundled payment system; and
(C) a blended payment system.
(3) "Blended payment system" means a system for
compensating a physician or other health care provider that
includes at least one or more features of a global payment system
and an episode-based bundled payment system, but that may also
include a system under which a portion of the compensation paid to a
physician or other health care provider is based on a
fee-for-service payment arrangement.
(4) "Child health plan program," "commission,"
"executive commissioner," and "health and human services agencies"
have the meanings assigned by Section 531.001.
(5) "Episode-based bundled payment system" means a
system for compensating a physician or other health care provider
for arranging for or providing health care services to child health
plan program enrollees or Medicaid recipients that is based on a
flat payment for all services provided in connection with a single
episode of medical care.
(6) "Exclusive provider benefit plan" means a managed
care plan subject to 28 T.A.C. Part 1, Chapter 3, Subchapter KK.
(7) "Freestanding emergency medical care facility"
means a facility licensed under Chapter 254, Health and Safety
Code.
(8) "Global payment system" means a system for
compensating a physician or other health care provider for
arranging for or providing a defined set of covered health care
services to child health plan program enrollees or Medicaid
recipients for a specified period that is based on a predetermined
payment per enrollee or recipient, as applicable, for the specified
period, without regard to the quantity of services actually
provided.
(9) "Health care provider" means any person,
partnership, professional association, corporation, facility, or
institution licensed, certified, registered, or chartered by this
state to provide health care. The term includes an employee,
independent contractor, or agent of a health care provider acting
in the course and scope of the employment or contractual
relationship.
(10) "Hospital" means a public or private institution
licensed under Chapter 241 or 577, Health and Safety Code,
including a general or special hospital as defined by Section
241.003, Health and Safety Code.
(11) "Managed care organization" means a person that
is authorized or otherwise permitted by law to arrange for or
provide a managed care plan. The term includes health maintenance
organizations and exclusive provider organizations.
(12) "Managed care plan" means a plan, including an
exclusive provider benefit plan, under which a person undertakes to
provide, arrange for, pay for, or reimburse any part of the cost of
any health care services. A part of the plan must consist of
arranging for or providing health care services as distinguished
from indemnification against the cost of those services on a
prepaid basis through insurance or otherwise. The term does not
include a plan that indemnifies a person for the cost of health care
services through insurance.
(13) "Medicaid program" means the medical assistance
program established under Chapter 32, Human Resources Code.
(14) "Physician" means a person licensed to practice
medicine in this state under Subtitle B, Title 3, Occupations Code.
(15) "Potentially preventable admission" means an
admission of a person to a hospital or long-term care facility that
may have reasonably been prevented with adequate access to
ambulatory care or health care coordination.
(16) "Potentially preventable ancillary service"
means a health care service provided or ordered by a physician or
other health care provider to supplement or support the evaluation
or treatment of a patient, including a diagnostic test, laboratory
test, therapy service, or radiology service, that may not be
reasonably necessary for the provision of quality health care or
treatment.
(17) "Potentially preventable complication" means a
harmful event or negative outcome with respect to a person,
including an infection or surgical complication, that:
(A) occurs after the person's admission to a
hospital or long-term care facility; and
(B) may have resulted from the care, lack of
care, or treatment provided during the hospital or long-term care
facility stay rather than from a natural progression of an
underlying disease.
(18) "Potentially preventable event" means a
potentially preventable admission, a potentially preventable
ancillary service, a potentially preventable complication, a
potentially preventable emergency room visit, a potentially
preventable readmission, or a combination of those events.
(19) "Potentially preventable emergency room visit"
means treatment of a person in a hospital emergency room or
freestanding emergency medical care facility for a condition that
may not require emergency medical attention because the condition
could be, or could have been, treated or prevented by a physician or
other health care provider in a nonemergency setting.
(20) "Potentially preventable readmission" means a
return hospitalization of a person within a period specified by the
commission that may have resulted from deficiencies in the care or
treatment provided to the person during a previous hospital stay or
from deficiencies in post-hospital discharge follow-up. The term
does not include a hospital readmission necessitated by the
occurrence of unrelated events after the discharge. The term
includes the readmission of a person to a hospital for:
(A) the same condition or procedure for which the
person was previously admitted;
(B) an infection or other complication resulting
from care previously provided;
(C) a condition or procedure that indicates that
a surgical intervention performed during a previous admission was
unsuccessful in achieving the anticipated outcome; or
(D) another condition or procedure of a similar
nature, as determined by the executive commissioner after
consulting with the advisory committee.
(21) "Quality-based payment system" means a system for
compensating a physician or other health care provider, including
an alternative payment system, that provides incentives to the
physician or other health care provider for providing high-quality,
cost-effective care and bases some portion of the payment made to
the physician or other health care provider on quality of care
outcomes, which may include the extent to which the physician or
other health care provider reduces potentially preventable events.
Sec. 536.002. MEDICAID AND CHIP QUALITY-BASED PAYMENT
ADVISORY COMMITTEE. (a) The Medicaid and CHIP Quality-Based
Payment Advisory Committee is established to advise the commission
on establishing, for purposes of the child health plan and Medicaid
programs administered by the commission or a health and human
services agency:
(1) reimbursement systems used to compensate
physicians or other health care providers under those programs that
reward the provision of high-quality, cost-effective health care
and quality performance and quality of care outcomes with respect
to health care services;
(2) standards and benchmarks for quality performance,
quality of care outcomes, efficiency, and accountability by managed
care organizations and physicians and other health care providers;
(3) programs and reimbursement policies that
encourage high-quality, cost-effective health care delivery models
that increase appropriate provider collaboration, promote wellness
and prevention, and improve health outcomes; and
(4) outcome and process measures under Section
536.003.
(b) The executive commissioner shall appoint the members of
the advisory committee. The committee must consist of physicians
and other health care providers, representatives of health care
facilities, representatives of managed care organizations, and
other stakeholders interested in health care services provided in
this state, including:
(1) at least one member who is a physician with
clinical practice experience in obstetrics and gynecology;
(2) at least one member who is a physician with
clinical practice experience in pediatrics;
(3) at least one member who is a physician with
clinical practice experience in internal medicine or family
medicine;
(4) at least one member who is a physician with
clinical practice experience in geriatric medicine;
(5) at least one member who is or who represents a
health care provider that primarily provides long-term care
services;
(6) at least one member who is a consumer
representative; and
(7) at least one member who is a member of the Advisory
Panel on Health Care-Associated Infections and Preventable Adverse
Events who meets the qualifications prescribed by Section
98.052(a)(4), Health and Safety Code.
(c) The executive commissioner shall appoint the presiding
officer of the advisory committee.
Sec. 536.003. DEVELOPMENT OF QUALITY-BASED OUTCOME AND
PROCESS MEASURES. (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. The commission, in developing outcome measures under this
section, must consider measures addressing potentially preventable
events.
(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; and
(4) that are similar to outcome and process measures
used in the private sector, as appropriate.
(c) The commission shall, to the extent feasible, align
outcome and process measures developed under this section with
measures required or recommended under reporting guidelines
established by the federal Centers for Medicare and Medicaid
Services, the Agency for Healthcare Research and Quality, or
another federal agency.
(d) The executive commissioner by rule may require managed
care organizations and physicians and other health care providers
participating in the child health plan and Medicaid programs to
report to the commission in a format specified by the executive
commissioner information necessary to develop outcome and process
measures under this section.
(e) If the commission increases physician and other health
care provider reimbursement rates under the child health plan or
Medicaid program as a result of an increase in the amounts
appropriated for the programs for a state fiscal biennium as
compared to the preceding state fiscal biennium, the commission
shall, to the extent permitted under federal law and to the extent
otherwise possible considering other relevant factors, correlate
the increased reimbursement rates with the quality-based outcome
and process measures developed under this section.
Sec. 536.004. DEVELOPMENT OF QUALITY-BASED PAYMENT
SYSTEMS. (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 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.
(b) The commission shall develop quality-based payment
systems in the manner specified by this chapter. To the extent
necessary, the commission shall coordinate the timeline for the
development and implementation of a payment system with the
implementation of other initiatives such as the Medicaid
Information Technology Architecture (MITA) initiative of the
Center for Medicaid and State Operations, the ICD-10 code sets
initiative, or the ongoing Enterprise Data Warehouse (EDW) planning
process in order to maximize the receipt of federal funds or reduce
any administrative burden.
(c) In developing quality-based payment systems under this
chapter, the commission shall examine and consider implementing:
(1) an alternative payment system;
(2) any existing performance-based payment system
used under the Medicare program that meets the requirements of this
chapter, modified as necessary to account for programmatic
differences, if implementing the system would:
(A) reduce unnecessary administrative burdens;
and
(B) align quality-based payment incentives for
physicians and other health care providers with the Medicare
program; and
(3) alternative payment methodologies within the
system that are used in the Medicare program, modified as necessary
to account for programmatic differences, and that will achieve cost
savings and improve quality of care in the child health plan and
Medicaid programs.
(d) In developing quality-based payment systems under this
chapter, the commission shall ensure that a managed care
organization or physician or other health care provider will not be
rewarded by the system for withholding or delaying the provision of
medically necessary care.
(e) The commission may modify a quality-based payment
system developed under this chapter to account for programmatic
differences between the child health plan and Medicaid programs and
delivery systems under those programs.
Sec. 536.005. CONVERSION OF PAYMENT METHODOLOGY. (a) To
the extent possible, the commission shall convert hospital
reimbursement systems under the child health plan and Medicaid
programs to a diagnosis-related groups (DRG) methodology that will
allow the commission to more accurately classify specific patient
populations and account for severity of patient illness and
mortality risk.
(b) Subsection (a) does not authorize the commission to
direct a managed care organization to compensate physicians and
other health care providers providing services under the
organization's managed care plan based on a diagnosis-related
groups (DRG) methodology.
Sec. 536.006. TRANSPARENCY. The commission and the
advisory committee shall:
(1) ensure transparency in the development and
establishment of:
(A) quality-based payment and reimbursement
systems under Section 536.004 and Subchapters B, C, and D,
including the development of outcome and process measures under
Section 536.003; and
(B) quality-based payment initiatives under
Subchapter E, including the development of quality of care and
cost-efficiency benchmarks under Section 536.204(a) and efficiency
performance standards under Section 536.204(b);
(2) develop guidelines establishing procedures for
providing notice and information to, and receiving input from,
managed care organizations, health care providers, including
physicians and experts in the various medical specialty fields, and
other stakeholders, as appropriate, for purposes of developing and
establishing the quality-based payment and reimbursement systems
and initiatives described under Subdivision (1); and
(3) in developing and establishing the quality-based
payment and reimbursement systems and initiatives described under
Subdivision (1), consider that as the performance of a managed care
organization or physician or other health care provider improves
with respect to an outcome or process measure, quality of care and
cost-efficiency benchmark, or efficiency performance standard, as
applicable, there will be a diminishing rate of improved
performance over time.
Sec. 536.007. PERIODIC EVALUATION. (a) At least once each
two-year period, the commission shall evaluate the outcomes and
cost-effectiveness of any quality-based payment system or other
payment initiative implemented under this chapter.
(b) The commission shall:
(1) present the results of its evaluation under
Subsection (a) to the advisory committee for the committee's input
and recommendations; and
(2) provide a process by which managed care
organizations and physicians and other health care providers may
comment and provide input into the committee's recommendations
under Subdivision (1).
Sec. 536.008. ANNUAL REPORT. (a) The commission shall
submit an annual report to the legislature regarding:
(1) the quality-based outcome and process measures
developed under Section 536.003; and
(2) the progress of the implementation of
quality-based payment systems and other payment initiatives
implemented under this chapter.
(b) The commission shall report outcome and process
measures under Subsection (a)(1) by health care service region and
service delivery model.
[Sections 536.009-536.050 reserved for expansion]
SUBCHAPTER B. QUALITY-BASED PAYMENTS RELATING TO MANAGED CARE
ORGANIZATIONS
Sec. 536.051. DEVELOPMENT OF QUALITY-BASED PREMIUM
PAYMENTS; PERFORMANCE REPORTING. (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, including
outcome measures addressing potentially preventable events.
(b) The commission shall make available information
relating to the performance of a managed care organization with
respect to outcome and process measures under this subchapter to
child health plan program enrollees and Medicaid recipients before
those enrollees and recipients choose their managed care plans.
Sec. 536.052. PAYMENT AND CONTRACT AWARD INCENTIVES FOR
MANAGED CARE ORGANIZATIONS. (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.
(b) The commission, after consulting with the advisory
committee, shall develop quality of care and cost-efficiency
benchmarks, including benchmarks based on a managed care
organization's performance with respect to reducing potentially
preventable events and containing the growth rate of health care
costs.
(c) The commission may include in a contract between a
managed care organization and the commission financial incentives
that are based on the organization's successful implementation of
quality initiatives under Subsection (a) or success in achieving
quality of care and cost-efficiency benchmarks under Subsection
(b).
(d) In awarding contracts to managed care organizations
under the child health plan and Medicaid programs, the commission
shall, in addition to considerations under Section 533.003 of this
code and Section 62.155, Health and Safety Code, give preference to
an organization that offers a managed care plan that successfully
implements quality initiatives under Subsection (a) as determined
by the commission based on data or other evidence provided by the
organization or meets quality of care and cost-efficiency
benchmarks under Subsection (b).
(e) The commission may implement financial incentives under
this section only if implementing the incentives would be
cost-effective.
[Sections 536.053-536.100 reserved for expansion]
SUBCHAPTER C. QUALITY-BASED HEALTH HOME PAYMENT SYSTEMS
Sec. 536.101. DEFINITIONS. In this subchapter:
(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 child health plan and
Medicaid programs.
(2) "Participating enrollee" means a child health plan
program enrollee or Medicaid recipient who has a health home.
Sec. 536.102. QUALITY-BASED HEALTH HOME PAYMENTS.
(a) Subject to this subchapter, the commission, after consulting
with the advisory committee, may develop and implement
quality-based payment systems for health homes designed to improve
quality of care and reduce the provision of unnecessary medical
services. A quality-based payment system developed under this
section must:
(1) base payments made to a participating enrollee's
health home 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 health home, and ensuring quality of
care outcomes, including a reduction in potentially preventable
events; and
(2) allow for the examination of measurable wellness
and prevention criteria, use of evidence-based best practices, and
quality of care outcomes based on the type of primary or specialty
care provider practice.
