Omnibus Medicaid Reform
Senate Bill 10 by Sen. Jane Nelson (R-Lewisville) and Rep. Diane
Delisi (R-Temple) is the omnibus Medicaid reform bill for 2007. The
bill contains numerous provisions to test promising new approaches
in the financing and delivery of Medicaid services, which included
promoting prevention and wellness initiatives to improve patients'
health status at lower costs. SB 10 also outlined a new "health
opportunity pool" to use Medicaid dollars as a financing tool to
expand private health insurance to low-income Texans. TMA worked
closely with bill authors, primary care specialty societies, and
other stakeholders to ensure the legislation would promote
high-quality patient care without imposing new administrative
burdens and costs on patients or physicians. The bill also includes
safeguards to protect the financial viability of safety-net
institutions that would contribute funds to help finance the
low-income pool.
Provisions in SB 10 of importance to medicine include:
1. Directs HHSC to establish a pilot in one region of the
state to provide positive incentives to Medicaid patients who
adopt healthier lifestyles, such as participating in weight
management and smoking cessation programs or participating in
disease management initiatives. The rewards may include setting
up individual accounts that allow Medicaid patients to earn
credits to exchange for health-related items not covered by
Medicaid or other positive incentives that promote healthy
lifestyles. By Dec. 1, 2010, HHSC must submit a report to the
legislature on the results of the pilot.
2. Allows HHSC to develop and implement incentives to
encourage children to obtain timely Early Periodic Screening
Diagnosis and Treatment (EPSDT) visits. The EPSDT program is
called "Texas Health Steps" in Texas. HHSC also must develop
incentives for Medicaid health plans and participating physicians
and providers to deliver and document complete EPSDT
screenings.
3. Directs HHSC, if cost-effective and feasible, to test a
voluntary health savings account (HSA) model for adult Medicaid
patients. TMA requested that children be exempt. Patients who opt
to participate in an HSA but subsequently change their mind may
return to traditional Medicaid, though they would forfeit any
money in the account. The HSA pilot must be implemented by Sept.
1, 2008.
4. Allows HHSC to seek a federal Medicaid waiver to establish
"tailored benefit packages" to meet the specific needs of each
Medicaid population. The goal is to improve health outcomes and
access to care, reduce costs, and increase efficiency, and reduce
administrative complexity of delivering benefits. Under the
provision, HHSC is required to develop a tailored benefit model
for children with special health care needs (CSHCN). Other
populations that HHSC may target are children and families,
adults with special health needs or disabilities, and the
elderly. With the exception of the CSHCN initiative, HHSC may not
implement tailored benefits packages before Sept. 1, 2009.
The state has two specialized Medicaid managed care plans:
STAR, which is geared toward children, pregnant women, and
low-income parents; and STAR+PLUS, which targets patients who
are elderly or have disabilities. The intent of the provision
is to augment and expand these efforts by developing a
tailored-benefit model geared toward children with special
health care needs or disabilities. The bill specifies that HHSC
has broad discretion in developing the tailored benefit
packages, and must:
a. Provide a basic set of benefits across all benefit
packages;
b. Include additional benefits customized to meet the health
care needs of patients covered by the plan;
c. Include, as appropriate, services to integrate acute and
long-term care services; and
d. Increase the state's flexibility with respect to Medicaid
funding.
HHSC may not reduce benefits available under the
state Medicaid plan. However, HHSC may add benefits not included
under the Medicaid state plan or under any federal waiver, such
as preventive health or wellness services. Further, at the
request of TMA, the bill stipulates that any package developed
for children must include at least the services required by the
EPSDT program. If HHSC develops tailored benefit packages, it
must submit a report to standing oversight committees of the
legislature. The report must detail the benefits and services
available. HHSC also may develop tailored benefit packages for
non-Medicaid populations.
Lastly, the provision states that tailored benefit
provisions do not apply to waiver programs or similar packages
implemented prior to Sept. 1, 2007 (e.g., the women's health
waiver).
