Bill Text: TX HB4561 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to the system redesign for delivery of Medicaid acute care services and long term services and supports to persons with an intellectual or developmental disability and a pilot for certain populations with similar functional needs receiving services in managed care.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2019-03-26 - Referred to Human Services [HB4561 Detail]
Download: Texas-2019-HB4561-Introduced.html
By: Klick | H.B. No. 4561 |
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relating to the system redesign for delivery of Medicaid acute care | ||
services and long term services and supports to persons with an | ||
intellectual or developmental disability and a pilot for certain | ||
populations with similar functional needs receiving services in | ||
managed care. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 534.001, Subchapter A, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.001. DEFINITIONS. In this chapter: | ||
(3) [ |
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Services Commission or an agency operating part of the state | ||
Medicaid managed care program, as appropriate. | ||
(4) "Comprehensive long term services and supports | ||
provider" is defined as a provider of long term services and | ||
supports specified under this chapter that ensures the coordinated, | ||
seamless provision of the full range of services as approved in | ||
participants' program plans as described under Section 534.1045 | ||
(b), (b-2),(c), and (d). A comprehensive service provider includes: | ||
(A) an ICF/IID program provider who is authorized | ||
to deliver services in the program defined under Section 534.001 | ||
(8), and | ||
(B) a Medicaid waiver program provider who is | ||
authorized to deliver services in the programs specified under | ||
Section 534.001 (12) and certified in accordance with 534.301 (b). | ||
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an individual's services and supports needs, including the | ||
individual's intellectual, psychiatric, medical, and physical | ||
support needs. | ||
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provided to an individual with acquiring, retaining, or improving: | ||
(A) skills related to the activities of daily | ||
living; and | ||
(B) the social and adaptive skills necessary to | ||
enable the individual to live and fully participate in the | ||
community. | ||
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serving individuals with an intellectual or developmental | ||
disability who receive care in intermediate care facilities other | ||
than a state supported living center. | ||
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Medicaid serving individuals with an intellectual or developmental | ||
disability who reside in and receive care from: | ||
(A) intermediate care facilities licensed under | ||
Chapter 252, Health and Safety Code; or | ||
(B) community-based intermediate care facilities | ||
operated by local intellectual and developmental disability | ||
authorities. | ||
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disability authority" has the meaning assigned by Section 531.002, | ||
Health and Safety Code. | ||
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plan," and "potentially preventable event" have the meanings | ||
assigned under Section 536.001. | ||
(10) Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, | ||
Sec. 2.287(17), eff. April 2, 2015. | ||
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following programs that are authorized under Section 1915(c) of the | ||
federal Social Security Act (42 U.S.C. Section 1396n(c)) for the | ||
provision of services to persons with an intellectual or | ||
developmental disability: | ||
(A) the community living assistance and support | ||
services (CLASS) waiver program; | ||
(B) the home and community-based services (HCS) | ||
waiver program; | ||
(C) the deaf-blind with multiple disabilities | ||
(DBMD) waiver program; and | ||
(D) the Texas home living (TxHmL) waiver program. | ||
(13) "Residential Services" means services provided | ||
for an individual with intellectual or developmental disability in | ||
a community-based ICF/IID, a three or four persons home and host | ||
home/companion service offered through the 1915(c) home and | ||
community-based waiver services program, or a group home in the | ||
Deaf Blind Multiple Disabilities program. | ||
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meaning assigned by Section 531.002, Health and Safety Code. | ||
SECTION 2. Section 534.051, Subchapter B, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.051. ACUTE CARE SERVICES AND LONG-TERM SERVICES | ||
AND SUPPORTS SYSTEM FOR INDIVIDUALS WITH AN INTELLECTUAL OR | ||
DEVELOPMENTAL DISABILITY. In accordance with this chapter, the | ||
commission [ |
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implement an acute care services and long-term services and | ||
supports system for individuals with an intellectual or | ||
developmental disability that supports the following goals: | ||
(1) provide Medicaid services to more individuals in a | ||
cost-efficient manner by providing the type and amount of services | ||
most appropriate to the individuals' needs and preferences in the | ||
most integrated and least restrictive setting; | ||
SECTION 3. Section 534.052, Subchapter B, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.052. IMPLEMENTATION OF SYSTEM REDESIGN. The | ||
commission [ |
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collaboration with the advisory committee, [ |
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acute care services and long-term services and supports system for | ||
individuals with an intellectual or developmental disability in the | ||
manner and in the stages described in this chapter. | ||
SECTION 4. Section 534.053, Subchapter B, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.053. INTELLECTUAL AND DEVELOPMENTAL DISABILITY | ||
SYSTEM REDESIGN ADVISORY COMMITTEE. (a) The Intellectual and | ||
Developmental Disability System Redesign Advisory Committee shall | ||
advise the commission [ |
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the acute care services and long-term services and supports system | ||
redesign under this chapter. Subject to Subsection (b), the | ||
