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  H.B. No. 2658
 
 
 
 
AN ACT
  relating to the Medicaid program, including the administration and
  operation of the Medicaid managed care program.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter B, Chapter 531, Government Code, is
  amended by adding Sections 531.0501 and 531.0512 to read as
  follows:
         Sec. 531.0501.  MEDICAID WAIVER PROGRAMS: INTEREST LIST
  MANAGEMENT. (a) The commission, in consultation with the
  Intellectual and Developmental Disability System Redesign Advisory
  Committee established under Section 534.053, shall study the
  feasibility of creating an online portal for individuals to request
  to be placed and check the individual's placement on a Medicaid
  waiver program interest list.  As part of the study, the commission
  shall determine the most cost-effective automated method for
  determining the level of need of an individual seeking services
  through a Medicaid waiver program.
         (b)  Not later than January 1, 2023, the commission shall
  prepare and submit a report to the governor, the lieutenant
  governor, the speaker of the house of representatives, and the
  standing legislative committees with primary jurisdiction over
  health and human services that summarizes the commission's findings
  and conclusions from the study.
         (c)  Subsections (a) and (b) and this subsection expire
  September 1, 2023.
         (d)  The commission shall develop a protocol in the office of
  the ombudsman to improve the capture and updating of contact
  information for an individual who contacts the office of the
  ombudsman regarding Medicaid waiver programs or services.
         Sec. 531.0512.  NOTIFICATION REGARDING CONSUMER DIRECTION
  MODEL. The commission shall:
               (1)  develop a procedure to:
                     (A)  verify that a Medicaid recipient or the
  recipient's parent or legal guardian is informed regarding the
  consumer direction model and provided the option to choose to
  receive care under that model; and
                     (B)  if the individual declines to receive care
  under the consumer direction model, document the declination; and
               (2)  ensure that each Medicaid managed care
  organization implements the procedure.
         SECTION 2.  Section 533.00251, Government Code, is amended
  by adding Subsection (h) to read as follows:
         (h)  In addition to the minimum performance standards the
  commission establishes for nursing facility providers seeking to
  participate in the STAR+PLUS Medicaid managed care program, the
  executive commissioner shall adopt rules establishing minimum
  performance standards applicable to nursing facility providers
  that participate in the program. The commission is responsible for
  monitoring provider performance in accordance with the standards
  and requiring corrective actions, as the commission determines
  necessary, from providers that do not meet the standards. The
  commission shall share data regarding the requirements of this
  subsection with STAR+PLUS Medicaid managed care organizations as
  appropriate.
         SECTION 3.  Section 533.005(a), Government Code, is amended
  to read as follows:
         (a)  A contract between a managed care organization and the
  commission for the organization to provide health care services to
  recipients must contain:
               (1)  procedures to ensure accountability to the state
  for the provision of health care services, including procedures for
  financial reporting, quality assurance, utilization review, and
  assurance of contract and subcontract compliance;
               (2)  capitation rates that:
                     (A)  include acuity and risk adjustment
  methodologies that consider the costs of providing acute care
  services and long-term services and supports, including private
  duty nursing services, provided under the plan; and
                     (B)  ensure the cost-effective provision of
  quality health care;
               (3)  a requirement that the managed care organization
  provide ready access to a person who assists recipients in
  resolving issues relating to enrollment, plan administration,
  education and training, access to services, and grievance
  procedures;
               (4)  a requirement that the managed care organization
  provide ready access to a person who assists providers in resolving
  issues relating to payment, plan administration, education and
  training, and grievance procedures;
               (5)  a requirement that the managed care organization
  provide information and referral about the availability of
  educational, social, and other community services that could
  benefit a recipient;
               (6)  procedures for recipient outreach and education;
               (7)  a requirement that the managed care organization
  make payment to a physician or provider for health care services
  rendered to a recipient under a managed care plan on any claim for
  payment that is received with documentation reasonably necessary
  for the managed care organization to process the claim:
                     (A)  not later than:
                           (i)  the 10th day after the date the claim is
  received if the claim relates to services provided by a nursing
