Bill Text: TX HB3226 | 2023-2024 | 88th Legislature | Introduced

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Bill Title: Relating to the development and implementation of the Live Well Texas program to provide health benefit coverage to certain individuals; imposing penalties.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2023-03-15 - Referred to Health Care Reform, Select [HB3226 Detail]

Download: Texas-2023-HB3226-Introduced.html

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88R10277 JG-D
By: Allison H.B. No. 3226

A BILL TO BE ENTITLED
AN ACT
relating to the development and implementation of the Live Well
Texas program to provide health benefit coverage to certain
individuals; imposing penalties.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle I, Title 4, Government Code, is amended
by adding Chapter 537A to read as follows:
CHAPTER 537A. LIVE WELL TEXAS PROGRAM
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 537A.0001. DEFINITIONS. In this chapter:
(1) "Basic plan" means the program health benefit plan
described by Section 537A.0202.
(2) "Eligible individual" means an individual who is
eligible to participate in the program.
(3) "Participant" means an individual who is:
(A) enrolled in a program health benefit plan; or
(B) receiving health care financial assistance
under Subchapter H.
(4) "Plus plan" means the program health benefit plan
described by Section 537A.0203.
(5) "POWER account" means a personal wellness and
responsibility account the commission establishes for a
participant under Section 537A.0251.
(6) "Program" means the Live Well Texas program
established under this chapter.
(7) "Program health benefit plan" includes:
(A) the basic plan; and
(B) the plus plan.
(8) "Program health benefit plan provider" means a
health benefit plan provider that contracts with the commission
under Section 537A.0107 to arrange for the provision of health care
services through a program health benefit plan.
SUBCHAPTER B. FEDERAL WAIVER FOR LIVE WELL TEXAS PROGRAM
Sec. 537A.0051. FEDERAL AUTHORIZATION FOR PROGRAM. (a)
Notwithstanding any other law, the executive commissioner shall
develop and seek a waiver under Section 1115 of the Social Security
Act (42 U.S.C. Section 1315) to the state Medicaid plan to implement
the Live Well Texas program to assist individuals in obtaining
health benefit coverage through a program health benefit plan or
health care financial assistance.
(b) The terms of a waiver the executive commissioner seeks
under this section must:
(1) be designed to:
(A) provide health benefit coverage options for
eligible individuals;
(B) produce better health outcomes for
participants;
(C) create incentives for participants to
transition from receiving public assistance benefits to achieving
stable employment;
(D) promote personal responsibility and engage
participants in making decisions regarding health care based on
cost and quality;
(E) support participants' self-sufficiency by
requiring unemployed participants to be referred to work search and
job training programs and actively seek employment;
(F) support participants' overall wellness by
requiring participants to receive preventative care services and
maintain relationships with preventative care providers;
(G) support participants who become ineligible
to participate in a program health benefit plan in transitioning to
private health benefit coverage; and
(H) leverage enhanced federal medical assistance
percentage funding to minimize or eliminate the need for a program
enrollment cap; and
(2) allow for the operation of the program consistent
with the requirements of this chapter.
Sec. 537A.0052. FUNDING. Subject to approval of the waiver
described by Section 537A.0051, the commission shall implement the
program using enhanced federal medical assistance percentage
funding available under the Patient Protection and Affordable Care
Act (Pub. L. No. 111-148) as amended by the Health Care and
Education Reconciliation Act of 2010 (Pub. L. No. 111-152).
Sec. 537A.0053. NOT AN ENTITLEMENT; TERMINATION OF PROGRAM.
(a) This chapter does not establish an entitlement to health
benefit coverage or health care financial assistance under the
program for eligible individuals.
(b) The program terminates at the time federal funding
terminates under the Patient Protection and Affordable Care Act
(Pub. L. No. 111-148) as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. No. 111-152), unless a
successor program providing federal funding that is at least equal
to the federal funding under that Act is created.