executive commissioner [ |
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advisory committee who are stakeholders from the intellectual and | ||
developmental disabilities community, including: | ||
(b) To the greatest extent possible, the executive | ||
commissioner [ |
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reflect the geographic diversity of the state and include members | ||
who represent rural Medicaid recipients. | ||
(e-1) The advisory committee may establish work groups that | ||
meet at other times for purposes of studying and making | ||
recommendations on issues the committee considers appropriate. | ||
[(g) |
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(g) On the [ |
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commission completes implementation of the transition required | ||
under Section 534.202: | ||
(1) the advisory committee is abolished; and | ||
(2) this section expires. | ||
SECTION 5. Section 534.054, Subchapter B, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.054. ANNUAL REPORT ON IMPLEMENTATION. | ||
(b) On the two-year anniversary of the date the commission | ||
completes implementation of the transition required under Section | ||
534.202 this [ |
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SECTION 6. Section 534.101, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.101. Pilot Program Workgroup [ |
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accordance with Section 534.053 (e-1), for puposes of [ |
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subchapter the advisory committee shall establish a h Workgroup | ||
that includes representatives from the advisory committee, | ||
stakeholders representing individuals with an intellectual and | ||
developmental disability, individuals with similar functional | ||
needs, and the STAR+PLUS managed care organizations. [ |
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SECTION 7. Section 534.102, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.102. PILOT PROGRAM [ |
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MANAGED CARE STRATEGIES AND IMPROVEMENTS BASED ON CAPITATION. The | ||
commission [ |
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collaboration with the advisory committee and Pilot Program | ||
Workgroup, shall develop and implement a pilot program[ |
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accordance with this subchapter to test, through the STAR+PLUS | ||
Medicaid managed care program, the delivery of [ |
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534.1065. | ||
SECTION 8. Section 534.103, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.103. STAKEHOLDER INPUT. As part of developing and | ||
implementing a pilot program under this subchapter, the | ||
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the advisory committee and Pilot Program Workgroup, shall develop a | ||
process to receive and evaluate input from statewide stakeholders | ||
and stakeholders from the STAR+PLUS service area [ |
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state in which the pilot program will be implemented and other | ||
evaluations and data. | ||
SECTION 9. Chaoter 534, Government Code is amended to add | ||
new Section 534.1035, SELECTION OF MANAGED CARE ORGANIZATION | ||
VENDORS, to read as follows: | ||
Sec.534.1035. SELECTON OF MANAGED CARE ORGANIZATION PILOT | ||
VENDORS. (a) The commission shall select and contract with no more | ||
than two managed care organizations contracted to provide services | ||
under the STAR+PLUS Medicaid managed care program to participate in | ||
the pilot. | ||
(b) The commission, in consultation and collaboration with | ||
the advisory committee and Pilot Program Workgroup, shall develop | ||
criteria regarding the selection of managed care organizations to | ||
conduct the pilot program. | ||
SECTION 10. Section 534.104, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.104. PILOT DESIGN [ |
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this subchapter must be designed to: | ||
(1) increase access to long-term services and | ||
supports; | ||
(2) improve quality of acute care services and | ||
long-term services and supports; | ||
(3) promote informed choice and meaningful outcomes by | ||
using person-centered planning, flexible consumer directed | ||
services, individualized budgeting, and self-determination, and | ||
promote community inclusion and engagement; | ||
(4) promote integrated service coordination of acute | ||
care services and long-term services and supports; | ||
(5) promote efficiency and the best use of funding | ||
based on the individual's needs and preferences; | ||
(6) promote [ |
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housing stability through housing supports and navigation services | ||
that is the most integrated and least restrictive setting | ||
appropriate to the individual's needs and preferences; | ||
(7) promote employment assistance and customized, | ||
integrated, and competitive employment; | ||
(8) provide fair hearing and appeals processes in | ||
accordance with applicable federal and state law; and | ||
(9) promote sufficient flexibility to achieve the | ||
goals listed in this section through the pilot program [ |
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(10) promote the use of innovative technology and | ||
benefits, including telemonitoring and testing of remote | ||
monitoring for individuals participating in the pilot. The remote | ||
monitoring and telemonitoring is voluntary and shall ensure an | ||
individual's privacy and health and welfare and allow access to | ||
housing in the most integrated and least restrictive environment. | ||
Innovations may include transportation and other innovations that | ||
support community integration. If a pilot participant voluntarily | ||
decides to use telemonitoring or remote monitoring or other | ||
innovative technologies, the managed care organization providing | ||
the pilot services shall deliver the telemonitoring, remote | ||
monitoring and/or innovative technology services in a way that: | ||
(A) assesses individual needs and preferences in | ||
a manner that promotes autonomy, self-determination, consumer | ||
directed services, privacy and increases personal independence; | ||
(B) determines the extent in which remote | ||
monitoring, telemedicine and other innovative technologies will be | ||