(b) The commission may develop a quality-based payment
system for health homes under this subchapter only if implementing
the system would be feasible and cost-effective.
Sec. 536.103. PROVIDER ELIGIBILITY. To be eligible to
receive reimbursement under a quality-based payment system under
this subchapter, a health home provider must:
(1) provide participating enrollees, directly or
indirectly, with access to health care services outside of regular
business hours;
(2) educate participating enrollees about the
availability of health care services outside of regular business
hours; and
(3) provide evidence satisfactory to the commission
that the provider meets the requirement of Subdivision (1).
[Sections 536.104-536.150 reserved for expansion]
SUBCHAPTER D. QUALITY-BASED HOSPITAL REIMBURSEMENT SYSTEM
Sec. 536.151 [531.913]. COLLECTION AND REPORTING OF
CERTAIN [HOSPITAL HEALTH] INFORMATION [EXCHANGE]. (a) [In this
section, "potentially preventable readmission" means a return
hospitalization of a person within a period specified by the
commission that results from deficiencies in the care or treatment
provided to the person during a previous hospital stay or from
deficiencies in post-hospital discharge follow-up. The term does
not include a hospital readmission necessitated by the occurrence
of unrelated events after the discharge. The term includes the
readmission of a person to a hospital for:
[(1) the same condition or procedure for which the
person was previously admitted;
[(2) an infection or other complication resulting from
care previously provided;
[(3) a condition or procedure that indicates that a
surgical intervention performed during a previous admission was
unsuccessful in achieving the anticipated outcome; or
[(4) another condition or procedure of a similar
nature, as determined by the executive commissioner.
[(b)] The executive commissioner shall adopt rules for
identifying potentially preventable readmissions of child health
plan program enrollees and Medicaid recipients and potentially
preventable complications experienced by child health plan program
enrollees and Medicaid recipients. The [and the] commission shall
collect [exchange] data from [with] hospitals on
present-on-admission indicators for purposes of this section.
(b) [(c)] The commission shall establish a [health
information exchange] program to provide a [exchange] confidential
report to [information with] each hospital in this state that
participates in the child health plan or Medicaid program regarding
the hospital's performance with respect to potentially preventable
readmissions and potentially preventable complications. To the
extent possible, a report provided under this section should
include potentially preventable 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 [received from the
commission] to physicians and other health care providers providing
services at the hospital.
(c) A report provided to a hospital under this section is
confidential and is not subject to Chapter 552.
Sec. 536.152. REIMBURSEMENT ADJUSTMENTS. (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, 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.
(b) The commission must provide the report required under
Section 536.151(b) to a hospital at least one year before the
commission adjusts child health plan and Medicaid reimbursements to
the hospital under this section.
[Sections 536.153-536.200 reserved for expansion]
SUBCHAPTER E. QUALITY-BASED PAYMENT INITIATIVES
Sec. 536.201. DEFINITION. In this subchapter, "payment
initiative" means a quality-based payment initiative established
under this subchapter.
Sec. 536.202. PAYMENT INITIATIVES; DETERMINATION OF
BENEFIT TO STATE. (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.
(b) The commission shall:
(1) establish a process by which managed care
organizations and physicians and other health care providers may
submit proposals for payment initiatives described by Subsection
(a); and
(2) determine whether it is feasible and
cost-effective to implement one or more of the proposed payment
initiatives.
Sec. 536.203. PURPOSE AND IMPLEMENTATION OF PAYMENT
INITIATIVES. (a) If the commission determines under Section
536.202 that implementation of one or more payment initiatives is
feasible and cost-effective for this state, the commission shall
establish one or more payment initiatives as provided by this
subchapter.
(b) The commission shall administer any payment initiative
established under this subchapter. The executive commissioner may
adopt rules, plans, and procedures and enter into contracts and
other agreements as the executive commissioner considers
appropriate and necessary to administer this subchapter.
(c) The commission may limit a payment initiative to:
(1) one or more regions in this state;
(2) one or more organized networks of physicians and
other health care providers; or
(3) specified types of services provided under the
child health plan or Medicaid program, or specified types of
enrollees or recipients under those programs.
(d) A payment initiative implemented under this subchapter
must be operated for at least one calendar year.
Sec. 536.204. STANDARDS; PROTOCOLS. (a) The executive
commissioner shall:
(1) consult with the advisory committee to develop
quality of care and cost-efficiency benchmarks and measurable goals
that a payment initiative must meet to ensure high-quality and
cost-effective health care services and healthy outcomes; and
(2) approve benchmarks and goals developed as provided
by Subdivision (1).
(b) In addition to the benchmarks and goals under Subsection
(a), the executive commissioner may approve efficiency performance
standards that may include the sharing of realized cost savings
with physicians and other health care providers who provide health
care services that exceed the efficiency performance standards.
The efficiency performance standards may not create any financial
incentive for or involve making a payment to a physician or other
health care provider that directly or indirectly induces the
limitation of medically necessary services.
Sec. 536.205. PAYMENT RATES UNDER PAYMENT INITIATIVES. The
executive commissioner may contract with appropriate entities,
including qualified actuaries, to assist in determining
appropriate payment rates for a payment initiative implemented
under this subchapter.
(b) The Health and Human Services Commission shall convert
the hospital reimbursement systems used under the child health plan
program under Chapter 62, Health and Safety Code, and medical
assistance program under Chapter 32, Human Resources Code, to the
diagnosis-related groups (DRG) methodology to the extent possible
as required by Section 536.005, Government Code, as added by this
section, as soon as practicable after the effective date of this
Act, but not later than:
(1) September 1, 2013, for reimbursements paid to
children's hospitals; and
(2) September 1, 2012, for reimbursements paid to
other hospitals under those programs.
(c) Not later than September 1, 2012, the Health and Human
Services Commission shall begin providing performance reports to
hospitals regarding the hospitals' performances with respect to
potentially preventable complications as required by Section
536.151, Government Code, as designated and amended by this
section.
(d) Subject to Subsection (b), Section 536.004, Government
Code, as added by this section, the Health and Human Services
Commission shall begin making adjustments to child health plan and
Medicaid reimbursements to hospitals as required by Section
536.152, Government Code, as added by this section:
(1) not later than September 1, 2012, based on the
hospitals' performances with respect to reducing potentially
preventable readmissions; and
(2) not later than September 1, 2013, based on the
hospitals' performances with respect to reducing potentially
preventable complications.
SECTION 1.14. (a) The heading to Section 531.912,
Government Code, is amended to read as follows:
Sec. 531.912. COMMON PERFORMANCE MEASUREMENTS AND
PAY-FOR-PERFORMANCE INCENTIVES FOR [QUALITY OF CARE HEALTH
INFORMATION EXCHANGE WITH] CERTAIN NURSING FACILITIES.
(b) Subsections (b), (c), and (f), Section 531.912,
Government Code, are amended to read as follows:
(b) If feasible, the executive commissioner by rule may
[shall] establish an incentive payment program for [a quality of
care health information exchange with] nursing facilities that
choose to participate. The [in a] program must be designed to
improve the quality of care and services provided to medical
assistance recipients. Subject to Subsection (f), the program may
provide incentive payments in accordance with this section to
encourage facilities to participate in the program.
(c) In establishing an incentive payment [a quality of care
health information exchange] program under this section, the
executive commissioner shall, subject to Subsection (d), adopt
common [exchange information with participating nursing facilities
regarding] performance measures to be used in evaluating nursing
facilities that are related to structure, process, and outcomes
that positively correlate to nursing facility quality and
improvement. The common performance measures:
(1) must be:
(A) recognized by the executive commissioner as
valid indicators of the overall quality of care received by medical
assistance recipients; and
(B) designed to encourage and reward
evidence-based practices among nursing facilities; and
(2) may include measures of:
(A) quality of care, as determined by clinical
performance ratings published by the federal Centers for Medicare
and Medicaid Services, the Agency for Healthcare Research and
Quality, or another federal agency [life];
(B) direct-care staff retention and turnover;
(C) recipient satisfaction, including the
satisfaction of recipients who are short-term and long-term
residents of facilities, and family satisfaction, as determined by
the Nursing Home Consumer Assessment of Health Providers and
Systems survey relied upon by the federal Centers for Medicare and
Medicaid Services;
(D) employee satisfaction and engagement;
(E) the incidence of preventable acute care
emergency room services use;
(F) regulatory compliance;
(G) level of person-centered care; and
(H) direct-care staff training, including a
facility's [level of occupancy or of facility] utilization of
independent distance learning programs for the continuous training
of direct-care staff.
(f) The commission may make incentive payments under the
program only if money is [specifically] appropriated for that
purpose.
(c) The Department of Aging and Disability Services shall
conduct a study to evaluate the feasibility of expanding any
incentive payment program established for nursing facilities under
Section 531.912, Government Code, as amended by this section, by
providing incentive payments for the following types of providers
of long-term care services, as defined by Section 22.0011, Human
Resources Code, under the medical assistance program:
(1) intermediate care facilities for persons with
mental retardation licensed under Chapter 252, Health and Safety
Code; and
(2) providers of home and community-based services, as
described by 42 U.S.C. Section 1396n(c), who are licensed or
otherwise authorized to provide those services in this state.
(d) Not later than September 1, 2012, the Department of
Aging and Disability Services shall submit to the legislature a
written report containing the findings of the study conducted under
Subsection (c) of this section and the department's
recommendations.
SECTION 1.15. Section 780.004, Health and Safety Code, is
amended by amending Subsection (a) and adding Subsection (j) to
read as follows:
(a) The commissioner:
(1) [,] with advice and counsel from the chairpersons
of the trauma service area regional advisory councils, shall use
money appropriated from the account established under this chapter
to fund designated trauma facilities, county and regional emergency
medical services, and trauma care systems in accordance with this
section; and
(2) after consulting with the executive commissioner
of the Health and Human Services Commission, may transfer to an
account in the general revenue fund money appropriated from the
account established under this chapter to maximize the receipt of
federal funds under the medical assistance program established
under Chapter 32, Human Resources Code, and to fund provider
reimbursement payments as provided by Subsection (j).
(j) Money in the account described by Subsection (a)(2) may
be appropriated only to the Health and Human Services Commission to
fund provider reimbursement payments under the medical assistance
program established under Chapter 32, Human Resources Code,
including reimbursement enhancements to the statewide dollar
amount (SDA) rate used to reimburse designated trauma hospitals
under the program.
SECTION 1.16. Subchapter B, Chapter 531, Government Code,
is amended by adding Section 531.0697 to read as follows:
Sec. 531.0697. PRIOR APPROVAL AND PROVIDER ACCESS TO
CERTAIN COMMUNICATIONS WITH CERTAIN RECIPIENTS. (a) This section
applies to:
(1) the vendor drug program for the Medicaid and child
health plan programs;
(2) the kidney health care program;
(3) the children with special health care needs
program; and
(4) any other state program administered by the
commission that provides prescription drug benefits.
(b) A managed care organization, including a health
maintenance organization, or a pharmacy benefit manager, that
administers claims for prescription drug benefits under a program
to which this section applies shall, at least 10 days before the
date the organization or pharmacy benefit manager intends to
deliver a communication to recipients collectively under a program:
(1) submit a copy of the communication to the
commission for approval; and
(2) if applicable, allow the pharmacy providers of
recipients who are to receive the communication access to the
communication.
SECTION 1.17. (a) Subchapter A, Chapter 61, Health and
Safety Code, is amended by adding Section 61.012 to read as follows:
Sec. 61.012. REIMBURSEMENT FOR SERVICES. (a) In this
section, "sponsored alien" means a person who has been lawfully
admitted to the United States for permanent residence under the
Immigration and Nationality Act (8 U.S.C. Section 1101 et seq.) and
who, as a condition of admission, was sponsored by a person who
executed an affidavit of support on behalf of the person.
(b) A public hospital or hospital district that provides
health care services to a sponsored alien under this chapter may
recover from a person who executed an affidavit of support on behalf
of the alien the costs of the health care services provided to the
alien.
(c) A public hospital or hospital district described by
Subsection (b) must notify a sponsored alien and a person who
executed an affidavit of support on behalf of the alien, at the time
the alien applies for health care services, that a person who
executed an affidavit of support on behalf of a sponsored alien is
liable for the cost of health care services provided to the alien.
(b) Section 61.012, Health and Safety Code, as added by this
section, applies only to health care services provided by a public
hospital or hospital district on or after the effective date of this
Act.
SECTION 1.18. Subchapter B, Chapter 531, Government Code,
is amended by adding Sections 531.024181 and 531.024182 to read as
follows:
Sec. 531.024181. VERIFICATION OF IMMIGRATION STATUS OF
APPLICANTS FOR CERTAIN BENEFITS WHO ARE QUALIFIED ALIENS.
(a) This section applies only with respect to the following
benefits programs:
(1) the child health plan program under Chapter 62,
Health and Safety Code;
(2) the financial assistance program under Chapter 31,
Human Resources Code;
(3) the medical assistance program under Chapter 32,
Human Resources Code; and
(4) the nutritional assistance program under Chapter
33, Human Resources Code.
(b) If, at the time of application for benefits under a
program to which this section applies, a person states that the
person is a qualified alien, as that term is defined by 8 U.S.C.
Section 1641(b), the commission shall, to the extent allowed by
federal law, verify information regarding the immigration status of
the person using an automated system or systems where available.
(c) The executive commissioner shall adopt rules necessary
to implement this section.
(d) Nothing in this section adds to or changes the
eligibility requirements for any of the benefits programs to which
this section applies.
Sec. 531.024182. VERIFICATION OF SPONSORSHIP INFORMATION
FOR CERTAIN BENEFITS RECIPIENTS; REIMBURSEMENT. (a) In this
section, "sponsored alien" means a person who has been lawfully
admitted to the United States for permanent residence under the
Immigration and Nationality Act (8 U.S.C. Section 1101 et seq.) and
who, as a condition of admission, was sponsored by a person who
executed an affidavit of support on behalf of the person.
