Manuel Health Plan Bill Creates A Seven-Member Med-Pool Board

The text as introduced · 3,746 words

89R11869 JG-F

By: Manuel
H.B. No. 5244

A BILL TO BE ENTITLED

AN ACT

relating to the development and implementation of the Texas Plan

demonstration program to fund the purchase by and provision to

certain eligible individuals of health care services.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subtitle I, Title 4, Government Code, is amended

by adding Chapter 532A to read as follows:

CHAPTER 532A. TEXAS PLAN DEMONSTRATION PROGRAM

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 532A.0001. DEFINITIONS. In this chapter:

(1) "Board" means the board of directors of the

med-pool.

(2) "Eligible individual" means an individual who is

eligible to participate in the program.

(3) "Health benefit account" means a health benefit

account the comptroller establishes for a participant under

Subchapter E.

(4) "Health care provider" means:

(A) a primary care provider;

(B) a specialty and major medical care provider;

and

(C) an integrated health care organization.

(5) "Integrated health care organization" means a

health care organization that provides all of a participant's

health care needs, including primary care and specialty and major

medical care services, using a capitated payment model.

(6) "Med-pool" means the risk pool established under

Subchapter F to provide specialty and major medical care services

to participants.

(7) "Nondiscriminatory price" means a fixed,

transparent, nonnegotiable price for a health care service that a

health care provider charges each individual for the service

regardless of the payment model used to pay for the service.

(8) "Participant" means an individual who is enrolled

in the program.

(9) "Primary care provider" means a provider of

primary care services.

(10) "Primary care services" includes whole-person,

integrated, and accessible health care provided by

interprofessional teams that are engaged to address the majority of

an individual's health and wellness needs across different health

care settings through sustained relationships with patients,

families, and communities in order to achieve better health

outcomes, better care, and lower health care prices.

(11) "Program" means the Texas Plan demonstration

program established under this chapter.

(12) "Specialty and major medical care provider" means

a provider of specialty and major medical care services.

(13) "Specialty and major medical care services" means

health care services other than primary care services. The term

includes:

(A) emergency care;

(B) urgent care;

(C) hospital care;

(D) allergy and immunology;

(E) anesthesiology;

(F) cardiology;

(G) dermatology;

(H) diagnostic radiology;

(I) medical genetics;

(J) nephrology;

(K) neurology;

(L) nuclear medicine;

(M) obstetrics and gynecology;

(N) oncology;

(O) ophthalmology;

(P) orthopedics;

(Q) pathology;

(R) pediatrics;

(S) physical medicine and rehabilitation;

(T) psychiatry;

(U) radiation oncology;

(V) surgery; and

(W) urology.

Sec. 532A.0002. FEDERAL AUTHORIZATION FOR PROGRAM. (a)

The executive commissioner shall develop and seek a waiver under

Section 1115 of the Social Security Act (42 U.S.C. Section 1315) or,

if available, a block grant or comparable funding system that may be

used for this purpose to obtain any federal money available for

implementing the Texas Plan demonstration program to assist

eligible individuals in obtaining health care services.

(b) The terms of the waiver the executive commissioner seeks

must:

(1) be designed to:

(A) make high value health care services more

accessible to eligible individuals;

(B) provide money to cover the costs of a

participant's primary care services, specialty and major medical

care services, dental health services, prescription drugs, and

other eligible out-of-pocket health care expenses;

(C) for the purpose of shifting costs from

hospital care to prevention, emphasize the provision of capitated,

whole-person, person-centered primary care, including case

management, mental health services, and health system navigation,

as a core component of the program's overall health goals;

(D) improve health outcomes of participants

based on the value of care the program offers, including by:

(i) when diagnosing and treating a

participant, considering nonmedical factors that impact the

participant's health, including nutrition, transportation,

housing, and employment; and

(ii) to the extent possible, coordinating

with community health organizations and other local resources

available to address the nonmedical factors;

(E) emphasize and encourage price and quality

transparency by program health care providers to enable:

(i) a participant to make informed

decisions regarding health care price and quality; and

(ii) the commission and board to collect

accurate and current pricing information for each provider,

including nondiscriminatory price information;

