reglab/statecodes huggingface dataset:
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0101. Definitions

Text of section effective on April 01, 2025
Sec. 542.0101.  DEFINITIONS.  In this subchapter:
(1)  "Capitation" means a method of compensating a provider on a monthly basis for providing or coordinating the provision of a defined set of services and supports that is based on a predetermined payment per services recipient.
(2)  "Pilot program" means the pilot program established under this subchapter.
(3)  "Pilot program participant" means an individual who is enrolled in and receives services through the pilot program.
(4)  "Pilot program work group" means the pilot program work group established under Section 542.0104.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0103. Alternative Payment Rate or Methodology

Text of section effective on April 01, 2025
Sec. 542.0103.  ALTERNATIVE PAYMENT RATE OR METHODOLOGY.  (a)  The pilot program must be designed to test the use of innovative payment rates and methodologies for the provision of long-term services and supports to achieve the goals of the pilot program.  The payment methodologies must include:
(1)  the payment of a bundled amount without downside risk to a comprehensive 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 comprehensive long-term services and supports providers based on the completion of predetermined outcomes or quality metrics; and
(3)  any other payment model the commission approves.
(b)  An alternative payment rate or methodology may be used for a managed care organization and comprehensive long-term services and supports provider only if the organization and provider agree in advance and in writing to use the rate or methodology.
(c)  In developing an alternative payment rate or methodology, the commission, managed care organizations, and comprehensive long-term services and supports providers shall consider:
(1)  the historical costs of long-term services and supports, including Medicaid fee-for-service rates;
(2)  reasonable cost estimates for new services under the pilot program; and
(3)  whether an alternative payment rate or methodology is sufficient to promote quality outcomes and ensure a provider's continued participation in the pilot program.
(d)  An alternative payment rate or methodology may not reduce the minimum payment a provider receives for delivering long-term services and supports under the pilot program to an amount that is less than the fee-for-service reimbursement rate the provider received for delivering those services before participating in the pilot program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0104. Pilot Program Work Group

Text of section effective on April 01, 2025
Sec. 542.0104.  PILOT PROGRAM WORK GROUP.  (a)  The executive commissioner, in consultation with the advisory committee, shall establish a pilot program work group to assist in developing and provide advice on the operation of the pilot program.
(b)  The pilot program work group is composed of:
(1)  representatives of the advisory committee;
(2)  stakeholders representing individuals with an intellectual or developmental disability;
(3)  stakeholders representing individuals with similar functional needs as the individuals described by Subdivision (2); and
(4)  representatives of managed care organizations that contract with the commission to provide services under the STAR+PLUS Medicaid managed care program.
(c)  Chapter 2110 applies to the pilot program work group.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0105. Stakeholder Input

Text of section effective on April 01, 2025
Sec. 542.0105.  STAKEHOLDER INPUT.  As part of developing and implementing the pilot program, the commission, in collaboration with the advisory committee and pilot program work group, shall develop a process to receive and evaluate:
(1)  input from:
(A)  statewide stakeholders; and
(B)  stakeholders from a STAR+PLUS Medicaid managed care service area in which the pilot program will be implemented; and
(2)  other evaluations and data.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0106. Measurable Goals

Text of section effective on April 01, 2025
Sec. 542.0106.  MEASURABLE GOALS.  (a)  The commission, in collaboration with the advisory committee and pilot program work group, shall:
(1)  identify, using national core indicators, the National Quality Forum long-term services and supports measures, and other appropriate Consumer Assessment of Healthcare Providers and Systems measures, measurable goals the pilot program is to achieve;
(2)  develop specific strategies and performance measures for achieving the identified goals; and
(3)  ensure that mechanisms to report, track, and assess specific strategies and performance measures for achieving the identified goals are established before implementing the pilot program.
(b)  A strategy proposed under Subsection (a)(2) may be evidence-based if an evidence-based strategy is available for meeting the identified goals.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0107. Managed Care Organization Selection