  facility, intermediate care facility, or group home;
                           (ii)  the 30th day after the date the claim
  is received if the claim relates to the provision of long-term
  services and supports not subject to Subparagraph (i); and
                           (iii)  the 45th day after the date the claim
  is received if the claim is not subject to Subparagraph (i) or (ii);
  or
                     (B)  within a period, not to exceed 60 days,
  specified by a written agreement between the physician or provider
  and the managed care organization;
               (7-a)  a requirement that the managed care organization
  demonstrate to the commission that the organization pays claims
  described by Subdivision (7)(A)(ii) on average not later than the
  21st day after the date the claim is received by the organization;
               (8)  a requirement that the commission, on the date of a
  recipient's enrollment in a managed care plan issued by the managed
  care organization, inform the organization of the recipient's
  Medicaid certification date;
               (9)  a requirement that the managed care organization
  comply with Section 533.006 as a condition of contract retention
  and renewal;
               (10)  a requirement that the managed care organization
  provide the information required by Section 533.012 and otherwise
  comply and cooperate with the commission's office of inspector
  general and the office of the attorney general;
               (11)  a requirement that the managed care
  organization's usages of out-of-network providers or groups of
  out-of-network providers may not exceed limits for those usages
  relating to total inpatient admissions, total outpatient services,
  and emergency room admissions determined by the commission;
               (12)  if the commission finds that a managed care
  organization has violated Subdivision (11), a requirement that the
  managed care organization reimburse an out-of-network provider for
  health care services at a rate that is equal to the allowable rate
  for those services, as determined under Sections 32.028 and
  32.0281, Human Resources Code;
               (13)  a requirement that, notwithstanding any other
  law, including Sections 843.312 and 1301.052, Insurance Code, the
  organization:
                     (A)  use advanced practice registered nurses and
  physician assistants in addition to physicians as primary care
  providers to increase the availability of primary care providers in
  the organization's provider network; and
                     (B)  treat advanced practice registered nurses
  and physician assistants in the same manner as primary care
  physicians with regard to:
                           (i)  selection and assignment as primary
  care providers;
                           (ii)  inclusion as primary care providers in
  the organization's provider network; and
                           (iii)  inclusion as primary care providers
  in any provider network directory maintained by the organization;
               (14)  a requirement that the managed care organization
  reimburse a federally qualified health center or rural health
  clinic for health care services provided to a recipient outside of
  regular business hours, including on a weekend day or holiday, at a
  rate that is equal to the allowable rate for those services as
  determined under Section 32.028, Human Resources Code, if the
  recipient does not have a referral from the recipient's primary
  care physician;
               (15)  a requirement that the managed care organization
  develop, implement, and maintain a system for tracking and
  resolving all provider appeals related to claims payment, including
  a process that will require:
                     (A)  a tracking mechanism to document the status
  and final disposition of each provider's claims payment appeal;
                     (B)  the contracting with physicians who are not
  network providers and who are of the same or related specialty as
  the appealing physician to resolve claims disputes related to
  denial on the basis of medical necessity that remain unresolved
  subsequent to a provider appeal;
                     (C)  the determination of the physician resolving
  the dispute to be binding on the managed care organization and
  provider; and
                     (D)  the managed care organization to allow a
  provider with a claim that has not been paid before the time
  prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
  claim;
               (16)  a requirement that a medical director who is
  authorized to make medical necessity determinations is available to
  the region where the managed care organization provides health care
  services;
               (17)  a requirement that the managed care organization
  ensure that a medical director and patient care coordinators and
  provider and recipient support services personnel are located in
  the South Texas service region, if the managed care organization
  provides a managed care plan in that region;
               (18)  a requirement that the managed care organization
  provide special programs and materials for recipients with limited
  English proficiency or low literacy skills;
               (19)  a requirement that the managed care organization
  develop and establish a process for responding to provider appeals