(F) provide a framework for the commission and

board to use existing data sources or develop new data sources to

obtain and publish information on high-value care that:

(i) identifies health care providers who

provide low health care prices and high quality of care, including

health care centers of excellence; and

(ii) facilitates a participant's ability to

navigate between health care providers to obtain high-value care;

and

(G) subject to Section 532A.0104, provide

continuous coverage for participants for the duration of the

program;

(2) because some participants may have limited primary

care options, recognize a broad range of primary care arrangements

and providers under the program, including:

(A) direct primary care, advanced primary care,

and similar primary care service arrangements provided virtually or

on-site;

(B) federally qualified health centers, as

defined by 42 U.S.C. Section 1396d(l)(2)(B); and

(C) commercial retailers that provide primary

care services at a published, nondiscriminatory price for each

offered service;

(3) allow health care services to be provided remotely

as telehealth services or telemedicine medical services; and

(4) allow for the operation of the program consistent

with the requirements of this chapter for a period of five years,

except to the extent deviation from the requirements is necessary

to obtain the waiver.

Sec. 532A.0003. FUNDING. (a) Subject to approval of the

waiver described by Section 532A.0002, the commission shall

implement the program using federal money obtained and state money

available for that purpose.

(b) The commission shall implement the program in

accordance with the following spending requirements:

(1) except as provided by Subdivision (2), the

commission shall use state money appropriated for the program to

cover:

(A) the administrative costs of implementing and

operating the program; and

(B) the costs of med-pool health care claims and

excess loss coverage to protect the med-pool against financial

losses that may place the med-pool's solvency in financial

jeopardy; and

(2) except as provided by Subsection (c), the

commission shall use federal money received for the program and an

amount of state money appropriated for the program that the

commission determines necessary to cover the costs of providing

health care services to program participants by distributing the

money among each participant on a per capita basis in the following

proportions and manner:

(A) 25 percent of allocated money must be:

(i) used to cover the costs of providing a

participant's primary care services, including dental health and

prescription drug costs related to those services; and

(ii) deposited into the participant's

health benefit account in accordance with Subchapter E; and

(B) 75 percent of allocated money must be:

(i) used to cover the costs of providing a

participant's specialty and major medical care services, including

prescription drug costs related to those services; and

(ii) disbursed to the med-pool.

(c) For a participant who receives all of the participant's

health care needs from an integrated health care organization, the

commission shall:

(1) disburse 96 percent of the per capita amount

described by Subsection (b)(2) to the organization to cover the

costs of providing the participant's health care services; and

(2) deposit the remaining four percent into the

participant's health benefit account in accordance with Subchapter

E to cover the costs of eligible out-of-pocket health care

expenses.

Sec. 532A.0004. EXPIRATION. The program concludes and this

chapter expires September 1, 2031.

SUBCHAPTER B. PROGRAM ADMINISTRATION

Sec. 532A.0051. PROGRAM OBJECTIVE. The program's objective

is to enable eligible individuals to obtain, and to provide money to

participants to cover the costs of, health care services, including

dental health services, and prescription drugs in a manner that:

(1) offers convenient access to high-value care;

(2) prioritizes whole-person, person-centered,

coordinated primary care services; and

(3) lowers the overall costs for providing health care

services to participants over the course of the program.

Sec. 532A.0052. PROGRAM PROMOTION. The commission shall

promote and provide information on the program to individuals who

are potentially eligible to participate in the program. The

commission shall ensure the program's promotion is designed in a

manner to reach as many eligible individuals as possible.

Sec. 532A.0053. COMMISSION'S AUTHORITY RELATED TO

ELIGIBILITY AND MEDICAID COORDINATION. The commission may:

(1) accept applications for program participation and

implement program eligibility screening and enrollment procedures;

(2) resolve grievances related to eligibility

determinations; and

(3) to the extent possible, coordinate the program

with Medicaid and any exchange offering a health benefit plan under

the Patient Protection and Affordable Care Act (Pub. L. No.

111-148), as amended by the Health Care and Education

Reconciliation Act of 2010 (Pub. L. No. 111-152).

