Bill Text: TX HB4127 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to the Healthy Texas Program; authorizing a fee.
Spectrum: Partisan Bill (Democrat 4-0)
Status: (Introduced - Dead) 2019-04-09 - Left pending in committee [HB4127 Detail]
Download: Texas-2019-HB4127-Introduced.html
86R1044 LED-F | ||
By: Hinojosa | H.B. No. 4127 |
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relating to the Healthy Texas Program; authorizing a fee. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Title 8, Insurance Code, is amended by adding | ||
Subtitle N to read as follows: | ||
SUBTITLE N. HEALTHY TEXAS PROGRAM | ||
CHAPTER 1698. HEALTHY TEXAS PROGRAM | ||
SUBCHAPTER A. GENERAL PROVISIONS | ||
Sec. 1698.001. DEFINITIONS. In this chapter: | ||
(1) "Affordable Care Act" means 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). | ||
(2) "Allied health practitioner": | ||
(A) means a health care professional who: | ||
(i) works to prevent disease transmission, | ||
or diagnose, treat, or rehabilitate individuals; and | ||
(ii) delivers direct patient care, | ||
rehabilitation, treatment, diagnostics, and health improvement | ||
interventions to restore and maintain optimal physical, sensory, | ||
psychological, cognitive, and social functions; and | ||
(B) includes technical and support staff, | ||
audiologists, occupational therapists, social workers, and | ||
radiographers. | ||
(3) "Board" means the Healthy Texas Board established | ||
under Section 1698.051. | ||
(4) "Care coordination" means the services described | ||
by Section 1698.152. | ||
(5) "Care coordinator" means a person approved by the | ||
board to provide care coordination. | ||
(6) "Child health plan program" means the state | ||
children's health insurance program established under Title XXI, | ||
Social Security Act (42 U.S.C. Section 1397aa et seq.), or the | ||
programs established under Chapters 62 and 63, Health and Safety | ||
Code, as appropriate. | ||
(7) "Essential community provider" means a person | ||
acting as a safety net clinic, safety net health care provider, or | ||
rural hospital. | ||
(8) "Federally matched public health program" means: | ||
(A) Medicaid; or | ||
(B) the child health plan program. | ||
(9) "Fund" means the healthy Texas fund established | ||
under Section 1698.252. | ||
(10) "Health benefit plan issuer" means an insurance | ||
company or health maintenance organization regulated by the | ||
department and authorized to issue a health insurance policy or | ||
other health benefit plan. The term includes: | ||
(A) a stock life, health, or accident insurance | ||
company; | ||
(B) a mutual life, health, or accident insurance | ||
company; | ||
(C) a stock casualty insurance company; | ||
(D) a mutual casualty insurance company; | ||
(E) a Lloyd's plan; | ||
(F) a reciprocal or interinsurance exchange; | ||
(G) a fraternal benefit society; | ||
(H) a stipulated premium company; | ||
(I) a nonprofit hospital, medical, or dental | ||
service corporation, including a company subject to Chapter 842; | ||
and | ||
(J) a health maintenance organization. | ||
(11) "Health care organization" means a | ||
not-for-profit or public organization that is approved by the board | ||
to provide health care services to members under the program. | ||
(12) "Health care provider" means a person that is | ||
licensed, certified, or otherwise authorized by the laws of this | ||
state to provide or render health care in the ordinary course of | ||
business or practice of a profession. | ||
(13) "Health care providers' representative" means a | ||
third party that is authorized by health care providers to | ||
negotiate on their behalf with the program related to terms and | ||
conditions affecting those health care providers. | ||
(14) "Health care service" means any health care | ||
service, including care coordination, that is included as a benefit | ||
under the program. | ||
(15) "Integrated health care delivery system" means a | ||
provider organization that is: | ||
(A) fully integrated operationally and | ||
clinically to provide a broad range of health care services, | ||
including preventive care, prenatal and well-baby care, | ||
immunizations, screening diagnostics, emergency services, hospital | ||
and medical services, surgical services, and ancillary services; | ||
and | ||
(B) compensated by the program using capitation | ||
or facility budgets for the provision of health care services. | ||
(16) "Long-term care services" has the meaning | ||
assigned by Section 22.0011, Human Resources Code. | ||
(17) "Medicaid" means the medical assistance program | ||
established under Title XIX, Social Security Act (42 U.S.C. Section | ||
1396 et seq.), or the medical assistance program established under | ||
Chapter 32, Human Resources Code, as appropriate. | ||
(18) "Medicare" means the Health Insurance for the | ||
Aged Act under Title XVIII of the Social Security Act (42 U.S.C. | ||
Section 1395 et seq.). | ||
(19) "Member" means an individual who is enrolled in | ||
the program. | ||
(20) "Out-of-state health care service": | ||
(A) means a health care service that: | ||
(i) is provided in person to a member while | ||
the member is physically located outside this state; and | ||
(ii) is: | ||
(a) medically necessary to be | ||
provided while the member is physically outside this state; or | ||
(b) clinically appropriate and | ||
necessary and cannot be provided in this state because the health | ||
care service can be provided only by a particular health care | ||
provider physically located outside this state; and | ||
(B) does not include a health care service | ||
provided to a member by a health care provider qualified under | ||
Section 1698.151 that is physically located outside this state. | ||
(21) "Participating provider" means: | ||
(A) a person that is a health care provider | ||
qualified under Section 1698.151 that provides health care services | ||
to members under the program; or | ||
(B) a health care organization. | ||
(22) "Prescription drug" has the meaning assigned by | ||
Section 551.003, Occupations Code. | ||
(23) "Program" means the Healthy Texas Program | ||
established under this chapter. | ||
(24) "Resident" means an individual whose primary | ||
place of residence is located in this state without regard to the | ||
individual's immigration status. | ||
Sec. 1698.002. COVERAGE NOT EXCLUSIVE. This chapter does | ||
not preempt a political subdivision from adopting additional health | ||
care coverage that provides additional protections and benefits to | ||
residents in the political subdivision's jurisdiction. | ||
Sec. 1698.003. CONFLICT WITH OTHER LAW. (a) To the extent | ||
any provision of state law is inconsistent with this chapter, this | ||
chapter prevails, except as explicitly provided otherwise by this | ||
chapter. | ||
(b) This chapter may not be construed to alter in any way the | ||
professional practice of health care providers or licensure | ||
standards established under Title 3, Occupations Code. | ||
SUBCHAPTER B. HEALTHY TEXAS BOARD | ||
Sec. 1698.051. HEALTHY TEXAS BOARD. The Healthy Texas | ||
Board is an agency of this state. | ||
Sec. 1698.052. COMPOSITION OF BOARD. The board is composed | ||
of the following nine members: | ||
(1) four appointed by the governor; | ||
(2) two appointed by the lieutenant governor; | ||
(3) two appointed by the speaker of the house of | ||
representatives; and | ||
(4) the executive commissioner of the Health and Human | ||
Services Commission, or the executive commissioner's designee, who | ||
serves as a voting, ex officio member. | ||
Sec. 1698.053. TERM; VACANCY. (a) Board members other than | ||
an ex officio member shall be appointed for a term of two years. | ||
(b) A vacancy must be filled for the unexpired term in the | ||
same manner as the original appointment. | ||
Sec. 1698.054. BOARD MEMBER QUALIFICATIONS. (a) Each | ||
board member must: | ||
(1) be a resident; and | ||
(2) have demonstrated and acknowledged expertise in | ||
health care. | ||
(b) An individual may not be a board member unless the | ||
individual is a member of the program. This subsection does not | ||
apply to an ex officio member. | ||
(c) Of the eight board members appointed by the governor, | ||