SUBCHAPTER C. PROGRAM ADMINISTRATION
Sec. 537A.0101. PROGRAM OBJECTIVE. The program's principal
objective is to provide primary and preventative health care
through high deductible program health benefit plans to eligible
individuals.
Sec. 537A.0102. PROGRAM PROMOTION. The commission shall
promote and provide information about the program to individuals
who:
(1) are potentially eligible to participate in the
program; and
(2) live in medically underserved areas of this state.
Sec. 537A.0103. COMMISSION'S AUTHORITY RELATED TO HEALTH
BENEFIT PLAN PROVIDER CONTRACTS. The commission may:
(1) enter into contracts with health benefit plan
providers under Section 537A.0107;
(2) monitor program health benefit plan providers
through reporting requirements and other means to ensure contract
performance and quality delivery of services;
(3) monitor the quality of services delivered to
participants through outcome measurements; and
(4) provide payment under the contracts to program
health benefit plan providers.
Sec. 537A.0104. COMMISSION'S AUTHORITY RELATED TO
ELIGIBILITY AND MEDICAID COORDINATION. The commission may:
(1) accept applications for health benefit coverage
under the program and implement program eligibility screening and
enrollment procedures;
(2) resolve grievances related to eligibility
determinations; and
(3) to the extent possible, coordinate the program
with Medicaid.
Sec. 537A.0105. THIRD-PARTY ADMINISTRATOR CONTRACT FOR
PROGRAM IMPLEMENTATION. (a) In administering the program, the
commission may contract with a third-party administrator to provide
enrollment and related services.
(b) If the commission contracts with a third-party
administrator under this section, the commission shall:
(1) monitor the third-party administrator through
reporting requirements and other means to ensure contract
performance and quality delivery of services; and
(2) provide payment under the contract to the
third-party administrator.
(c) The executive commissioner shall retain all
policymaking authority over the program.
(d) The commission shall procure each contract with a
third-party administrator, as applicable, through a competitive
procurement process that complies with all federal and state laws.
Sec. 537A.0106. TEXAS DEPARTMENT OF INSURANCE DUTIES. (a)
At the commission's request, the Texas Department of Insurance
shall provide any necessary assistance with the program. The
department shall monitor the quality of the services provided by
program health benefit plan providers and resolve grievances
related to those providers.
(b) The commission and the Texas Department of Insurance may
adopt a memorandum of understanding that addresses the
responsibilities of each agency with respect to the program.
(c) The Texas Department of Insurance, in consultation with
the commission, shall adopt rules as necessary to implement this
section.
Sec. 537A.0107. HEALTH BENEFIT PLAN PROVIDER CONTRACTS.
The commission shall select through a competitive procurement
process that complies with all federal and state laws and contract
with health benefit plan providers to provide health care services
under the program. To be eligible for a contract under this section,
an entity must:
(1) be a Medicaid managed care organization;
(2) hold a certificate of authority issued by the
Texas Department of Insurance that authorizes the entity to provide
the types of health care services offered under the program; and
(3) satisfy, except as provided by this chapter, any
applicable requirement of the Insurance Code or another insurance
law of this state.
Sec. 537A.0108. HEALTH CARE PROVIDERS. (a) A health care
provider who provides health care services under the program must
meet certification and licensure requirements required by
commission rules and other law.
(b) In adopting rules governing the program, the executive
commissioner shall ensure that a health care provider who provides
health care services under the program is reimbursed at a rate that
is at least equal to the rate paid under Medicare for the provision
of the same or substantially similar services.
Sec. 537A.0109. PROHIBITION ON CERTAIN HEALTH CARE
PROVIDERS. The executive commissioner shall adopt rules that
prohibit a health care provider from providing program health care
services for a reasonable period, as determined by the executive
commissioner, if the health care provider:
(1) fails to repay program overpayments; or
(2) owns, controls, manages, or is otherwise
affiliated with and has financial, managerial, or administrative
influence over a health care provider who has been suspended or
prohibited from providing program health care services.