5. Establishes a new "Texas Health Opportunity Pool" (THOP) as
a means to expand health insurance coverage for low-income
Texans. Under the proposal, HHSC is authorized to pursue a
federal Medicaid waiver to establish the pool. Funding for the
pool would come from (1) Medicaid disproportionate share (DSH)
and upper payment limit (UPL) programs, which are used currently
to offset hospital uncompensated care costs; (2) money provided
by the federal government in lieu of some or all of the hospital
supplemental payments; or (3) a combination approach. Funding for
the physician UPL payments made to state medical schools will not
be included in the THOP. HHSC also may identify other state and
local spending not currently being matched with federal funds and
explore using those dollars to draw down additional federal
monies. Funding for the pool - as much as $62 million in general
revenue over the next two years - also will be generated from a
new $5 per customer fee on certain sexually oriented businesses
as required by House Bill 1751.
To protect the financial viability of safety-net facilities,
any waiver pursued by HHSC must include safeguards to ensure that
aggregate federal DSH and UPL funding for safety-net hospitals
does not decline below existing funding levels and, to the extent
allowed by federal law or regulation, preserves federal
supplemental payments to hospitals. HHSC must seek within the
waiver, though it is not a requirement, maximum flexibility with
respect to using the money in the pool as well as annual
adjustments to account for inflation, population, and other
demographic factors that impact the availability of funding
within the pool.
Once established, monies designated for the pool would be
placed in an account outside the treasury. In general, funds may
be used for the following unless specified otherwise within the
federal waiver: (1) offset, at least partially, hospitals'
uncompensated care costs; (2) reduce the number of uninsured
Texans; and (3) reduce the need for uncompensated health care
provided by hospitals by expanding the pool of insured patients.
Unless otherwise specified by the waiver, the bill states that to
be eligible for funding from the pool to help offset
uncompensated care costs, hospitals or political subdivisions
must use a portion of the funds in the pool (to be specified via
rule) on implementing strategies to reduce uncompensated
outpatient and inpatient hospital care as well as ER usage,
including:
a. Fostering primary care systems of care that promote a
"medical home";
b. Promoting premium payment assistance initiatives, such as
three-share models;
c. Making contributions to eligible patients' health savings
accounts; and
d. Improving health care efficiency by promoting use of
electronic medical records.
In other words, SB 10 aims to redirect Medicaid funding for
indigent care from institutions to the community. Additionally,
up to 10 percent of the funds in the pool may be used to improve
the physician and provider infrastructure needed to care for the
Medicaid and uninsured population and to promote efficiency in
health care such as through greater use of health information
technology (HIT). To reduce the number of uninsured, hospitals
may implement strategies such as premium assistance programs,
contributions to health savings accounts, or other innovative
mechanisms.
In developing the federal waiver, HHSC must seek broad
stakeholder input. Once the waiver is approved, HHSC must also
seek stakeholder input on the rules relating to allocation of
funds from THOP. To oversee the development of the waiver,
including implementation of the THOP and other reforms outlined
within the bill, SB 10 directs the lieutenant governor and
speaker of the House to appoint no later than Oct. 1, 2007, a
joint Legislative Oversight Committee consisting of four senators
and four representatives.
6. Allows county commissioners to establish regional or local
health care programs, also known as "three-share" models, for
employees of small employers. Programs may be established in a
single county or in a multi-county alliance. The bill specifies
the governance of the local or regional programs, participation
requirements for small employers, and the health care services
and benefits. Funds from the new THOP may be used to facilitate
the local or regional health care programs, subject to meeting
eligibility criteria. HHSC also may establish a grant program to
support the program's development.
7. HHSC and the Texas Department of Insurance (TDI) are
charged with jointly developing premium assistance programs such
as three-share initiatives, and adopting rules specifying
eligibility, premium levels, and reporting requirements.
