HB5244 - Relating to the development and implementation of the Texas Plan demonstration program to fund the purchase by and provision to certain eligible individuals of health care services.

  89R11869 JG-F     By: Manuel H.B. No. 5244       A BILL TO BE ENTITLED   AN ACT   relating to the development and implementation of the Texas Plan   demonstration program to fund the purchase by and provision to   certain eligible individuals of health care services.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subtitle I, Title 4, Government Code, is amended   by adding Chapter 532A to read as follows:   CHAPTER 532A. TEXAS PLAN DEMONSTRATION PROGRAM   SUBCHAPTER A. GENERAL PROVISIONS           Sec. 532A.0001.  DEFINITIONS. In this chapter:                 (1)     "Board" means the board of directors of the   med-pool.                 (2)     "Eligible individual" means an individual who is   eligible to participate in the program.                 (3)     "Health benefit account" means a health benefit   account the comptroller establishes for a participant under   Subchapter E.                 (4)  "Health care provider" means:                       (A)  a primary care provider;                       (B)     a specialty and major medical care provider;   and                       (C)  an integrated health care organization.                 (5)     "Integrated health care organization" means a   health care organization that provides all of a participant's   health care needs, including primary care and specialty and major   medical care services, using a capitated payment model.                 (6)     "Med-pool" means the risk pool established under   Subchapter F to provide specialty and major medical care services   to participants.                 (7)     "Nondiscriminatory price" means a fixed,   transparent, nonnegotiable price for a health care service that a   health care provider charges each individual for the service   regardless of the payment model used to pay for the service.                 (8)     "Participant" means an individual who is enrolled   in the program.                 (9)     "Primary care provider" means a provider of   primary care services.                 (10)     "Primary care services" includes whole-person,   integrated, and accessible health care provided by   interprofessional teams that are engaged to address the majority of   an individual's health and wellness needs across different health   care settings through sustained relationships with patients,   families, and communities in order to achieve better health   outcomes, better care, and lower health care prices.                 (11)     "Program" means the Texas Plan demonstration   program established under this chapter.                 (12)     "Specialty and major medical care provider" means   a provider of specialty and major medical care services.                 (13)     "Specialty and major medical care services" means   health care services other than primary care services. The term   includes:                       (A)  emergency care;                       (B)  urgent care;                       (C)  hospital care;                       (D)  allergy and immunology;                       (E)  anesthesiology;                       (F)  cardiology;                       (G)  dermatology;                       (H)  diagnostic radiology;                       (I)  medical genetics;                       (J)  nephrology;                       (K)  neurology;                       (L)  nuclear medicine;                       (M)  obstetrics and gynecology;                       (N)  oncology;                       (O)  ophthalmology;                       (P)  orthopedics;                       (Q)  pathology;                         (R)  pediatrics;                       (S)  physical medicine and rehabilitation;                       (T)  psychiatry;                       (U)  radiation oncology;                         (V)  surgery; and                       (W)  urology.           Sec.   532A.0002.     FEDERAL AUTHORIZATION FOR PROGRAM. (a)   The executive commissioner shall develop and seek a waiver under   Section 1115 of the Social Security Act (42 U.S.C. Section 1315) or,   if available, a block grant or comparable funding system that may be   used for this purpose to obtain any federal money available for   implementing the Texas Plan demonstration program to assist   eligible individuals in obtaining health care services.           (b)     The terms of the waiver the executive commissioner seeks   must:                 (1)  be designed to:                       (A)     make high value health care services more   accessible to eligible individuals;                       (B)     provide money to cover the costs of a   participant's primary care services, specialty and major medical   care services, dental health services, prescription drugs, and   other eligible out-of-pocket health care expenses;                       (C)     for the purpose of shifting costs from   hospital care to prevention, emphasize the provision of capitated,   whole-person, person-centered primary care, including case   management, mental health services, and health system navigation,   as a core component of the program's overall health goals;                       (D)     improve health outcomes of participants   based on the value of care the program offers, including by:                             (i)     when diagnosing and treating a   participant, considering nonmedical factors that impact the   participant's health, including nutrition, transportation,   housing, and employment; and                             (ii)     to the extent possible, coordinating   with community health organizations and other local resources   available to address the nonmedical factors;                       (E)     emphasize and encourage price and quality   transparency by program health care providers to enable:                             (i)     a participant to make informed   decisions regarding health care price and quality; and                             (ii)     the commission and board to collect   accurate and current pricing information for each provider,   including nondiscriminatory price information;                       (F)     provide a framework for the commission and   board to use existing data sources or develop new data sources to   obtain and publish information on high-value care that:                             (i)     identifies health care providers who   provide low health care prices and high quality of care, including   health care centers of excellence; and                             (ii)     facilitates a participant's ability to   navigate between health care providers to obtain high-value care;   and                       (G)     subject to Section 532A.0104, provide   continuous coverage for participants for the duration of the   program;                 (2)     because some participants may have limited primary   care options, recognize a broad range of primary care arrangements   and providers under the program, including:                       (A)     direct primary care, advanced primary care,   and similar primary care service arrangements provided virtually or   on-site;                       (B)     federally qualified health centers, as   defined by 42 U.S.C. Section 1396d(l)(2)(B); and                       (C)     commercial retailers that provide primary   care services at a published, nondiscriminatory price for each   offered service;                 (3)     allow health care services to be provided remotely   as telehealth services or telemedicine medical services; and                 (4)     allow for the operation of the program consistent   with the requirements of this chapter for a period of five years,   except to the extent deviation from the requirements is necessary   to obtain the waiver.           Sec.   532A.0003.     FUNDING. (a)   Subject to approval of the   waiver described by Section 532A.0002, the commission shall   implement the program using federal money obtained and state money   available for that purpose.      &#xA0 [Text truncated for display. Full text available on Congress.gov.]