SUBCHAPTER C. PROGRAM ELIGIBILITY

Sec. 532A.0101. ELIGIBILITY REQUIREMENTS. An individual is

eligible to participate in the program if:

(1) the individual is a:

(A) citizen or permanent resident of the United

States; and

(B) resident of this state;

(2) the individual is 19 years of age or older but

younger than 65 years of age;

(3) applying the eligibility criteria in effect in

this state on December 31, 2024, the individual is not eligible for

Medicaid; and

(4) federal money is available to provide benefits to

the individual under the program.

Sec. 532A.0102. APPLICATION FORM AND PROCEDURES. (a) The

executive commissioner shall adopt an application form and

application procedures for the program. The form and procedures

may be coordinated with Medicaid forms and procedures to ensure

there is a single consolidated application process to seek health

care services under the program or Medicaid.

(b) To the extent possible, the commission shall make the

application form available in languages other than English.

(c) The executive commissioner may permit an individual to

apply by mail, over the telephone, or through the Internet.

Sec. 532A.0103. ELIGIBILITY SCREENING AND ENROLLMENT. (a)

The executive commissioner shall adopt eligibility screening and

enrollment procedures or use the Texas Integrated Enrollment

Services eligibility determination system or a compatible or

successor system to screen individuals and enroll eligible

individuals in the program.

(b) The eligibility screening and enrollment procedures

must ensure that an individual applying for the program who appears

eligible for Medicaid is identified and assisted with obtaining

Medicaid coverage. If the individual is denied Medicaid coverage

but is otherwise determined eligible to participate in the program,

the commission shall enroll the individual in the program without

additional application or qualification.

(c) Not later than the 30th day after the date an individual

submits a complete application form and unless the individual is

identified and assisted with obtaining Medicaid coverage under

Subsection (b), the commission shall ensure that the individual's

eligibility to participate in the program is determined and that

the individual is enrolled in the program.

(d) At the time an eligible individual is enrolled in the

program and using the database the commission establishes under

Section 532A.0152, the commission shall assist the individual in

selecting an accessible, high-value primary care provider under the

program. A participant may:

(1) change the participant's primary care provider at

any time; and

(2) contact the commission for assistance in selecting

a new primary care provider.

Sec. 532A.0104. CONTINUOUS COVERAGE; ELIGIBILITY

REDETERMINATION AND DISENROLLMENT. (a) If authorized by the terms

of the waiver the executive commissioner seeks under Section

532A.0002, the commission shall ensure that an individual who is

initially determined to be eligible to participate in the program

remains enrolled in the program until the program concludes.

(b) If the terms of the waiver the executive commissioner

seeks under Section 532A.0002 do not authorize continuous coverage

described by Subsection (a), the commission shall:

(1) redetermine a participant's eligibility to

participate in the program during the later of the 12th month

following the date the participant is initially enrolled in the

program or was most recently redetermined eligible for the program;

(2) to the extent possible, conduct an eligibility

redetermination automatically without requiring information from

the participant using information from verifiable electronic data

sources or that is otherwise available to the commission;

(3) not later than the 60th day before the expiration

of a participant's coverage period, take all reasonable steps to

notify the participant regarding the eligibility redetermination

process and request documentation necessary to redetermine the

participant's eligibility;

(4) disenroll a participant from the program if:

(A) the participant does not submit the requested

eligibility redetermination documentation on or before the last day

of the participant's coverage period; or

(B) the commission, based on the submitted

documentation, determines the participant is no longer eligible to

participate in the program; and

(5) ensure the eligibility redetermination process is

as seamless and contains as little administrative burden for the

participant as possible to facilitate the participant's successful

eligibility redetermination.

SUBCHAPTER D. HEALTH CARE PROVIDERS AND PROVISION OF HEALTH CARE

UNDER PROGRAM

Sec. 532A.0151. HEALTH CARE PROVIDER REGISTRATION AND

PRICING INFORMATION. (a) The commission shall establish a

streamlined registration process through which a health care

provider may register to participate in the program.