8. Directs HHSC and TDI to conduct a joint study on small
employer premium assistance programs to provide financial
assistance for small employers to purchase health insurance.
9. Directs HHSC, if feasible and cost-effective, to implement
copayments for patients who use the ER for non-emergent needs
when an alternative, lower-cost provider is available. The
Deficit Reduction Act gave states the option to apply this
provision to all Medicaid patients, including those living below
poverty. However, according to information provided by HHSC in
the SB 10 fiscal note, cost sharing will be limited to patients
with incomes above 100 percent of poverty. For higher income
patients, cost sharing will be on a sliding scale basis: $5 for
patients between 100 percent to 150 percent of poverty and $15
for those with higher incomes. SB 10 specifies that HHSC may not
reduce hospital payments to reflect anticipated collection of
copayments.
10. Requires HHSC to include within Medicaid HMO contracts
outcomes-based performance measures and incentives that
facilitate and increase patients' access to appropriate health
care. The measures may be graduated, promoting incremental and
continued improvement over time. Additionally, directs HHSC to
assess the feasibility and cost-effectiveness of including in
Medicaid HMO contracts provisions that require plans to provide
to participating physicians and hospitals pay-for-performance
"opportunities" to support quality improvement. At TMA's request,
HHSC may consult physicians and hospitals in assessing the
feasibility of pay for performance and must base the assessment
on publicly available, scientifically valid, evidence-based
criteria appropriate to the Medicaid population. Pay for
performance may include incentives for physicians and providers
who offer after-hours care or participate in the EPSDT program.
If HHSC determines that pay for performance is cost-effective, it
must establish a pilot in at least one region of the state.
Specifies that HHSC must, to the extent feasible, encourage
Medicaid HMOs to offer additional benefits that have the
potential to improve the health status of patients.
Contractually, Medicaid HMOs already have this authority, so this
provision of the bill is not clear.
Requires HHSC to post on its Web site in a comprehensive and
understandable format the financial statistical data of each
Medicaid HMO. The data will allow the public to determine how
much each HMO spends on administration versus direct patient
care.
11. Expands the number of women who may receive treatment
under the Breast and Cervical Cancer Treatment Act (BCCTA).
Currently, a woman must be screened by a designated provider to
be eligible for treatment. The provision specifies that a woman
eligible for Medicaid coverage may receive treatment even if the
screen was not performed by a designated BCCTA provider, and even
if federal matching funds are not available. HB 1 allocates state
general revenue to provide additional coverage.
12. Allows HHSC to adopt rules to permit, facilitate, and
implement use of health information technology within Medicaid,
including use of electronic mechanisms to verify eligibility and
enrollment, obtain prior approval for health services, update
practice information, and promote exchange of information via
e-prescribing or electronic health records. The provision
also specifies that HHSC may promote the adoption of HIT,
including incentives for physicians and providers, and must
ensure than a paper record is not required if it is permitted or
required to be filed electronically. HHSC is required to consult
with physicians and other stakeholders prior to developing any
rules regarding use of HIT.
13. Directs HHSC to develop and implement a pilot program, if
funding is appropriated, to promote adoption of EHRs by
participating high-volume primary care physicians and providers.
Participation would be voluntary. A report on the pilot must be
submitted to the legislature by Dec. 1, 2008.
14. Directs HHSC to implement outreach efforts to inform
patients who have access to group health insurance about the
Medicaid Health Insurance Premium Payment (HIPP) program. Under
HIPP, if group health premiums are at or below what Medicaid
would have paid, the state will pay the patient's premiums. This
allows the patient to enroll in the employer-sponsored plan
instead of Medicaid. Medicaid also pays for the patient's cost
sharing and copayments, and provides "wrap around" services not
covered by the employer plan.