lieutenant governor, and speaker of the house of representatives: | ||
(1) at least one board member must represent a labor | ||
organization representing registered nurses; | ||
(2) at least one board member must represent the | ||
general public; | ||
(3) at least one board member must represent a labor | ||
organization; and | ||
(4) at least one board member must represent the | ||
medical provider community. | ||
(d) The governor, lieutenant governor, and speaker of the | ||
house of representatives shall consider: | ||
(1) the expertise of each board member and attempt to | ||
make appointments so that the board's composition reflects a | ||
diversity of expertise in the various aspects of health care; and | ||
(2) the cultural, ethnic, and geographic diversity of | ||
the state and attempt to make appointments so that the board's | ||
composition reflects the communities of Texas. | ||
(e) Each board member shall: | ||
(1) meet the requirements of this chapter, the | ||
Affordable Care Act, and all applicable state and federal laws and | ||
regulations; | ||
(2) serve the public interest of the individuals, | ||
employers, and taxpayers seeking health care coverage through the | ||
program; and | ||
(3) ensure the operational well-being and fiscal | ||
solvency of the program. | ||
(f) A board member or employee of the board may not: | ||
(1) be employed by, a consultant to, a member of the | ||
board of directors of, affiliated with, or otherwise a | ||
representative of a health care provider, a health care facility, | ||
or a health clinic while serving on the board or as an employee of | ||
the board; | ||
(2) be a member, a board member, or an employee of a | ||
trade association of health care facilities, health clinics, or | ||
health care providers while serving on the board or as an employee | ||
of the board; or | ||
(3) be a health care provider unless the board member | ||
or employee receives no compensation for rendering services as a | ||
health care provider and does not have an ownership interest in a | ||
health care practice. | ||
Sec. 1698.055. BOARD MEMBER COMPENSATION. A board member | ||
may not receive compensation but is entitled to reimbursement of | ||
the travel expenses incurred by the board member while conducting | ||
the business of the board, as provided in the General | ||
Appropriations Act. | ||
Sec. 1698.056. CONFLICT OF INTEREST. (a) A board member | ||
may not make, participate in making, or in any way attempt to make | ||
use of the board member's official position to influence the making | ||
of a decision the board member knows or has reason to know will have | ||
a material financial effect, distinguishable from its effect on the | ||
public generally, on: | ||
(1) the board member or a member of the board member's | ||
immediate family; | ||
(2) a person or entity that was the source of a benefit | ||
or benefits aggregating $250 or more in value received by or | ||
promised to the board member within 12 months before the date the | ||
decision is made; or | ||
(3) a business entity in which the board member is a | ||
director, officer, partner, trustee, or employee, or holds any | ||
position of management. | ||
(b) For purposes of Subsection (a), "benefit" has the | ||
meaning assigned by Section 36.01, Penal Code, but does not | ||
include: | ||
(1) a gift; or | ||
(2) a loan by a commercial lending institution in the | ||
regular course of business on terms available to the public. | ||
Sec. 1698.057. IMMUNITY. The following persons are not | ||
liable, and a cause of action does not arise against any of the | ||
following persons, for a good faith act or omission in exercising | ||
powers and performing duties under this chapter: | ||
(1) the board; | ||
(2) a board member; or | ||
(3) an officer or employee of the board. | ||
Sec. 1698.058. BOARD ELECTION. The board annually shall | ||
elect a chairperson. | ||
Sec. 1698.059. EXECUTIVE DIRECTOR. The board shall hire an | ||
executive director to organize, administer, and manage the program | ||
and the operations of the board. The executive director serves at | ||
the pleasure of the board. | ||
Sec. 1698.060. OPEN MEETINGS; OPEN RECORDS. The board is | ||
subject to Chapters 551 and 552, Government Code. The board may | ||
conduct a closed meeting to deliberate: | ||
(1) business and financial issues relating to a | ||
contract being negotiated; or | ||
(2) rates to be paid under the program. | ||
Sec. 1698.061. RULES. (a) The board may adopt rules | ||
necessary to implement and enforce this chapter. | ||
(b) The board by rule shall set fees in amounts reasonable | ||
and necessary to implement this chapter. | ||
(c) The board by rule shall establish dispute resolution | ||
procedures to address member disputes. Dispute resolution | ||
procedures must: | ||
(1) include a patient advocate to assist members in | ||
the dispute resolution process; and | ||
(2) provide for a member to withdraw from the program. | ||
(d) The board may adopt narrowly focused rules relating | ||
solely to health care organizations for the specific purpose of | ||
ensuring consistent compliance with this chapter. | ||
Sec. 1698.062. ADVISORY COMMITTEE. (a) The executive | ||
commissioner of the Health and Human Services Commission shall | ||
establish an advisory committee to advise the board on all policy | ||
matters for the program. | ||
(b) The advisory committee is composed of 22 members | ||
appointed by the governor, lieutenant governor, or speaker of the | ||
house of representatives as follows: | ||
(1) the governor shall appoint: | ||
(A) one board-certified physician; | ||
(B) one dentist; | ||
(C) one representative of private hospitals; | ||
(D) one representative of public hospitals; | ||
(E) one representative of an integrated health | ||
care delivery system; | ||
(F) two consumers of health care, one of whom is a | ||
person with a disability; and | ||
(G) one representative of a business that employs | ||
fewer than 25 people; | ||
(2) the lieutenant governor shall appoint: | ||
(A) one board-certified physician; | ||
(B) two registered nurses; | ||
(C) one mental health care provider; | ||
(D) one consumer of health care who is at least 65 | ||
years of age; | ||
(E) one representative of essential community | ||
providers; and | ||
(F) one member of organized labor; and | ||
(3) the speaker of the house shall appoint: | ||
(A) two board-certified physicians, both of whom | ||
must be primary care providers; | ||
(B) one allied health practitioner who holds a | ||
license to practice a health care profession; | ||
(C) one pharmacist; | ||
(D) one consumer of health care; | ||
(E) one representative of organized labor; and | ||
(F) one representative of a business that employs | ||
more than 250 people. | ||
(c) Of the board-certified physicians appointed under | ||
Subsections (b)(1)(A), (b)(2)(A), and (b)(3)(A), at least one must | ||
be a psychiatrist. | ||
(d) In making appointments under this section, the | ||
governor, lieutenant governor, and speaker of the house of | ||
representatives shall attempt to reflect the geographic and | ||
economic diversity of the state. Appointments to the committee | ||
shall be made without regard to the race, color, sex, religion, age, | ||
or national origin of the appointees. | ||
(e) A committee member serves a four-year term and may be | ||
reappointed. | ||
(f) The executive commissioner of the Health and Human | ||
Services Commission shall notify the appropriate appointing | ||
authority of any expected vacancies on the advisory committee. If a | ||
vacancy occurs on the committee, the appropriate appointing | ||
authority shall appoint a successor, in the same manner as the | ||
original appointment, to serve for the remainder of the unexpired | ||
term. The appropriate appointing authority shall appoint the | ||
successor not later than the 30th day after the date the vacancy | ||
occurs. | ||
(g) A committee member: | ||
(1) may not receive compensation for serving on the | ||
committee; | ||
(2) is entitled to reimbursement for travel expenses | ||
incurred by the committee member while conducting the business of | ||
the committee; and | ||