used, including but not limited to, times of day, where the | ||
equipment can be used, what types of telemonitoring and/or remote | ||
monitoring, for what tasks; | ||
(C) is identified and agreed to through the | ||
person centered planning process; | ||
(D) ensures the staff overseeing remote | ||
monitoring, telemedicine and other innovative technologies review | ||
person-centered plans and implementation plans of each individual | ||
they are monitoring prior to monitoring that individual and | ||
demonstrate competency regarding the support needs of each | ||
individual they are monitoring; and | ||
(E) ensures an individual can request to remove | ||
the remote monitoring and other innovative technology equipment at | ||
any point during the IDD pilot and the managed care organizations | ||
must remove the equipment immediately. | ||
(F) ensures individuals can choose not to use | ||
telemedicine at any point during participation in the pilot and | ||
that the pilot participating managed care organization must arrange | ||
for services that do not require the use of telemedicine. | ||
(11) ensure an adequate provider network that includes | ||
comprehensive long term services and supports providers as | ||
described in Section 534.001 (4) and Section 534.107 (a)(2) and | ||
choice from among these providers; | ||
(12) ensure timely initiation and consistent | ||
provision of long term services and supports in accordance with an | ||
individual's person centered care plan; | ||
(13) ensure individuals with complex behavioral, | ||
medical and physical needs receive services based on assessed needs | ||
and in the most integrated, least restrictive setting according to | ||
the each individual's needs and preferences; | ||
(14) increase, expand flexibility and promote use of | ||
the consumer directed services model ; and | ||
(15) promote independence, self-determination, | ||
consumer directed services and decision making by using | ||
alternatives to guardianship, including supported decision-making | ||
agreements under Chapter 1357, Estates Code. | ||
(b) The pilot program shall be designed to test innovations | ||
and payment models for the provision of long-term services and | ||
supports to achieve the goals outlined in subsection (a) utilizing | ||
methods such as: | ||
(1) payment of a bundled amount without downside risk | ||
to a long term services and supports provider for some or all | ||
services delivered as part of a comprehensive array of long term | ||
services and supports; | ||
(2) enhanced incentive payments to providers of long | ||
term services and supports based on meeting pre-determined outcome | ||
or quality metrics; and | ||
(3) any other payment models approved by the | ||
commission. | ||
(c) The alternative payment rates or methodologies tested | ||
under subsection (b) must be agreed to in writing by the managed | ||
care organization and participating long term services and supports | ||
provider. In developing the alternative payment rates or | ||
methodologies, the parties must utilize: | ||
(1) the historical costs of long term services and | ||
supports, including Medicaid fee-for-service rates; and | ||
(2) reasonable cost estimates for new pilot program | ||
services; and | ||
(3) whether alternative payment rates or | ||
methodologies are sufficient to ensure the provider's continued | ||
participation in the pilot program and promote quality outcomes. | ||
(d) For long term services and supports delivered under the | ||
pilot, the alternative payment models tested under subsection (b) | ||
shall not reduce the minimum payment to providers below the current | ||
fee for service reimbursement rates. | ||
(e) The pilot program must allow existing providers of | ||
long-term services and supports for persons with intellectual and | ||
developmental disabilities, as defined in Section 534.001 (4), and | ||
providers of long term services and supports for persons with | ||
similar functional needs to voluntarily participate in one or more | ||
pilot projects. Failure to participate in a pilot project does not | ||
affect the contracting status of any provider as a significant | ||
traditional provider. | ||
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(f) [ |
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pilot program, the [ |
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participating managed care organizations shall provide long-term | ||
services and supports under Medicaid to persons with an | ||
intellectual or developmental disability, and other individuals | ||
with disabilities with similar functional needs, to test its | ||
managed care strategy based on capitation. | ||
(g) The [ |
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collaboration with the advisory committee and Pilot Program | ||
Workgroup, shall analyze information provided by the [ |
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any information collected by the [ |
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operation of the pilot program[ |
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recommendation about a system of programs and services for | ||
implementation through future state legislation or rules. | ||
(h) The analysis under Subsection (g) must include an | ||
assessment of the effect of the managed care strategies implemented | ||
in the pilot program[ |
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(a), (b), (c) and (d). [ |
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(i) Prior to implementation of the pilot program, the | ||
commission, in consultation and collaboration with the advisory | ||
committee and Pilot Program Workgroup, shall develop a process to | ||
ensure 12 months continuous Medicaid eligibility for pilot | ||
participants. | ||
SECTION 11. Chapter 534, Government Code is amended to add | ||
new section 534.1045, PILOT BENEFITS AND PROVIDER QUALIFICATIONS as | ||
follows: | ||
Sec. 534.1045. PILOT BENEFITS AND PROVIDER QUALIFICATIONS. | ||
(a) The pilot program must ensure that participating managed care | ||
organizations provide: | ||
(1) all Medicaid state plan acute care benefits | ||
available under the STAR+PLUS program; | ||
(2) long term services and supports in the Medicaid | ||
state plan, including: | ||
(A) Community First Choice services; | ||
(B) Personal Assistant services; | ||