  in the region where the organization provides health care services;
               (20)  a requirement that the managed care organization:
                     (A)  develop and submit to the commission, before
  the organization begins to provide health care services to
  recipients, a comprehensive plan that describes how the
  organization's provider network complies with the provider access
  standards established under Section 533.0061;
                     (B)  as a condition of contract retention and
  renewal:
                           (i)  continue to comply with the provider
  access standards established under Section 533.0061; and
                           (ii)  make substantial efforts, as
  determined by the commission, to mitigate or remedy any
  noncompliance with the provider access standards established under
  Section 533.0061;
                     (C)  pay liquidated damages for each failure, as
  determined by the commission, to comply with the provider access
  standards established under Section 533.0061 in amounts that are
  reasonably related to the noncompliance; and
                     (D)  regularly, as determined by the commission,
  submit to the commission and make available to the public a report
  containing data on the sufficiency of the organization's provider
  network with regard to providing the care and services described
  under Section 533.0061(a) and specific data with respect to access
  to primary care, specialty care, long-term services and supports,
  nursing services, and therapy services on the average length of
  time between:
                           (i)  the date a provider requests prior
  authorization for the care or service and the date the organization
  approves or denies the request; and
                           (ii)  the date the organization approves a
  request for prior authorization for the care or service and the date
  the care or service is initiated;
               (21)  a requirement that the managed care organization
  demonstrate to the commission, before the organization begins to
  provide health care services to recipients, that, subject to the
  provider access standards established under Section 533.0061:
                     (A)  the organization's provider network has the
  capacity to serve the number of recipients expected to enroll in a
  managed care plan offered by the organization;
                     (B)  the organization's provider network
  includes:
                           (i)  a sufficient number of primary care
  providers;
                           (ii)  a sufficient variety of provider
  types;
                           (iii)  a sufficient number of providers of
  long-term services and supports and specialty pediatric care
  providers of home and community-based services; and
                           (iv)  providers located throughout the
  region where the organization will provide health care services;
  and
                     (C)  health care services will be accessible to
  recipients through the organization's provider network to a
  comparable extent that health care services would be available to
  recipients under a fee-for-service or primary care case management
  model of Medicaid managed care;
               (22)  a requirement that the managed care organization
  develop a monitoring program for measuring the quality of the
  health care services provided by the organization's provider
  network that:
                     (A)  incorporates the National Committee for
  Quality Assurance's Healthcare Effectiveness Data and Information
  Set (HEDIS) measures or, as applicable, the national core
  indicators adult consumer survey and the national core indicators
  child family survey for individuals with an intellectual or
  developmental disability;
                     (B)  focuses on measuring outcomes; and
                     (C)  includes the collection and analysis of
  clinical data relating to prenatal care, preventive care, mental
  health care, and the treatment of acute and chronic health
  conditions and substance abuse;
               (23)  subject to Subsection (a-1), a requirement that
  the managed care organization develop, implement, and maintain an
  outpatient pharmacy benefit plan for its enrolled recipients:
                     (A)  that, except as provided by Paragraph
  (L)(ii), exclusively employs the vendor drug program formulary and
  preserves the state's ability to reduce waste, fraud, and abuse
  under Medicaid;
                     (B)  that adheres to the applicable preferred drug
  list adopted by the commission under Section 531.072;
                     (C)  that, except as provided by Paragraph (L)(i),
  includes the prior authorization procedures and requirements
  prescribed by or implemented under Sections 531.073(b), (c), and
  (g) for the vendor drug program;
                     (C-1)  that does not require a clinical,
  nonpreferred, or other prior authorization for any antiretroviral
  drug, as defined by Section 531.073, or a step therapy or other
  protocol, that could restrict or delay the dispensing of the drug
  except to minimize fraud, waste, or abuse;
                     (D)  for purposes of which the managed care
  organization:
                           (i)  may not negotiate or collect rebates