(b) As part of the registration process, a health care

provider may submit to the commission:

(1) information on:

(A) the provider's office location; and

(B) specific pricing information the provider

charges for a health care service, including pricing information

on, as applicable:

(i) capitated arrangements;

(ii) bundled services;

(iii) fee-for-service prices; and

(iv) health care services for which the

provider charges a nondiscriminatory price; and

(2) other information or data the provider determines

relevant to allow the commission and board to assess the provider's

value of care based on metrics that include:

(A) patient-reported health outcomes for

patients the provider serves; and

(B) the provider's quality of care provided based

on objective clinical metrics.

(c) The commission shall ensure a health care provider is

able to easily and timely update any information the provider

submits.

(d) A primary care provider charging a monthly or annual

capitated rate may not charge a participant for a health care

service, regardless of the payment model used to pay for the

service, in an amount that is greater than the amount specified for

that service in the pricing information submitted under this

section but may charge participants different amounts in accordance

with price categories the provider establishes based on age or

gender only if the provider charges the same price for all

participants in those price categories.

(e) The commission, in collaboration with the board, may

develop processes to ensure information on a health care provider's

pricing and quality of care is accurate and up-to-date to enable the

commission and board to adequately and meaningfully measure and

assess the provider's value of services for the purpose of

compiling and processing data under Section 532A.0152.

Sec. 532A.0152. VALUE OF CARE METRICS AND DATA; PROVIDER

DATABASE. (a) The commission may develop and use metrics to

measure and assess the value of care provided by program health care

providers who submit to the commission the information described by

Section 532A.0151. The metrics may:

(1) include measurements that demonstrate

improvements in an individual's objective and subjective health

outcomes relative to the cost of achieving those improvements; and

(2) be designed to measure as broad a range of health

care services as is practicable, including:

(A) primary care services; and

(B) specialty and major medical care services.

(b) The commission may compile and process data on a health

care provider's value of care based on the measurements and

assessments submitted to the commission by the provider or based on

information independently obtained by the commission or board. The

commission shall ensure the data is sufficient to enable a

participant to make informed decisions in selecting, including at

the time the participant is initially enrolled in the program,

health care providers that:

(1) are accessible to the participant; and

(2) provide high-value care.

(c) The commission may develop and maintain a public

machine-readable database of high-value program health care

providers as the commission and board determine in accordance with

this section.

(d) The commission shall collaborate with the board in

implementing this section.

Sec. 532A.0153. SPECIALTY AND MAJOR MEDICAL CARE. (a) The

med-pool or integrated health care organization with which a

participant enrolls shall pay the costs for providing the

participant's specialty and major medical care services, including

prescription drug costs related to those services.

(b) The board and commission shall develop and implement

procedures for a participant to seek and obtain payment for

specialty and major medical care costs the participant incurs.

Sec. 532A.0154. EMERGENCY CARE PRICING. Unless the board

determines otherwise or contracts for a lesser rate, emergency care

services provided to a participant through the med-pool or an

integrated health care organization will be reimbursed at the same

rate at which those services are reimbursed under the Medicare

program.

SUBCHAPTER E. HEALTH BENEFIT ACCOUNTS

Sec. 532A.0201. ESTABLISHMENT OF HEALTH BENEFIT ACCOUNTS.

(a) The comptroller, in collaboration with the commission and

board, shall establish and maintain for each participant a health

benefit account that is funded in accordance with this subchapter.

The comptroller may contract with a qualified entity to perform the

comptroller's duties under this subchapter.

(b) The comptroller shall establish an electronic portal or

similar system through which a participant may electronically

access and manage money in and information regarding the

participant's health benefit account.

Sec. 532A.0202. HEALTH BENEFIT ACCOUNT FUNDING. Subject to

Section 532A.0003, the comptroller shall fund each participant's

health benefit account with federal and state money in accordance

with Section 532A.0003(b). The amount deposited must be:

(1) equal for each participant based on the program's

total funding and the spending requirements prescribed in Section

532A.0003; and

(2) in excess of money remaining in a participant's

health benefit account from a preceding coverage period, as

applicable.

Sec. 532A.0203. USE OF HEALTH BENEFIT ACCOUNT MONEY. (a) A

participant may use money in the participant's health benefit

account to pay primary care costs, including dental health costs,

prescription drug costs related to primary care services, and other

eligible out-of-pocket health care expenses. The comptroller shall

issue to the participant an electronic payment card that allows the

participant to use the card to pay costs described by this section.