(b) If, at the time of application for benefits, a person
stated that the person is a sponsored alien, the commission may, to
the extent allowed by federal law, verify information relating to
the sponsorship, using an automated system or systems where
available, after the person is determined eligible for and begins
receiving benefits under any of the following benefits programs:
(1) the child health plan program under Chapter 62,
Health and Safety Code;
(2) the financial assistance program under Chapter 31,
Human Resources Code;
(3) the medical assistance program under Chapter 32,
Human Resources Code; or
(4) the nutritional assistance program under Chapter
33, Human Resources Code.
(c) If the commission verifies that a person who receives
benefits under a program listed in Subsection (b) is a sponsored
alien, the commission may seek reimbursement from the person's
sponsor for benefits provided to the person under those programs to
the extent allowed by federal law, provided the commission
determines that seeking reimbursement is cost-effective.
(d) If, at the time a person applies for benefits under a
program listed in Subsection (b), the person states that the person
is a sponsored alien, the commission shall make a reasonable effort
to notify the person that the commission may seek reimbursement
from the person's sponsor for any benefits the person receives
under those programs.
(e) The executive commissioner shall adopt rules necessary
to implement this section, including rules that specify the most
cost-effective procedures by which the commission may seek
reimbursement under Subsection (c).
(f) Nothing in this section adds to or changes the
eligibility requirements for any of the benefits programs listed in
Subsection (b).
SECTION 1.19. Subchapter B, Chapter 32, Human Resources
Code, is amended by adding Section 32.0314 to read as follows:
Sec. 32.0314. REIMBURSEMENT FOR DURABLE MEDICAL EQUIPMENT
AND SUPPLIES. The executive commissioner of the Health and Human
Services Commission shall adopt rules requiring the electronic
submission of any claim for reimbursement for durable medical
equipment and supplies under the medical assistance program.
SECTION 1.20. (a) Subchapter A, Chapter 531, Government
Code, is amended by adding Section 531.0025 to read as follows:
Sec. 531.0025. RESTRICTIONS ON AWARDS TO FAMILY PLANNING
SERVICE PROVIDERS. (a) Notwithstanding any other law, money
appropriated to the Department of State Health Services for the
purpose of providing family planning services must be awarded:
(1) to eligible entities in the following order of
descending priority:
(A) public entities that provide family planning
services, including state, county, and local community health
clinics;
(B) nonpublic entities that provide
comprehensive primary and preventive care services in addition to
family planning services; and
(C) nonpublic entities that provide family
planning services but do not provide comprehensive primary and
preventive care services; or
(2) as otherwise directed by the legislature in the
General Appropriations Act.
(b) Notwithstanding Subsection (a), the Department of State
Health Services shall, in compliance with federal law, ensure
distribution of funds for family planning services in a manner that
does not severely limit or eliminate access to those services in any
region of the state.
(b) Section 32.024, Human Resources Code, is amended by
adding Subsection (c-1) to read as follows:
(c-1) The department shall ensure that money spent for
purposes of the demonstration project for women's health care
services under former Section 32.0248, Human Resources Code, or a
similar successor program is not used to perform or promote
elective abortions, or to contract with entities that perform or
promote elective abortions or affiliate with entities that perform
or promote elective abortions.
SECTION 1.21. If before implementing any provision of this
article 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.
ARTICLE 2. LEGISLATIVE FINDINGS AND INTENT; COMPLIANCE WITH
ANTITRUST LAWS
SECTION 2.01. (a) The legislature finds that it would
benefit the State of Texas to:
(1) explore innovative health care delivery and
payment models to improve the quality and efficiency of health care
in this state;
(2) improve health care transparency;
(3) give health care providers the flexibility to
collaborate and innovate to improve the quality and efficiency of
health care; and
(4) create incentives to improve the quality and
efficiency of health care.
(b) The legislature finds that the use of certified health
care collaboratives will increase pro-competitive effects as the
ability to compete on the basis of quality of care and the
furtherance of the quality of care through a health care
collaborative will overcome any anticompetitive effects of joining
competitors to create the health care collaboratives and the
payment mechanisms that will be used to encourage the furtherance
of quality of care. Consequently, the legislature finds it
appropriate and necessary to authorize health care collaboratives
to promote the efficiency and quality of health care.
(c) The legislature intends to exempt from antitrust laws
and provide immunity from federal antitrust laws through the state
action doctrine a health care collaborative that holds a
certificate of authority under Chapter 848, Insurance Code, as
added by Article 4 of this Act, and that collaborative's
negotiations of contracts with payors. The legislature does not
intend or authorize any person or entity to engage in activities or
to conspire to engage in activities that would constitute per se
violations of federal antitrust laws.
(d) The legislature intends to permit the use of alternative
payment mechanisms, including bundled or global payments and
quality-based payments, among physicians and other health care
providers participating in a health care collaborative that holds a
certificate of authority under Chapter 848, Insurance Code, as
added by Article 4 of this Act. The legislature intends to
authorize a health care collaborative to contract for and accept
payments from governmental and private payors based on alternative
payment mechanisms, and intends that the receipt and distribution
of payments to participating physicians and health care providers
is not a violation of any existing state law.
ARTICLE 3. TEXAS INSTITUTE OF HEALTH CARE QUALITY AND EFFICIENCY
SECTION 3.01. Title 12, Health and Safety Code, is amended
by adding Chapter 1002 to read as follows:
CHAPTER 1002. TEXAS INSTITUTE OF HEALTH CARE QUALITY AND
EFFICIENCY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1002.001. DEFINITIONS. In this chapter:
(1) "Board" means the board of directors of the Texas
Institute of Health Care Quality and Efficiency established under
this chapter.
(2) "Commission" means the Health and Human Services
Commission.
(3) "Department" means the Department of State Health
Services.
(4) "Executive commissioner" means the executive
commissioner of the Health and Human Services Commission.
(5) "Health care collaborative" has the meaning
assigned by Section 848.001, Insurance Code.
(6) "Health care facility" means:
(A) a hospital licensed under Chapter 241;
(B) an institution licensed under Chapter 242;
(C) an ambulatory surgical center licensed under
Chapter 243;
(D) a birthing center licensed under Chapter 244;
(E) an end stage renal disease facility licensed
under Chapter 251; or
(F) a freestanding emergency medical care
facility licensed under Chapter 254.
(7) "Institute" means the Texas Institute of Health
Care Quality and Efficiency established under this chapter.
(8) "Potentially preventable admission" means an
admission of a person to a hospital or long-term care facility that
may have reasonably been prevented with adequate access to
ambulatory care or health care coordination.
(9) "Potentially preventable ancillary service" means
a health care service provided or ordered by a physician or other
health care provider to supplement or support the evaluation or
treatment of a patient, including a diagnostic test, laboratory
test, therapy service, or radiology service, that may not be
reasonably necessary for the provision of quality health care or
treatment.
(10) "Potentially preventable complication" means a
harmful event or negative outcome with respect to a person,
including an infection or surgical complication, that:
(A) occurs after the person's admission to a
hospital or long-term care facility; and
(B) may have resulted from the care, lack of
care, or treatment provided during the hospital or long-term care
facility stay rather than from a natural progression of an
underlying disease.
(11) "Potentially preventable event" means a
potentially preventable admission, a potentially preventable
ancillary service, a potentially preventable complication, a
potentially preventable emergency room visit, a potentially
preventable readmission, or a combination of those events.
(12) "Potentially preventable emergency room visit"
means treatment of a person in a hospital emergency room or
freestanding emergency medical care facility for a condition that
may not require emergency medical attention because the condition
could be, or could have been, treated or prevented by a physician or
other health care provider in a nonemergency setting.
(13) "Potentially preventable readmission" means a
return hospitalization of a person within a period specified by the
commission that may have resulted from deficiencies in the care or
treatment provided to the person during a previous hospital stay or
from deficiencies in post-hospital discharge follow-up. The term
does not include a hospital readmission necessitated by the
occurrence of unrelated events after the discharge. The term
includes the readmission of a person to a hospital for:
(A) the same condition or procedure for which the
person was previously admitted;
(B) an infection or other complication resulting
from care previously provided; or
(C) a condition or procedure that indicates that
a surgical intervention performed during a previous admission was
unsuccessful in achieving the anticipated outcome.
Sec. 1002.002. ESTABLISHMENT; PURPOSE. The Texas Institute
of Health Care Quality and Efficiency is established to improve
health care quality, accountability, education, and cost
containment in this state by encouraging health care provider
collaboration, effective health care delivery models, and
coordination of health care services.
[Sections 1002.003-1002.050 reserved for expansion]
SUBCHAPTER B. ADMINISTRATION
Sec. 1002.051. APPLICATION OF SUNSET ACT. The institute is
subject to Chapter 325, Government Code (Texas Sunset Act). Unless
continued in existence as provided by that chapter, the institute
is abolished and this chapter expires September 1, 2017.
Sec. 1002.052. COMPOSITION OF BOARD OF DIRECTORS. (a) The
institute is governed by a board of 15 directors appointed by the
governor.
(b) The following ex officio, nonvoting members also serve
on the board:
(1) the commissioner of the department;
(2) the executive commissioner;
(3) the commissioner of insurance;
(4) the executive director of the Employees Retirement
System of Texas;
(5) the executive director of the Teacher Retirement
System of Texas;
(6) the state Medicaid director of the Health and
Human Services Commission;
(7) the executive director of the Texas Medical Board;
(8) the commissioner of the Department of Aging and
Disability Services;
(9) the executive director of the Texas Workforce
Commission;
(10) the commissioner of the Texas Higher Education
Coordinating Board; and
(11) a representative from each state agency or system
of higher education that purchases or provides health care
services, as determined by the governor.
(c) The governor shall appoint as board members health care
providers, payors, consumers, and health care quality experts or
persons who possess expertise in any other area the governor finds
necessary for the successful operation of the institute.
(d) A person may not serve as a voting member of the board if
the person serves on or advises another board or advisory board of a
state agency.
Sec. 1002.053. TERMS OF OFFICE. (a) Appointed members of
the board serve staggered terms of four years, with the terms of as
close to one-half of the members as possible expiring January 31 of
each odd-numbered year.
(b) Board members may serve consecutive terms.
Sec. 1002.054. ADMINISTRATIVE SUPPORT. (a) The institute
is administratively attached to the commission.
(b) The commission shall coordinate administrative
responsibilities with the institute to streamline and integrate the
institute's administrative operations and avoid unnecessary
duplication of effort and costs.
(c) The institute may collaborate with, and coordinate its
administrative functions, including functions related to research
and reporting activities with, other public or private entities,
including academic institutions and nonprofit organizations, that
perform research on health care issues or other topics consistent
with the purpose of the institute.
Sec. 1002.055. EXPENSES. (a) Members of the board serve
without compensation but, subject to the availability of
appropriated funds, may receive reimbursement for actual and
necessary expenses incurred in attending meetings of the board.
(b) Information relating to the billing and payment of
expenses under this section is subject to Chapter 552, Government
Code.
Sec. 1002.056. OFFICER; CONFLICT OF INTEREST. (a) The
governor shall designate a member of the board as presiding officer
to serve in that capacity at the pleasure of the governor.
(b) Any board member or a member of a committee formed by the
board with direct interest, personally or through an employer, in a
matter before the board shall abstain from deliberations and
actions on the matter in which the conflict of interest arises and
shall further abstain on any vote on the matter, and may not
otherwise participate in a decision on the matter.
(c) Each board member shall:
(1) file a conflict of interest statement and a
statement of ownership interests with the board to ensure
disclosure of all existing and potential personal interests related
to board business; and
(2) update the statements described by Subdivision (1)
at least annually.
(d) A statement filed under Subsection (c) is subject to
Chapter 552, Government Code.
Sec. 1002.057. PROHIBITION ON CERTAIN CONTRACTS AND
EMPLOYMENT. (a) The board may not compensate, employ, or contract
with any individual who serves as a member of the board of, or on an
advisory board or advisory committee for, any other governmental
body, including any agency, council, or committee, in this state.
(b) The board may not compensate, employ, or contract with
any person that provides financial support to the board, including
a person who provides a gift, grant, or donation to the board.
Sec. 1002.058. MEETINGS. (a) The board may meet as often
as necessary, but shall meet at least once each calendar quarter.
(b) The board shall develop and implement policies that
provide the public with a reasonable opportunity to appear before
the board and to speak on any issue under the authority of the
institute.
Sec. 1002.059. BOARD MEMBER IMMUNITY. (a) A board member
may not be held civilly liable for an act performed, or omission
made, in good faith in the performance of the member's powers and
duties under this chapter.
(b) A cause of action does not arise against a member of the
board for an act or omission described by Subsection (a).
Sec. 1002.060. PRIVACY OF INFORMATION. (a) Protected
health information and individually identifiable health
information collected, assembled, or maintained by the institute is
confidential and is not subject to disclosure under Chapter 552,
Government Code.
(b) The institute shall comply with all state and federal
laws and rules relating to the protection, confidentiality, and
transmission of health information, including the Health Insurance
Portability and Accountability Act of 1996 (Pub. L. No. 104-191)
and rules adopted under that Act, 42 U.S.C. Section 290dd-2, and 42
C.F.R. Part 2.
(c) The commission, department, or institute or an officer
or employee of the commission, department, or institute, including
a board member, may not disclose any information that is
confidential under this section.
(d) Information, documents, and records that are
confidential as provided by this section are not subject to
subpoena or discovery and may not be introduced into evidence in any
civil or criminal proceeding.
(e) An officer or employee of the commission, department, or
institute, including a board member, may not be examined in a civil,
criminal, special, administrative, or other proceeding as to
information that is confidential under this section.
Sec. 1002.061. FUNDING. (a) The institute may be funded
through the General Appropriations Act and may request, accept, and
use gifts, grants, and donations as necessary to implement its
functions.
(b) The institute may participate in other
revenue-generating activity that is consistent with the
institute's purposes.
(c) Except as otherwise provided by law, each state agency
represented on the board as a nonvoting member shall provide funds
to support the institute and implement this chapter. The
commission shall establish a funding formula to determine the level
of support each state agency is required to provide.