(C) Day Activity Health Services; | ||
(D) Habilitation services defined under Section | ||
534/001 (6); | ||
(3) long term services and supports in the STAR+PLUS | ||
home and community-based services waiver, including: | ||
(A) assisted living | ||
(B) personal assistance services; | ||
(C) employment assistance; | ||
(D) supported employment; | ||
(E) adult foster care; | ||
(F) dental care; | ||
(G) nursing care; | ||
(H) respite care; | ||
(I) home-delivered meals; | ||
(J) cogniticve rehabilitative therapy; | ||
(K) physical therapy; | ||
(L) occupational therapy; | ||
(M) speech-language pathology; | ||
(N) medical supplies; | ||
(O) minor home modifcations; | ||
(P) adaptive aids; | ||
(4) long term services and supports available in the | ||
Medicaid waiver programs defined in Section 534.001 (12), | ||
including: | ||
(A) enhanced behavioral health services; | ||
(B) behavioral supports; | ||
(C) day habilitation; | ||
(D) community support transporation; | ||
(5) additional long term services and supports, | ||
including: | ||
(A) housing supports; | ||
(B) behavioral health crisis intervention; | ||
(C) high medical needs services; and | ||
(6) Other non-residential long term services and | ||
supports the commission, in consultation and coordination with the | ||
advisory committee and Pilot Program Workgroup, determines | ||
appropriate and consistent with the regulations governing the 1915 | ||
(c) waiver programs defined in Section 534.001 (12), | ||
person-centered approaches, home and community-based settings | ||
requirements, and the most integrated and least restrictive setting | ||
according to an individual's needs and preferences. | ||
(b) A comprehensive long term services and supports | ||
provider is authorized to deliver services listed under under | ||
subsections (a)(2)(A), (a)(2)(D), (a)(3)(B), (a)(3)(C), (a)(3)(D), | ||
(a)(3)(G), (a)(3)(H), (a)(3)(J), (a)(3)(K), (a)(3)(L), (a)(3)(M), | ||
and (a)(3)(4),if they also deliver the service in a Medicaid waiver | ||
defined under Section 534.001 (12). | ||
(b-2) A comprehensive long term services and supports | ||
provider may deliver services under subsections (a)(5) and (a)(6) | ||
if agreed to under contract with the pilot participating managed | ||
care organization. | ||
(c) Day habilitation services under (a)(4)(c) may be | ||
delivered by a provider who is contracted or subcontracted under a | ||
1915 (c) Medicaid waiver as defined under Section 534.001 (12) or an | ||
ICF/IID program as defined under Section 534.001 (8). | ||
(d) A comprehensive long term services and supports | ||
provider works in consultation with the pilot participating managed | ||
care organization's care coordinators to ensure the seamless | ||
delivery of acute care and long term services and supports on a | ||
day-to-day basis in accordance with an individual's plan of care | ||
and may be reimbursed by the managed care organization for this | ||
coordination. | ||
(e) Prior to implementation of the pilot program, the | ||
commission, in consultation and collaboration with the advisory | ||
committee and Pilot Program Workgroup, shall: | ||
(1) develop recommendations to modify, for the pilot | ||
program only, the Adult Foster Care, Supported Employment and | ||
Employment Assistance benefits to ensure increased access to and | ||
availability of this service, and | ||
(2) as needed, definitions for services described | ||
under subsection (a)(4) and (5), and any services added under | ||
subsection (6). | ||
SECTION 12. Section 534.105, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.105. PILOT PROGRAM: MEASURABLE GOALS. (a) The | ||
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the advisory committee and Pilot Program Workgroup, shall identify | ||
measurable goals using National Core Indicators, National Quality | ||
Forum LTSS measures and other appropriate CAHPS measures to be | ||
achieved by [ |
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subchapter. [ |
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(b) The [ |
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collaboration with the advisory committee and Pilot Program | ||
Workgroup, shall [ |
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performance measures for achieving the identified goals. A proposed | ||
strategy may be evidence-based if there is an evidence-based | ||
strategy available for meeting the pilot program's goals. | ||
(c) The commission, in consultation and collaboration with | ||
the advisory committee and Pilot Program Workgroup, shall ensure | ||
that the mechanisms to report, track and assess the specific | ||
strategies and performance measures for achieving the identified | ||
goals are established prior to implementation of the pilot program. | ||
SECTION 13. Section 534.106, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.106. IMPLEMENTATION, LOCATION, AND DURATION. (a) | ||
The commission [ |
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program[ |
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September 1, [ |
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(b) A pilot program established under this subchapter [ |
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shall operate for at least [ |
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(c) A pilot program established under this subchapter shall | ||
be conducted in [ |
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selected by the [ |
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SECTION 14. Section 534.1065, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.1065. RECIPIENT ENROLLMENT, PARTICIPATION AND | ||
ELIGIBILITY [ |
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[ |
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subchapter by an individual [ |
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receive long-term services and supports from a provider through | ||
that program [ |
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individual's legally authorized representative. | ||
(1) The commission, in consultation and collaboration | ||
with the advisory committee and Pilot Program Workgroup, shall | ||
develop a timeline and process for and informational materials | ||
related to educating pilot participants about the pilot including | ||
its benefits, impact on current services and other related | ||