15. Allows Medicaid patients who have access to group health
insurance to "opt out" of Medicaid entirely. Similar to HIPP,
under this provision, Medicaid would pay the employee's premium
up to the amount Medicaid would have paid. However, the patient
would be responsible for any amount exceeding what Medicaid pays
and any cost-sharing requirements such as deductibles. Under
HIPP, patients do not pay cost sharing. Opting out of Medicaid
would be voluntary. Prior to the patient leaving Medicaid, HHSC
would be required to offer extensive counseling to inform the
patient of his or her cost-sharing obligations in an opt-out
arrangement. Additionally, HHSC would be required to adopt
guidelines specifying under what conditions a patient may return
to Medicaid (e.g., such as loss of job). Patients who elect to
opt out would be limited to the benefits covered by their
employer-sponsored plan. The provision specifies that patients
who choose this option will remain eligible for Medicaid
community-based long-term care services.
16. Allows Medicaid patients to obtain covered nonsurgical eye
care from an ophthalmologist or therapeutic optometrist without a
referral from a primary care physician or provider, or obtaining
any other prior approval. HHSC may require the ophthalmologist or
optometrist to forward to the patient's PCP information about the
eye care provided. The section specifies that nothing in the
provision may be construed to expand the scope of eye health
services provided under Medicaid. For patients enrolled in PCCM
or an HMO, they may choose to obtain nonsurgical eye care without
a referral from any in-network ophthalmologist or therapeutic
optometrist.
17. Directs HHSC to evaluate the feasibility and
cost-effectiveness of expanding the Integrated Care Management
(ICM) model to rural communities and urban communities where
STAR+PLUS is not available. Directs HHSC to actively encourage
Medicaid health plans to offer value-added benefits and services
that may improve the health of patients.
18. Directs HHSC, if cost-effective and feasible, to require
patients enrolled in traditional Medicaid to select a primary
care physician. Under Medicaid managed care, patients would
continue to follow PCP selection requirements of either the HMO
or PCCM model.
19. Directs the governor's Texas Health Care Policy Council,
in coordination with health science centers and TMB, to study
mechanisms for increasing the number of medical residency
programs in the state and the number of physicians practicing in
medical specialties. The study must examine the feasibility of
using a percentage of physician licensing fees to increase the
number of medical residency programs and medical residents in the
state. Additionally, it must emphasize how to increase medical
residency programs in underserved communities and for physicians
who ultimately practice in those areas. Lastly, the study must
determine the number of medical residents that obtain a license
after completing a residency in Texas. The study must be
submitted by Dec. 1, 2008.
20. Establishes a study to assess the feasibility of using
technology to improve detection and deterrence of fraud within
Medicaid, including using technology to verify a person's
citizenship and eligibility for coverage. Given Texas' extensive
fraud and abuse detection system, it is not immediately clear
what additional measures are envisioned.
21. Requires HHSC to conduct a study on the feasibility of
using a "medical passport" in children's Medicaid and CHIP to
promote integrated health records.
22. Establishes a legislative committee to study and recommend
measures to promote the purchase of health and long-term care
insurance. This includes mechanisms to reduce the need for
patients to rely on Medicaid coverage and to provide incentives
to expand improve coverage for the uninsured. The committee will
include chairs of the respective House and Senate health and
insurance committees and three business leaders appointed by the
governor. The comptroller and commissioners of insurance and
health and health services will serve ex-officio.
Other important provisions of SB 10:
- Directs HHSC to promote Medicaid patient access to federally
qualified health centers (FQHCs) and rural health clinics as well
as appropriate payments for those centers.
- Establishes a "billing coordination system" that identifies
electronically and within 24 hours of submission of a
fee-for-service claim any third-party payer who has primary
responsibility for paying for the Medicaid patient's care. The
provision specifies that the system may not increase the Medicaid
claims payment error rates. If it is determined to be
cost-effective and feasible, HHSC must implement the system on or
before Mar. 1, 2008.
- Requires HHSC to establish a standard definition for hospital
uncompensated care and to establish hospital reporting
requirements. HHSC must establish a workgroup to help develop the
new requirements. The bill also specifies that hospitals that
fail to report as required may be penalized.