  associated with pharmacy products on the vendor drug program
  formulary; and
                           (ii)  may not receive drug rebate or pricing
  information that is confidential under Section 531.071;
                     (E)  that complies with the prohibition under
  Section 531.089;
                     (F)  under which the managed care organization may
  not prohibit, limit, or interfere with a recipient's selection of a
  pharmacy or pharmacist of the recipient's choice for the provision
  of pharmaceutical services under the plan through the imposition of
  different copayments;
                     (G)  that allows the managed care organization or
  any subcontracted pharmacy benefit manager to contract with a
  pharmacist or pharmacy providers separately for specialty pharmacy
  services, except that:
                           (i)  the managed care organization and
  pharmacy benefit manager are prohibited from allowing exclusive
  contracts with a specialty pharmacy owned wholly or partly by the
  pharmacy benefit manager responsible for the administration of the
  pharmacy benefit program; and
                           (ii)  the managed care organization and
  pharmacy benefit manager must adopt policies and procedures for
  reclassifying prescription drugs from retail to specialty drugs,
  and those policies and procedures must be consistent with rules
  adopted by the executive commissioner and include notice to network
  pharmacy providers from the managed care organization;
                     (H)  under which the managed care organization may
  not prevent a pharmacy or pharmacist from participating as a
  provider if the pharmacy or pharmacist agrees to comply with the
  financial terms and conditions of the contract as well as other
  reasonable administrative and professional terms and conditions of
  the contract;
                     (I)  under which the managed care organization may
  include mail-order pharmacies in its networks, but may not require
  enrolled recipients to use those pharmacies, and may not charge an
  enrolled recipient who opts to use this service a fee, including
  postage and handling fees;
                     (J)  under which the managed care organization or
  pharmacy benefit manager, as applicable, must pay claims in
  accordance with Section 843.339, Insurance Code;
                     (K)  under which the managed care organization or
  pharmacy benefit manager, as applicable:
                           (i)  to place a drug on a maximum allowable
  cost list, must ensure that:
                                 (a)  the drug is listed as "A" or "B"
  rated in the most recent version of the United States Food and Drug
  Administration's Approved Drug Products with Therapeutic
  Equivalence Evaluations, also known as the Orange Book, has an "NR"
  or "NA" rating or a similar rating by a nationally recognized
  reference; and
                                 (b)  the drug is generally available
  for purchase by pharmacies in the state from national or regional
  wholesalers and is not obsolete;
                           (ii)  must provide to a network pharmacy
  provider, at the time a contract is entered into or renewed with the
  network pharmacy provider, the sources used to determine the
  maximum allowable cost pricing for the maximum allowable cost list
  specific to that provider;
                           (iii)  must review and update maximum
  allowable cost price information at least once every seven days to
  reflect any modification of maximum allowable cost pricing;
                           (iv)  must, in formulating the maximum
  allowable cost price for a drug, use only the price of the drug and
  drugs listed as therapeutically equivalent in the most recent
  version of the United States Food and Drug Administration's
  Approved Drug Products with Therapeutic Equivalence Evaluations,
  also known as the Orange Book;
                           (v)  must establish a process for
  eliminating products from the maximum allowable cost list or
  modifying maximum allowable cost prices in a timely manner to
  remain consistent with pricing changes and product availability in
  the marketplace;
                           (vi)  must:
                                 (a)  provide a procedure under which a
  network pharmacy provider may challenge a listed maximum allowable
  cost price for a drug;
                                 (b)  respond to a challenge not later
  than the 15th day after the date the challenge is made;
                                 (c)  if the challenge is successful,
  make an adjustment in the drug price effective on the date the
  challenge is resolved and make the adjustment applicable to all
  similarly situated network pharmacy providers, as determined by the
  managed care organization or pharmacy benefit manager, as
  appropriate;
                                 (d)  if the challenge is denied,
  provide the reason for the denial; and
                                 (e)  report to the commission every 90
  days the total number of challenges that were made and denied in the
  preceding 90-day period for each maximum allowable cost list drug
  for which a challenge was denied during the period;
                           (vii)  must notify the commission not later