(d) This section does not permit the sale of information
that is confidential under Section 1002.060.
[Sections 1002.062-1002.100 reserved for expansion]
SUBCHAPTER C. POWERS AND DUTIES
Sec. 1002.101. GENERAL POWERS AND DUTIES. The institute
shall make recommendations to the legislature on:
(1) improving quality and efficiency of health care
delivery by:
(A) providing a forum for regulators, payors, and
providers to discuss and make recommendations for initiatives that
promote the use of best practices, increase health care provider
collaboration, improve health care outcomes, and contain health
care costs;
(B) researching, developing, supporting, and
promoting strategies to improve the quality and efficiency of
health care in this state;
(C) determining the outcome measures that are the
most effective measures of quality and efficiency:
(i) using nationally accredited measures;
or
(ii) if no nationally accredited measures
exist, using measures based on expert consensus;
(D) reducing the incidence of potentially
preventable events; and
(E) creating a state plan that takes into
consideration the regional differences of the state to encourage
the improvement of the quality and efficiency of health care
services;
(2) improving reporting, consolidation, and
transparency of health care information; and
(3) implementing and supporting innovative health
care collaborative payment and delivery systems under Chapter 848,
Insurance Code.
Sec. 1002.102. GOALS FOR QUALITY AND EFFICIENCY OF HEALTH
CARE; STATEWIDE PLAN. (a) The institute shall study and develop
recommendations to improve the quality and efficiency of health
care delivery in this state, including:
(1) quality-based payment systems that align payment
incentives with high-quality, cost-effective health care;
(2) alternative health care delivery systems that
promote health care coordination and provider collaboration;
(3) quality of care and efficiency outcome
measurements that are effective measures of prevention, wellness,
coordination, provider collaboration, and cost-effective health
care; and
(4) meaningful use of electronic health records by
providers and electronic exchange of health information among
providers.
(b) The institute shall study and develop recommendations
for measuring quality of care and efficiency across:
(1) all state employee and state retiree benefit
plans;
(2) employee and retiree benefit plans provided
through the Teacher Retirement System of Texas;
(3) the state medical assistance program under Chapter
32, Human Resources Code; and
(4) the child health plan under Chapter 62.
(c) In developing recommendations under Subsection (b), the
institute shall use nationally accredited measures or, if no
nationally accredited measures exist, measures based on expert
consensus.
(d) The institute may study and develop recommendations for
measuring the quality of care and efficiency in state or federally
funded health care delivery systems other than those described by
Subsection (b).
(e) In developing recommendations under Subsections (a) and
(b), the institute may not base its recommendations solely on
actuarial data.
(f) Using the studies described by Subsections (a) and (b),
the institute shall develop recommendations for a statewide plan
for quality and efficiency of the delivery of health care.
[Sections 1002.103-1002.150 reserved for expansion]
SUBCHAPTER D. HEALTH CARE COLLABORATIVE GUIDELINES AND SUPPORT
Sec. 1002.151. INSTITUTE STUDIES AND RECOMMENDATIONS
REGARDING HEALTH CARE PAYMENT AND DELIVERY SYSTEMS. (a) The
institute shall study and make recommendations for alternative
health care payment and delivery systems.
(b) The institute shall recommend methods to evaluate a
health care collaborative's effectiveness, including methods to
evaluate:
(1) the efficiency and effectiveness of
cost-containment methods used by the collaborative;
(2) alternative health care payment and delivery
systems used by the collaborative;
(3) the quality of care;
(4) health care provider collaboration and
coordination;
(5) the protection of patients;
(6) patient satisfaction; and
(7) the meaningful use of electronic health records by
providers and electronic exchange of health information among
providers.
[Sections 1002.152-1002.200 reserved for expansion]
SUBCHAPTER E. IMPROVED TRANSPARENCY
Sec. 1002.201. HEALTH CARE ACCOUNTABILITY; IMPROVED
TRANSPARENCY. (a) With the assistance of the department, the
institute shall complete an assessment of all health-related data
collected by the state, what information is available to the
public, and how the public and health care providers currently
benefit and could potentially benefit from this information,
including health care cost and quality information.
(b) The institute shall develop a plan:
(1) for consolidating reports of health-related data
from various sources to reduce administrative costs to the state
and reduce the administrative burden to health care providers and
payors;
(2) for improving health care transparency to the
public and health care providers by making information available in
the most effective format; and
(3) providing recommendations to the legislature on
enhancing existing health-related information available to health
care providers and the public, including provider reporting of
additional information not currently required to be reported under
existing law, to improve quality of care.
Sec. 1002.202. ALL PAYOR CLAIMS DATABASE. (a) The
institute shall study the feasibility and desirability of
establishing a centralized database for health care claims
information across all payors.
(b) The study described by Subsection (a) shall:
(1) use the assessment described by Section 1002.201
to develop recommendations relating to the adequacy of existing
data sources for carrying out the state's purposes under this
chapter and Chapter 848, Insurance Code;
(2) determine whether the establishment of an all
payor claims database would reduce the need for some data
submissions provided by payors;
(3) identify the best available sources of data
necessary for the state's purposes under this chapter and Chapter
848, Insurance Code, that are not collected by the state under
existing law;
(4) describe how an all payor claims database may
facilitate carrying out the state's purposes under this chapter and
Chapter 848, Insurance Code;
(5) identify national standards for claims data
collection and use, including standardized data sets, standardized
methodology, and standard outcome measures of health care quality
and efficiency; and
(6) estimate the costs of implementing an all payor
claims database, including:
(A) the costs to the state for collecting and
processing data;
(B) the cost to the payors for supplying the
data; and
(C) the available funding mechanisms that might
support an all payor claims database.
(c) The institute shall consult with the department and the
Texas Department of Insurance to develop recommendations to submit
to the legislature on the establishment of the centralized claims
database described by Subsection (a).
SECTION 3.02. Chapter 109, Health and Safety Code, is
repealed.
SECTION 3.03. On the effective date of this Act:
(1) the Texas Health Care Policy Council established
under Chapter 109, Health and Safety Code, is abolished; and
(2) any unexpended and unobligated balance of money
appropriated by the legislature to the Texas Health Care Policy
Council established under Chapter 109, Health and Safety Code, as
it existed immediately before the effective date of this Act, is
transferred to the Texas Institute of Health Care Quality and
Efficiency created by Chapter 1002, Health and Safety Code, as
added by this Act.
SECTION 3.04. (a) The governor shall appoint voting
members of the board of directors of the Texas Institute of Health
Care Quality and Efficiency under Section 1002.052, Health and
Safety Code, as added by this Act, as soon as practicable after the
effective date of this Act.
(b) In making the initial appointments under this section,
the governor shall designate seven members to terms expiring
January 31, 2013, and eight members to terms expiring January 31,
2015.
SECTION 3.05. (a) Not later than December 1, 2012, the
Texas Institute of Health Care Quality and Efficiency shall submit
a report regarding recommendations for improved health care
reporting to the governor, the lieutenant governor, the speaker of
the house of representatives, and the chairs of the appropriate
standing committees of the legislature outlining:
(1) the initial assessment conducted under Subsection
(a), Section 1002.201, Health and Safety Code, as added by this Act;
(2) the plans initially developed under Subsection
(b), Section 1002.201, Health and Safety Code, as added by this Act;
(3) the changes in existing law that would be
necessary to implement the assessment and plans described by
Subdivisions (1) and (2) of this subsection; and
(4) the cost implications to state agencies, small
businesses, micro businesses, payors, and health care providers to
implement the assessment and plans described by Subdivisions (1)
and (2) of this subsection.
(b) Not later than December 1, 2012, the Texas Institute of
Health Care Quality and Efficiency shall submit a report regarding
recommendations for an all payor claims database to the governor,
the lieutenant governor, the speaker of the house of
representatives, and the chairs of the appropriate standing
committees of the legislature outlining:
(1) the feasibility and desirability of establishing a
centralized database for health care claims;
(2) the recommendations developed under Subsection
(c), Section 1002.202, Health and Safety Code, as added by this Act;
(3) the changes in existing law that would be
necessary to implement the recommendations described by
Subdivision (2) of this subsection; and
(4) the cost implications to state agencies, small
businesses, micro businesses, payors, and health care providers to
implement the recommendations described by Subdivision (2) of this
subsection.
SECTION 3.06. (a) The Texas Institute of Health Care
Quality and Efficiency under Chapter 1002, Health and Safety Code,
as added by this Act, with the assistance of and in coordination
with the Texas Department of Insurance, shall conduct a study:
(1) evaluating how the legislature may promote a
consumer-driven health care system, including by increasing the
adoption of high-deductible insurance products with health savings
accounts by consumers and employers to lower health care costs and
increase personal responsibility for health care; and
(2) examining the issue of differing amounts of
payment in full accepted by a provider for the same or similar
health care services or supplies, including bundled health care
services and supplies, and addressing:
(A) the extent of the differences in the amounts
accepted as payment in full for a service or supply;
(B) the reasons that amounts accepted as payment
in full differ for the same or similar services or supplies;
(C) the availability of information to the
consumer regarding the amount accepted as payment in full for a
service or supply;
(D) the effects on consumers of differing amounts
accepted as payment in full; and
(E) potential methods for improving consumers'
access to information in relation to the amounts accepted as
payment in full for health care services or supplies, including the
feasibility and desirability of requiring providers to:
(i) publicly post the amount that is
accepted as payment in full for a service or supply; and
(ii) adhere to the posted amount.
(b) The Texas Institute of Health Care Quality and
Efficiency shall submit a report to the legislature outlining the
results of the study conducted under this section and any
recommendations for potential legislation not later than January 1,
2013.
(c) This section expires September 1, 2013.
ARTICLE 4. HEALTH CARE COLLABORATIVES
SECTION 4.01. Subtitle C, Title 6, Insurance Code, is
amended by adding Chapter 848 to read as follows:
CHAPTER 848. HEALTH CARE COLLABORATIVES
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 848.001. DEFINITIONS. In this chapter:
(1) "Affiliate" means a person who controls, is
controlled by, or is under common control with one or more other
persons.
(2) "Health care collaborative" means an entity:
(A) that undertakes to arrange for medical and
health care services for insurers, health maintenance
organizations, and other payors in exchange for payments in cash or
in kind;
(B) that accepts and distributes payments for
medical and health care services;
(C) that consists of:
(i) physicians;
(ii) physicians and other health care
providers;
(iii) physicians and insurers or health
maintenance organizations; or
(iv) physicians, other health care
providers, and insurers or health maintenance organizations; and
(D) that is certified by the commissioner under
this chapter to lawfully accept and distribute payments to
physicians and other health care providers using the reimbursement
methodologies authorized by this chapter.
(3) "Health care services" means services provided by
a physician or health care provider to prevent, alleviate, cure, or
heal human illness or injury. The term includes:
(A) pharmaceutical services;
(B) medical, chiropractic, or dental care; and
(C) hospitalization.
(4) "Health care provider" means any person,
partnership, professional association, corporation, facility, or
institution licensed, certified, registered, or chartered by this
state to provide health care services. The term includes a hospital
but does not include a physician.
(5) "Health maintenance organization" means an
organization operating under Chapter 843.
(6) "Hospital" means a general or special hospital,
including a public or private institution licensed under Chapter
241 or 577, Health and Safety Code.
(7) "Institute" means the Texas Institute of Health
Care Quality and Efficiency established under Chapter 1002, Health
and Safety Code.
(8) "Physician" means:
(A) an individual licensed to practice medicine
in this state;
(B) a professional association organized under
the Texas Professional Association Act (Article 1528f, Vernon's
Texas Civil Statutes) or the Texas Professional Association Law by
an individual or group of individuals licensed to practice medicine
in this state;
(C) a partnership or limited liability
partnership formed by a group of individuals licensed to practice
medicine in this state;
(D) a nonprofit health corporation certified
under Section 162.001, Occupations Code;
(E) a company formed by a group of individuals
licensed to practice medicine in this state under the Texas Limited
Liability Company Act (Article 1528n, Vernon's Texas Civil
Statutes) or the Texas Professional Limited Liability Company Law;
or
(F) an organization wholly owned and controlled
by individuals licensed to practice medicine in this state.
(9) "Potentially preventable event" has the meaning
assigned by Section 1002.001, Health and Safety Code.
Sec. 848.002. EXCEPTION: DELEGATED ENTITIES. (a) This
section applies only to an entity, other than a health maintenance
organization, that:
(1) by itself or through a subcontract with another
entity, undertakes to arrange for or provide medical care or health
care services to enrollees in exchange for predetermined payments
on a prospective basis; and
(2) accepts responsibility for performing functions
that are required by:
(A) Chapter 222, 251, 258, or 1272, as
applicable, to a health maintenance organization; or
(B) Chapter 843, Chapter 1271, Section 1367.053,
Subchapter A, Chapter 1452, or Subchapter B, Chapter 1507, as
applicable, solely on behalf of health maintenance organizations.
(b) An entity described by Subsection (a) is subject to
Chapter 1272 and is not required to obtain a certificate of
authority or determination of approval under this chapter.
Sec. 848.003. USE OF INSURANCE-RELATED TERMS BY HEALTH CARE
COLLABORATIVE. A health care collaborative that is not an insurer
or health maintenance organization may not use in its name,
contracts, or literature:
(1) the following words or initials:
(A) "insurance";
(B) "casualty";
(C) "surety";
(D) "mutual";
(E) "health maintenance organization"; or
(F) "HMO"; or
(2) any other words or initials that are:
(A) descriptive of the insurance, casualty,
surety, or health maintenance organization business; or
(B) deceptively similar to the name or
description of an insurer, surety corporation, or health
maintenance organization engaging in business in this state.
Sec. 848.004. APPLICABILITY OF INSURANCE LAWS. (a) An
organization may not arrange for or provide health care services to
enrollees on a prepaid or indemnity basis through health insurance
or a health benefit plan, including a health care plan, as defined
by Section 843.002, unless the organization as an insurer or health
maintenance organization holds the appropriate certificate of
authority issued under another chapter of this code.