SUBCHAPTER D. ELIGIBILITY FOR PROGRAM HEALTH BENEFIT COVERAGE
Sec. 537A.0151. ELIGIBILITY REQUIREMENTS. (a) An
individual is eligible to enroll in a program health benefit plan
if:
(1) the individual is:
(A) a citizen or permanent resident of the United
States; and
(B) a resident of this state;
(2) the individual is 19 years of age or older but
younger than 65 years of age;
(3) applying the eligibility criteria in effect in
this state on December 31, 2022, the individual is not eligible for
Medicaid; and
(4) federal matching funds are available under the
Patient Protection and Affordable Care Act (Pub. L. No. 111-148) as
amended by the Health Care and Education Reconciliation Act of 2010
(Pub. L. No. 111-152) to provide benefits to the individual under
the federal medical assistance program established under Title XIX,
Social Security Act (42 U.S.C. Section 1396 et seq.).
(b) An individual who is a parent or caretaker relative to
whom 42 C.F.R. Section 435.110 applies is eligible to enroll in a
program health benefit plan.
(c) In determining eligibility for the program, the
commission shall apply the same eligibility criteria regarding
residency and citizenship in effect for Medicaid in this state on
December 31, 2022.
Sec. 537A.0152. CONTINUOUS COVERAGE. The commission shall
ensure that an individual who is initially determined or
redetermined to be eligible to participate in the program and
enroll in a program health benefit plan will remain eligible for
coverage under the plan for a period of 12 months beginning on the
first day of the month following the date eligibility was
determined or redetermined, subject to Section 537A.0252(f).
Sec. 537A.0153. APPLICATION FORM AND PROCEDURES. (a) The
executive commissioner shall adopt an application form and
application procedures for the program. The form and procedures
must be coordinated with forms and procedures under Medicaid to
ensure that there is a single consolidated application process to
seek health benefit coverage under the program or Medicaid.
(b) To the extent possible, the commission shall make the
application form available in languages other than English.
(c) The executive commissioner may permit an individual to
apply by mail, over the telephone, or through the Internet.
Sec. 537A.0154. ELIGIBILITY SCREENING AND ENROLLMENT. (a)
The executive commissioner shall adopt eligibility screening and
enrollment procedures or use the Texas Integrated Enrollment
Services eligibility determination system or a compatible system to
screen individuals and enroll eligible individuals in the program.
(b) The eligibility screening and enrollment procedures
must ensure that an individual applying for the program who appears
eligible for Medicaid is identified and assisted with obtaining
Medicaid coverage. If the individual is denied Medicaid coverage
but is determined eligible to enroll in a program health benefit
plan, the commission shall enroll the individual in a program
health benefit plan of the individual's choosing and for which the
individual is eligible without further application or
qualification.
(c) Not later than the 30th day after the date an individual
submits a complete application form and unless the individual is
identified and assisted with obtaining Medicaid coverage under
Subsection (b), the commission shall ensure that the individual's
eligibility to participate in the program is determined and that
the individual is provided with information on program health
benefit plans and program health benefit plan providers. The
commission shall enroll the individual in the program health
benefit plan and with the program health benefit plan provider of
the individual's choosing in a timely manner, as determined by the
commission.
(d) The executive commissioner may establish enrollment
periods for the program.
Sec. 537A.0155. ELIGIBILITY REDETERMINATION PROCESS;
DISENROLLMENT. (a) Not later than the 90th day before a
participant's coverage period expires, the commission shall notify
the participant regarding the eligibility redetermination process
and request documentation necessary to redetermine the
participant's eligibility.
(b) The commission shall provide written notice of
termination of eligibility to a participant not later than the 30th
day before the date the participant's eligibility will terminate.
The commission shall disenroll the participant from the program if:
(1) the participant does not submit the requested
eligibility redetermination documentation before the last day of
the participant's coverage period; or
(2) the commission, based on the submitted
documentation, determines the participant is no longer eligible for
the program, subject to Subchapter H.
