2023 Texas Statutes › Government Code › Title 4 - Executive Branch › Subtitle I - Health and Human Services › Chapter 534 - System Redesign for Delivery of Medicaid Acute Care Services and Long-Term Services and Supports to Persons With an Intellectual or Developmental Disability › Subchapter C. Stage One: Pilot Program for Improving Service Delivery Models › Section 534.1045. Pilot Program Benefits and Provider Qualifications

Text of section effective until April 01, 2025
Sec. 534.1045.  PILOT PROGRAM BENEFITS AND PROVIDER QUALIFICATIONS.  (a)  Subject to Subsection (b), the commission shall ensure that a managed care organization participating in the pilot program provides:
(1)  all Medicaid state plan acute care benefits available under the STAR+PLUS Medicaid managed care program;
(2)  long-term services and supports under the Medicaid state plan, including:
(A)  Community First Choice services;
(B)  personal assistance services;
(C)  day activity health services; and
(D)  habilitation services;
(3)  long-term services and supports under the STAR+PLUS home and community-based services (HCBS) waiver program, including:
(A)  assisted living services;
(B)  personal assistance services;
(C)  employment assistance;
(D)  supported employment;
(E)  adult foster care;
(F)  dental care;
(G)  nursing care;
(H)  respite care;
(I)  home-delivered meals;
(J)  cognitive rehabilitative therapy;
(K)  physical therapy;
(L)  occupational therapy;
(M)  speech-language pathology;
(N)  medical supplies;
(O)  minor home modifications; and
(P)  adaptive aids;
(4)  the following long-term services and supports under a Medicaid waiver program:
(A)  enhanced behavioral health services;
(B)  behavioral supports;
(C)  day habilitation; and
(D)  community support transportation;
(5)  the following additional long-term services and supports:
(A)  housing supports;
(B)  behavioral health crisis intervention services; and
(C)  high medical needs services;
(6)  other nonresidential long-term services and supports that the commission, in consultation and collaboration with the advisory committee and pilot program workgroup, determines are appropriate and consistent with applicable requirements governing the Medicaid waiver programs, person-centered approaches, home and community-based setting requirements, and achieving the most integrated and least restrictive setting based on an individual's needs and preferences; and
(7)  dental services benefits in accordance with Subsection (a-1).
(a-1)  In developing the pilot program, the commission shall:
(1)  evaluate dental services benefits provided through Medicaid waiver programs and dental services benefits provided as a value-added service under the Medicaid managed care delivery model;
(2)  determine which dental services benefits are the most cost-effective in reducing emergency room and inpatient hospital admissions due to poor oral health; and
(3)  based on the determination made under Subdivision (2), provide the most cost-effective dental services benefits to pilot program participants.
(b)  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)  Subsections (a)(2)(A) and (D);
(2)  Subsections (a)(3)(B), (C), (D), (G), (H), (J), (K), (L), and (M); and
(3)  Subsection (a)(4).
(c)  A comprehensive long-term services and supports provider may deliver services listed under Subsections (a)(5) and (6) only if the managed care organization in the network of which the provider participates agrees to, in a contract with the provider, the provision of those services.
(d)  Day habilitation services listed under Subsection (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.
(e)  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 delivery of acute care and long-term services and supports on a daily basis in accordance with an individual's plan of care.  A comprehensive long-term services and supports provider may be reimbursed by a managed care organization for coordinating with care coordinators under this subsection.
(f)  Before implementing the pilot program, the commission, in consultation and collaboration with the advisory committee and pilot program workgroup, shall:
(1)  for purposes of the pilot program only, develop recommendations to modify adult foster care and supported employment and employment assistance benefits to increase access to and availability of those services; and
(2)  as necessary, define services listed under Subsections (a)(4) and (5) and any other services determined to be appropriate under Subsection (a)(6).
Added by Acts 2019, 86th Leg., R.S., Ch. 1330 (H.B. 4533), Sec. 17, eff. September 1, 2019.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.