(3) is entitled to the per diem provided by the General | ||
Appropriations Act for attending meetings of the committee. | ||
(h) The advisory committee shall meet at least six times per | ||
year in a place convenient to the public. | ||
(i) The advisory committee is subject to Chapters 551 and | ||
552, Government Code. | ||
(j) The advisory committee shall elect a chairperson who | ||
shall serve for two years and may be reelected for an additional two | ||
years. | ||
(k) To be eligible for appointment to the advisory | ||
committee, an individual must have worked in the field the | ||
individual represents on the committee for a period of at least two | ||
years before being appointed to the committee. | ||
(l) An advisory committee member or individual working with | ||
or for a committee member may not use for personal benefit any | ||
information that is filed with or obtained by the committee and that | ||
is not generally available to the public. | ||
(m) The board shall provide administrative support, | ||
including staff, for the advisory committee. | ||
(n) The advisory committee is not subject to Chapter 2110, | ||
Government Code. | ||
Sec. 1698.063. POWERS AND DUTIES OF BOARD; HEALTHY TEXAS | ||
PROGRAM. (a) The board has all the powers and duties necessary to | ||
establish and implement the program. | ||
(b) The board shall, to the extent possible, organize, | ||
administer, and market the program and services as a comprehensive | ||
universal single-payer program under the name "Healthy Texas | ||
Program" or any other name the board adopts. The program shall be | ||
administered regardless of the law or source in which the | ||
definition of a benefit is found, including, subject to the | ||
election of the retiree, retiree health benefits. | ||
(c) In implementing this chapter, the board shall avoid | ||
jeopardizing federal financial participation in the federally | ||
supported programs that are incorporated into the program. | ||
(d) The board shall promote public understanding and | ||
awareness of available benefits and programs. | ||
(e) The board may consider any matter necessary to implement | ||
this chapter and the purposes of this chapter. The board does not | ||
have any executive, administrative, or appointive duties except as | ||
provided by this chapter or other law. | ||
(f) The board shall employ necessary staff and authorize | ||
reasonable expenditures, as necessary, from the fund to pay program | ||
expenses and to administer the program. | ||
(g) The board may: | ||
(1) sue and be sued; | ||
(2) receive and accept gifts, grants, or donations of | ||
money from any agency of the federal government, any agency of this | ||
state, or any municipality, county, or other political subdivision | ||
of this state; | ||
(3) receive and accept gifts, grants, or donations | ||
from individuals, associations, private foundations, or | ||
corporations, in compliance with the conflict-of-interest | ||
provisions adopted by board rule; and | ||
(4) share information with relevant state | ||
governmental entities, in a manner that is consistent with the | ||
confidentiality provisions in this chapter, necessary for | ||
administering the program. | ||
Sec. 1698.064. CONTRACTS. (a) The board may enter into any | ||
necessary contracts, including contracts with health care | ||
providers, integrated health care delivery systems, and care | ||
coordinators. | ||
(b) The board may contract with a not-for-profit | ||
organization to provide assistance to: | ||
(1) consumers with respect to selecting a care | ||
coordinator or health care organization, enrolling to obtain | ||
services available through the program, obtaining health care | ||
services, withdrawing from the program or from an aspect of the | ||
program, and other matters relating to the program; or | ||
(2) health care providers providing, seeking, or | ||
considering whether to provide health care services under the | ||
program with respect to participating in a health care organization | ||
and interacting with a health care organization. | ||
Sec. 1698.065. DATA TRANSPARENCY. (a) To promote | ||
transparency, assess adherence to patient care standards, compare | ||
patient outcomes, and review use of health care services paid for by | ||
the program, the board shall provide for the collection and | ||
availability of: | ||
(1) inpatient discharge data, including acuity and | ||
risk of mortality; | ||
(2) emergency department and ambulatory surgery data, | ||
including charge data, length of stay, and patients' unit of | ||
observation; and | ||
(3) hospital annual financial data, including: | ||
(A) community benefits by hospital in dollar | ||
value; | ||
(B) number and classification of employees by | ||
hospital unit; | ||
(C) number of hours worked by hospital unit; | ||
(D) employee wage information by job title and | ||
hospital unit; | ||
(E) number of registered nurses per staffed bed | ||
by hospital unit; | ||
(F) type and value of health information | ||
technology; and | ||
(G) annual spending on health information | ||
technology, including purchases, upgrades, and maintenance. | ||
(b) The board shall make all disclosed data collected under | ||
Subsection (a) publicly available and searchable on an Internet | ||
website established and maintained by the Department of State | ||
Health Services. | ||
(c) The board shall, directly and through grants to | ||
not-for-profit entities, conduct programs using data collected | ||
through the program to promote and protect public, environmental, | ||
and occupational health, including cooperation with other data | ||
collection and research programs of the Department of State Health | ||
Services and the Health and Human Services Commission, consistent | ||
with this chapter and other applicable law. | ||
Sec. 1698.066. DISCLOSURE OF PERSONALLY IDENTIFIABLE | ||
INFORMATION. (a) Notwithstanding any other law, the board, the | ||
program, a state or local agency, or a public employee acting under | ||
color of law may not provide or disclose to anyone, including the | ||
federal government, any personally identifiable information | ||
obtained under this chapter, including an individual's religious | ||
beliefs, practices, or affiliation, national origin, ethnicity, or | ||
immigration status for law enforcement or immigration purposes. | ||
(b) Notwithstanding any other law, a law enforcement agency | ||
may not use the money, facilities, property, equipment, or | ||
personnel of the board or the program to investigate, enforce, or | ||
assist in the investigation or enforcement of any criminal, civil, | ||
or administrative violation or warrant for a violation of any | ||
requirement that individuals register with the federal government | ||
or any federal agency based on religion, national origin, | ||
ethnicity, or immigration status. | ||
SUBCHAPTER C. ELIGIBILITY AND ENROLLMENT | ||
Sec. 1698.101. ELIGIBILITY AND ENROLLMENT. (a) Every | ||
resident is eligible and entitled to enroll as a member under the | ||
program. | ||
(b) A member may not be required to pay: | ||
(1) any fee, payment, or other charge for enrolling in | ||
or being a member under the program; or | ||
(2) any premium, co-payment, coinsurance, deductible, | ||
or any other form of cost sharing for all covered benefits. | ||
(c) A college, university, or other institution of higher | ||
education in this state may purchase coverage under the program for | ||
a student, or a student's dependent, who is not a resident. | ||
SUBCHAPTER D. BENEFITS | ||
Sec. 1698.121. BENEFITS. (a) Covered health care benefits | ||
under the program include all medical care determined to be | ||
medically appropriate by a member's health care provider. | ||
(b) Covered health care benefits for a member include: | ||
(1) inpatient and outpatient medical and health | ||
facility services; | ||
(2) inpatient and outpatient professional health care | ||
provider medical services; | ||
(3) diagnostic imaging, laboratory services, and | ||
other diagnostic and evaluative services; | ||
(4) medical equipment, appliances, and assistive | ||
technology, including prosthetics, eyeglasses, and hearing aids | ||
and the repair, technical support, and customization needed for | ||