(b) Except as provided by Subsection (c), the following
provisions of this code apply to a health care collaborative in the
same manner and to the same extent as they apply to an individual or
entity otherwise subject to the provision:
(1) Section 38.001;
(2) Subchapter A, Chapter 542;
(3) Chapter 541;
(4) Chapter 543;
(5) Chapter 602;
(6) Chapter 701;
(7) Chapter 803; and
(8) Chapter 804.
(c) The remedies available under this chapter in the manner
provided by Chapter 541 do not include:
(1) a private cause of action under Subchapter D,
Chapter 541; or
(2) a class action under Subchapter F, Chapter 541.
Sec. 848.005. CERTAIN INFORMATION CONFIDENTIAL.
(a) Except as provided by Subsection (b), an application, filing,
or report required under this chapter is public information subject
to disclosure under Chapter 552, Government Code.
(b) The following information is confidential and is not
subject to disclosure under Chapter 552, Government Code:
(1) a contract, agreement, or document that
establishes another arrangement:
(A) between a health care collaborative and a
governmental or private entity for all or part of health care
services provided or arranged for by the health care collaborative;
or
(B) between a health care collaborative and
participating physicians and health care providers;
(2) a written description of a contract, agreement, or
other arrangement described by Subdivision (1);
(3) information relating to bidding, pricing, or other
trade secrets submitted to:
(A) the department under Sections 848.057(a)(5)
and (6); or
(B) the attorney general under Section 848.059;
(4) information relating to the diagnosis, treatment,
or health of a patient who receives health care services from a
health care collaborative under a contract for services; and
(5) information relating to quality improvement or
peer review activities of a health care collaborative.
Sec. 848.006. COVERAGE BY HEALTH CARE COLLABORATIVE NOT
REQUIRED. (a) Except as provided by Subsection (b) and subject to
Chapter 843 and Section 1301.0625, an individual may not be
required to obtain or maintain coverage under:
(1) an individual health insurance policy written
through a health care collaborative; or
(2) any plan or program for health care services
provided on an individual basis through a health care
collaborative.
(b) This chapter does not require an individual to obtain or
maintain health insurance coverage.
(c) Subsection (a) does not apply to an individual:
(1) who is required to obtain or maintain health
benefit plan coverage:
(A) written by an institution of higher education
at which the individual is or will be enrolled as a student; or
(B) under an order requiring medical support for
a child; or
(2) who voluntarily applies for benefits under a state
administered program under Title XIX of the Social Security Act (42
U.S.C. Section 1396 et seq.), or Title XXI of the Social Security
Act (42 U.S.C. Section 1397aa et seq.).
(d) Except as provided by Subsection (e), a fine or penalty
may not be imposed on an individual if the individual chooses not to
obtain or maintain coverage described by Subsection (a).
(e) Subsection (d) does not apply to a fine or penalty
imposed on an individual described in Subsection (c) for the
individual's failure to obtain or maintain health benefit plan
coverage.
[Sections 848.007-848.050 reserved for expansion]
SUBCHAPTER B. AUTHORITY TO ENGAGE IN BUSINESS
Sec. 848.051. OPERATION OF HEALTH CARE COLLABORATIVE. A
health care collaborative that is certified by the department under
this chapter may provide or arrange to provide health care services
under contract with a governmental or private entity.
Sec. 848.052. FORMATION AND GOVERNANCE OF HEALTH CARE
COLLABORATIVE. (a) A health care collaborative is governed by a
board of directors.
(b) The person who establishes a health care collaborative
shall appoint an initial board of directors. Each member of the
initial board serves a term of not more than 18 months. Subsequent
members of the board shall be elected to serve two-year terms by
physicians and health care providers who participate in the health
care collaborative as provided by this section. The board shall
elect a chair from among its members.
(c) If the participants in a health care collaborative are
all physicians, each member of the board of directors must be an
individual physician who is a participant in the health care
collaborative.
(d) If the participants in a health care collaborative are
both physicians and other health care providers, the board of
directors must consist of:
(1) an even number of members who are individual
physicians, selected by physicians who participate in the health
care collaborative;
(2) a number of members equal to the number of members
under Subdivision (1) who represent health care providers, one of
whom is an individual physician, selected by health care providers
who participate in the health care collaborative; and
(3) one individual member with business expertise,
selected by unanimous vote of the members described by Subdivisions
(1) and (2).
(e) The board of directors must include at least three
nonvoting ex officio members who represent the community in which
the health care collaborative operates.
(f) An individual may not serve on the board of directors of
a health care collaborative if the individual has an ownership
interest in, serves on the board of directors of, or maintains an
officer position with:
(1) another health care collaborative that provides
health care services in the same service area as the health care
collaborative; or
(2) a physician or health care provider that:
(A) does not participate in the health care
collaborative; and
(B) provides health care services in the same
service area as the health care collaborative.
(g) In addition to the requirements of Subsection (f), the
board of directors of a health care collaborative shall adopt a
conflict of interest policy to be followed by members.
(h) The board of directors may remove a member for cause. A
member may not be removed from the board without cause.
(i) The organizational documents of a health care
collaborative may not conflict with any provision of this chapter,
including this section.
Sec. 848.053. COMPENSATION ADVISORY COMMITTEE; SHARING OF
CERTAIN DATA. (a) The board of directors of a health care
collaborative shall establish a compensation advisory committee to
develop and make recommendations to the board regarding charges,
fees, payments, distributions, or other compensation assessed for
health care services provided by physicians or health care
providers who participate in the health care collaborative. The
committee must include:
(1) a member of the board of directors; and
(2) if the health care collaborative consists of
physicians and other health care providers:
(A) a physician who is not a participant in the
health care collaborative, selected by the physicians who are
participants in the collaborative; and
(B) a member selected by the other health care
providers who participate in the collaborative.
(b) A health care collaborative shall establish and enforce
policies to prevent the sharing of charge, fee, and payment data
among nonparticipating physicians and health care providers.
Sec. 848.054. CERTIFICATE OF AUTHORITY AND DETERMINATION OF
APPROVAL REQUIRED. (a) An organization may not organize or
operate a health care collaborative in this state unless the
organization holds a certificate of authority issued under this
chapter.
(b) The commissioner shall adopt rules governing the
application for a certificate of authority under this subchapter.
Sec. 848.055. EXCEPTIONS. (a) An organization is not
required to obtain a certificate of authority under this chapter if
the organization holds an appropriate certificate of authority
issued under another chapter of this code.
(b) A person is not required to obtain a certificate of
authority under this chapter to the extent that the person is:
(1) a physician engaged in the delivery of medical
care; or
(2) a health care provider engaged in the delivery of
health care services other than medical care as part of a health
maintenance organization delivery network.
(c) A medical school, medical and dental unit, or health
science center as described by Section 61.003, 61.501, or 74.601,
Education Code, is not required to obtain a certificate of
authority under this chapter to the extent that the medical school,
medical and dental unit, or health science center contracts to
deliver medical care services within a health care collaborative.
This chapter is otherwise applicable to a medical school, medical
and dental unit, or health science center.
(d) An entity licensed under the Health and Safety Code that
employs a physician under a specific statutory authority is not
required to obtain a certificate of authority under this chapter to
the extent that the entity contracts to deliver medical care
services and health care services within a health care
collaborative. This chapter is otherwise applicable to the entity.
Sec. 848.056. APPLICATION FOR CERTIFICATE OF AUTHORITY.
(a) An organization may apply to the commissioner for and obtain a
certificate of authority to organize and operate a health care
collaborative.
(b) An application for a certificate of authority must:
(1) comply with all rules adopted by the commissioner;
(2) be verified under oath by the applicant or an
officer or other authorized representative of the applicant;
(3) be reviewed by the division within the office of
attorney general that is primarily responsible for enforcing the
antitrust laws of this state and of the United States under Section
848.059;
(4) demonstrate that the health care collaborative
contracts with a sufficient number of primary care physicians in
the health care collaborative's service area;
(5) state that enrollees may obtain care from any
physician or health care provider in the health care collaborative;
and
(6) identify a service area within which medical
services are available and accessible to enrollees.
(c) Not later than the 190th day after the date an applicant
submits an application to the commissioner under this section, the
commissioner shall approve or deny the application.
(d) The commissioner by rule may:
(1) extend the date by which an application is due
under this section; and
(2) require the disclosure of any additional
information necessary to implement and administer this chapter,
including information necessary to antitrust review and oversight.
Sec. 848.057. REQUIREMENTS FOR APPROVAL OF APPLICATION.
(a) The commissioner shall issue a certificate of authority on
payment of the application fee prescribed by Section 848.152 if the
commissioner is satisfied that:
(1) the applicant meets the requirements of Section
848.056;
(2) with respect to health care services to be
provided, the applicant:
(A) has demonstrated the willingness and
potential ability to ensure that the health care services will be
provided in a manner that:
(i) increases collaboration among health
care providers and integrates health care services;
(ii) promotes improvement in quality-based
health care outcomes, patient safety, patient engagement, and
coordination of services; and
(iii) reduces the occurrence of potentially
preventable events;
(B) has processes that contain health care costs
without jeopardizing the quality of patient care;
(C) has processes to develop, compile, evaluate,
and report statistics on performance measures relating to the
quality and cost of health care services, the pattern of
utilization of services, and the availability and accessibility of
services; and
(D) has processes to address complaints made by
patients receiving services provided through the organization;
(3) the applicant is in compliance with all rules
adopted by the commissioner under Section 848.151;
(4) the applicant has working capital and reserves
sufficient to operate and maintain the health care collaborative
and to arrange for services and expenses incurred by the health care
collaborative;
(5) the applicant's proposed health care collaborative
is not likely to reduce competition in any market for physician,
hospital, or ancillary health care services due to:
(A) the size of the health care collaborative; or
(B) the composition of the collaborative,
including the distribution of physicians by specialty within the
collaborative in relation to the number of competing health care
providers in the health care collaborative's geographic market; and
(6) the pro-competitive benefits of the applicant's
proposed health care collaborative are likely to substantially
outweigh the anticompetitive effects of any increase in market
power.
(b) A certificate of authority is effective for a period of
one year, subject to Section 848.060(d).
Sec. 848.058. DENIAL OF CERTIFICATE OF AUTHORITY. (a) The
commissioner may not issue a certificate of authority if the
commissioner determines that the applicant's proposed plan of
operation does not meet the requirements of Section 848.057.
(b) If the commissioner denies an application for a
certificate of authority under Subsection (a), the commissioner
shall notify the applicant that the plan is deficient and specify
the deficiencies.
Sec. 848.059. CONCURRENCE OF ATTORNEY GENERAL. (a) If the
commissioner determines that an application for a certificate of
authority filed under Section 848.056 complies with the
requirements of Section 848.057, the commissioner shall forward the
application, and all data, documents, and analysis considered by
the commissioner in making the determination, to the attorney
general. The attorney general shall review the application and the
data, documents, and analysis and, if the attorney general concurs
with the commissioner's determination under Sections 848.057(a)(5)
and (6), the attorney general shall notify the commissioner.
(b) If the attorney general does not concur with the
commissioner's determination under Sections 848.057(a)(5) and (6),
the attorney general shall notify the commissioner.
(c) A determination under this section shall be made not
later than the 60th day after the date the attorney general receives
the application and the data, documents, and analysis from the
commissioner.
(d) If the attorney general lacks sufficient information to
make a determination under Sections 848.057(a)(5) and (6), within
60 days of the attorney general's receipt of the application and the
data, documents, and analysis the attorney general shall inform the
commissioner that the attorney general lacks sufficient
information as well as what information the attorney general
requires. The commissioner shall then either provide the
additional information to the attorney general or request the
additional information from the applicant. The commissioner shall
promptly deliver any such additional information to the attorney
general. The attorney general shall then have 30 days from receipt
of the additional information to make a determination under
Subsection (a) or (b).
(e) If the attorney general notifies the commissioner that
the attorney general does not concur with the commissioner's
determination under Sections 848.057(a)(5) and (6), then,
notwithstanding any other provision of this subchapter, the
commissioner shall deny the application.
(f) In reviewing the commissioner's determination, the
attorney general shall consider the findings, conclusions, or
analyses contained in any other governmental entity's evaluation of
the health care collaborative.
(g) The attorney general at any time may request from the
commissioner additional time to consider an application under this
section. The commissioner shall grant the request and notify the
applicant of the request. A request by the attorney general or an
order by the commissioner granting a request under this section is
not subject to administrative or judicial review.
Sec. 848.060. RENEWAL OF CERTIFICATE OF AUTHORITY AND
DETERMINATION OF APPROVAL. (a) Not later than the 180th day
before the one-year anniversary of the date on which a health care
collaborative's certificate of authority was issued or most
recently renewed, the health care collaborative shall file with the
commissioner an application to renew the certificate.
(b) An application for renewal must:
(1) be verified by at least two principal officers of
the health care collaborative; and
(2) include:
(A) a financial statement of the health care
collaborative, including a balance sheet and receipts and
disbursements for the preceding calendar year, certified by an
independent certified public accountant;
(B) a description of the service area of the
health care collaborative;
(C) a description of the number and types of
physicians and health care providers participating in the health
care collaborative;
(D) an evaluation of the quality and cost of
health care services provided by the health care collaborative;
(E) an evaluation of the health care
collaborative's processes to promote evidence-based medicine,
patient engagement, and coordination of health care services
provided by the health care collaborative;
(F) the number, nature, and disposition of any
complaints filed with the health care collaborative under Section
848.107; and
(G) any other information required by the
commissioner.
(c) If a completed application for renewal is filed under
this section:
(1) the commissioner shall conduct a review under
Section 848.057 as if the application for renewal were a new
application, and, on approval by the commissioner, the attorney
general shall review the application under Section 848.059 as if
the application for renewal were a new application; and
(2) the commissioner shall renew or deny the renewal
of a certificate of authority at least 20 days before the one-year
anniversary of the date on which a health care collaborative's
certificate of authority was issued.
(d) If the commissioner does not act on a renewal
application before the one-year anniversary of the date on which a
health care collaborative's certificate of authority was issued or
renewed, the health care collaborative's certificate of authority
expires on the 90th day after the date of the one-year anniversary
unless the renewal of the certificate of authority or determination
of approval, as applicable, is approved before that date.