  than the 21st day after implementing a practice of using a maximum
  allowable cost list for drugs dispensed at retail but not by mail;
  and
                           (viii)  must provide a process for each of
  its network pharmacy providers to readily access the maximum
  allowable cost list specific to that provider; and
                     (L)  under which the managed care organization or
  pharmacy benefit manager, as applicable:
                           (i)  may not require a prior authorization,
  other than a clinical prior authorization or a prior authorization
  imposed by the commission to minimize the opportunity for waste,
  fraud, or abuse, for or impose any other barriers to a drug that is
  prescribed to a child enrolled in the STAR Kids managed care program
  for a particular disease or treatment and that is on the vendor drug
  program formulary or require additional prior authorization for a
  drug included in the preferred drug list adopted under Section
  531.072;
                           (ii)  must provide for continued access to a
  drug prescribed to a child enrolled in the STAR Kids managed care
  program, regardless of whether the drug is on the vendor drug
  program formulary or, if applicable on or after August 31, 2023, the
  managed care organization's formulary;
                           (iii)  may not use a protocol that requires a
  child enrolled in the STAR Kids managed care program to use a
  prescription drug or sequence of prescription drugs other than the
  drug that the child's physician recommends for the child's
  treatment before the managed care organization provides coverage
  for the recommended drug; and
                           (iv)  must pay liquidated damages to the
  commission for each failure, as determined by the commission, to
  comply with this paragraph in an amount that is a reasonable
  forecast of the damages caused by the noncompliance;
               (24)  a requirement that the managed care organization
  and any entity with which the managed care organization contracts
  for the performance of services under a managed care plan disclose,
  at no cost, to the commission and, on request, the office of the
  attorney general all discounts, incentives, rebates, fees, free
  goods, bundling arrangements, and other agreements affecting the
  net cost of goods or services provided under the plan;
               (25)  a requirement that the managed care organization
  not implement significant, nonnegotiated, across-the-board
  provider reimbursement rate reductions unless:
                     (A)  subject to Subsection (a-3), the
  organization has the prior approval of the commission to make the
  reductions; or
                     (B)  the rate reductions are based on changes to
  the Medicaid fee schedule or cost containment initiatives
  implemented by the commission; and
               (26)  a requirement that the managed care organization
  make initial and subsequent primary care provider assignments and
  changes.
         SECTION 4.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.00515 to read as follows:
         Sec. 533.00515.  MEDICATION THERAPY MANAGEMENT. The
  executive commissioner shall collaborate with Medicaid managed
  care organizations to implement medication therapy management
  services to lower costs and improve quality outcomes for recipients
  by reducing adverse drug events.
         SECTION 5.  Section 533.009(c), Government Code, is amended
  to read as follows:
         (c)  The executive commissioner, by rule, shall prescribe
  the minimum requirements that a managed care organization, in
  providing a disease management program, must meet to be eligible to
  receive a contract under this section. The managed care
  organization must, at a minimum, be required to:
               (1)  provide disease management services that have
  performance measures for particular diseases that are comparable to
  the relevant performance measures applicable to a provider of
  disease management services under Section 32.057, Human Resources
  Code; [and]
               (2)  show evidence of ability to manage complex
  diseases in the Medicaid population; and
               (3)  if a disease management program provided by the
  organization has low active participation rates, identify the
  reason for the low rates and develop an approach to increase active
  participation in disease management programs for high-risk
  recipients.
         SECTION 6.  Section 32.054, Human Resources Code, is amended
  by adding Subsection (f) to read as follows:
         (f)  To prevent serious medical conditions and reduce
  emergency room visits necessitated by complications resulting from
  a lack of access to dental care, the commission shall provide
  medical assistance reimbursement for preventive dental services,
  including reimbursement for one preventive dental care visit per
  year, for an adult recipient with a disability who is enrolled in
  the STAR+PLUS Medicaid managed care program. This subsection does
  not apply to an adult recipient who is enrolled in the STAR+PLUS
  home and community-based services (HCBS) waiver program.  This
  subsection may not be construed to reduce dental services available
  to persons with disabilities that are otherwise reimbursable under
  the medical assistance program.