individual use; | ||
(5) inpatient and outpatient rehabilitative care; | ||
(6) emergency care services; | ||
(7) emergency transportation; | ||
(8) necessary transportation for health care services | ||
for an individual with a disability or who may qualify as low | ||
income; | ||
(9) child and adult immunizations and preventive care; | ||
(10) health and wellness education; | ||
(11) hospice care; | ||
(12) care in a skilled nursing facility; | ||
(13) home health care, including health care provided | ||
in an assisted living facility; | ||
(14) mental health services; | ||
(15) substance abuse treatment; | ||
(16) dental care; | ||
(17) vision care; | ||
(18) prescription drugs; | ||
(19) pediatric care; | ||
(20) prenatal and postnatal care; | ||
(21) podiatric care; | ||
(22) chiropractic care; | ||
(23) acupuncture; | ||
(24) therapies that are shown by the National | ||
Institutes of Health, National Center for Complementary and | ||
Integrative Health to be safe and effective; | ||
(25) blood and blood products; | ||
(26) dialysis; | ||
(27) adult day care; | ||
(28) rehabilitative and habilitative services; | ||
(29) ancillary health care or social services covered | ||
by a local health care system before the effective date of the | ||
program; | ||
(30) ancillary health care or social services covered | ||
by a community center for persons with developmental disabilities | ||
under Chapter 534, Health and Safety Code, before the effective | ||
date of the program; | ||
(31) case management and care coordination; | ||
(32) language interpretation and translation for | ||
health care services, including sign language, Braille, or other | ||
services needed for individuals with communication barriers; and | ||
(33) health care and long-term supportive services | ||
covered under Medicaid or the child health plan program before the | ||
effective date of the program. | ||
(c) Covered health care benefits for a member also include | ||
all health care services required to be covered under any of the | ||
following programs or by the following providers, without regard to | ||
whether the member would otherwise be eligible for or covered by the | ||
program or source listed: | ||
(1) the child health plan program; | ||
(2) Medicaid; | ||
(3) Medicare; | ||
(4) a health benefit plan issuer under this code; | ||
(5) any additional health care service authorized to | ||
be added to the program's benefits by the board; and | ||
(6) all essential health benefits mandated by the | ||
Affordable Care Act. | ||
Sec. 1698.122. BENEFITS OFFERED BY A HEALTH BENEFIT PLAN | ||
ISSUER. (a) Except as provided by Subsection (b), a health benefit | ||
plan issuer may not offer benefits or cover any services for which | ||
coverage is offered to individuals under the program but may, if | ||
otherwise authorized, offer benefits to cover health care services | ||
that are not offered to individuals under the program. | ||
(b) This chapter does not prohibit a health benefit plan | ||
issuer from offering benefits to or for individuals, including | ||
their families, who are employed or self-employed in this state but | ||
who are not residents. | ||
SUBCHAPTER E. DELIVERY OF CARE | ||
Sec. 1698.151. HEALTH CARE PROVIDERS. (a) A health care | ||
provider may participate in the program to perform services in this | ||
state. | ||
(b) The board shall establish and maintain procedures and | ||
standards for recognizing health care providers physically located | ||
outside this state to provide coverage under the program for | ||
members who require out-of-state health care services while | ||
temporarily located outside this state. | ||
(c) A participating provider may provide covered health | ||
care services under the program that the provider is authorized to | ||
perform for the member under the applicable circumstances. | ||
(d) A member may choose to receive health care services | ||
under the program from any participating provider, consistent with: | ||
(1) this chapter; | ||
(2) the willingness or availability of the provider, | ||
subject to provisions of this chapter relating to discrimination; | ||
and | ||
(3) the applicable clinically relevant circumstances. | ||
(e) Subject to Subsection (f), a member who chooses to | ||
enroll with an integrated health care delivery system, group | ||
medical practice, or essential community provider that offers | ||
comprehensive services must retain membership with the system, | ||
practice, or provider until the first anniversary of the date an | ||
initial 90-day evaluation period expires. The member may withdraw | ||
from the system, practice, or provider for any reason during the | ||
evaluation period. The initial 90-day evaluation period commences | ||
on the date the member first sees a primary care provider. | ||
(f) A member who wants to withdraw after the initial 90-day | ||
evaluation period must request a withdrawal under the dispute | ||
resolution procedures established by the board and may request | ||
assistance from the patient advocate in resolving the dispute. The | ||
dispute must be resolved in a timely manner and may not have an | ||
adverse effect on the care the member receives. | ||
Sec. 1698.152. CARE COORDINATION. (a) A member's care | ||
coordinator shall provide care coordination to the member. A care | ||
coordinator may employ or use the services of other individuals or | ||
entities to assist in providing care coordination for the member | ||
consistent with board rules, statutory requirements, and | ||
applicable occupational regulations. | ||
(b) Care coordination includes administrative tracking and | ||
medical recordkeeping services for members, except as otherwise | ||
specified for integrated health care delivery systems. | ||
(c) Care coordination administrative tracking and medical | ||
recordkeeping services for members may not be required to use a | ||
certified electronic health record, meet any other requirements of | ||
the Health Information Technology for Economic and Clinical Health | ||
Act, enacted under the American Recovery and Reinvestment Act of | ||
2009 (Pub. L. No. 111-5), or meet certification requirements of the | ||
Centers for Medicare and Medicaid Services' electronic health | ||
record incentive programs, including meaningful use requirements. | ||
(d) A referral from a care coordinator is not required for a | ||
member to see an eligible provider. | ||
Sec. 1698.153. CARE COORDINATORS. (a) A care coordinator | ||
shall comply with all federal and state privacy laws, including: | ||
(1) the Health Insurance Portability and | ||
Accountability Act of 1996 (Pub. L. No. 104-191) and regulations | ||
adopted under that Act; | ||
(2) state law relating to the confidentiality of | ||
medical information, including Chapter 181, Health and Safety Code; | ||
(3) Subtitle D, Title 5; and | ||
(4) Title 11, Business & Commerce Code. | ||
(b) A care coordinator may be an individual or entity | ||
approved by the program that is: | ||
(1) a health care practitioner who is: | ||
(A) the member's primary care provider; | ||
(B) the member's provider of primary | ||
gynecological care; or | ||
(C) at the option of a member who has a chronic | ||
condition that requires specialty care, a specialist health care | ||
practitioner who regularly and continually provides treatment to | ||
the member for that condition; | ||
(2) an entity that is: | ||
(A) a health facility; | ||
(B) a health maintenance organization; | ||
(C) a nursing facility or assisted living | ||
facility under Chapter 242 or 247, Health and Safety Code, or a | ||
program for long-term care services coverage developed by the | ||
board; | ||
(D) a county medical facility; | ||
(E) a residential care facility for individuals | ||
with chronic, life-threatening illness; | ||
(F) an Alzheimer's day care resource center; | ||
(G) a residential care facility for the elderly; | ||
(H) a home health agency; | ||
(I) a private duty nursing agency; | ||
(J) a hospice; | ||
(K) a pediatric day health and respite care | ||
facility; | ||
(L) a home care service; or | ||
(M) a mental health care provider; | ||
(3) a health care organization; | ||
(4) a jointly managed trust authorized under 29 U.S.C. | ||