(e) A health care collaborative shall report to the
department a material change in the size or composition of the
collaborative. On receipt of a report under this subsection, the
department may require the collaborative to file an application for
renewal before the date required by Subsection (a).
[Sections 848.061-848.100 reserved for expansion]
SUBCHAPTER C. GENERAL POWERS AND DUTIES OF HEALTH CARE
COLLABORATIVE
Sec. 848.101. PROVIDING OR ARRANGING FOR SERVICES. (a) A
health care collaborative may provide or arrange for health care
services through contracts with physicians and health care
providers or with entities contracting on behalf of participating
physicians and health care providers.
(b) A health care collaborative may not prohibit a physician
or other health care provider, as a condition of participating in
the health care collaborative, from participating in another health
care collaborative.
(c) A health care collaborative may not use a covenant not
to compete to prohibit a physician from providing medical services
or participating in another health care collaborative in the same
service area.
(d) Except as provided by Subsection (f), on written consent
of a patient who was treated by a physician participating in a
health care collaborative, the health care collaborative shall
provide the physician with the medical records of the patient,
regardless of whether the physician is participating in the health
care collaborative at the time the request for the records is made.
(e) Records provided under Subsection (d) shall be made
available to the physician in the format in which the records are
maintained by the health care collaborative. The health care
collaborative may charge the physician a fee for copies of the
records, as established by the Texas Medical Board.
(f) If a physician requests a patient's records from a
health care collaborative under Subsection (d) for the purpose of
providing emergency treatment to the patient:
(1) the health care collaborative may not charge a fee
to the physician under Subsection (e); and
(2) the health care collaborative shall provide the
records to the physician regardless of whether the patient has
provided written consent.
Sec. 848.102. INSURANCE, REINSURANCE, INDEMNITY, AND
REIMBURSEMENT. A health care collaborative may contract with an
insurer authorized to engage in business in this state to provide
insurance, reinsurance, indemnification, or reimbursement against
the cost of health care and medical care services provided by the
health care collaborative. This section does not affect the
requirement that the health care collaborative maintain sufficient
working capital and reserves.
Sec. 848.103. PAYMENT BY GOVERNMENTAL OR PRIVATE ENTITY.
(a) A health care collaborative may:
(1) contract for and accept payments from a
governmental or private entity for all or part of the cost of
services provided or arranged for by the health care collaborative;
and
(2) distribute payments to participating physicians
and health care providers.
(b) Notwithstanding any other law, a health care
collaborative that is in compliance with this code, including
Chapters 841, 842, and 843, as applicable, may contract for,
accept, and distribute payments from governmental or private payors
based on fee-for-service or alternative payment mechanisms,
including:
(1) episode-based or condition-based bundled
payments;
(2) capitation or global payments; or
(3) pay-for-performance or quality-based payments.
(c) Except as provided by Subsection (d), a health care
collaborative may not contract for and accept from a governmental
or private entity payments on a prospective basis, including
bundled or global payments, unless the health care collaborative is
licensed under Chapter 843.
(d) A health care collaborative may contract for and accept
from an insurance company or a health maintenance organization
payments on a prospective basis, including bundled or global
payments.
Sec. 848.104. CONTRACTS FOR ADMINISTRATIVE OR MANAGEMENT
SERVICES. A health care collaborative may contract with any
person, including an affiliated entity, to perform administrative,
management, or any other required business functions on behalf of
the health care collaborative.
Sec. 848.105. CORPORATION, PARTNERSHIP, OR ASSOCIATION
POWERS. A health care collaborative has all powers of a
partnership, association, corporation, or limited liability
company, including a professional association or corporation, as
appropriate under the organizational documents of the health care
collaborative, that are not in conflict with this chapter or other
applicable law.
Sec. 848.106. QUALITY AND COST OF HEALTH CARE SERVICES.
(a) A health care collaborative shall establish policies to
improve the quality and control the cost of health care services
provided by participating physicians and health care providers that
are consistent with prevailing professionally recognized standards
of medical practice. The policies must include standards and
procedures relating to:
(1) the selection and credentialing of participating
physicians and health care providers;
(2) the development, implementation, monitoring, and
evaluation of evidence-based best practices and other processes to
improve the quality and control the cost of health care services
provided by participating physicians and health care providers,
including practices or processes to reduce the occurrence of
potentially preventable events;
(3) the development, implementation, monitoring, and
evaluation of processes to improve patient engagement and
coordination of health care services provided by participating
physicians and health care providers; and
(4) complaints initiated by participating physicians,
health care providers, and patients under Section 848.107.
(b) The governing body of a health care collaborative shall
establish a procedure for the periodic review of quality
improvement and cost control measures.
Sec. 848.107. COMPLAINT SYSTEMS. (a) A health care
collaborative shall implement and maintain complaint systems that
provide reasonable procedures to resolve an oral or written
complaint initiated by:
(1) a patient who received health care services
provided by a participating physician or health care provider; or
(2) a participating physician or health care provider.
(b) The complaint system for complaints initiated by
patients must include a process for the notice and appeal of a
complaint.
(c) A health care collaborative may not take a retaliatory
or adverse action against a physician or health care provider who
files a complaint with a regulatory authority regarding an action
of the health care collaborative.
Sec. 848.108. DELEGATION AGREEMENTS. (a) Except as
provided by Subsection (b), a health care collaborative that enters
into a delegation agreement described by Section 1272.001 is
subject to the requirements of Chapter 1272 in the same manner as a
health maintenance organization.
(b) Section 1272.301 does not apply to a delegation
agreement entered into by a health care collaborative.
(c) A health care collaborative may enter into a delegation
agreement with an entity licensed under Chapter 841, 842, or 883 if
the delegation agreement assigns to the entity responsibility for:
(1) a function regulated by:
(A) Chapter 222;
(B) Chapter 841;
(C) Chapter 842;
(D) Chapter 883;
(E) Chapter 1272;
(F) Chapter 1301;
(G) Chapter 4201;
(H) Section 1367.053; or
(I) Subchapter A, Chapter 1507; or
(2) another function specified by commissioner rule.
(d) A health care collaborative that enters into a
delegation agreement under this section shall maintain reserves and
capital in addition to the amounts required under Chapter 1272, in
an amount and form determined by rule of the commissioner to be
necessary for the liabilities and risks assumed by the health care
collaborative.
(e) A health care collaborative that enters into a
delegation agreement under this section is subject to Chapters 404,
441, and 443 and is considered to be an insurer for purposes of
those chapters.
Sec. 848.109. VALIDITY OF OPERATIONS AND TRADE PRACTICES OF
HEALTH CARE COLLABORATIVES. The operations and trade practices of
a health care collaborative that are consistent with the provisions
of this chapter, the rules adopted under this chapter, and
applicable federal antitrust laws are presumed to be consistent
with Chapter 15, Business & Commerce Code, or any other applicable
provision of law.
Sec. 848.110. RIGHTS OF PHYSICIANS; LIMITATIONS ON
PARTICIPATION. (a) Before a complaint against a physician under
Section 848.107 is resolved, or before a physician's association
with a health care collaborative is terminated, the physician is
entitled to an opportunity to dispute the complaint or termination
through a process that includes:
(1) written notice of the complaint or basis of the
termination;
(2) an opportunity for a hearing not earlier than the
30th day after receiving notice under Subdivision (1);
(3) the right to provide information at the hearing,
including testimony and a written statement; and
(4) a written decision that includes the specific
facts and reasons for the decision.
(b) A health care collaborative may limit a physician or
group of physicians from participating in the health care
collaborative if the limitation is based on an established
development plan approved by the board of directors. Each
applicant physician or group shall be provided with a copy of the
development plan.
[Sections 848.111-848.150 reserved for expansion]
SUBCHAPTER D. REGULATION OF HEALTH CARE COLLABORATIVES
Sec. 848.151. RULES. The commissioner and the attorney
general may adopt reasonable rules as necessary and proper to
implement the requirements of this chapter.
Sec. 848.152. FEES AND ASSESSMENTS. (a) The commissioner
shall, within the limits prescribed by this section, prescribe the
fees to be charged and the assessments to be imposed under this
section.
(b) Amounts collected under this section shall be deposited
to the credit of the Texas Department of Insurance operating
account.
(c) A health care collaborative shall pay to the department:
(1) an application fee in an amount determined by
commissioner rule; and
(2) an annual assessment in an amount determined by
commissioner rule.
(d) The commissioner shall set fees and assessments under
this section in an amount sufficient to pay the reasonable expenses
of the department and attorney general in administering this
chapter, including the direct and indirect expenses incurred by the
department and attorney general in examining and reviewing health
care collaboratives. Fees and assessments imposed under this
section shall be allocated among health care collaboratives on a
pro rata basis to the extent that the allocation is feasible.
Sec. 848.153. EXAMINATIONS. (a) The commissioner may
examine the financial affairs and operations of any health care
collaborative or applicant for a certificate of authority under
this chapter.
(b) A health care collaborative shall make its books and
records relating to its financial affairs and operations available
for an examination by the commissioner or attorney general.
(c) On request of the commissioner or attorney general, a
health care collaborative shall provide to the commissioner or
attorney general, as applicable:
(1) a copy of any contract, agreement, or other
arrangement between the health care collaborative and a physician
or health care provider; and
(2) a general description of the fee arrangements
between the health care collaborative and the physician or health
care provider.
(d) Documentation provided to the commissioner or attorney
general under this section is confidential and is not subject to
disclosure under Chapter 552, Government Code.
(e) The commissioner or attorney general may disclose the
results of an examination conducted under this section or
documentation provided under this section to a governmental agency
that contracts with a health care collaborative for the purpose of
determining financial stability, readiness, or other contractual
compliance needs.
[Sections 848.154-848.200 reserved for expansion]
SUBCHAPTER E. ENFORCEMENT
Sec. 848.201. ENFORCEMENT ACTIONS. (a) After notice and
opportunity for a hearing, the commissioner may:
(1) suspend or revoke a certificate of authority
issued to a health care collaborative under this chapter;
(2) impose sanctions under Chapter 82;
(3) issue a cease and desist order under Chapter 83; or
(4) impose administrative penalties under Chapter 84.
(b) The commissioner may take an enforcement action listed
in Subsection (a) against a health care collaborative if the
commissioner finds that the health care collaborative:
(1) is operating in a manner that is:
(A) significantly contrary to its basic
organizational documents; or
(B) contrary to the manner described in and
reasonably inferred from other information submitted under Section
848.057;
(2) does not meet the requirements of Section 848.057;
(3) cannot fulfill its obligation to provide health
care services as required under its contracts with governmental or
private entities;
(4) does not meet the requirements of Chapter 1272, if
applicable;
(5) has not implemented the complaint system required
by Section 848.107 in a manner to resolve reasonably valid
complaints;
(6) has advertised or merchandised its services in an
untrue, misrepresentative, misleading, deceptive, or unfair manner
or a person on behalf of the health care collaborative has
advertised or merchandised the health care collaborative's
services in an untrue, misrepresentative, misleading, deceptive,
or unfair manner;
(7) has not complied substantially with this chapter
or a rule adopted under this chapter;
(8) has not taken corrective action the commissioner
considers necessary to correct a failure to comply with this
chapter, any applicable provision of this code, or any applicable
rule or order of the commissioner not later than the 30th day after
the date of notice of the failure or within any longer period
specified in the notice and determined by the commissioner to be
reasonable; or
(9) has or is utilizing market power in an
anticompetitive manner, in accordance with established antitrust
principles of market power analysis.
Sec. 848.202. OPERATIONS DURING SUSPENSION OR AFTER
REVOCATION OF CERTIFICATE OF AUTHORITY. (a) During the period a
certificate of authority of a health care collaborative is
suspended, the health care collaborative may not:
(1) enter into a new contract with a governmental or
private entity; or
(2) advertise or solicit in any way.
(b) After a certificate of authority of a health care
collaborative is revoked, the health care collaborative:
(1) shall proceed, immediately following the
effective date of the order of revocation, to conclude its affairs;
(2) may not conduct further business except as
essential to the orderly conclusion of its affairs; and
(3) may not advertise or solicit in any way.
(c) Notwithstanding Subsection (b), the commissioner may,
by written order, permit the further operation of the health care
collaborative to the extent that the commissioner finds necessary
to serve the best interest of governmental or private entities that
have entered into contracts with the health care collaborative.
Sec. 848.203. INJUNCTIONS. If the commissioner believes
that a health care collaborative or another person is violating or
has violated this chapter or a rule adopted under this chapter, the
attorney general at the request of the commissioner may bring an
action in a Travis County district court to enjoin the violation and
obtain other relief the court considers appropriate.
Sec. 848.204. NOTICE. The commissioner shall:
(1) report any action taken under this subchapter to:
(A) the relevant state licensing or certifying
agency or board; and
(B) the United States Department of Health and
Human Services National Practitioner Data Bank; and
(2) post notice of the action on the department's
Internet website.
Sec. 848.205. INDEPENDENT AUTHORITY OF ATTORNEY GENERAL.
(a) The attorney general may:
(1) investigate a health care collaborative with
respect to anticompetitive behavior that is contrary to the goals
and requirements of this chapter; and
(2) request that the commissioner:
(A) impose a penalty or sanction;
(B) issue a cease and desist order; or
(C) suspend or revoke the health care
collaborative's certificate of authority.
(b) This section does not limit any other authority or power
of the attorney general.
SECTION 4.02. Paragraph (A), Subdivision (12), Subsection
(a), Section 74.001, Civil Practice and Remedies Code, is amended
to read as follows:
(A) "Health care provider" means any person,
partnership, professional association, corporation, facility, or
institution duly licensed, certified, registered, or chartered by
the State of Texas to provide health care, including:
(i) a registered nurse;
(ii) a dentist;
(iii) a podiatrist;
(iv) a pharmacist;
(v) a chiropractor;
(vi) an optometrist; [or]
(vii) a health care institution; or
(viii) a health care collaborative
certified under Chapter 848, Insurance Code.