         SECTION 7.  Subchapter B, Chapter 32, Human Resources Code,
  is amended by adding Section 32.0317 to read as follows:
         Sec. 32.0317.  REIMBURSEMENT FOR SERVICES PROVIDED UNDER
  SCHOOL HEALTH AND RELATED SERVICES PROGRAM. The executive
  commissioner shall adopt rules requiring parental consent for
  services provided under the school health and related services
  program in order for a school district to receive reimbursement for
  the services. The rules must allow a school district to seek a
  waiver to receive reimbursement for services provided to a student
  who does not have a parent or legal guardian who can provide
  consent.
         SECTION 8.  Section 32.0261, Human Resources Code, is
  amended to read as follows:
         Sec. 32.0261.  CONTINUOUS ELIGIBILITY.  (a) This section
  applies only to a child younger than 19 years of age who is
  determined eligible for medical assistance under this chapter.
         (b)  The executive commissioner shall adopt rules in
  accordance with 42 U.S.C. Section 1396a(e)(12), as amended, to
  provide for two consecutive periods of [a period of continuous]
  eligibility for a child between each certification and
  recertification of the child's eligibility, subject to Subsections
  (f) and (h) [under 19 years of age who is determined to be eligible
  for medical assistance under this chapter].
         (c)  The first of the two consecutive periods of eligibility
  described by Subsection (b) must be continuous in accordance with
  Subsection (d). The second of the two consecutive periods of
  eligibility is not continuous and may be affected by changes in a
  child's household income, regardless of whether those changes
  occurred or whether the commission became aware of the changes
  during the first or second of the two consecutive periods of
  eligibility.
         (d)  A [The rules shall provide that the] child remains
  eligible for medical assistance during the first of the two
  consecutive periods of eligibility, without additional review by
  the commission and regardless of changes in the child's household
  [resources or] income, until [the earlier of:
               [(1)]  the end of the six-month period following the
  date on which the child's eligibility was determined, except as
  provided by Subsections (f)(1) and (h) [; or
               [(2)  the child's 19th birthday].
         (e)  During the sixth month following the date on which a
  child's eligibility for medical assistance is certified or
  recertified, the commission shall, in a manner that complies with
  federal law, including verification plan requirements under 42
  C.F.R. Section 435.945(j), review the child's household income
  using electronic income data available to the commission. The
  commission may conduct this review only once during the child's two
  consecutive periods of eligibility.  Based on the review:
               (1)  the commission shall, if the review indicates that
  the child's household income does not exceed the maximum income for
  eligibility for the medical assistance program, provide for a
  second consecutive period of eligibility for the child until the
  child's required annual recertification, except as provided by
  Subsection (h) and subject to Subsection (c); or
               (2)  the commission may, if the review indicates that
  the child's household income exceeds the maximum income for
  eligibility for the medical assistance program, request additional
  documentation to verify the child's household income in a manner
  that complies with federal law.
         (f)  If, after reviewing a child's household income under
  Subsection (e), the commission determines that the household income
  exceeds the maximum income for eligibility for the medical
  assistance program, the commission shall continue to provide
  medical assistance to the child until:
               (1)  the commission provides the child's parent or
  guardian with a period of not less than 30 days to provide
  documentation demonstrating that the child's household income does
  not exceed the maximum income for eligibility; and
               (2)  the child's parent or guardian fails to provide the
  documentation during the period described by Subdivision (1).
         (g)  If a child's parent or guardian provides to the
  commission within the period described by Subsection (f)
  documentation demonstrating that the child's household income does
  not exceed the maximum income for eligibility for the medical
  assistance program, the commission shall provide for a second
  consecutive period of eligibility for the child until the child's
  required annual recertification, except as provided by Subsection
  (h) and subject to Subsection (c).
         (h)  Notwithstanding any other period prescribed by this
  section, a child's eligibility for medical assistance ends on the
  child's 19th birthday.
         (i)  The commission may not recertify a child's eligibility
  for medical assistance more frequently than every 12 months as
  required by federal law.