information to ensure prospective pilot participants are able to | ||
make an informed decision regarding participation. The process must | ||
ensure: | ||
(A) the timeline for development and | ||
distribution of the pilot informational materials allows for | ||
sufficient advance notification to and education of individuals | ||
eligible for pilot participation, their families and other | ||
individuals actively involved in their lives; | ||
(B) individuals eligible for pilot | ||
participation, including new and current STAR+PLUS enrollees and | ||
other individuals specified in subsection (a) (1) (A), receive oral | ||
and written information about the pilot prior to participation, | ||
(C) the information provided is written in clear, | ||
simple language and presented in a manner individuals are able to | ||
understand and, at a minimum, explains that: | ||
(i) upon conclusion of the pilot, | ||
individuals will be requested to provide input on their pilot | ||
participation experience, including whether the pilot was able to | ||
meet their unique support needs; | ||
(ii) participation in the pilot does not | ||
remove individuals from any Interest List or, in accordance with | ||
Section 534.1065 (c), the right to select an enrollment, transition | ||
or diversion offer; and | ||
(iii) individuals have choice among acute | ||
care and long term services providers, including the consumer | ||
directed services model and the comprehensive services model. | ||
(b) The commission, in consultation and coordination with | ||
the advisory committee and Pilot Program Workgroup, shall develop | ||
pilot program participant eligibility criteria. The criteria must | ||
ensure pilot participants include: | ||
(1) individuals with an intellectual and | ||
developmental disability including autism and individuals with | ||
significant complex behavioral, medical and physical needs | ||
receiving home and community-based services through STAR+PLUS or a | ||
STAR+PLUS member who is also on a Medicaid Waiver Interest List or | ||
is a STAR+PLUS member meeting criteria for intellectual | ||
disabilities. It does not include individuals who are receiving | ||
only acute care services under STAR+PLUS and enrolled in the | ||
community-based ICF/IID program or one of the Medicaid waiver | ||
programs defined under Section 534.001 (12). | ||
(2) individuals receiving services under the | ||
STAR+PLUS Medicaid managed care program who have a traumatic brain | ||
injury that occurred after the age of 22; and | ||
(3) other individuals with disabilities who have | ||
similar functional needs independent of age of onset or diagnosis. | ||
(c) Individuals participating in the pilot who, during the | ||
pilot's implementation, are offered enrollment in one of the 1915 | ||
(c) Medicaid waiver programs defined under Section 534.001 (12) | ||
shall be eligible to accept the enrollment, transition or diversion | ||
offer. | ||
SECTION 15. Section 534.107, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.107. [ |
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RESPONSIBILTIES. (a) [ |
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shall require managed care organizations participating in the pilot | ||
program to: | ||
(1) ensure individuals participating in the pilot have | ||
choice among acute care and comprehensive long term services and | ||
supports providers and service delivery options including the | ||
consumer directed services model as specified under Section | ||
534.109. [ |
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(2) demonstrate to the satisfaction of the commission | ||
that their network of acute care, long term services and supports | ||
and comprehensive service providers have experience and expertise | ||
providing services for individuals with an intellectual or | ||
developmental disability and individuals with similar functional | ||
needs; | ||
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(3) have a process for preventing inappropriate | ||
institutionalizations of individuals; and | ||
(4) ensure timely initiation and consistent provision | ||
of services in accordance with an individual's person-centered plan | ||
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(b) For the duration of the pilot the commission must ensure | ||
that comprehensive long term services and supports providers as | ||
defined under Section 534.001(4) are deemed significant | ||
traditional providers and included in the provider network of the | ||
managed care organizations participating in the pilot. | ||
SECTION 16. Section 534.108, Subchapter C., Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Section 534.108. Pilot Program Information. (a) The | ||
commission [ |
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with the advisory committee and Pilot Program Workgroup, shall | ||
determine the information to be collected from each managed care | ||
organization participating in the pilot for use in the evaluation | ||
and reports required under Section 534.121. [ |
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(b) For the duration of the pilot each managed care | ||
organization participating in the pilot shall submit to the | ||
commission and the advisory committee a quarterly report on the | ||
services provided to each pilot participant that includes the | ||
following information: | ||
(A) the level of services requested, and the | ||
authorization and utilization rates of services for each pilot | ||
service; | ||
(B) timeliness of services requested, | ||
authorized, initiated, and number and duration of unplanned service | ||
breaks; | ||
(C) number of pilot participants using | ||
employment assistance and supported employment services; | ||
(D) number of service denials and fair hearings, | ||
and disposition of fair hearings; | ||
(E) number of complaints and inquiries received | ||
by the commission and managed care organizations participating in | ||
the pilot and the outcome of the complaints; and | ||
(F) number of participants who select the | ||
consumer directed services model and reasons participants did not | ||
select the service model. | ||
(c) The commission shall ensure that the mechanisms to | ||
report and track the information and data required in subsections | ||
(a) and (b) are established prior to implementation of the pilot | ||
program. | ||