- Reestablishes that HHSC shall directly supervise the
administration and operation of the Medicaid medical
transportation program (now managed by the Texas Department of
Transportation). TX DOT must transfer responsibility for the
medical transportation program by Sept. 1, 2008.
- Allows Bexar County to establish a needle exchange program to
prevent spread of HIV, hepatitis B or C, and other infectious
diseases.
- Allows HHSC to establish a "physician-centered" nursing
facility pilot to determine whether paying enhanced Medicaid
rates to nursing homes with onsite, continuous supervision by a
geriatric physician improves residents' health and lowers costs
by reducing hospitalizations and pharmacy costs.
- Specifies that former foster children up to age of 23 who are
enrolled in a Texas institution of higher education are eligible
to receive Medicaid coverage.
- Requires TDI to conduct a study on a "Healthy Texas Program"
under which small employer health plan coverage would be offered
to persons eligible for that coverage. The study must include a
market analysis to assist in identifying underserved segments of
the voluntary small employer group health plan market. HHSC must
submit a study to the legislature by Nov. 1, 2008, that includes
advantages and disadvantages of the program, prospective
structure, function, design and administration, eligibility
criteria, and potential economic impact on the small employer
insurance market.
Children's Health Insurance Program Eligibility Improvements
House Bill 109 by Rep. Sylvester Turner (D-Houston) and Sen. Kip
Averitt (R-Waco) restores most of the eligibility changes made to
CHIP in 2003 in the wake of a severe budget shortfall. The bill had
broad bipartisan support. While the complete list of HB 109 authors
and sponsors is too lengthy to list, some merit specific mention:
Reps. John Davis (R-Houston) and Patrick Rose (D-Dripping Springs)
and Sen. Leticia Van de Putte, all of whom worked tirelessly to
pass the bill.
Medicine, working side-by-side with consumer advocates, business
leaders, hospitals, and health plans, advocated vigorously for the
bill, which passed overwhelmingly in the House with strong
bipartisan support. However, the bill lingered in the Senate for
weeks after the lieutenant governor raised concerns about extending
12 months' continuous coverage to all children covered under
CHIP.
In the end, the Senate overwhelmingly approved the bill after
the two sides struck a compromise in the waning hours of the 80
th
legislative session: HB 109 ensures 12 months' continuous coverage
for children in a family up to 185 percent of poverty ($31,765 per
year/$2,647 per month for a family of three in 2007). Review of a
family's income for higher-income children is at six months. The
review may include electronic verification if "accurate and
appropriate." If a family's income appears to exceed 200 percent of
poverty, the state must contact the family to ascertain if the
information is correct. If the child is found to be no longer
eligible, HHSC must give families at least 30 days' notice before
terminating the child's coverage. The goal of the new review
process is to use electronic, third-party databases to check
income. To ensure that the new review process is accurate and
reliable, HHSC will phase it in over the next year, with full
implementation by Sept. 1, 2008.
Other provisions of the HB 109:
- Requires HHSC to conduct a community-outreach campaign, in
collaboration with community-based organizations, about the
availability and importance of child health insurance. The
campaign must be conducted in English and Spanish and must
include a toll-free hotline for families to call for more
information.
- Allows families to deduct child care expenses from their
gross incomes in accordance with Medicaid policy: $200 per month
for each child under age 2 and $175 per month for each older
child.
- Increases the asset limit from $5,000 to $10,000 (the asset
test only applies to families with incomes between 150 percent
and 200 percent of poverty) and increases the exemption value for
cars: $18,000 for the first vehicle and $7,500 for an additional
vehicle (if a car is worth more, the amount is applied to the
$10,000 asset limit). HB 109 also clarifies that some cars, such
as those modified for patients with disabilities, are fully
exempt.