SECTION 4.03. Subchapter B, Chapter 1301, Insurance Code,
is amended by adding Section 1301.0625 to read as follows:
Sec. 1301.0625. HEALTH CARE COLLABORATIVES. (a) Subject
to the requirements of this chapter, a health care collaborative
may be designated as a preferred provider under a preferred
provider benefit plan and may offer enhanced benefits for care
provided by the health care collaborative.
(b) A preferred provider contract between an insurer and a
health care collaborative may use a payment methodology other than
a fee-for-service or discounted fee methodology. A reimbursement
methodology used in a contract under this subsection is not subject
to Chapter 843.
(c) A contract authorized by Subsection (b) must specify
that the health care collaborative and the physicians or providers
providing health care services on behalf of the collaborative will
hold an insured harmless for payment of the cost of covered health
care services if the insurer or the health care collaborative do not
pay the physician or health care provider for the services.
(d) An insurer issuing an exclusive provider benefit plan
authorized by another law of this state may limit access to only
preferred providers participating in a health care collaborative if
the limitation is consistent with all requirements applicable to
exclusive provider benefit plans.
SECTION 4.04. Subtitle F, Title 4, Health and Safety Code,
is amended by adding Chapter 315 to read as follows:
CHAPTER 315. ESTABLISHMENT OF HEALTH CARE COLLABORATIVES
Sec. 315.001. AUTHORITY TO ESTABLISH HEALTH CARE
COLLABORATIVE. A public hospital created under Subtitle C or D or a
hospital district created under general or special law may form and
sponsor a nonprofit health care collaborative that is certified
under Chapter 848, Insurance Code.
SECTION 4.05. Section 102.005, Occupations Code, is amended
to read as follows:
Sec. 102.005. APPLICABILITY TO CERTAIN ENTITIES. Section
102.001 does not apply to:
(1) a licensed insurer;
(2) a governmental entity, including:
(A) an intergovernmental risk pool established
under Chapter 172, Local Government Code; and
(B) a system as defined by Section 1601.003,
Insurance Code;
(3) a group hospital service corporation; [or]
(4) a health maintenance organization that
reimburses, provides, offers to provide, or administers hospital,
medical, dental, or other health-related benefits under a health
benefits plan for which it is the payor; or
(5) a health care collaborative certified under
Chapter 848, Insurance Code.
SECTION 4.06. Subdivision (5), Subsection (a), Section
151.002, Occupations Code, is amended to read as follows:
(5) "Health care entity" means:
(A) a hospital licensed under Chapter 241 or 577,
Health and Safety Code;
(B) an entity, including a health maintenance
organization, group medical practice, nursing home, health science
center, university medical school, hospital district, hospital
authority, or other health care facility, that:
(i) provides or pays for medical care or
health care services; and
(ii) follows a formal peer review process
to further quality medical care or health care;
(C) a professional society or association of
physicians, or a committee of such a society or association, that
follows a formal peer review process to further quality medical
care or health care; [or]
(D) an organization established by a
professional society or association of physicians, hospitals, or
both, that:
(i) collects and verifies the authenticity
of documents and other information concerning the qualifications,
competence, or performance of licensed health care professionals;
and
(ii) acts as a health care facility's agent
under the Health Care Quality Improvement Act of 1986 (42 U.S.C.
Section 11101 et seq.); or
(E) a health care collaborative certified under
Chapter 848, Insurance Code.
SECTION 4.07. Not later than September 1, 2012, the
commissioner of insurance and the attorney general shall adopt
rules as necessary to implement this article.
SECTION 4.08. As soon as practicable after the effective
date of this Act, the commissioner of insurance shall designate or
employ staff with antitrust expertise sufficient to carry out the
duties required by this Act.
ARTICLE 5. PATIENT IDENTIFICATION
SECTION 5.01. Subchapter A, Chapter 311, Health and Safety
Code, is amended by adding Section 311.004 to read as follows:
Sec. 311.004. STANDARDIZED PATIENT RISK IDENTIFICATION
SYSTEM. (a) In this section:
(1) "Department" means the Department of State Health
Services.
(2) "Hospital" means a general or special hospital as
defined by Section 241.003. The term includes a hospital
maintained or operated by this state.
(b) The department shall coordinate with hospitals to
develop a statewide standardized patient risk identification
system under which a patient with a specific medical risk may be
readily identified through the use of a system that communicates to
hospital personnel the existence of that risk. The executive
commissioner of the Health and Human Services Commission shall
appoint an ad hoc committee of hospital representatives to assist
the department in developing the statewide system.
(c) The department shall require each hospital to implement
and enforce the statewide standardized patient risk identification
system developed under Subsection (b) unless the department
authorizes an exemption for the reason stated in Subsection (d).
(d) The department may exempt from the statewide
standardized patient risk identification system a hospital that
seeks to adopt another patient risk identification methodology
supported by evidence-based protocols for the practice of medicine.
(e) The department shall modify the statewide standardized
patient risk identification system in accordance with
evidence-based medicine as necessary.
(f) The executive commissioner of the Health and Human
Services Commission may adopt rules to implement this section.
ARTICLE 6. REPORTING OF HEALTH CARE-ASSOCIATED INFECTIONS
SECTION 6.01. Section 98.001, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended by adding Subdivisions (8-a) and
(10-a) to read as follows:
(8-a) "Health care professional" means an individual
licensed, certified, or otherwise authorized to administer health
care, for profit or otherwise, in the ordinary course of business or
professional practice. The term does not include a health care
facility.
(10-a) "Potentially preventable complication" and
"potentially preventable readmission" have the meanings assigned
by Section 1002.001, Health and Safety Code.
SECTION 6.02. Subsection (c), Section 98.102, Health and
Safety Code, as added by Chapter 359 (S.B. 288), Acts of the 80th
Legislature, Regular Session, 2007, is amended to read as follows:
(c) The data reported by health care facilities to the
department must contain sufficient patient identifying information
to:
(1) avoid duplicate submission of records;
(2) allow the department to verify the accuracy and
completeness of the data reported; and
(3) for data reported under Section 98.103 [or
98.104], allow the department to risk adjust the facilities'
infection rates.
SECTION 6.03. Section 98.103, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended by amending Subsection (b) and
adding Subsection (d-1) to read as follows:
(b) A pediatric and adolescent hospital shall report the
incidence of surgical site infections, including the causative
pathogen if the infection is laboratory-confirmed, occurring in the
following procedures to the department:
(1) cardiac procedures, excluding thoracic cardiac
procedures;
(2) ventricular [ventriculoperitoneal] shunt
procedures; and
(3) spinal surgery with instrumentation.
(d-1) The executive commissioner by rule may designate the
federal Centers for Disease Control and Prevention's National
Healthcare Safety Network, or its successor, to receive reports of
health care-associated infections from health care facilities on
behalf of the department. A health care facility must file a report
required in accordance with a designation made under this
subsection in accordance with the National Healthcare Safety
Network's definitions, methods, requirements, and procedures. A
health care facility shall authorize the department to have access
to facility-specific data contained in a report filed with the
National Healthcare Safety Network in accordance with a designation
made under this subsection.
SECTION 6.04. Section 98.1045, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended by adding Subsection (c) to read
as follows:
(c) The executive commissioner by rule may designate an
agency of the United States Department of Health and Human Services
to receive reports of preventable adverse events by health care
facilities on behalf of the department. A health care facility
shall authorize the department to have access to facility-specific
data contained in a report made in accordance with a designation
made under this subsection.
SECTION 6.05. Subchapter C, Chapter 98, Health and Safety
Code, as added by Chapter 359 (S.B. 288), Acts of the 80th
Legislature, Regular Session, 2007, is amended by adding Sections
98.1046 and 98.1047 to read as follows:
Sec. 98.1046. PUBLIC REPORTING OF CERTAIN POTENTIALLY
PREVENTABLE EVENTS FOR HOSPITALS. (a) In consultation with the
Texas Institute of Health Care Quality and Efficiency under Chapter
1002, the department, using data submitted under Chapter 108, shall
publicly report for hospitals in this state risk-adjusted outcome
rates for those potentially preventable complications and
potentially preventable readmissions that the department, in
consultation with the institute, has determined to be the most
effective measures of quality and efficiency.
(b) The department shall make the reports compiled under
Subsection (a) available to the public on the department's Internet
website.
(c) The department may not disclose the identity of a
patient or health care professional in the reports authorized in
this section.
Sec. 98.1047. STUDIES ON LONG-TERM CARE FACILITY REPORTING
OF ADVERSE HEALTH CONDITIONS. (a) In consultation with the Texas
Institute of Health Care Quality and Efficiency under Chapter 1002,
the department shall study which adverse health conditions commonly
occur in long-term care facilities and, of those health conditions,
which are potentially preventable.
(b) The department shall develop recommendations for
reporting adverse health conditions identified under Subsection
(a).
SECTION 6.06. Section 98.105, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended to read as follows:
Sec. 98.105. REPORTING SYSTEM MODIFICATIONS. Based on the
recommendations of the advisory panel, the executive commissioner
by rule may modify in accordance with this chapter the list of
procedures that are reportable under Section 98.103 [or 98.104].
The modifications must be based on changes in reporting guidelines
and in definitions established by the federal Centers for Disease
Control and Prevention.
SECTION 6.07. Subsections (a), (b), and (d), Section
98.106, Health and Safety Code, as added by Chapter 359 (S.B. 288),
Acts of the 80th Legislature, Regular Session, 2007, are amended to
read as follows:
(a) The department shall compile and make available to the
public a summary, by health care facility, of:
(1) the infections reported by facilities under
Section [Sections] 98.103 [and 98.104]; and
(2) the preventable adverse events reported by
facilities under Section 98.1045.
(b) Information included in the departmental summary with
respect to infections reported by facilities under Section
[Sections] 98.103 [and 98.104] must be risk adjusted and include a
comparison of the risk-adjusted infection rates for each health
care facility in this state that is required to submit a report
under Section [Sections] 98.103 [and 98.104].
(d) The department shall publish the departmental summary
at least annually and may publish the summary more frequently as the
department considers appropriate. Data made available to the
public must include aggregate data covering a period of at least a
full calendar quarter.
SECTION 6.08. Subchapter C, Chapter 98, Health and Safety
Code, as added by Chapter 359 (S.B. 288), Acts of the 80th
Legislature, Regular Session, 2007, is amended by adding Section
98.1065 to read as follows:
Sec. 98.1065. STUDY OF INCENTIVES AND RECOGNITION FOR
HEALTH CARE QUALITY. The department, in consultation with the
Texas Institute of Health Care Quality and Efficiency under Chapter
1002, shall conduct a study on developing a recognition program to
recognize exemplary health care facilities for superior quality of
health care and make recommendations based on that study.
SECTION 6.09. Section 98.108, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended to read as follows:
Sec. 98.108. FREQUENCY OF REPORTING. (a) In consultation
with the advisory panel, the executive commissioner by rule shall
establish the frequency of reporting by health care facilities
required under Sections 98.103[, 98.104,] and 98.1045.
(b) Except as provided by Subsection (c), facilities
[Facilities] may not be required to report more frequently than
quarterly.
(c) The executive commissioner may adopt rules requiring
reporting more frequently than quarterly if more frequent reporting
is necessary to meet the requirements for participation in the
federal Centers for Disease Control and Prevention's National
Healthcare Safety Network.
SECTION 6.10. Subsection (a), Section 98.109, Health and
Safety Code, as added by Chapter 359 (S.B. 288), Acts of the 80th
Legislature, Regular Session, 2007, is amended to read as follows:
(a) Except as provided by Sections 98.1046, 98.106, and
98.110, all information and materials obtained or compiled or
reported by the department under this chapter or compiled or
reported by a health care facility under this chapter, and all
related information and materials, are confidential and:
(1) are not subject to disclosure under Chapter 552,
Government Code, or discovery, subpoena, or other means of legal
compulsion for release to any person; and
(2) may not be admitted as evidence or otherwise
disclosed in any civil, criminal, or administrative proceeding.
SECTION 6.11. Section 98.110, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is amended to read as follows:
Sec. 98.110. DISCLOSURE AMONG CERTAIN AGENCIES.
(a) Notwithstanding any other law, the department may disclose
information reported by health care facilities under Section
98.103[, 98.104,] or 98.1045 to other programs within the
department, to the Health and Human Services Commission, [and] to
other health and human services agencies, as defined by Section
531.001, Government Code, and to the federal Centers for Disease
Control and Prevention, or any other agency of the United States
Department of Health and Human Services, for public health research
or analysis purposes only, provided that the research or analysis
relates to health care-associated infections or preventable
adverse events. The privilege and confidentiality provisions
contained in this chapter apply to such disclosures.
(b) If the executive commissioner designates an agency of
the United States Department of Health and Human Services to
receive reports of health care-associated infections or
preventable adverse events, that agency may use the information
submitted for purposes allowed by federal law.
SECTION 6.12. Section 98.104, Health and Safety Code, as
added by Chapter 359 (S.B. 288), Acts of the 80th Legislature,
Regular Session, 2007, is repealed.
SECTION 6.13. Not later than December 1, 2012, the
Department of State Health Services shall submit a report regarding
recommendations for improved health care reporting to the governor,
the lieutenant governor, the speaker of the house of
representatives, and the chairs of the appropriate standing
committees of the legislature outlining:
(1) the initial assessment in the study conducted
under Section 98.1065, Health and Safety Code, as added by this Act;
(2) based on the study described by Subdivision (1) of
this subsection, the feasibility and desirability of establishing a
recognition program to recognize exemplary health care facilities
for superior quality of health care;
(3) the recommendations developed under Section
98.1065, Health and Safety Code, as added by this Act; and
(4) the changes in existing law that would be
necessary to implement the recommendations described by
Subdivision (3) of this subsection.
ARTICLE 7. INFORMATION MAINTAINED BY DEPARTMENT OF STATE HEALTH
SERVICES
SECTION 7.01. Section 108.002, Health and Safety Code, is
amended by adding Subdivisions (4-a) and (8-a) and amending
Subdivision (7) to read as follows:
(4-a) "Commission" means the Health and Human Services
Commission.
(7) "Department" means the [Texas] Department of State
Health Services.
(8-a) "Executive commissioner" means the executive
commissioner of the Health and Human Services Commission.