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SECTION 17. Section 534.109, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.109. PERSON-CENTERED PLANNING. The commission, in | ||
consultation and collaboration [ |
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advisory committee and Pilot Program Workgroup, shall ensure that | ||
each individual[ |
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who receives services and supports under Medicaid through a pilot | ||
program established under this subchapter, or the individual's | ||
legally authorized representative, has access to a comprehensive | ||
facilitated, person-centered plan that identifies outcomes for the | ||
individual and drives the development of the individualized budget. | ||
The consumer directed services[ |
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Section 531.051, [ |
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available option for individuals to achieve self-determination, | ||
choice and control. | ||
SECTION 18. Section 534.110, Subchapter C., Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.110. TRANSITION BETWEEN PROGRAMS; CONTINUITY OF | ||
SERVICES. (a) During the evaluation of the pilot required under | ||
Section 534.121,[ |
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protect continuity of care. If the commission determines not to | ||
continue the pilot during the evaluation, the commission, in | ||
consultation and collaboration with the advisory committee and | ||
Pilot Program Workgroup, shall ensure that there is a comprehensive | ||
plan for transitioning the provision of Medicaid benefits provided | ||
to pilot participants to the services provided before the pilot. | ||
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(b) The transition plan shall be developed in consultation | ||
and collaboration with the advisory committee and with stakeholder | ||
input as described by Section 534.103. | ||
SECTION 19. Section 534.111, Subchapter C, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.111. CONCLUSION OF PILOT PROGRAM[ |
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Contingent on the decision made under Section 534.110, [ |
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September 1, [ |
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(1) [ |
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subchapter [ |
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conclude. |
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SECTION 21. Chapter 534, Government Code,is amended to add | ||
new Subchapter C-1 to read as follows: SUBCHAPTER C-1. PILOT | ||
EVALUATION AND REPORT | ||
Section 534.121. EVALUATION OF AND REPORT ON PILOT PROGRAM. | ||
(a) The commission, in consultation and collaboration with the | ||
advisory committee and Pilot Program Workgroup, shall review and | ||
evaluate the progress and outcomes of the pilot program implemented | ||
under Subchapter C of this Chapter and submit, as part of the annual | ||
report required by Section 534.054, a report on the status of the | ||
pilot program. The report must include recommendations for program | ||
improvement. | ||
(b) Upon conclusion of the pilot program required under | ||
Subchapter C, the commission, in consultation and collaboration | ||
with the advisory committee and Pilot Program Workgroup, shall | ||
evaluate the pilot program and prepare and submit a report to the | ||
legislature based on a comprehensive analysis of the pilot. | ||
(c) The comprehensive analysis must: | ||
(1) include an assessment of the effect of the pilot | ||
on: | ||
(A) access to and improved quality of long-term | ||
services and supports; | ||
(B) informed choice and meaningful outcomes | ||
using person-centered planning, flexible consumer directed | ||
services, individualized budgeting, and self-determination, | ||
including a person's inclusion in the community; | ||
(C) the integration of service coordination of | ||
acute care services and long-term services and supports; | ||
(D) employment assistance and customized, | ||
integrated, competitive employment options; | ||
(E) the number, types and dispositions of fair | ||
hearing and appeals processes in accordance with applicable federal | ||
and state law; | ||
(F) increasing use and flexibility of the | ||
consumer directed service model; | ||
(G) increasing use of alternatives to | ||
guardianship, including supported decision-making agreements under | ||
Chapter 1357, Estates Code; | ||
(H) achieving cost effectiveness and best use of | ||
funding based on individuals' needs and preferences; and | ||
(I) attendant recruitment and retention; | ||
(2) provide an analysis of the experience and outcome | ||
of the following systems changes: | ||
(A) the IDD assessment tool required under | ||
Chapter 533, Subchapter B, Section 533.0335, Health and Safety | ||
Code; | ||
(B) the 21st Century Cures Act; | ||
(C) implementation of the federal HCBS Settings | ||
regulations; and | ||
(D) the provision of basic attendant and | ||
habilitation services required under Section 534.152 of this | ||
Chapter, and | ||
(E) the benefits of providing STAR+PLUS services | ||
to persons based on functional needs; | ||
(3) include input from the individuals with | ||
intellectual and developmental disabilities and participants of | ||
similar functional needs, families and other individuals actively | ||
involved in the lives of the individuals; and providers of long term | ||
services and supports programs defined under Section 534.001 (8) | ||
and (12) who participated in the pilot about their experiences; | ||
(4) be incorporated into the annual report to the | ||
legislature required under Section 534.054; and | ||
(5) include recommendations about a system of programs | ||
and services for consideration by the legislature, including | ||
recommendations for needed statutory changes and whether to | ||
transition the pilot to a statewide program under the STAR+PLUS | ||
program for individuals who meet the eligibility criteria specified | ||
in Section 534.1065. | ||
SECTION 22. The heading to Subchapter E, Chapter 534, | ||
Government Code, is amended to read as follows: SUBCHAPTER E. STAGE | ||
TWO: TRANSITION OF ICF-IID PROGRAM RECIPIENTS AND LONG-TERM CARE | ||
MEDICAID WAIVER PROGRAM RECIPIENTS TO INTEGRATED MANAGED CARE | ||
SYSTEM | ||
SECTION 23. Section 534.201, Subchapter E, Chapter 534, | ||