Text of section effective on April 01, 2025
Sec. 542.0107.  MANAGED CARE ORGANIZATION SELECTION.  The commission shall:
(1)  in collaboration with the advisory committee and pilot program work group, develop criteria regarding the selection of a managed care organization to participate in the pilot program; and
(2)  select and contract with not more than two managed care organizations that contract with the commission to provide services under the STAR+PLUS Medicaid managed care program to participate in the pilot program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0108. Managed Care Organization Participation Requirements

Text of section effective on April 01, 2025
Sec. 542.0108.  MANAGED CARE ORGANIZATION PARTICIPATION REQUIREMENTS.  The commission shall require that a managed care organization participating in the pilot program:
(1)  ensures that pilot program participants have a choice among acute care and comprehensive long-term services and supports providers and service delivery options, including the consumer direction model;
(2)  demonstrates to the commission's satisfaction that the organization's network of acute care, long-term services and supports, and comprehensive long-term services and supports providers have experience and expertise in providing services for individuals with an intellectual or developmental disability and individuals with similar functional needs;
(3)  has a process for preventing the inappropriate institutionalization of pilot program participants; and
(4)  ensures the timely initiation and consistent provision of services in accordance with a pilot program participant's person-centered plan.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0110. Provider Participation

Text of section effective on April 01, 2025
Sec. 542.0110.  PROVIDER PARTICIPATION.  (a)  The pilot program must allow a comprehensive long-term services and supports provider for individuals with an intellectual or developmental disability or similar functional needs that contracts with the commission to provide Medicaid services before the date the pilot program is implemented to voluntarily participate in the pilot program.  A provider's choice not to participate in the pilot program does not affect the provider's status as a significant traditional provider.
(b)  For the duration of the pilot program, the commission shall ensure that comprehensive long-term services and supports providers are:
(1)  considered significant traditional providers; and
(2)  included in the provider network of a managed care organization participating in the pilot program.
(c)  A comprehensive long-term services and supports provider may deliver services listed under the following provisions only if the provider also delivers the services under a Medicaid waiver program:
(1)  Sections 542.0109(a)(2)(A) and (D);
(2)  Sections 542.0109(a)(3)(B), (C), (D), (G), (H), (J), (K), (L), and (M); and
(3)  Section 542.0109(a)(4).
(d)  A comprehensive long-term services and supports provider may deliver services listed under Sections 542.0109(a)(5) and (6) only if the managed care organization in the network of which the provider participates agrees, in a contract with the provider, to the provision of those services.
(e)  Day habilitation services listed under Section 542.0109(a)(4)(C) may be delivered by a provider who contracts or subcontracts with the commission to provide day habilitation services under the home and community-based services (HCS) waiver program or the ICF-IID program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0111. Care Coordination

Text of section effective on April 01, 2025
Sec. 542.0111.  CARE COORDINATION.  (a)  A comprehensive long-term services and supports provider participating in the pilot program shall work in coordination with the care coordinators of a managed care organization participating in the pilot program to ensure the seamless daily delivery of acute care and long-term services and supports in accordance with a pilot program participant's plan of care.
(b)  A managed care organization may reimburse a comprehensive long-term services and supports provider for coordinating with care coordinators under this section.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0112. Person-Centered Planning

Text of section effective on April 01, 2025
Sec. 542.0112.  PERSON-CENTERED PLANNING.  The commission, in collaboration with the advisory committee and pilot program work group, shall ensure that each pilot program participant or the participant's legally authorized representative has access to a comprehensive, facilitated, person-centered plan that identifies outcomes for the participant and drives the development of the individualized budget.  The consumer direction model must be an available option for a participant to achieve self-determination, choice, and control.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0113. Use of Innovative Technology