(c) An individual may submit the requested eligibility
redetermination documentation not later than the 90th day after the
date the commission disenrolls the individual from the program. If
the commission determines that the individual continues to meet
program eligibility requirements, the commission shall reenroll
the individual in the program without any additional application
requirements.
(d) An individual who does not complete the eligibility
redetermination process in accordance with this section and who the
commission disenrolls from the program may not participate in the
program for a period of 180 days beginning on the date of
disenrollment. This subsection does not apply to an individual:
(1) described by Section 537A.0206 or 537A.0208; or
(2) who is:
(A) pregnant; or
(B) younger than 21 years of age.
(e) At the time the commission disenrolls a participant from
the program, the commission shall provide to the participant:
(1) notice that the participant may be eligible to
receive health care financial assistance under Subchapter H in
transitioning to private health benefit coverage; and
(2) information on and the eligibility requirements
for that financial assistance.
SUBCHAPTER E. BASIC AND PLUS PLANS
Sec. 537A.0201. BASIC AND PLUS PLAN COVERAGE GENERALLY.
(a) The basic and plus plans offered under the program must:
(1) comply with this subchapter and coverage
requirements prescribed by other law; and
(2) at a minimum, provide coverage for essential
health benefits required under 42 U.S.C. Section 18022(b).
(b) In modifying covered health benefits under the basic and
plus plans, the executive commissioner shall consider the health
care needs of healthy individuals and individuals with special
health care needs.
(c) The basic and plus plans must allow a participant with a
chronic, disabling, or life-threatening illness to select an
appropriate specialist as the participant's primary care
physician.
Sec. 537A.0202. BASIC PLAN: COVERAGE AND INCOME
ELIGIBILITY. (a) The program must include a basic plan that is
sufficient to meet the basic health care needs of individuals who
enroll in the plan.
(b) The covered health benefits under the basic plan must
include:
(1) primary care physician services;
(2) prenatal and postpartum care;
(3) specialty care physician visits;
(4) home health services, not to exceed 100 visits per
year;
(5) outpatient surgery;
(6) allergy testing;
(7) chemotherapy;
(8) intravenous infusion services;
(9) radiation therapy;
(10) dialysis;
(11) emergency care hospital services;
(12) emergency transportation, including ambulance
and air ambulance;
(13) urgent care clinic services;
(14) hospitalization, including for:
(A) general inpatient hospital care;
(B) inpatient physician services;
(C) inpatient surgical services;
(D) non-cosmetic reconstructive surgery;
(E) a transplant;
(F) treatment for a congenital abnormality;
(G) anesthesia;
(H) hospice care; and
(I) care in a skilled nursing facility for a
period not to exceed 100 days per occurrence;
(15) inpatient and outpatient behavioral health
services;
(16) inpatient, outpatient, and residential substance
use treatment;
(17) prescription drugs, including tobacco cessation
drugs;
(18) inpatient and outpatient rehabilitative and
habilitative care, including physical, occupational, and speech
therapy, not to exceed 60 combined visits per year;
(19) medical equipment, appliances, and assistive
technology, including prosthetics and hearing aids, and the repair,
technical support, and customization needed for individual use;
(20) laboratory and pathology tests and services;
(21) diagnostic imaging, including x-rays, magnetic
resonance imaging, computed tomography, and positron emission
tomography;
(22) preventative care services as described by
Section 537A.0204; and
(23) services under the early and periodic screening,
diagnostic, and treatment program for participants who are younger
than 21 years of age.
(c) To be eligible for health care benefits under the basic
plan, an individual who is eligible for the program must have an
annual household income that is equal to or less than 100 percent of
the federal poverty level.
Sec. 537A.0203. PLUS PLAN: COVERAGE AND INCOME ELIGIBILITY.