         (j)  If a child's parent or guardian fails to provide to the
  commission within the period described by Subsection (f)
  documentation demonstrating that the child's household income does
  not exceed the maximum income for eligibility for the medical
  assistance program, the commission shall provide the child's parent
  or guardian with written notice of termination following that
  period. The notice must include a statement that the child may be
  eligible for enrollment in the child health plan under Chapter 62,
  Health and Safety Code.
         (k)  In developing the notice, the commission shall consult
  with health care providers, children's health care advocates,
  family members of children enrolled in the medical assistance
  program, and other stakeholders to determine the most user-friendly
  method to provide the notice to a child's parent or guardian.
         (l)  The executive commissioner may adopt rules as necessary
  to implement this section.
         SECTION 9.  (a) In this section, "commission," "executive
  commissioner," and "Medicaid" have the meanings assigned by Section
  531.001, Government Code.
         (b)  Using existing resources, the commission shall:
               (1)  review the commission's staff rate enhancement
  programs to:
                     (A)  identify and evaluate methods for improving
  administration of those programs to reduce administrative barriers
  that prevent an increase in direct care staffing and direct care
  wages and benefits in nursing homes; and
                     (B)  develop recommendations for increasing
  participation in the programs;
               (2)  revise the commission's policies regarding the
  quality incentive payment program (QIPP) to require improvements to
  staff-to-patient ratios in nursing facilities participating in the
  program by January 1, 2025; and
               (3)  identify factors influencing active participation
  by Medicaid recipients in disease management programs by examining
  variations in:
                     (A)  eligibility criteria for the programs; and
                     (B)  participation rates by health plan, disease
  management program, and year.
         (c)  The executive commissioner may approve a capitation
  payment system that provides for reimbursement for physicians under
  a primary care capitation model or total care capitation model.
         SECTION 10.  (a) In this section, "commission" and
  "Medicaid" have the meanings assigned by Section 531.001,
  Government Code.
         (b)  As soon as practicable after the effective date of this
  Act, the commission shall conduct a study to determine the
  cost-effectiveness and feasibility of providing to Medicaid
  recipients who have been diagnosed with diabetes, including Type 1
  diabetes, Type 2 diabetes, and gestational diabetes:
               (1)  diabetes self-management education and support
  services that follow the National Standards for Diabetes
  Self-Management Education and Support and that may be delivered by
  a certified diabetes educator; and
               (2)  medical nutrition therapy services.
         (c)  If the commission determines that providing one or both
  of the types of services described by Subsection (b) of this section
  would improve health outcomes for Medicaid recipients and lower
  Medicaid costs, the commission shall, notwithstanding Section
  32.057, Human Resources Code, or Section 533.009, Government Code,
  and to the extent allowed by federal law develop a program to
  provide the benefits and seek prior approval from the Legislative
  Budget Board before implementing the program.
         SECTION 11.  (a) In this section, "commission" and
  "Medicaid" have the meanings assigned by Section 531.001,
  Government Code.
         (b)  As soon as practicable after the effective date of this
  Act, the commission shall conduct a study to:
               (1)  identify benefits and services provided under
  Medicaid that are not provided in this state under the Medicaid
  managed care model; and
               (2)  evaluate the feasibility, cost-effectiveness, and
  impact on Medicaid recipients of providing the benefits and
  services identified under Subdivision (1) of this subsection
  through the Medicaid managed care model.
         (c)  Not later than December 1, 2022, the commission shall
  prepare and submit a report to the legislature that includes:
               (1)  a summary of the commission's evaluation under
  Subsection (b)(2) of this section; and
               (2)  a recommendation as to whether the commission
  should implement providing benefits and services identified under
  Subsection (b)(1) of this section through the Medicaid managed care
  model.
         SECTION 12.  (a) In this section:
               (1)  "Commission," "Medicaid," and "Medicaid managed
  care organization" have the meanings assigned by Section 531.001,
  Government Code.
               (2)  "Dually eligible individual" has the meaning
  assigned by Section 531.0392, Government Code.