Text of section effective on April 01, 2025
Sec. 542.0113.  USE OF INNOVATIVE TECHNOLOGY.  A pilot program participant is not required to use an innovative technology described by Section 542.0102(c)(9).  If a participant chooses to use an innovative technology described by that subdivision, the commission shall ensure that:
(1)  services associated with the technology are delivered in a manner that:
(A)  ensures the participant's privacy, health, and well-being;
(B)  provides access to housing in the most integrated and least restrictive environment;
(C)  assesses individual needs and preferences to promote autonomy, self-determination, the use of the consumer direction model, and privacy;
(D)  increases personal independence;
(E)  specifies the extent to which the innovative technology will be used, including:
(i)  the times of day during which the technology will be used;
(ii)  the place in which the technology is authorized to be used;
(iii)  the types of telemonitoring or remote monitoring that will be used; and
(iv)  the purposes for which the technology will be used; and
(F)  is consistent with and agreed on during the person-centered planning process;
(2)  staff overseeing the use of the innovative technology:
(A)  review the person-centered and implementation plans for each participant before overseeing the use of the innovative technology; and
(B)  demonstrate competency regarding the support needs of each participant using the innovative technology;
(3)  a participant using the innovative technology is able to request the removal of equipment associated with the technology and, on receipt of a request for the removal, the equipment is immediately removed; and
(4)  a participant is not required to use telemedicine at any point during the pilot program and, if the participant refuses to use telemedicine, the managed care organization providing pilot program health care services to the participant arranges for services that do not include telemedicine.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0114. Informational Materials

Text of section effective on April 01, 2025
Sec. 542.0114.  INFORMATIONAL MATERIALS.  (a)  To ensure that prospective pilot program participants are able to make an informed decision on whether to participate in the pilot program, the commission, in collaboration with the advisory committee and pilot program work group, shall develop and distribute informational materials that describe the pilot program's benefits and impact on current services and other related information.
(b)  The commission shall establish a timeline and process for developing and distributing the informational materials and ensure that:
(1)  the materials are developed and distributed to individuals eligible to participate in the pilot program with sufficient time to educate the individuals, their families, and other persons actively involved in their lives regarding the pilot program;
(2)  individuals eligible to participate in the pilot program, including individuals enrolled in the STAR+PLUS Medicaid managed care program, their families, and other persons actively involved in their lives receive the materials and oral information on the pilot program;
(3)  the materials contain clear, simple language presented in a manner that is easy to understand; and
(4)  at a minimum, the materials explain that:
(A)  on the pilot program's conclusion, each pilot program participant will be asked to provide feedback on the participant's experience, including feedback on whether the pilot program was able to meet the participant's unique support needs;
(B)  participation in the pilot program does not remove an individual from any Medicaid waiver program interest list;
(C)  a pilot program participant who, during the pilot program's operation, is offered enrollment in a Medicaid waiver program may accept the enrollment, transition, or diversion offer; and
(D)  a pilot program participant has a choice among acute care and comprehensive long-term services and supports providers and service delivery options, including the consumer direction model and comprehensive services model.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0115. Implementation, Location, and Duration

Text of section effective on April 01, 2025
Sec. 542.0115.  IMPLEMENTATION, LOCATION, AND DURATION.  The commission shall:
(1)  implement the pilot program on September 1, 2023;
(2)  conduct the pilot program in a STAR+PLUS Medicaid managed care service area the commission selects; and
(3)  operate the pilot program for at least 24 months.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0116. Recipient Enrollment, Participation, and Eligibility

Text of section effective on April 01, 2025
Sec. 542.0116.  RECIPIENT ENROLLMENT, PARTICIPATION, AND ELIGIBILITY.  (a)  The commission, in collaboration with the advisory committee and pilot program work group, shall develop pilot program participant eligibility criteria.  The criteria must ensure that pilot program participants:
(1)  include individuals with an intellectual or developmental disability or a cognitive disability, including:
(A)  individuals with autism;
(B)  individuals with significant complex behavioral, medical, and physical needs who are receiving home and community-based services through the STAR+PLUS Medicaid managed care program;
(C)  individuals enrolled in the STAR+PLUS Medicaid managed care program who:
(i)  are on a Medicaid waiver program interest list;
(ii)  meet the criteria for an intellectual or developmental disability; or
(iii)  have a traumatic brain injury that occurred after the age of 21; and
(D)  other individuals with disabilities who have similar functional needs without regard to the age of onset or diagnosis; and
(2)  do not include individuals who are receiving only acute care services under the STAR+PLUS Medicaid managed care program and are enrolled in the community-based ICF-IID program or another Medicaid waiver program.
(b)  An individual who is eligible to participate in the pilot program will be enrolled automatically.  The decision to opt out of participating may be made only by the individual or the individual's legally authorized representative.
(c)  Before implementing the pilot program, the commission, in collaboration with the advisory committee and pilot program work group, shall develop and implement a process to ensure that pilot program participants remain eligible for Medicaid for 12 consecutive months during the pilot program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0117. Pilot Program Information Collection and Analysis