(a) The program must include a plus plan that includes the covered
health benefits listed in Section 537A.0202 and the following
additional enhanced health benefits:
(1) services related to the treatment of conditions
affecting the temporomandibular joint;
(2) dental care;
(3) vision care;
(4) notwithstanding Section 537A.0202(b)(18),
inpatient and outpatient rehabilitative and habilitative care,
including physical, occupational, and speech therapy, not to exceed
75 combined visits per year;
(5) bariatric surgery; and
(6) other services the commission considers
appropriate.
(b) An individual who is eligible for the program and whose
annual household income exceeds 100 percent of the federal poverty
level will automatically be enrolled in and receive health benefits
under the plus plan. An individual who is eligible for the program
and whose annual household income is equal to or less than 100
percent of the federal poverty level may choose to enroll in the
plus plan.
(c) A participant enrolled in the plus plan is required to
make POWER account contributions in accordance with Section
537A.0252.
Sec. 537A.0204. PREVENTATIVE CARE SERVICES. (a) The
commission shall provide to each participant a list of health care
services that qualify as preventative care services based on the
participant's age, gender, and preexisting conditions. In
developing the list, the commission shall consult with the federal
Centers for Disease Control and Prevention.
(b) A program health benefit plan shall, at no cost to the
participant, provide coverage for:
(1) preventative care services described by 42 U.S.C.
Section 300gg-13; and
(2) a maximum of $500 per year of preventative care
services other than those described by Subdivision (1).
(c) A participant who receives preventative care services
not described by Subsection (b) that are covered under the
participant's program health benefit plan is subject to deductible
and copayment requirements for the services in accordance with the
terms of the plan.
Sec. 537A.0205. COPAYMENTS. (a) A participant enrolled in
the basic plan shall pay a copayment for each covered health benefit
except for a preventative care or family planning service. The
executive commissioner by rule shall adopt a copayment schedule for
basic plan services, subject to Subsection (c).
(b) Except as provided by Subsection (c), a participant
enrolled in the plus plan may not be required to pay a copayment for
a covered service.
(c) A participant enrolled in the basic or plus plan shall
pay a copayment in an amount set by commission rule not to exceed
$25 for nonemergency use of hospital emergency department services
unless:
(1) the participant has met the cost-sharing maximum
for the calendar quarter, as prescribed by commission rule;
(2) the participant is referred to the hospital
emergency department by a health care provider;
(3) the visit is a true emergency, as defined by
commission rule; or
(4) the participant is pregnant.
Sec. 537A.0206. CERTAIN PARTICIPANTS ELIGIBLE FOR STATE
MEDICAID PLAN BENEFITS. (a) A participant described by 42 C.F.R.
Section 440.315 who is enrolled in the basic or plus plan is
entitled to receive under the program all health benefits that
would be available under the state Medicaid plan.
(b) A participant to which this section applies is subject
to the cost-sharing requirements, including copayment and POWER
account contribution requirements, of the program health benefit
plan in which the participant is enrolled.
(c) The commission shall develop screening measures to
identify participants to which this section applies.
Sec. 537A.0207. PREGNANT PARTICIPANTS. (a) A participant
who becomes pregnant while enrolled in the program and who meets the
eligibility requirements for Medicaid may choose to remain in the
program or enroll in Medicaid.
(b) A pregnant participant described by Subsection (a) who
is enrolled in the basic or plus plan and who remains in the program
is:
(1) notwithstanding Section 537A.0205, not subject to
any cost-sharing requirements, including copayment and POWER
account contribution requirements, of the program health benefit
plan in which the participant is enrolled until the expiration of
the sixth month following the month in which the pregnancy ends;
(2) entitled to receive as a Medicaid wrap-around
benefit all Medicaid services a pregnant woman enrolled in Medicaid
is entitled to receive, including a pharmacy benefit, when the
participant exceeds coverage limits under the participant's
program health benefit plan or if a service is not covered by the
plan; and
(3) eligible for additional vision and dental care
benefits.