- Reestablishes the original 90-day waiting period, meaning
that only children who have had health insurance within the past
three months must wait to obtain coverage, with certain
exceptions (e.g., the child involuntarily loses coverage due to a
parent's job loss, or the health insurance premiums exceed 10
percent of net income). Since the 2003 changes, all children,
even those who have never had insurance, were required to wait 90
days for coverage.
- Requires in statute that the state verify a family's reported
income. (HHSC has been doing this all along, but the requirement
is now statutory.)
HHSC estimates that HB 109 will result in an additional 127,500
children obtaining coverage. This forecast is higher than the LBB
forecast of 96,396. If caseload reaches the higher level, with LBB
approval, HHSC may transfer funds to avoid enacting a waiting
list.
HHSC Integrated Eligibility and Benefits Determination System
House Bill 3575 by Representative Rose and Senator Nelson is in
response to serious deficiencies in the state's efforts to
implement an integrated eligibility system using private
contractors. The bill specifies that contracts for the provision of
call centers or written communications must include performance
standards relating to effectiveness, promptness, and accuracy,
including measures for clients needing language assistance.
The bill outlines the goals for an "enhanced eligibility
system": better quality of and access to services, more efficient
business processes that reduce application processing times, and an
enrollment process and application that are simpler and enhance
program integrity. HB 3575 establishes a transition plan for moving
from the previous contractor to a more fully functional system no
later than Jan. 1, 2009. The state auditor must establish an
independent validation and verification program for the eligibility
system during the transition to assure that HHSC meet its
goals.
Lastly, the bill establishes a seven-member legislative
oversight committee to oversee the continued implementation of the
integrated eligibility system. Members of the committee include
three senators, three representatives, and one member appointed by
the governor.
Efforts to Prevent Gaps in Coverage in Children's Medicaid or
CHIP
HB 1, the 2008-09 appropriations act, includes two important budget
riders sponsored by Rep. Garnet Coleman (D-Houston) and Rep. Eliot
Naishtat (D-Austin) directing HHSC to minimize gaps in coverage for
children transitioning from Medicaid to CHIP or vice versa. HHSC is
required to provide simultaneous screening for children who apply
to either CHIP or children's Medicaid using a consolidated
application. Children who are found to be eligible for either
Medicaid or CHIP must be enrolled automatically without further
application. If HHSC finds that a child is no longer eligible for
children's Medicaid, the state must, before terminating coverage,
determine whether the child is eligible for CHIP using currently
available information. If the child is eligible, he or she must be
enrolled unless the parent objects. If the state finds a child is
no longer eligible for CHIP, the state must assess whether the
child qualifies for Medicaid and enroll the child if found
eligible. The riders further specify that HHSC must ensure that
Medicaid and CHIP applications and redeterminations are completed
within state and federal timeliness standards
Due to the termination of HHSC's contract with Accenture, who
was hired to manage the eligibility call centers and other
functions, a separate rider within HB 1 gives HHSC the ability to
add eligibility workers to replace contracted workers and meet all
federal performance standards.
Electronic Data Exchange in Medicaid
Electronic Database of Participating Physicians and Providers
House Bill 2042 by Rep. Dawnna Dukes (D-Austin) and Senator Nelson
will establish an Internet-based, searchable database of all
physicians and providers who participate in Medicaid. The database
will include, at a minimum, the physician's or provider's name;
specialty; location; telephone number; office hours, including
after-hours services; and whether the physician or provider is
accepting new Medicaid recipients and Medicaid managed care plans.
Additionally, the database will describe any practice limitations,
such as what age ranges are accepted; which languages, other than
English, are spoken; and a list of the medical assistance programs
in which the physician or provider participates, such as Texas
Health Steps (the preventive health component of Medicaid).