Text of section effective on April 01, 2025
Sec. 542.0117.  PILOT PROGRAM INFORMATION COLLECTION AND ANALYSIS.  (a)  The commission, in collaboration with the advisory committee and pilot program work group, shall determine the information to collect from a managed care organization participating in the pilot program for use in conducting the evaluation and preparing the report under Section 542.0119.
(b)  For the duration of the pilot program, a managed care organization participating in the pilot program shall submit to the commission and the advisory committee quarterly reports on the services provided to each pilot program participant.  The reports must include information on:
(1)  the level of each requested service and the authorization and utilization rates for those services;
(2)  timelines of:
(A)  the authorization of each requested service;
(B)  the initiation of each requested service;
(C)  the delivery of each requested service; and
(D)  each unplanned break in the delivery of requested services and the duration of the break;
(3)  the number of pilot program participants using employment assistance and supported employment services;
(4)  the number of service denials and fair hearings and the dispositions of the fair hearings;
(5)  the number of complaints and inquiries the managed care organization received and the outcome of each complaint; and
(6)  the number of pilot program participants who choose the consumer direction model and the reasons other participants did not choose the consumer direction model.
(c)  The commission shall ensure that the mechanisms to report and track the information and data required by Subsections (a) and (b) are established before implementing the pilot program.
(d)  For purposes of making a recommendation about a system of programs and services for implementation through future state legislation or rules, the commission, in collaboration with the advisory committee and pilot program work group, shall analyze:
(1)  information provided by managed care organizations participating in the pilot program; and
(2)  any information the commission collects during the operation of the pilot program.
(e)  The analysis under Subsection (d) must include an assessment of the effect of the managed care strategies implemented in the pilot program on the goals described by Sections 542.0102(b) and (c), 542.0103, 542.0110(a), 542.0113, and 542.0116(c).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0118. Pilot Program Conclusion; Publication of Continuation

Text of section effective on April 01, 2025
Sec. 542.0118.  PILOT PROGRAM CONCLUSION; PUBLICATION OF CONTINUATION.  On September 1, 2025, the pilot program is concluded unless the commission continues the pilot program under Section 542.0120.  If the commission continues the pilot program, the commission shall publish notice of that continuation in the Texas Register not later than September 1, 2025.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0120. Transition Between Programs; Continuity of Care

Text of section effective on April 01, 2025
Sec. 542.0120.  TRANSITION BETWEEN PROGRAMS; CONTINUITY OF CARE.  (a)  During the evaluation of the pilot program required under Section 542.0119, the commission may continue the pilot program to ensure continuity of care for pilot program participants.  If, following the evaluation, the commission does not continue the pilot program, the commission shall ensure that there is a comprehensive plan for transitioning the provision of Medicaid benefits for pilot program participants to the benefits provided before participation in the pilot program.
(b)  A transition plan under Subsection (a) shall be developed in collaboration with the advisory committee and pilot program work group and with stakeholder input as described by Section 542.0105.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 542.0121. Service Transition Requirements