Section 141 et seq. that contains a plan of benefits for employees | ||
that is negotiated in a collective bargaining agreement governing | ||
wages, hours, and working conditions of the employer that is | ||
authorized under 29 U.S.C. Section 157; or | ||
(5) a not-for-profit or governmental entity approved | ||
by the program. | ||
(c) Subsection (b)(4) does not preclude a trust described by | ||
Subsection (b)(4) from becoming a care coordinator under Subsection | ||
(b)(5) or a health care organization under Section 1698.158. | ||
(d) To maintain approval as a care coordinator under the | ||
program, a care coordinator must: | ||
(1) renew its license every three years as prescribed | ||
by board rule; and | ||
(2) provide to the program any data required by the | ||
Department of State Health Services under Chapter 108, Health and | ||
Safety Code, that would enable the board to evaluate the impact of | ||
care coordinators on quality, outcomes, and cost of health care. | ||
(e) An individual or entity may not be a care coordinator | ||
unless the services included in care coordination are within the | ||
individual's professional scope of practice or the entity's legal | ||
authority. | ||
Sec. 1698.154. ENROLLMENT WITH CARE COORDINATOR. (a) | ||
Before receiving health care services to be paid for under the | ||
program, a member must be encouraged to enroll with a care | ||
coordinator that agrees to provide care coordination. If a member | ||
receives health care services before choosing a care coordinator, | ||
the program shall assist the member, when appropriate, with | ||
choosing a care coordinator. The member must remain enrolled with | ||
that care coordinator until the member becomes enrolled with a | ||
different care coordinator or ceases to be a member. A member may | ||
change care coordinators on terms at least as permissive as those | ||
under Medicaid relating to an individual changing primary care | ||
providers or managed care organizations. | ||
(b) A health care provider may be reimbursed for services | ||
only if the member is enrolled with a care coordinator at the time | ||
the health care service is provided. | ||
(c) A health care organization may establish rules relating | ||
to care coordination for its members that are different from this | ||
subchapter but otherwise consistent with this chapter and other | ||
applicable laws. | ||
Sec. 1698.155. PROCEDURES AND STANDARDS FOR CARE | ||
COORDINATION. (a) The board by rule shall develop and implement | ||
procedures and standards for an individual or entity to be approved | ||
as a care coordinator in the program, including procedures and | ||
standards relating to the revocation, suspension, limitation, or | ||
annulment of approval on a determination that the individual or | ||
entity: | ||
(1) is incompetent to be a care coordinator; | ||
(2) has exhibited a course of conduct that is | ||
inconsistent with program standards and rules; | ||
(3) exhibits an unwillingness to comply with program | ||
standards and rules; or | ||
(4) is a potential threat to the public health or | ||
safety. | ||
(b) The procedures and standards adopted by the board must | ||
be consistent with professional practice, licensure standards, and | ||
rules established under the Government Code, Health and Safety | ||
Code, Human Resources Code, Insurance Code, and Occupations Code, | ||
as applicable. | ||
(c) In developing and implementing standards of approval of | ||
care coordinators for individuals receiving chronic mental health | ||
care services, the board shall consult with the Health and Human | ||
Services Commission. | ||
Sec. 1698.156. OCCUPATIONAL LAWS NOT AFFECTED. Nothing in | ||
Section 1698.152, 1698.153, 1698.154, or 1698.155 authorizes an | ||
individual to engage in any act in violation of Title 3, Occupations | ||
Code. | ||
Sec. 1698.157. PAYMENT FOR HEALTH CARE SERVICES AND CARE | ||
COORDINATION. (a) The board shall adopt rules related to | ||
contracting and establishing payment methodologies for covered | ||
health care services and care coordination provided to members | ||
under the program by participating providers, care coordinators, | ||
and health care organizations. A variety of different payment | ||
methodologies may be used, including those established on a | ||
demonstration basis. All payment rates under the program shall be | ||
reasonable and reasonably related to the cost of efficiently | ||
providing the health care service and ensuring an adequate and | ||
accessible supply of health care services. | ||
(b) Health care services provided to a member under the | ||
program, except for care coordination, must be paid for on a | ||
fee-for-service basis unless the board establishes another payment | ||
methodology. | ||
(c) Notwithstanding Subsection (b), integrated health care | ||
delivery systems, essential community providers, and group medical | ||
practices that provide comprehensive, coordinated services may | ||
choose to be reimbursed on the basis of a capitated system operating | ||
budget or a non-capitated system operating budget that covers all | ||
costs of providing health care services. | ||
(d) The program shall engage in good faith negotiations with | ||
health care providers' representatives under Subchapter H, | ||
including in relation to rates of payment for health care services, | ||
rates of payment for prescription and nonprescription drugs, and | ||
payment methodologies. Those negotiations shall be through a single | ||
entity on behalf of the entire program for prescription and | ||
nonprescription drugs. | ||
(e) Payment for health care services established under this | ||
chapter is considered payment in full. A participating provider may | ||
not charge a rate in excess of the payment established under this | ||
chapter for any health care service provided to a member under the | ||
program and may not solicit or accept payment from any member or | ||
third party for any health care service, except as provided under a | ||
federal program. This section does not preclude the program from | ||
acting as a primary or secondary payer in conjunction with another | ||
third-party payer when permitted by a federal program. | ||
(f) The board by rule may adopt payment methodologies for | ||
the payment of capital-related expenses for specifically | ||
identified capital expenditures incurred by not-for-profit or | ||
governmental entities that are health facilities under Subtitle B, | ||
Title 4, Health and Safety Code. Any capital-related expense | ||
generated by a capital expenditure that requires prior approval | ||
must have received that approval before being paid by the program. | ||
The approval must be based on achievement of the program standards | ||
described by Subchapter F. | ||
(g) Payment methodologies and payment rates must include a | ||
distinct component of reimbursement for direct and indirect | ||
graduate medical education. | ||
(h) The board by rule shall adopt payment methodologies and | ||
procedures for paying for health care services provided to a member | ||
while the member is located outside this state. | ||
Sec. 1698.158. HEALTH CARE ORGANIZATIONS. (a) A member may | ||
choose to enroll with and receive program care coordination and | ||
ancillary health care services from a health care organization. | ||
(b) The health care organization must be a not-for-profit or | ||
governmental entity that is approved by the board and is: | ||
(1) a local health care system; or | ||
(2) a community center for persons with developmental | ||
disabilities under Chapter 534, Health and Safety Code. | ||
(c) To maintain approval under the program, a health care | ||
organization must: | ||
(1) renew the approval as frequently as prescribed by | ||
board rule; and | ||
(2) provide to the program any data required by the | ||
Department of State Health Services under Chapter 108, Health and | ||
Safety Code, that would enable the board to evaluate the impact of | ||
health care organizations on quality outcomes, and cost of health | ||
care. | ||
Sec. 1698.159. PROCEDURES AND STANDARDS FOR HEALTH CARE | ||
ORGANIZATIONS. (a) The board by rule shall develop and implement | ||