Patients, physicians, and providers will be able to search the
database by managed care plan or by name of the physician or
provider. To make the database easy to update, participating
physicians/providers will be allowed to update their practice
information electronically via the Internet. HHSC is required to
post updates to the database at least once a month. The bill allows
the executive commissioner to contract for the development and
maintenance of the database, though the executive commissioner will
retain the ability to oversee the contractor's activities. Access
to the database will be free for Medicaid patients, physicians, and
providers. TMA and the Texas Primary Care Coalition helped draft
the bill with input from HHSC. HHSC anticipates the database will
be operational by September 2007.
Authorization to Use Electronic Signatures
House Bill 3261 by Rep. Norma Chavez (D-El Paso) and Senator Nelson
directs HHSC to establish standards for the use of electronic
signatures within Medicaid. The standards must be in accordance
with the Uniform Electronic Transactions Act. The intent of the
legislation is to reduce the paperwork burden of the Medicaid
program and to make it easier for physicians, providers, and
patients to use the system. The provision takes effect Sept. 1,
2007.
Importation of Electronic Eligibility Information
House Bill 321 by Representative Dukes and Sen. Robert Deuell, MD
(R-Greenville), directs HHSC to establish a pilot in at least one
urban area to import electronic eligibility information obtained by
the regional indigent care collaborative system.
Reimbursement for After-Hours Care
House Bill 1579 by Rep. Ryan Guillen (D-Rio Grande City) and
Senator Deuell specifies that when a Medicaid managed care enrollee
- either in an HMO or Primary Care Case Management model - receives
after-hours care in a federally qualified health center, rural
health clinic, or public health clinic, the clinic shall be
reimbursed its allowable rate without having to obtain prior
approval from the patient's primary care physician or provider. TMA
advocated that the bill be broadened to include private practicing
physicians, but that change caused HHSC to include a fiscal note on
the bill. TMA will continue to work with the state to address
issues regarding after-hours coverage and payment.
Public/Private Outreach Initiatives
House Bill 3571 by Representative Rose and Sen. Carlos Uresti
(D-San Antonio) requires HHSC to develop a pilot project in South
Texas allowing a private retail business that participates in the
food stamp program to enter into an agreement with HHSC to support
outreach and eligibility determinations. HHSC may require the
business to provide informational materials, including eligibility
guidelines, and provide space for HHSC or contractors to conduct
outreach efforts. Important to medicine, the agreement may also
authorize the business to implement strategies to encourage food
stamp and Medicaid recipients to engage in healthy behaviors or
provide incentives for children to obtain timely Texas Health Step
services. HHSC must submit a report on the pilot by Dec. 1,
2008.
Expedited Medicaid Eligibility for Members of the Armed Forces
House Bill 1633 by Rep. Charlie Green (R-Ft. Worth) and Senator
Deuell requires HHSC to develop and implement expedited eligibility
and enrollment processes for patients who are active duty members
of the armed forces, reserves, or National Guard, or are the spouse
or dependent of that person.
"Insure Texas Kids" License Plates
Senate Bill 1032 by Senator Uresti and Rep. Pat Haggerty (R-El
Paso) requires the Texas Department of Transportation to issue
specialty license plates stating "Insure Texas Kids." Funds
collected from selling the specialty plates, after deducting the
department's administrative costs, will be available for HHSC to
fund outreach efforts designed to insure more Texas children.
Medicaid Fair Hearing Process
House Bill 2256 by Rep. Jim McReynolds (D-Lufkin) and Senator
Deuell requires HHSC to put in place a fair hearing process for
services that require prior authorization. The bill also specifies
that HHSC must provide a patient 10 days' notice prior to
terminating or reducing Medicaid services. HHSC also must notify
the patient of the fair hearing mechanism. Federal regulations
require Medicaid to provide an opportunity for a fair hearing to
any patient who believes the agency has erroneously terminated,
suspended, or reduced a Medicaid service. Under the federal rules,
states must continue the service until it has been
reviewed. Current HHSC rules exempt services that require
prior authorization, including private duty nursing. If a client
requests a hearing, the state will not maintain the nursing
services pending the outcome of the hearing.