SECTION 7.02. Chapter 108, Health and Safety Code, is
amended by adding Section 108.0026 to read as follows:
Sec. 108.0026. TRANSFER OF DUTIES; REFERENCE TO COUNCIL.
(a) The powers and duties of the Texas Health Care Information
Council under this chapter were transferred to the Department of
State Health Services in accordance with Section 1.19, Chapter 198
(H.B. 2292), Acts of the 78th Legislature, Regular Session, 2003.
(b) In this chapter or other law, a reference to the Texas
Health Care Information Council means the Department of State
Health Services.
SECTION 7.03. Subsection (h), Section 108.009, Health and
Safety Code, is amended to read as follows:
(h) The department [council] shall coordinate data
collection with the data submission formats used by hospitals and
other providers. The department [council] shall accept data in the
format developed by the American National Standards Institute
[National Uniform Billing Committee (Uniform Hospital Billing Form
UB 92) and HCFA-1500] or its successor [their successors] or other
nationally [universally] accepted standardized forms that
hospitals and other providers use for other complementary purposes.
SECTION 7.04. Section 108.013, Health and Safety Code, is
amended by amending Subsections (a) through (d), (g), (i), and (j)
and adding Subsections (k) through (n) to read as follows:
(a) The data received by the department under this chapter
[council] shall be used by the department and commission [council]
for the benefit of the public. Subject to specific limitations
established by this chapter and executive commissioner [council]
rule, the department [council] shall make determinations on
requests for information in favor of access.
(b) The executive commissioner [council] by rule shall
designate the characters to be used as uniform patient identifiers.
The basis for assignment of the characters and the manner in which
the characters are assigned are confidential.
(c) Unless specifically authorized by this chapter, the
department [council] may not release and a person or entity may not
gain access to any data obtained under this chapter:
(1) that could reasonably be expected to reveal the
identity of a patient;
(2) that could reasonably be expected to reveal the
identity of a physician;
(3) disclosing provider discounts or differentials
between payments and billed charges;
(4) relating to actual payments to an identified
provider made by a payer; or
(5) submitted to the department [council] in a uniform
submission format that is not included in the public use data set
established under Sections 108.006(f) and (g), except in accordance
with Section 108.0135.
(d) Except as provided by this section, all [All] data
collected and used by the department [and the council] under this
chapter is subject to the confidentiality provisions and criminal
penalties of:
(1) Section 311.037;
(2) Section 81.103; and
(3) Section 159.002, Occupations Code.
(g) Unless specifically authorized by this chapter, the
department [The council] may not release data elements in a manner
that will reveal the identity of a patient. The department
[council] may not release data elements in a manner that will reveal
the identity of a physician.
(i) Notwithstanding any other law and except as provided by
this section, the [council and the] department may not provide
information made confidential by this section to any other agency
of this state.
(j) The executive commissioner [council] shall by rule[,
with the assistance of the advisory committee under Section
108.003(g)(5),] develop and implement a mechanism to comply with
Subsections (c)(1) and (2).
(k) The department may disclose data collected under this
chapter that is not included in public use data to any department or
commission program if the disclosure is reviewed and approved by
the institutional review board under Section 108.0135.
(l) Confidential data collected under this chapter that is
disclosed to a department or commission program remains subject to
the confidentiality provisions of this chapter and other applicable
law. The department shall identify the confidential data that is
disclosed to a program under Subsection (k). The program shall
maintain the confidentiality of the disclosed confidential data.
(m) The following provisions do not apply to the disclosure
of data to a department or commission program:
(1) Section 81.103;
(2) Sections 108.010(g) and (h);
(3) Sections 108.011(e) and (f);
(4) Section 311.037; and
(5) Section 159.002, Occupations Code.
(n) Nothing in this section authorizes the disclosure of
physician identifying data.
SECTION 7.05. Section 108.0135, Health and Safety Code, is
amended to read as follows:
Sec. 108.0135. INSTITUTIONAL [SCIENTIFIC] REVIEW BOARD
[PANEL]. (a) The department [council] shall establish an
institutional [a scientific] review board [panel] to review and
approve requests for access to data not contained in [information
other than] public use data. The members of the institutional
review board must [panel shall] have experience and expertise in
ethics, patient confidentiality, and health care data.
(b) To assist the institutional review board [panel] in
determining whether to approve a request for information, the
executive commissioner [council] shall adopt rules similar to the
federal Centers for Medicare and Medicaid Services' [Health Care
Financing Administration's] guidelines on releasing data.
(c) A request for information other than public use data
must be made on the form prescribed [created] by the department
[council].
(d) Any approval to release information under this section
must require that the confidentiality provisions of this chapter be
maintained and that any subsequent use of the information conform
to the confidentiality provisions of this chapter.
SECTION 7.06. Effective September 1, 2014, Subdivisions (5)
and (18), Section 108.002, Section 108.0025, and Subsection (c),
Section 108.009, Health and Safety Code, are repealed.
ARTICLE 8. ADOPTION OF VACCINE PREVENTABLE DISEASES POLICY BY
HEALTH CARE FACILITIES
SECTION 8.01. The heading to Subtitle A, Title 4, Health and
Safety Code, is amended to read as follows:
SUBTITLE A. FINANCING, CONSTRUCTING, REGULATING, AND INSPECTING
HEALTH FACILITIES
SECTION 8.02. Subtitle A, Title 4, Health and Safety Code,
is amended by adding Chapter 224 to read as follows:
CHAPTER 224. POLICY ON VACCINE PREVENTABLE DISEASES
Sec. 224.001. DEFINITIONS. In this chapter:
(1) "Covered individual" means:
(A) an employee of the health care facility;
(B) an individual providing direct patient care
under a contract with a health care facility; or
(C) an individual to whom a health care facility
has granted privileges to provide direct patient care.
(2) "Health care facility" means:
(A) a facility licensed under Subtitle B,
including a hospital as defined by Section 241.003; or
(B) a hospital maintained or operated by this
state.
(3) "Regulatory authority" means a state agency that
regulates a health care facility under this code.
(4) "Vaccine preventable diseases" means the diseases
included in the most current recommendations of the Advisory
Committee on Immunization Practices of the Centers for Disease
Control and Prevention.
Sec. 224.002. VACCINE PREVENTABLE DISEASES POLICY
REQUIRED. (a) Each health care facility shall develop and
implement a policy to protect its patients from vaccine preventable
diseases.
(b) The policy must:
(1) require covered individuals to receive vaccines
for the vaccine preventable diseases specified by the facility
based on the level of risk the individual presents to patients by
the individual's routine and direct exposure to patients;
(2) specify the vaccines a covered individual is
required to receive based on the level of risk the individual
presents to patients by the individual's routine and direct
exposure to patients;
(3) include procedures for verifying whether a covered
individual has complied with the policy;
(4) include procedures for a covered individual to be
exempt from the required vaccines for the medical conditions
identified as contraindications or precautions by the Centers for
Disease Control and Prevention;
(5) for a covered individual who is exempt from the
required vaccines, include procedures the individual must follow to
protect facility patients from exposure to disease, such as the use
of protective medical equipment, such as gloves and masks, based on
the level of risk the individual presents to patients by the
individual's routine and direct exposure to patients;
(6) prohibit discrimination or retaliatory action
against a covered individual who is exempt from the required
vaccines for the medical conditions identified as
contraindications or precautions by the Centers for Disease Control
and Prevention, except that required use of protective medical
equipment, such as gloves and masks, may not be considered
retaliatory action for purposes of this subdivision;
(7) require the health care facility to maintain a
written or electronic record of each covered individual's
compliance with or exemption from the policy; and
(8) include disciplinary actions the health care
facility is authorized to take against a covered individual who
fails to comply with the policy.
(c) The policy may include procedures for a covered
individual to be exempt from the required vaccines based on reasons
of conscience, including a religious belief.
Sec. 224.003. DISASTER EXEMPTION. (a) In this section,
"public health disaster" has the meaning assigned by Section
81.003.
(b) During a public health disaster, a health care facility
may prohibit a covered individual who is exempt from the vaccines
required in the policy developed by the facility under Section
224.002 from having contact with facility patients.
Sec. 224.004. DISCIPLINARY ACTION. A health care facility
that violates this chapter is subject to an administrative or civil
penalty in the same manner, and subject to the same procedures, as
if the facility had violated a provision of this code that
specifically governs the facility.
Sec. 224.005. RULES. The appropriate rulemaking authority
for each regulatory authority shall adopt rules necessary to
implement this chapter.
SECTION 8.03. Not later than June 1, 2012, a state agency
that regulates a health care facility subject to Chapter 224,
Health and Safety Code, as added by this Act, shall adopt the rules
necessary to implement that chapter.
SECTION 8.04. Notwithstanding Chapter 224, Health and
Safety Code, as added by this Act, a health care facility subject to
that chapter is not required to have a policy on vaccine preventable
diseases in effect until September 1, 2012.
ARTICLE 9. TEXAS EMERGENCY AND TRAUMA CARE EDUCATION
PARTNERSHIP PROGRAM
SECTION 9.01. Chapter 61, Education Code, is amended by
adding Subchapter GG to read as follows:
SUBCHAPTER GG. TEXAS EMERGENCY AND TRAUMA CARE EDUCATION
PARTNERSHIP PROGRAM
Sec. 61.9801. DEFINITIONS. In this subchapter:
(1) "Emergency and trauma care education partnership"
means a partnership that:
(A) consists of one or more hospitals in this
state and one or more graduate professional nursing or graduate
medical education programs in this state; and
(B) serves to increase training opportunities in
emergency and trauma care for doctors and registered nurses at
participating graduate medical education and graduate professional
nursing programs.
(2) "Participating education program" means a
graduate professional nursing program as that term is defined by
Section 54.221 or a graduate medical education program leading to
board certification by the American Board of Medical Specialties
that participates in an emergency and trauma care education
partnership.
Sec. 61.9802. PROGRAM: ESTABLISHMENT; ADMINISTRATION;
PURPOSE. (a) The Texas emergency and trauma care education
partnership program is established.
(b) The board shall administer the program in accordance
with this subchapter and rules adopted under this subchapter.
(c) Under the program, to the extent funds are available
under Section 61.9805, the board shall make grants to emergency and
trauma care education partnerships to assist those partnerships to
meet the state's needs for doctors and registered nurses with
training in emergency and trauma care by offering one-year or
two-year fellowships to students enrolled in graduate professional
nursing or graduate medical education programs through
collaboration between hospitals and graduate professional nursing
or graduate medical education programs and the use of the existing
expertise and facilities of those hospitals and programs.
Sec. 61.9803. GRANTS: CONDITIONS; LIMITATIONS. (a) The
board may make a grant under this subchapter to an emergency and
trauma care education partnership only if the board determines
that:
(1) the partnership will meet applicable standards for
instruction and student competency for each program offered by each
participating education program;
(2) each participating education program will, as a
result of the partnership, enroll in the education program a
sufficient number of additional students as established by the
board;
(3) each hospital participating in an emergency and
trauma care education partnership will provide to students enrolled
in a participating education program clinical placements that:
(A) allow the students to take part in providing
or to observe, as appropriate, emergency and trauma care services
offered by the hospital; and
(B) meet the clinical education needs of the
students; and
(4) the partnership will satisfy any other requirement
established by board rule.
(b) A grant under this subchapter may be spent only on costs
related to the development or operation of an emergency and trauma
care education partnership that prepares a student to complete a
graduate professional nursing program with a specialty focus on
emergency and trauma care or earn board certification by the
American Board of Medical Specialties.
Sec. 61.9804. PRIORITY FOR FUNDING. In awarding a grant
under this subchapter, the board shall give priority to an
emergency and trauma care education partnership that submits a
proposal that:
(1) provides for collaborative educational models
between one or more participating hospitals and one or more
participating education programs that have signed a memorandum of
understanding or other written agreement under which the
participants agree to comply with standards established by the
board, including any standards the board may establish that:
(A) provide for program management that offers a
centralized decision-making process allowing for inclusion of each
entity participating in the partnership;
(B) provide for access to clinical training
positions for students in graduate professional nursing and
graduate medical education programs that are not participating in
the partnership; and
(C) specify the details of any requirement
relating to a student in a participating education program being
employed after graduation in a hospital participating in the
partnership, including any details relating to the employment of
students who do not complete the program, are not offered a position
at the hospital, or choose to pursue other employment;
(2) includes a demonstrable education model to:
(A) increase the number of students enrolled in,
the number of students graduating from, and the number of faculty
employed by each participating education program; and
(B) improve student or resident retention in each
participating education program;
(3) indicates the availability of money to match a
portion of the grant money, including matching money or in-kind
services approved by the board from a hospital, private or
nonprofit entity, or institution of higher education;
(4) can be replicated by other emergency and trauma
care education partnerships or other graduate professional nursing
or graduate medical education programs; and
(5) includes plans for sustainability of the
partnership.
Sec. 61.9805. GRANTS, GIFTS, AND DONATIONS. In addition to
money appropriated by the legislature, the board may solicit,
accept, and spend grants, gifts, and donations from any public or
private source for the purposes of this subchapter.
Sec. 61.9806. RULES. The board shall adopt rules for the
administration of the Texas emergency and trauma care education
partnership program. The rules must include:
(1) provisions relating to applying for a grant under
this subchapter; and
(2) standards of accountability consistent with other
graduate professional nursing and graduate medical education
programs to be met by any emergency and trauma care education
partnership awarded a grant under this subchapter.
Sec. 61.9807. ADMINISTRATIVE COSTS. A reasonable amount,
not to exceed three percent, of any money appropriated for purposes
of this subchapter may be used to pay the costs of administering
this subchapter.
SECTION 9.02. As soon as practicable after the effective
date of this article, the Texas Higher Education Coordinating Board
shall adopt rules for the implementation and administration of the
Texas emergency and trauma care education partnership program
established under Subchapter GG, Chapter 61, Education Code, as
added by this Act. The board may adopt the initial rules in the
manner provided by law for emergency rules.
ARTICLE 10. EFFECTIVE DATE
SECTION 10.01. Except as otherwise provided by this Act,
this Act takes effect on the 91st day after the last day of the
legislative session.