Text of section effective on April 01, 2025
Sec. 542.0121.  SERVICE TRANSITION REQUIREMENTS.  (a)  For purposes of implementing the pilot program and transitioning the provision of services provided to recipients under certain Medicaid waiver programs to a Medicaid managed care delivery model following completion of the pilot program, the commission shall:
(1)  implement and maintain a certification process for and maintain regulatory oversight over providers under the Texas home living (TxHmL) and home and community-based services (HCS) waiver programs; and
(2)  require managed care organizations to include in the organizations' provider networks providers who are certified in accordance with the certification process described by Subdivision (1).
(b)  For purposes of implementing the pilot program and transitioning the provision of services described by Section 542.0201 to the STAR+PLUS Medicaid managed care program, a comprehensive long-term services and supports provider:
(1)  must report to the managed care organization in the network of which the provider participates each encounter of any directly contracted service;
(2)  must provide to the managed care organization quarterly reports on:
(A)  coordinated services and time frames for the delivery of those services; and
(B)  the goals and objectives outlined in an individual's person-centered plan and progress made toward meeting those goals and objectives; and
(3)  may not be held accountable for the provision of services specified in an individual's service plan that are not authorized or are subsequently denied by the managed care organization.
(c)  On transitioning services under a Medicaid waiver program to a Medicaid managed care delivery model, the commission shall ensure that individuals do not lose benefits the individuals receive under the Medicaid waiver program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter D. Stage One: Provision of Acute Care and Certain Other Services › Section 542.0151. Delivery of Acute Care Services to Individuals With an Intellectual or Developmental Disability

Text of section effective on April 01, 2025
Sec. 542.0151.  DELIVERY OF ACUTE CARE SERVICES TO INDIVIDUALS WITH AN INTELLECTUAL OR DEVELOPMENTAL DISABILITY.  (a)  Subject to Sections 540.0701 and 540.0753, the commission shall:
(1)  provide acute care Medicaid benefits to individuals with an intellectual or developmental disability through the STAR+PLUS Medicaid managed care program or the most appropriate integrated capitated managed care program delivery model; and
(2)  monitor the provision of those benefits.
(b)  The commission, in collaboration with the advisory committee, shall analyze the outcomes of providing acute care Medicaid benefits to individuals with an intellectual or developmental disability under a model described by Subsection (a).  The analysis must:
(1)  include an assessment of the effects of the delivery model on:
(A)  access to and quality of acute care services; and
(B)  the number and types of fair hearing and appeals processes in accordance with federal law;
(2)  be incorporated into the annual report to the legislature required under Section 542.0054; and
(3)  include recommendations for delivery model improvements and implementation for the legislature's consideration, including recommendations for needed statutory changes.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter E. Stage Two: Transition of Icf-Iid Program Recipients and Long-Term Care Medicaid Waiver Program Recipients to Integrated Managed Care System › Section 542.0202. Recipient Choice of Delivery Model

Text of section effective on April 01, 2025
Sec. 542.0202.  RECIPIENT CHOICE OF DELIVERY MODEL.  (a)  If the commission determines under Section 542.0201(c)(2) that all or a portion of the long-term services and supports previously available under Medicaid waiver programs should be provided through a managed care program delivery model, 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 the commission selects.
(b)  A recipient who chooses under Subsection (a) to receive long-term services and supports through a managed care program delivery model may not subsequently choose to receive the services and supports under a Medicaid waiver program.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter E. Stage Two: Transition of Icf-Iid Program Recipients and Long-Term Care Medicaid Waiver Program Recipients to Integrated Managed Care System › Section 542.0203. Required Contract Provisions

Text of section effective on April 01, 2025
Sec. 542.0203.  REQUIRED CONTRACT PROVISIONS.  In addition to the requirements of Subchapter F, Chapter 540, a contract between a managed care organization and the commission for the organization to provide Medicaid benefits under Section 542.0201 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 direction model;
(2)  to the greatest extent possible, protects those individuals' continuity of care with respect to access to primary care providers, including through the use of single-case agreements with out-of-network providers; and
(3)  provides access to a member services telephone line for individuals or their legally authorized representatives to obtain information on and assistance with accessing services through network providers, including providers of primary and specialty services and other long-term services and supports.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 542 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Individuals With an Intellectual or Developmental Disability › Subchapter E. Stage Two: Transition of Icf-Iid Program Recipients and Long-Term Care Medicaid Waiver Program Recipients to Integrated Managed Care System › Section 542.0204. Responsibilities of Commission Under Subchapter