Government Code, is repealed: | ||
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SECTION 24. Section 534.202, Subchapter E, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.202. DETERMINATION TO TRANSITION [ |
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PROGRAM RECIPIENTS AND CERTAIN [ |
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RECIPIENTS TO MANAGED CARE PROGRAM. (a) This section applies to | ||
individuals with an intellectual or developmental disability who | ||
[ |
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supports under: | ||
(1) a Medicaid waiver program as defined under Section | ||
534.001 (12) [ |
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(2) an ICF-IID program. | ||
(b) After implementing the pilot [ |
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Subchapter C of this Chapter, completing the evaluation required | ||
under Section 534.121, and subject to subsection (g)[ |
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the advisory committee, shall develop a plan for the transition of | ||
all or a portion of the services provided through the programs | ||
defined in Sections 534.001 (8) and (12) which were not included in | ||
the pilot under Subchapter C. The plan must include: | ||
(1) The process for transitioning the services in the | ||
programs defined in Sections 534.001 (8) and (12) in a phased-in | ||
manner as follows: | ||
(A) Texas Home Living; | ||
(B) CLASS; | ||
(C) non-residential services provided through | ||
the 1915 (c) Home and Community-based Services and DBMD waivers; | ||
and | ||
(D) subject to subsection (b) (3), the | ||
residential services offered through the ICF/IID program and the | ||
HCS and DBMD waiver programs. | ||
(2) With the exception of the residential services | ||
provided through the programs specified in subsection (b) (1)(D), | ||
the schedule for transitioning the services and individuals into | ||
managed care must occur in the order specified under subsection | ||
(b)(1)beginning with TxHmL on September 1, 2027; CLASS on September | ||
1, 2029,; and the non-residential services provided through the | ||
Home and Community-based services and DBMD waivers on September 1, | ||
2031. | ||
(3) The process for evaluating the feasibility and | ||
cost efficiency of transitioning the residential services offered | ||
through the ICF/IID program and the HCS and DBMD waiver programs, | ||
and, as appropriate, transitioning to the managed care program. | ||
(A) The process for determining the transition of | ||
the residential services must be based on an evaluation of a two | ||
year pilot. | ||
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(c) [ |
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dates specified under Subsection (b) (2) and subject to subsection | ||
(g), the commission shall determine whether to: | ||
(1) continue operation of the Medicaid waiver programs | ||
only for purposes of providing, if applicable: | ||
(A) supplemental long-term services and supports | ||
not available under the managed care program delivery model | ||
selected by the commission; or | ||
(B) long term services and supports to Medicaid | ||
waiver program recipients who choose to continue receiving benefits | ||
under the waiver programs who choose to continue receiving benefits | ||
under the waiver program as provided by Subsection (g); or | ||
(2) subject to Subsection (g), provide all or a | ||
portion of the long-term services and supports previously available | ||
under the Medicaid waiver programs through the managed care program | ||
delivery model selected by the commission. | ||
(d) In implementing the transition described by Subsection | ||
(b)(2), the commission shall develop a process to receive and | ||
evaluate input from interested statewide stakeholders that is in | ||
addition to the input provided by the advisory committee. | ||
(e) The commission shall ensure that there is a | ||
comprehensive plan for transitioning the provision of Medicaid | ||
benefits under this section that protects the continuity of care | ||
provided to individuals to whom this section applies and ensures | ||
individuals have a choice among acute care and comprehensive long | ||
term services and supports providers and service delivery options | ||
including the consumer directed services model as specified under | ||
Subsection (i). | ||
(f) Before transitioning the provision of Medicaid benefits | ||
for children under this section, a managed care organization | ||
providing services under the managed care program delivery model | ||
selected by the commission must demonstrate to the satisfaction of | ||
the commission that the organization's network of providers has | ||
experience and expertise in the provision of services to children | ||
with an intellectual or developmental disability. Before | ||
transitioning the provision of Medicaid benefits for adults with an | ||
intellectual or developmental disability under this section, a | ||
managed care organization providing services under the managed care | ||
program delivery model selected by the commission must demonstrate | ||
to the satisfaction of the commission that the organization's | ||
network of providers has experience and expertise in the provision | ||
of services to adults with an intellectual or developmental | ||
disability. | ||
(g) If the commission determines that all or a portion of | ||
the long-term services and supports previously available under the | ||
Medicaid waiver programs should be provided through a managed care | ||
program delivery model under Subsection (c)(1), the commission | ||
shall, at the time of the transition, allow each recipient | ||
receiving long-term services and supports under a Medicaid waiver | ||
program the option of: | ||
(1) continuing to receive the services and supports | ||
under the Medicaid waiver program; or | ||
(2) receiving the services and supports through the | ||
managed care program delivery model selected by the commission. | ||
(h) A recipient who chooses to receive long-term services | ||
and supports through a managed care program delivery model under | ||
Subsection (g) may not, at a later time, choose to receive the | ||
services and supports under a Medicaid waiver program. | ||
(i) In addition to the requirements of Section 533.005, a | ||
contract between a managed care organization and the commission for | ||