procedures and standards for an entity to be approved as a health | ||
care organization in the program, including procedures and | ||
standards relating to the revocation, suspension, limitation, or | ||
annulment of approval on a determination that the entity: | ||
(1) is incompetent to be a health care organization; | ||
(2) has exhibited a course of conduct that is | ||
inconsistent with program standards and rules; | ||
(3) exhibits an unwillingness to comply with program | ||
standards and rules; or | ||
(4) is a potential threat to the public health or | ||
safety. | ||
(b) The procedures and standards adopted by the board must | ||
be consistent with professional practice, licensure standards, and | ||
rules established under the Government Code, Health and Safety | ||
Code, Human Resources Code, Insurance Code, and Occupations Code, | ||
as applicable. | ||
(c) In developing and implementing standards of approval of | ||
health care organizations, the board shall consult with the Health | ||
and Human Services Commission. | ||
Sec. 1698.160. BEST INTEREST OF THE PATIENT. A health care | ||
organization may not use health information technology or clinical | ||
practice guidelines that limit the effective exercise of the | ||
professional judgment of physicians and registered nurses. | ||
Physicians and registered nurses shall be free to override health | ||
information technology and clinical practice guidelines if, in | ||
their professional judgment, it is in the best interest of the | ||
patient and consistent with the patient's wishes. | ||
SUBCHAPTER F. PROGRAM STANDARDS | ||
Sec. 1698.201. PROGRAM STANDARDS. (a) The board by rule | ||
shall establish requirements and standards for the program and for | ||
health care organizations, care coordinators, and health care | ||
providers, consistent with this chapter and applicable | ||
professional practice, licensure standards, and rules of health | ||
care providers and health care professionals established under the | ||
Government Code, Health and Safety Code, Human Resources Code, | ||
Insurance Code, and Occupations Code, including requirements and | ||
standards related to: | ||
(1) the scope, quality, and accessibility of health | ||
care services; | ||
(2) relations between health care organizations or | ||
health care providers and members; and | ||
(3) relations between health care organizations and | ||
health care providers, including credentialing and participation | ||
in the health care organization, and terms, methods, and rates of | ||
payment. | ||
(b) The board by rule shall establish requirements and | ||
standards under the program that include provisions to promote: | ||
(1) simplification, transparency, uniformity, and | ||
fairness in health care provider credentialing and participation in | ||
health care organization networks, referrals, payment procedures | ||
and rates, claims processing, and approval of health care services, | ||
as applicable; | ||
(2) in-person primary and preventive care, care | ||
coordination, efficient and effective health care services, | ||
quality assurance, and promotion of public, environmental, and | ||
occupational health; | ||
(3) elimination of health care disparities; | ||
(4) nondiscrimination with respect to members and | ||
health care providers on the basis of race, color, ancestry, | ||
national origin, religion, citizenship, immigration status, | ||
primary language, mental or physical disability, age, sex, gender, | ||
sexual orientation, gender identity or expression, medical | ||
condition, genetic information, marital status, familial status, | ||
military or veteran status, or source of income; | ||
(5) accessibility of care coordination, health care | ||
organization services, and health care services, including | ||
accessibility for people with disabilities and people with limited | ||
ability to speak or understand English; and | ||
(6) the provision of care coordination, health care | ||
organization services, and health care services in a culturally | ||
competent manner. | ||
(c) Notwithstanding Subsection (b)(4), health care services | ||
provided under the program must be appropriate to the member's | ||
clinically relevant circumstances. | ||
(d) The board by rule shall establish requirements and | ||
standards, to the extent authorized by federal law, for replacing | ||
and merging with the program health care services and ancillary | ||
services currently provided by other programs, including: | ||
(1) Medicare; | ||
(2) the Affordable Care Act; and | ||
(3) other federally matched public health programs. | ||
Sec. 1698.202. EQUAL REQUIREMENTS AND STANDARDS. Any | ||
participating provider or care coordinator that is organized as a | ||
for-profit entity shall meet the same requirements and standards as | ||
entities organized as not-for-profit entities, and payments under | ||
the program paid to for-profit entities may not be calculated to | ||
accommodate the generation of profit, revenue for dividends, or | ||
other return on investment or the payment of taxes that would not be | ||
paid by a not-for-profit entity. | ||
Sec. 1698.203. INFORMATION REQUIRED. Each participating | ||
provider shall furnish information as required by the Department of | ||
State Health Services under Chapter 108, Health and Safety Code, | ||
and permit examination of that information by the program as may be | ||
reasonably required for purposes of reviewing accessibility and use | ||
of health care services, quality assurance, cost containment, the | ||
making of payments, and statistical or other studies of the | ||
operation of the program or for protection and promotion of public, | ||
environmental, and occupational health. | ||
Sec. 1698.204. CONSULTATION ON POLICY DETERMINATIONS. In | ||
developing requirements and standards and making other policy | ||
determinations under this subchapter, the board shall consult with | ||
representatives of members, health care providers, care | ||
coordinators, health care organizations, labor organizations | ||
representing health care employees, and other interested parties. | ||
SUBCHAPTER G. FUNDING | ||
Sec. 1698.251. FEDERAL HEALTH PROGRAMS AND FUNDING. (a) | ||
The board shall seek any federal waiver or other federal approval | ||
and arrangement and submit each state plan amendment necessary to | ||
operate the program. | ||
(b) The board shall apply to the United States secretary of | ||
health and human services or other appropriate federal official for | ||
any waiver of a requirement and make any other arrangement under | ||
Medicare, any federally matched public health program, the | ||
Affordable Care Act, and any other federal program that provides | ||
federal money for payment for health care services necessary so | ||
that: | ||
(1) each member receives all benefits under the | ||
program through the program; | ||
(2) the state may implement this chapter; and | ||
(3) the state receives all federal payments under the | ||
applicable program, including money that may be provided in lieu of | ||
premium tax credits, cost-sharing subsidies, and small business tax | ||
credits. | ||
(c) The state shall deposit money received under Subsection | ||
(b)(3) in the state treasury to the credit of the fund and shall use | ||
that money for the program and to implement this chapter. | ||
(d) To the extent possible, the board shall negotiate | ||
arrangements with the federal government to ensure that federal | ||
payments are paid to the program in place of federal funding of, or | ||
tax benefits for, federally matched public health programs or | ||
federal health programs. | ||
(e) The board may require members or applicants to provide | ||
information necessary for the program to comply with any waiver or | ||
arrangement under this chapter. Information provided by a member | ||
to the board for the purposes of this subsection may not be used for | ||
any other purpose. | ||
(f) The board may take any additional actions necessary to | ||
effectively fund implementation of the program to the extent | ||
possible as a single-payer program consistent with this chapter. | ||
(g) The board may take actions consistent with this | ||