Text of section effective on April 01, 2025
Sec. 542.0204.  RESPONSIBILITIES OF COMMISSION UNDER SUBCHAPTER.  In administering this subchapter, the commission shall ensure, on making a determination to transition services under Section 542.0201:
(1)  that the commission is responsible for setting the minimum reimbursement rate paid to an ICF-IID services or group home provider under the integrated managed care system, including the staff rate enhancement paid to an ICF-IID services or group home provider;
(2)  that an ICF-IID services or 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 the commission uses to reimburse an ICF-IID services or group home provider, as applicable;
(3)  the establishment of an electronic portal through which an ICF-IID services or 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; and
(4)  that the consumer direction model is an available option for each individual with an intellectual or developmental disability who receives Medicaid benefits in accordance with this subchapter to achieve self-determination, choice, and control and that the individual or the individual's legally authorized representative has access to a comprehensive, facilitated, person-centered plan that identifies outcomes for the individual.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter A. General Provisions › Section 543.0001. Effect of Chapter on Commission's Authority

Text of section effective on April 01, 2025
Sec. 543.0001.  EFFECT OF CHAPTER ON COMMISSION'S AUTHORITY.  This chapter does not affect the commission's authority, or give the commission additional authority, to:
(1)  affect any individual health care treatment decision for a Medicaid recipient;
(2)  replace or affect:
(A)  the process of determining Medicaid benefits, including the approval process for receiving benefits for durable medical equipment; or
(B)  any applicable approval process required for reimbursement for services or other equipment under Medicaid;
(3)  implement a clinical initiative or associated rule or program policy that is otherwise prohibited under state or federal law; or
(4)  implement any initiative that would expand eligibility for Medicaid benefits.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter A. General Provisions › Section 543.0002. Rules

Text of section effective on April 01, 2025
Sec. 543.0002.  RULES.  The executive commissioner shall adopt rules necessary to implement this chapter.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter A. General Provisions › Section 543.0003. Internet Website

Text of section effective on April 01, 2025
Sec. 543.0003.  INTERNET WEBSITE.  The commission shall maintain an Internet website related to the quality improvement process required under this chapter.  The website must include:
(1)  an explanation of the process for submission, preliminary review, analysis, and approval of a clinical initiative under this chapter;
(2)  an explanation of how members of the public may submit comments or research related to an initiative;
(3)  a copy of each initiative selected for analysis under Section 543.0054;
(4)  the status of each initiative in the approval process; and
(5)  a copy of each final report prepared under this chapter.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter B. Assessment of Clinical Initiatives › Section 543.0051. Medicaid Quality Improvement Process

Text of section effective on April 01, 2025
Sec. 543.0051.  MEDICAID QUALITY IMPROVEMENT PROCESS.  The commission shall, in accordance with this chapter, develop and implement a quality improvement process by which the commission:
(1)  receives suggestions for clinical initiatives designed to improve:
(A)  the quality of care provided under Medicaid; and
(B)  the cost-effectiveness of Medicaid;
(2)  conducts a preliminary review under Section 543.0053(2) of each suggestion received under Section 543.0052 to determine whether the suggestion warrants further consideration and analysis; and
(3)  conducts an analysis under Section 543.0054 of each suggestion that is selected for analysis in accordance with Subdivision (2).
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter B. Assessment of Clinical Initiatives › Section 543.0052. Solicitation of Suggestions for Clinical Initiatives

Text of section effective on April 01, 2025
Sec. 543.0052.  SOLICITATION OF SUGGESTIONS FOR CLINICAL INITIATIVES.  (a)  Subject to Subsection (b), the commission shall solicit and accept written or electronic suggestions for clinical initiatives from:
(1)  a member of the legislature;
(2)  the executive commissioner;
(3)  the commissioner of state health services;
(4)  the commissioner of the Department of Family and Protective Services; and
(5)  the medical care advisory committee appointed under Section 32.022, Human Resources Code.
(b)  The commission may not accept a suggestion for a clinical initiative that:
(1)  is undergoing clinical trials; or
(2)  expands a health care provider's scope of practice beyond the law governing the provider's practice.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter B. Assessment of Clinical Initiatives › Section 543.0053. Clinical Initiative Evaluation Process