the organization to provide Medicaid benefits under this section | ||
must contain a requirement that the organization implement a | ||
process for individuals with an intellectual or developmental | ||
disability that: | ||
(1) ensures that the individuals have a choice among | ||
acute care and comprehensive long term services and supports | ||
providers and service delivery options including the consumer | ||
directed services model; | ||
(2) to the greatest extent possible, protects those | ||
individuals' continuity of care with respect to access to primary | ||
care providers, including the use of single-case agreements with | ||
out-of-network providers; and | ||
(3) provides access to a member services phone line | ||
for individuals or their legally authorized representatives to | ||
obtain information on and assistance with accessing services | ||
through network providers, including providers of primary, | ||
specialty, and other long-term services and supports. | ||
SECTION 25. Section 534.203, Subchapter E, Chapter 534, | ||
Government Code, is amended to read as follows: | ||
Sec. 534.203. RESPONSIBILITIES OF COMMISSION UNDER | ||
SUBCHAPTER. In administering this subchapter, the commission shall | ||
ensure that upon a determination to transition services in the | ||
programs defined under Sections 534.001 (8) and (12): | ||
(1) that the commission is responsible for setting the | ||
minimum reimbursement rate paid to a provider of ICF-IID services | ||
or a group home provider under the integrated managed care system, | ||
including the staff rate enhancement paid to a provider of ICF-IID | ||
services or a group home provider; | ||
(2) that an ICF-IID service provider or a group home | ||
provider is paid not later than the 10th day after the date the | ||
provider submits a clean claim in accordance with the criteria used | ||
by the department for the reimbursement of ICF-IID service | ||
providers or a group home provider, as applicable; and | ||
(3) the establishment of an electronic portal through | ||
which a provider of ICF-IID services or a group home provider | ||
participating in the STAR + PLUS Medicaid managed care program | ||
delivery model or the most appropriate integrated capitated managed | ||
care program delivery model, as appropriate, may submit long-term | ||
services and supports claims to any participating managed care | ||
organization [ |
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(4) that each individual with an intellectual or | ||
developmental disability and the individual's legally authorized | ||
representative has access to a comprehensive facilitated, | ||
person-centered plan that identifies outcomes for the individual. | ||
The consumer directed services model must be promoted as an | ||
available option for individuals to achieve self-determination, | ||
choice and control. | ||
SECTION 26. Chapter 534, Government Code, is amended to add | ||
Subchapter F. to read as follows: | ||
SUBCHAPTER F. OTHER IMPLEMENTATION REQUIREMENTS AND | ||
RESPONSIBILITIES UNDER THIS CHAPTER | ||
Sec. 534.301. IMPLEMENTATION AND RESPONSIBILITIES UNDER | ||
THIS CHAPTER. (a) The commission is authorized to delay | ||
implementation of this Chapter or its subchapters without further | ||
investigation or adjustments or legislative intervention, if it | ||
determines any provision under the Chapter or other related mandate | ||
or initiative integral to implementation adversely affects the | ||
system of services and supports to persons and programs to which the | ||
Chapter applies. | ||
(b) For purpose of the pilot under Subchpater C. of this | ||
Chapter and any subsequent transition of recipients receiving | ||
services under certain Medicaid waiver programs defined under | ||
Section 534.001 (12) to a managed care program as specified under | ||
Section 534.202 (c), the commission must: | ||
(1) maintain a certification process and regulatory | ||
oversight of Texas Home Living and Home and Community-based | ||
Services providers; and | ||
(2) require managed care organizations include in | ||
their network of qualified long term services and supports | ||
providers certified Texas Home Living and Home and Community-based | ||
Services providers that specialize in services for persons with | ||
intellectual disabilities. | ||
(c) Subject to Section 534.202 (b) and (c), upon a decision | ||
to transition the long term services and supports under a Medicaid | ||
waiver program defined under Section 534.001 (12), the commission | ||
shall ensure individuals do not lose the benefits they are | ||
receiving through these Medicaid waiver programs. | ||
(d) For purposes of the pilot under Subchapter C. and any | ||
future transition of services specified under Section 534.202 into | ||
the STAR+PLUS program, the comprehensive long term services and | ||
supports provider defined in Section 534.001 (4): | ||
(1) must report encounters of any directly contracted | ||
services to the managed care organization; provide quarterly | ||
reporting of coordinated services and timeframes to the managed | ||
care organization, and provide quarterly progress on goals and | ||
objectives set by an individual's person centered plan; and | ||
(2) will not be held accountable for the provision of | ||
services on an individual's service plan for which a managed care | ||
organization denies or does not authorize access to in a timely | ||
manner. | ||
SECTION 27. If before implementing any provision of this | ||
Act a state agency determines that a waiver or authorization from a | ||
federal agency is necessary for implementation of that provision, | ||
the agency affected by the provision shall request the waiver or | ||
authorization and may delay implementing that provision until the | ||
waiver or authorization is granted. | ||
SECTION 28. If the Health and Human Services Commission | ||
determines that it is cost effective, the commission shall apply | ||
for and actively seek a waiver or authorization from the | ||
appropriate federal agency to allow the state to provide medical | ||
assistance under the waiver or authorization to medically fragile | ||
individuals; | ||
(1) Who are at least 21 years of age; and | ||
(2) Whose costs to receive care exceed cost limits | ||
under existing Medicaid waiver programs. | ||
SECTION 29. This act takes effect September 1, 2019. |