subchapter to enable the program to administer Medicare in this | ||
state, and the program shall be a provider of Medicare Part B | ||
supplemental insurance coverage and shall provide premium | ||
assistance drug coverage under Medicare Part D for eligible members | ||
of the program. | ||
(h) The board may waive or modify the applicability of any | ||
provision of this section relating to any federally matched public | ||
health program or Medicare, as necessary, to implement any waiver | ||
or arrangement under this section or to maximize the federal | ||
benefits to the program under this section, provided that the | ||
board, in consultation with the comptroller, determines that the | ||
waiver or modification is in the best interest of the state and | ||
members affected by the action. | ||
(i) The board may apply for coverage for, and enroll, any | ||
eligible member under any federally matched public health program | ||
or Medicare. Enrollment in a federally matched public health | ||
program or Medicare may not cause any member to lose any health care | ||
service provided by the federal program or Medicare or diminish any | ||
right the member would otherwise have. | ||
(j) Notwithstanding Subsection (i) or any other law, the | ||
board by rule shall increase the income eligibility level, increase | ||
or eliminate the resource test for eligibility, simplify any | ||
procedural or documentation requirement for enrollment, and | ||
increase the benefits for any federally matched public health | ||
program and for any program to reduce or eliminate an individual's | ||
coinsurance, cost-sharing, or premium obligations or increase an | ||
individual's eligibility for any federal financial support related | ||
to Medicare or the Affordable Care Act. The board may act under | ||
this subsection on a finding approved by the comptroller and the | ||
board that the action: | ||
(1) will help increase the number of members who are: | ||
(A) eligible for and enrolled in federally | ||
matched public health programs; or | ||
(B) eligible for any program to reduce or | ||
eliminate an individual's coinsurance, cost-sharing, or premium | ||
obligations or increase an individual's eligibility for any federal | ||
financial support related to Medicare or the Affordable Care Act; | ||
(2) will not diminish any individual's access to any | ||
health care service or right the individual would otherwise have; | ||
(3) is in the interest of the program; and | ||
(4) does not require or has received any necessary | ||
federal waiver or approval to ensure federal financial | ||
participation. | ||
(k) Any action taken under Subsection (j) may not apply to | ||
eligibility for payment for long-term care services. | ||
(l) To enable the board to apply for coverage for and enroll | ||
any eligible member under any federally matched public health | ||
program or Medicare, the board may require that each member or | ||
applicant provide the information necessary to enable the board to | ||
determine whether the applicant is eligible for a federally matched | ||
public health program or for Medicare, or any program or benefit | ||
under Medicare. | ||
(m) As a condition of continued eligibility for health care | ||
services under the program, a member who is eligible for benefits | ||
under Medicare must enroll in Medicare, including Parts A, B, and D. | ||
(n) The program shall provide premium assistance for each | ||
member enrolling in a Medicare Part D drug coverage plan under 42 | ||
U.S.C. Section 1395w-101 et seq., limited to the low-income | ||
benchmark premium amount established by the Centers for Medicare | ||
and Medicaid Services and any other amount the federal agency | ||
establishes under its de minimis premium policy, except that those | ||
payments made on behalf of a member enrolled in a Medicare advantage | ||
plan may exceed the low-income benchmark premium amount if | ||
determined to be cost effective to the program. | ||
(o) If the board has reasonable grounds to believe that a | ||
member may be eligible for an income-related subsidy under 42 | ||
U.S.C. Section 1395w-114, the member shall provide, and authorize | ||
the program to obtain, any information or documentation required to | ||
establish the member's eligibility for that subsidy. Before | ||
requesting information or documentation from a member under this | ||
section, the board shall attempt to obtain as much of the | ||
information and documentation as possible from records that are | ||
available to the board. | ||
(p) The program shall make a reasonable effort to notify | ||
each member of the member's obligations under this section. After a | ||
reasonable effort has been made to contact the member, the member | ||
shall be notified in writing that the member has 60 days to provide | ||
the required information. If the member does not provide the | ||
required information within the 60-day period, the member's | ||
coverage under the program may be terminated. Information provided | ||
by a member to the board for the purposes of this section may not be | ||
used for any other purpose. | ||
(q) The board shall assume responsibility for all benefits | ||
and services paid for by the federal government with that money. | ||
Sec. 1698.252. FUND; ADMINISTRATION. (a) The healthy | ||
Texas fund is a special fund in the state treasury outside the | ||
general revenue fund. | ||
(b) In conjunction with the enactment of the General | ||
Appropriations Act, the legislature shall develop a revenue plan, | ||
taking into consideration anticipated federal revenue available | ||
for the program, and appropriate money for the program as | ||
necessary. In developing the revenue plan, members of the | ||
legislature shall consult with appropriate officials and | ||
stakeholders. | ||
(c) Notwithstanding any other law, money in the fund may not | ||
be loaned to or borrowed by any other special fund or the general | ||
revenue fund. | ||
(d) The board shall establish and maintain a prudent reserve | ||
in the fund. | ||
(e) The board or staff of the board may not use any money | ||
intended for the administrative and operational expenses of the | ||
board for staff retreats, promotional giveaways, excessive | ||
executive compensation, or promotion of federal or state | ||
legislative or regulatory modifications. | ||
(f) Notwithstanding any other law, all interest earned on | ||
the money that has been deposited into the fund is retained in the | ||
fund and used for purposes consistent with the fund. | ||
(g) The fund consists of: | ||
(1) federal payments received as a result of any | ||
waiver of requirements granted or other arrangement agreed to by | ||
the United States secretary of health and human services or other | ||
appropriate federal official for health care programs established | ||
under Medicare, any federally matched public health program, or the | ||
Affordable Care Act; | ||
(2) amounts paid by the Health and Human Services | ||
Commission that are equivalent to the amounts that are paid on | ||
behalf of residents under Medicare, any federally matched public | ||
health program, or the Affordable Care Act for health benefits that | ||
are equivalent to health benefits covered under the program; | ||
(3) federal and state money for purposes of the | ||
provision of services authorized under Title XX of the Social | ||
Security Act (42 U.S.C. Section 1397 et seq.) that would otherwise | ||
be covered under the program; and | ||
(4) state money that would otherwise be appropriated | ||
to any governmental agency, office, program, instrumentality, or | ||
institution that provides health care services for services and | ||
benefits covered under the program. | ||
(h) Money in the fund may be used only for the purposes | ||
established in this chapter. | ||
SUBCHAPTER H. COLLECTIVE NEGOTIATION AND BARGAINING | ||
Sec. 1698.301. APPLICABILITY OF SUBCHAPTER. (a) This | ||
subchapter applies to a health care provider that is: | ||
(1) an individual who practices that profession as a | ||
health care provider or as an independent contractor; | ||
(2) an owner, officer, shareholder, or proprietor of a | ||
health care provider; or | ||
(3) an entity that employs or uses health care | ||