Text of section effective on April 01, 2025
Sec. 543.0053.  CLINICAL INITIATIVE EVALUATION PROCESS.  The commission shall establish and implement an evaluation process for the submission, preliminary review, analysis, and approval of a clinical initiative.  The process must:
(1)  require that a suggestion for a clinical initiative be submitted to the state Medicaid director;
(2)  allow the commission to conduct, with the assistance of an appropriate advisory committee or similar group as determined by the commission, a preliminary review of each suggested clinical initiative to determine whether the initiative warrants further consideration and analysis under Section 543.0054;
(3)  require the commission to publish on the Internet website maintained in accordance with Section 543.0003 the criteria the commission uses in the preliminary review under Subdivision (2) to determine whether an initiative warrants analysis under Section 543.0054;
(4)  limit the number of suggestions analyzed under Section 543.0054;
(5)  require that a suggestion for a clinical initiative selected for analysis under Section 543.0054 be published on the Internet website maintained in accordance with Section 543.0003 not later than the 30th day after the date the state Medicaid director receives the suggestion;
(6)  provide for a formal public comment period that lasts at least 30 days during which the public may submit comments and research relating to a suggested clinical initiative;
(7)  require commission employees to analyze, in accordance with Section 543.0054, each suggested clinical initiative selected for analysis; and
(8)  require the development and publication of a final report in accordance with Section 543.0055 on each clinical initiative selected for analysis under Section 543.0054 not later than the 180th day after the date the state Medicaid director receives the suggestion.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter B. Assessment of Clinical Initiatives › Section 543.0054. Analysis of Clinical Initiatives

Text of section effective on April 01, 2025
Sec. 543.0054.  ANALYSIS OF CLINICAL INITIATIVES.  After conducting a preliminary review of a clinical initiative under Section 543.0053(2), the commission shall analyze the clinical initiative if the commission selects the initiative for analysis.  The analysis must include a review of:
(1)  any public comments and submitted research relating to the initiative;
(2)  the available clinical research and historical utilization information relating to the initiative;
(3)  published medical literature relating to the initiative;
(4)  any adoption of the initiative by a medical society or other clinical group;
(5)  whether the initiative has been implemented under:
(A)  the Medicare program;
(B)  another state medical assistance program; or
(C)  a state-operated health care program, including the child health plan program;
(6)  the results of reports, research, pilot programs, or clinical studies relating to the initiative conducted by:
(A)  institutions of higher education, including related medical schools;
(B)  governmental entities and agencies; and
(C)  private and nonprofit think tanks and research groups;
(7)  the impact the initiative would have on Medicaid if the initiative were implemented in this state, including:
(A)  an estimate of the number of Medicaid recipients that would be impacted by implementing the initiative; and
(B)  a description of any potential cost savings to the state that would result from implementing the initiative; and
(8)  any statutory barriers to implementing the initiative.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.
2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 543 - Clinical Initiatives to Improve Medicaid Quality of Care and Cost-Effectiveness › Subchapter B. Assessment of Clinical Initiatives › Section 543.0055. Final Report on Clinical Initiative

Text of section effective on April 01, 2025
Sec. 543.0055.  FINAL REPORT ON CLINICAL INITIATIVE.  The commission shall prepare a final report based on the analysis of a clinical initiative conducted under Section 543.0054.  The final report must include:
(1)  a final determination of:
(A)  the feasibility of implementing the initiative;
(B)  the likely impact implementing the initiative would have on the quality of care provided under Medicaid; and
(C)  the anticipated cost savings to the state that would result from implementing the initiative;
(2)  a summary of the public comments, including a description of any opposition to the initiative;
(3)  an identification of any statutory barriers to implementing the initiative; and
(4)  if the initiative is not implemented, an explanation of that decision.
Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.