         (b)  The commission shall conduct a study regarding dually
  eligible individuals who are enrolled in the Medicaid managed care
  program. The study must include an evaluation of:
               (1)  Medicare cost-sharing requirements for those
  individuals;
               (2)  the cost-effectiveness for a Medicaid managed care
  organization to provide all Medicaid-eligible services not covered
  under Medicare and require cost-sharing for those services; and
               (3)  the impact on dually eligible individuals and
  Medicaid providers that would result from the implementation of
  Subdivision (2) of this subsection.
         (c)  Not later than September 1, 2022, the commission shall
  prepare and submit a report to the legislature that includes:
               (1)  a summary of the commission's findings from the
  study conducted under Subsection (b) of this section; and
               (2)  a recommendation as to whether the commission
  should implement Subsection (b)(2) of this section.
         SECTION 13.  (a)  Using existing resources, the Health and
  Human Services Commission shall conduct a study to assess the
  impact of revising the capitation rate setting strategy used to
  cover long-term care services and supports provided to recipients
  under the STAR+PLUS Medicaid managed care program from a strategy
  based on the setting in which services are provided to a strategy
  based on a blended rate. The study must:
               (1)  assess the potential impact using a blended
  capitation rate would have on recipients' choice of setting;
               (2)  include an actuarial analysis of the impact using
  a blended capitation rate would have on program spending; and
               (3)  consider the experience of other states that use a
  blended capitation rate to reimburse managed care organizations for
  the provision of long-term care services and supports under
  Medicaid.
         (b)  Not later than September 1, 2022, the Health and Human
  Services Commission shall prepare and submit a report that
  summarizes the findings of the study conducted under Subsection (a)
  of this section to the governor, the lieutenant governor, the
  speaker of the house of representatives, the House Human Services
  Committee, and the Senate Health and Human Services Committee.
         SECTION 14.  Notwithstanding Section 2, Chapter 1117 (H.B.
  3523), Acts of the 84th Legislature, Regular Session, 2015, Section
  533.00251(c), Government Code, as amended by Section 2 of that Act,
  takes effect September 1, 2023.
         SECTION 15.  (a) Section 533.005(a), Government Code, as
  amended by this Act, applies only to a contract between the Health
  and Human Services Commission and a managed care organization that
  is entered into or renewed on or after the effective date of this
  Act.
         (b)  To the extent permitted by the terms of the contract,
  the Health and Human Services Commission shall seek to amend a
  contract entered into before the effective date of this Act with a
  managed care organization to comply with Section 533.005(a),
  Government Code, as amended by this Act.
         SECTION 16.  As soon as practicable after the effective date
  of this Act, the Health and Human Services Commission shall conduct
  the study and make the determination required by Section
  531.0501(a), Government Code, as added by this Act.
         SECTION 17.  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 18.  The Health and Human Services Commission is
  required to implement this Act only if the legislature appropriates
  money specifically for that purpose. If the legislature does not
  appropriate money specifically for that purpose, the commission
  may, but is not required to, implement this Act using other
  appropriations available for the purpose.
         SECTION 19.  This Act takes effect September 1, 2021.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 2658 was passed by the House on April
  21, 2021, by the following vote:  Yeas 147, Nays 0, 2 present, not
  voting; that the House refused to concur in Senate amendments to
  H.B. No. 2658 on May 27, 2021, and requested the appointment of a
  conference committee to consider the differences between the two
  houses; and that the House adopted the conference committee report
  on H.B. No. 2658 on May 30, 2021, by the following vote:  Yeas 135,
  Nays 0, 2 present, not voting.
 
  ______________________________
  Chief Clerk of the House   
 
         I certify that H.B. No. 2658 was passed by the Senate, with
  amendments, on May 22, 2021, by the following vote:  Yeas 31, Nays
  0; at the request of the House, the Senate appointed a conference
  committee to consider the differences between the two houses; and
  that the Senate adopted the conference committee report on H.B. No.
  2658 on May 30, 2021, by the following vote:  Yeas 31, Nays 0.
 
  ______________________________
  Secretary of the Senate   
  APPROVED: __________________
                  Date       
   
           __________________
                Governor