(b) For purposes of this section, "eligible out-of-pocket

health care expense" means a health care-related expense not

covered by the primary care capitation rate, including copayments

for blood draws and other primary care services, over-the-counter

medications, vision care, and copayments that may be required for

specialty and major medical care services.

Sec. 532A.0204. CLOSING OF HEALTH BENEFIT ACCOUNT. If at

the end of a participant's coverage period the participant chooses

to cease participating in the program or is no longer eligible to

participate in the program, the comptroller shall close the

participant's health benefit account and the commission shall:

(1) recoup any money remaining in the account at the

time it is closed; and

(2) use the recouped money to continue to fund the

program in accordance with the spending requirements prescribed by

Section 532A.0003.

SUBCHAPTER F. MED-POOL

Sec. 532A.0251. ESTABLISHMENT. The med-pool is established

to provide specialty and major medical care services to

participants.

Sec. 532A.0252. BOARD OF DIRECTORS. (a) The med-pool is

governed by a board of directors. The board is composed of the

following seven members appointed by the executive commissioner:

(1) two members with appropriate expertise in health

insurance, risk pools, and the evaluation of risk within risk

pools;

(2) one member who is a licensed physician;

(3) one member with appropriate expertise in health

care technology;

(4) one member who is a representative of a federally

qualified health center;

(5) one member who is a representative of a community

health organization; and

(6) one public member.

(b) In making appointments under Subsection (a), the

executive commissioner shall make an effort to select board members

who reflect the ethnic and geographic diversity of this state.

(c) The board shall select from among the board members a

presiding officer.

Sec. 532A.0253. EXCESS LOSS COVERAGE AUTHORIZED. The board

may purchase excess loss coverage for the med-pool to the extent

available state money is insufficient to protect the med-pool

against actuarially projected financial losses the board

determines may place the med-pool's solvency in financial jeopardy.

Sec. 532A.0254. INVESTMENTS. (a) The board shall invest

med-pool money in accordance with Subchapter A, Chapter 2256,

Government Code, to the extent that law can be made applicable.

(b) In addition to investments authorized under Subchapter

A, Chapter 2256, Government Code, the board may invest med-pool

money in any investment authorized under Subtitle B, Title 9,

Property Code.

Sec. 532A.0255. AUDITS. (a) The board shall have the

med-pool's fiscal accounts and records audited annually by an

independent auditor. The audit must cover the med-pool's fiscal

year.

(b) The independent auditor must be a certified public

accountant or public accountant licensed by the Texas State Board

of Public Accountancy.

(c) The board shall file annually with the commission a copy

of the audit report. The commission shall make copies of the audit

reports available to the public on the commission's Internet

website.

Sec. 532A.0256. APPLICATION OF CERTAIN LAWS. The med-pool

is not:

(1) insurance or an insurer under the Insurance Code

and other laws of this state; or

(2) subject to regulation by the commissioner of

insurance or the Texas Department of Insurance.

Sec. 532A.0257. LOW-VALUE PROVIDER COPAYMENT. The med-pool

may require that a participant pay a copayment for services

received from a provider that the commission has designated as a

low-value provider unless a high-value provider is not available to

the participant. The participant may use money in the participant's

health benefit account to pay this expense.

SECTION 2. (a) The executive commissioner of the Health and

Human Services Commission shall:

(1) apply for and actively pursue from the Centers for

Medicare and Medicaid Services or another appropriate federal

agency the waiver as required by Section 532A.0002, Government

Code, as added by this Act, as soon as practicable after the

effective date of this Act; and

(2) begin operating the Texas Plan demonstration

program under Chapter 532A, Government Code, as added by this Act,

not later than September 1, 2026.

(b) The Health and Human Services Commission may delay

implementing this Act until the waiver described by Subsection

(a)(1) of this section is granted.

SECTION 3. This Act takes effect immediately if it receives

a vote of two-thirds of all the members elected to each house, as

provided by Section 39, Article III, Texas Constitution. If this

Act does not receive the vote necessary for immediate effect, this

Act takes effect September 1, 2025.