Administrative and Judicial Review Regarding Decisions Relating
to Public Benefits
HB 75 by Representative Naishtat and Sen. Jeff Wentworth (R-San
Antonio) specifies that applicants for Medicaid, food stamps, or
other public benefits who have been denied coverage may request an
administrative review to contest the decision. The applicant may
also file a petition with the district court in Travis County.
Medicaid Fraud Prevention and Detection
Violation of False Claims Act
House Bill 889 by Rep. Dianne Delisi (R-Temple) and Sen. Robert
Nichols (R-Jacksonville) specifies that any violation of the
federal False Claims Act is also a violation of the Texas Medicaid
Fraud Prevention Act.
State Funding for Medicaid Fraud Recovery
Senate Bill 362 by Sen. Kyle Janek, MD (R-Houston), and Rep. Dan
Gattis (R-Georgetown) brings Texas into compliance of Section 1909
of the Social Security Act relating to fraud prevention, making
Texas eligible to qualify for additional monies recovered under the
Medicaid False Claims Act. Specifically, the bill increases the
minimum penalties per false claim from $1,000 to $5,000 and makes
clear that the individual whistleblower may prosecute the case on
his own if the State declines to take over the case. On June 20,
2007, the Office of Inspector General of the U.S. Department of
Health and Human Services approved the amended plan, thus allowing
Texas to be eligible for an increase of 10 percentage points in its
share of any amounts recovered under a State action brought under
such a law.
Fraud Investigations and Criminal Offenses Involving the
Medicaid Program
Senate Bill 1694 by Senator Nelson and Rep. Jim Jackson
(R-Carrollton) allows state agencies that license, regulate,
register, or certify health professionals or managed care
organizations that participate in Medicaid to share information
with each other. This includes the Office of the Attorney General
regarding a health care professional or managed care organization
that is the subject of a fraud investigation. An agency that
receives a request for information shall provide the information
unless releasing it would jeopardize an investigation or is
prohibited by law. An agency that discovers fraud or abuse by a
health care professional or managed care organization may provide
that information to any other participating agency unless the law
prohibits its release. Confidential information shared with another
agency is subject to the same confidentiality requirements and
legal restrictions as the originating agency.
SB 1694 expands fraudulent behavior to include receiving an
inducement (not just providing one). The bill strengthens the
penalties for securing execution of a document by deception. It
increases the punishment to the next higher category of offense if
it involves the State Medicaid program. The bill makes it a State
jail felony to obstruct an investigation and broadens the acts that
qualify for obstruction of investigation violations.
The law currently states that illegal conduct involving
amounts ranging from $1,500 to $20,000 is a State jail felony.
The bill amends this provision to make any conduct that
involves an amount of payment or value of benefit that cannot be
reasonably ascertained
automatically
a State jail felony.
Language throughout this section changed to include "claims
for payment made," which presumably was altered to include
situations in which payment is not actually made or is made in an
amount that is less than the claim filed. Finally, the bill
would make any property used or intended to be used in the
commission of a felony under Chapter 32 of the Human Resources Code
or 35A (the Medicaid fraud provision) of the Penal Code fall into
the definition of "contraband."
TMA Medicaid/CHIP/Uninsured Staff Team:
Legislative: Michelle Romero
Policy: Helen Kent Davis and Rich Johnson
Legal: Kelly Walla and Rocky Wilcox
Overview
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Managed Care/Insurance Reform
|
Scope of Practice
|
Retail Health Clinics
|
Responsible Ownership
|
Corporate Practice of Medicine
|
Health Care Funding
|
Public Health
|
Border Health
|
Mental Health
|
Emergency Medical Services and
Trauma Care
|
Rural Health
|
Medical Science and Quality
|
Physician Workforce, Licensure,
and Discipline
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Health Information Technology
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Prescription Drugs
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Long-Term Care
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Workers' Compensation
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Abortion
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Franchise Tax Reform