Sec. 537A.0208. PARENTS AND CARETAKER RELATIVES. (a) A
parent or caretaker relative to whom 42 C.F.R. Section 435.110
applies is entitled to receive as a Medicaid wrap-around benefit
all Medicaid services to which the individual would be entitled
under the state Medicaid plan that are not covered under the
individual's program health benefit plan or exceed the plan's
coverage limits.
(b) An individual described by Subsection (a) who chooses to
participate in the program is subject to the cost-sharing
requirements, including copayment and POWER account contribution
requirements, of the program health benefit plan in which the
individual is enrolled.
SUBCHAPTER F. PERSONAL WELLNESS AND RESPONSIBILITY (POWER)
ACCOUNTS
Sec. 537A.0251. ESTABLISHMENT AND OPERATION OF POWER
ACCOUNTS. (a) The commission shall establish a personal wellness
and responsibility (POWER) account for each participant who is
enrolled in a program health benefit plan that is funded with money
contributed in accordance with this subchapter.
(b) The commission shall enable each participant to access
and manage money in and information regarding the participant's
POWER account through an electronic system. The commission may
contract with an entity that has appropriate experience and
expertise to establish, implement, or administer the electronic
system.
(c) Except as otherwise provided by Section 537A.0252, the
commission shall require each participant to contribute to the
participant's POWER account in amounts described by that section.
Sec. 537A.0252. POWER ACCOUNT CONTRIBUTIONS; DEDUCTIBLE.
(a) The executive commissioner by rule shall establish an annual
universal deductible for each participant enrolled in the basic or
plus plan.
(b) To ensure each participant's POWER account contains a
sufficient amount of money at the beginning of a coverage period,
the commission shall, before the beginning of that period, fund
each account with the following amounts:
(1) for a participant enrolled in the basic plan, the
annual universal deductible amount; and
(2) for a participant enrolled in the plus plan, the
difference between the annual universal deductible amount and the
participant's required annual contribution as determined by the
schedule established under Subsection (c).
(c) The executive commissioner by rule shall establish a
graduated annual POWER account contribution schedule for
participants enrolled in the plus plan that:
(1) is based on a participant's annual household
income, with participants whose annual household incomes are less
than the federal poverty level paying progressively less and
participants whose annual household incomes are equal to or greater
than the federal poverty level paying progressively more; and
(2) may not require a participant to contribute more
than a total of five percent of the participant's annual household
income to the participant's POWER account.
(d) A participant's employer may contribute on behalf of the
participant any amount of the participant's annual POWER account
contribution. A nonprofit organization may contribute on behalf of
a participant any amount of the participant's annual POWER account
contribution.
(e) Subject to the contribution cap described by Subsection
(c)(2) and not before the expiration of the participant's first
coverage period, the commission shall require a participant who
uses one or more tobacco products to contribute to the
participant's POWER account an annual POWER account contribution
amount that is one percent more than the participant would
otherwise be required to contribute under the schedule established
under Subsection (c).
(f) An annual POWER account contribution must be paid by or
on behalf of a participant monthly in installments that are at least
equal to one-twelfth of the total required contribution. The
coverage period for a participant whose annual household income
exceeds 100 percent of the federal poverty level may not begin until
the first day of the first month following the month in which the
first monthly installment is received.
Sec. 537A.0253. USE OF POWER ACCOUNT MONEY. A participant
may use money in the participant's POWER account to pay copayments
and deductible costs the participant's program health benefit plan
requires. The commission shall issue to each participant an
electronic payment card that allows the participant to use the card
to pay the program health benefit plan costs.
Sec. 537A.0254. PROGRAM HEALTH BENEFIT PLAN PROVIDER
REWARDS PROGRAM FOR ENGAGEMENT IN CERTAIN HEALTHY BEHAVIORS;
SMOKING CESSATION INITIATIVE. (a) A program health benefit plan
provider shall establish a rewards program through which a
participant receiving health care through a program health benefit
plan the program health benefit plan provider offers may earn money
to be contributed to the participant's POWER account.