providers to provide health care services, including a health | ||
facility licensed under the Health and Safety Code. | ||
(b) A health care provider under Title 3, Occupations Code, | ||
who practices as an employee of a health care provider is not a | ||
health care provider for purposes of this subchapter. | ||
Sec. 1698.302. COLLECTIVE NEGOTIATION AUTHORIZED. (a) | ||
Health care providers may meet and communicate for the purpose of | ||
collectively negotiating with the program on any matter relating to | ||
the program, including rates of payment for health care services, | ||
rates of payment for prescription and nonprescription drugs, and | ||
payment methodologies. | ||
(b) This subchapter may not be construed to allow or | ||
authorize: | ||
(1) an alteration of the terms of the internal and | ||
external review procedures prescribed by law; | ||
(2) a strike of the program by health care providers | ||
related to the collective negotiations; or | ||
(3) terms or conditions that would impede the ability | ||
of the program to obtain or retain accreditation by the National | ||
Committee for Quality Assurance or a similar body, or to comply with | ||
applicable state or federal law. | ||
Sec. 1698.303. COLLECTIVE NEGOTIATION. (a) Collective | ||
negotiation rights granted by this subchapter must provide that: | ||
(1) a health care provider may communicate with other | ||
health care providers regarding the terms and conditions to be | ||
negotiated with the program; | ||
(2) a health care provider may communicate with a | ||
health care providers' representative; | ||
(3) a health care providers' representative is the | ||
only party authorized to negotiate with the program on behalf of the | ||
health care providers as a group; | ||
(4) a health care provider may be bound by the terms | ||
and conditions negotiated by the health care providers' | ||
representative; and | ||
(5) in communicating or negotiating with the health | ||
care providers' representative, the program is entitled to offer | ||
and provide different terms and conditions to individual competing | ||
health care providers. | ||
(b) This subchapter does not affect or limit: | ||
(1) the right of a health care provider or group of | ||
health care providers to collectively petition a governmental | ||
entity for a change in a law or board rule; or | ||
(2) collective action or collective bargaining on the | ||
part of a health care provider with that health care provider's | ||
employer or any other lawful collective action or collective | ||
bargaining. | ||
Sec. 1698.304. DUTIES OF HEALTH CARE PROVIDERS' | ||
REPRESENTATIVE. (a) Before engaging in collective negotiations | ||
with the program on behalf of health care providers, a health care | ||
providers' representative shall file with the board, in the manner | ||
prescribed by the board, information identifying the | ||
representative, the representative's plan of operation, and the | ||
representative's procedures to ensure compliance with this | ||
subchapter. | ||
(b) Each person who acts as the representative of a | ||
negotiating party under this subchapter shall pay a fee, as adopted | ||
by board rule, to the board to act as a representative. | ||
Sec. 1698.305. PROHIBITED COLLECTIVE ACTION. (a) This | ||
subchapter does not authorize competing health care providers to | ||
act in concert in response to a health care providers' | ||
representative's discussions or negotiations with the program, | ||
except as authorized by other law. | ||
(b) A health care providers' representative may not | ||
negotiate any agreement that excludes, limits the participation or | ||
reimbursement of, or otherwise limits the scope of services to be | ||
provided by any health care provider or group of health care | ||
providers with respect to the performance of services that are | ||
within the health care provider's scope of practice, license, | ||
registration, or certificate. | ||
SECTION 2. Not later than two years after the effective date | ||
of this Act, the Healthy Texas Board created by this Act shall: | ||
(1) in consultation with an advisory committee | ||
appointed by the chairperson of the board, including | ||
representatives of consumers and potential consumers of long-term | ||
care services, providers of long-term care services, members of | ||
organized labor, and other interested parties, develop a proposal | ||
consistent with the principles of Chapter 1698, Insurance Code, as | ||
added by this Act, for providing and funding long-term care | ||
services coverage by the Healthy Texas Program; | ||
(2) develop a proposal for accommodating employer | ||
retiree health benefits for people who have been members of the | ||
Healthy Texas Program but live as retirees outside this state; | ||
(3) develop a proposal for accommodating employer | ||
retiree health benefits for people who earned or accrued those | ||
benefits while residing in this state before the implementation of | ||
the Healthy Texas Program and live as retirees outside this state; | ||
and | ||
(4) develop a proposal for Healthy Texas Program | ||
coverage of health care services currently covered under the | ||
workers' compensation system, including whether and how to continue | ||
funding for those services under that system and whether and how to | ||
incorporate an element of experience rating. | ||
SECTION 3. (a) The Healthy Texas Board created by this Act | ||
shall determine when individuals may begin enrolling in the Healthy | ||
Texas Program. An implementation period begins on the date that | ||
individuals may begin enrolling in the program and ends on a date | ||
determined by the board. During the implementation period, the | ||
Healthy Texas Program is subject to special eligibility and | ||
financing provisions determined by the board until the program is | ||
fully implemented. | ||
(b) This Act does not prohibit a health benefit plan issuer | ||
from offering any benefits during the implementation period to | ||
individuals who enrolled or may enroll as members of the Healthy | ||
Texas Program. | ||
(c) Before full implementation of the Healthy Texas | ||
Program, the board shall provide for the collection and | ||
availability of data on the number of patients served by hospitals | ||
and the dollar value of the care provided, at cost, for the | ||
following categories: | ||
(1) patients receiving charity care; | ||
(2) contractual adjustments of county and indigent | ||
programs, including traditional and managed care; and | ||
(3) bad debts. | ||
(d) Notwithstanding Section 1698.054(b), Insurance Code, as | ||
added by this Act, a board member is not required to enroll as a | ||
member of the Healthy Texas Program until the implementation period | ||
has ended. | ||
SECTION 4. The Healthy Texas Board created by this Act shall | ||
provide money from the healthy Texas fund established by Section | ||
1698.252, Insurance Code, as added by this Act or from funds | ||
otherwise appropriated for this purpose to the Texas Workforce | ||
Commission for a program for retraining and assisting job | ||
transition for individuals employed or previously employed in the | ||
fields of health insurance, health care service plans, and other | ||
third-party payments for health care or those individuals providing | ||
services to health care providers to deal with third-party payers | ||
for health care, whose jobs may be ending or have ended as a result | ||
of the implementation of the Healthy Texas Program. | ||
SECTION 5. (a) Notwithstanding any other law, Chapter 1698, | ||
Insurance Code, as added by this Act, may not be implemented until | ||
the date the executive commissioner of the Health and Human | ||
Services Commission notifies the secretary of the Texas Senate and | ||
the chief clerk of the Texas House of Representatives in writing | ||
that the executive commissioner has determined that the healthy | ||
Texas fund has the revenue to fund the costs of implementing Chapter | ||
1698. | ||
(b) The Health and Human Services Commission shall publish a | ||
copy of the notice required by Subsection (a) of this section on the | ||
commission's Internet website. | ||
SECTION 6. This Act takes effect September 1, 2019. |