(b) Under a rewards program, a program health benefit plan
provider shall contribute money to a participant's POWER account if
the participant engages in certain healthy behaviors. The
executive commissioner by rule shall determine:
(1) the behaviors in which a participant must engage
to receive a contribution, which must include behaviors related to:
(A) completion of a health risk assessment;
(B) smoking cessation; and
(C) as applicable, chronic disease management;
and
(2) the amount of money a program health benefit plan
provider shall contribute for each behavior described by
Subdivision (1).
(c) Subsection (b) does not prevent a program health benefit
plan provider from contributing money to a participant's POWER
account if the participant engages in a behavior not specified by
that subsection or a rule the executive commissioner adopts in
accordance with that subsection. If a program health benefit plan
provider chooses to contribute money under this subsection, the
program health benefit plan provider shall determine the amount of
money to be contributed for the behavior.
(d) A participant may use contributions a program health
benefit plan provider makes under a rewards program to offset a
maximum of 50 percent of the participant's required annual POWER
account contribution the executive commissioner establishes under
Section 537A.0252.
(e) Contributions a program health benefit plan provider
makes under a rewards program that result in a participant's POWER
account balance exceeding the participant's required annual POWER
account contribution may be rolled over into the next coverage
period in accordance with Section 537A.0256.
(f) During the first coverage period of a participant who
uses one or more tobacco products, a program health benefit plan
provider shall actively attempt to engage the participant in and
provide educational materials to the participant on:
(1) smoking cessation activities for which the
participant may receive a monetary contribution under this section;
and
(2) other smoking cessation programs or resources
available to the participant.
Sec. 537A.0255. MONTHLY STATEMENTS. The commission shall
distribute to each participant with a POWER account a monthly
statement that includes information on:
(1) the participant's POWER account activity during
the preceding month, including information on the cost of health
care services delivered to the participant during that month;
(2) the balance of money available in the POWER
account at the time the statement is issued; and
(3) the amount of any contributions due from the
participant.
Sec. 537A.0256. POWER ACCOUNT ROLL OVER. (a) The executive
commissioner by rule shall establish a process in accordance with
this section to roll over money in a participant's POWER account to
the succeeding coverage period. The commission shall calculate the
amount to be rolled over at the time the participant's program
eligibility is redetermined.
(b) For a participant enrolled in the basic plan, the
commission shall calculate the amount to be rolled over to a
subsequent coverage period POWER account from the participant's
current coverage period POWER account based on the amount of money
remaining in the participant's POWER account from the current
coverage period.
(c) For a participant enrolled in the plus plan who, as
determined by the commission, timely makes POWER account
contributions in accordance with this subchapter, the commission
shall calculate the amount to be rolled over to a subsequent
coverage period POWER account from the participant's current
coverage period POWER account based on:
(1) the amount of money remaining in the participant's
POWER account from the current coverage period; and
(2) the total amount of money the participant
contributed to the participant's POWER account during the current
coverage period.
(d) Except as provided by Subsection (e), a participant may
use money rolled over into the participant's POWER account for the
succeeding coverage period to offset required annual POWER account
contributions, as applicable, during that coverage period.
(e) A participant enrolled in the basic plan who rolls over
money into the participant's POWER account for the succeeding
coverage period and who chooses to enroll in the plus plan for that
coverage period may use the money rolled over to offset a maximum of
50 percent of the required annual POWER account contributions for
that coverage period.
Sec. 537A.0257. REFUND. If at the end of a participant's
coverage period the participant chooses to cease participating in a
program health benefit plan or is no longer eligible to participate
in a program health benefit plan, or if the commission disenrolls a
participant from the program health benefit plan under Section
537A.0258 for failure to pay required contributions, the commission
shall refund to the participant any money the participant
contributed that remains in the participant's POWER account at the
end of the coverage period or on the disenrollment date.
Sec. 537A.0258. PENALTIES FOR FAILURE TO MAKE POWER ACCOUNT
CONTRIBUTIONS. (a) For a participant whose annual household
income exceeds 100 percent of the federal poverty level and who
fails to make a contribution in accordance with Section 537A.0252,
the commission shall provide a 60-day grace period during which the
participant may make the contribution without penalty. If the
participant fails to make the contribution during the grace period,
the commission shall disenroll the participant from the program
health benefit plan in which the participant is enrolled and the
participant may not reenroll in a program health benefit plan
until:
(1) the 181st day after the disenrollment date; and
(2) the participant pays any debt accrued due to the
participant's failure to make the contribution.
(b) For a participant enrolled in the plus plan whose annual
household income is equal to or less than 100 percent of the federal
poverty level and who fails to make a contribution in accordance
with Section 537A.0252, the commission shall disenroll the
participant from the plus plan and enroll the participant in the
basic plan. A participant enrolled in the basic plan under this
subsection may not change enrollment to the plus plan until the
participant's program eligibility is redetermined.
SUBCHAPTER G. EMPLOYMENT AND WELLNESS INITIATIVES
Sec. 537A.0301. GATEWAY TO WORK PROGRAM. (a) The
commission shall develop and implement a gateway to work program
to:
(1) integrate existing job training and job search
programs available in this state through the Texas Workforce
Commission or other appropriate state agencies with the program;
and
(2) provide each participant with general information
on the job training and job search programs.
(b) Under the gateway to work program, the commission shall
refer each participant who is unemployed or working less than 20
hours a week to available job search and job training programs.
(c) Under the gateway to work program, the executive
commissioner by rule shall require as a condition to remain in the
program that each participant who is able to work demonstrate to the
commission's satisfaction a reasonable effort to secure and
maintain employment.
(d) The commission shall disenroll a participant from the
program if at the end of the participant's coverage period the
participant is unable to demonstrate a reasonable effort to secure
and maintain employment. A participant who is disenrolled from the
program under this section is ineligible to participate in the
program for a period of 12 months from the date of disenrollment.
Sec. 537A.0302. GATEWAY TO WELLNESS PROGRAM. (a) The
commission shall develop and implement a gateway to wellness
program to:
(1) integrate existing health care assistance
programs available in this state through the Texas Medical
Association, the Texas Department of Insurance, and other
appropriate state agencies with the program to ensure access to
preventative care services and providers under the program; and
(2) provide each participant with information on
available preventative care services and providers under the
program.
(b) Under the gateway to wellness program, the executive
commissioner by rule shall require as a condition to remain in the
program that each participant receive preventative care services
during a coverage period.
(c) The commission shall disenroll a participant from the
program if at the end of the participant's coverage period the
participant did not receive preventative care services required
under Subsection (b). A participant who is disenrolled from the
program under this section is ineligible to participate in the
program for a period of 12 months from the date of disenrollment.
SUBCHAPTER H. HEALTH CARE FINANCIAL ASSISTANCE FOR CERTAIN
PARTICIPANTS
Sec. 537A.0351. HEALTH CARE FINANCIAL ASSISTANCE FOR
CONTINUITY OF CARE. (a) The commission shall ensure continuity of
care by providing health care financial assistance in accordance
with and in the manner described by this subchapter for a
participant who:
(1) the commission disenrolls from a program health
benefit plan in accordance with Section 537A.0155 because the
participant's annual household income exceeds the income
eligibility requirements for enrollment in a program health benefit
plan; and
(2) seeks and obtains private health benefit coverage
within 12 months following the date of disenrollment.
(b) To receive health care financial assistance under this
subchapter, a participant must provide to the commission, in the
form and manner the commission requires, documentation showing the
participant has obtained or is actively seeking private health
benefit coverage.
(c) The commission may not impose an upper income
eligibility limit on a participant to receive health care financial
assistance under this subchapter.
Sec. 537A.0352. DURATION AND AMOUNT OF HEALTH CARE
FINANCIAL ASSISTANCE. (a) A participant described by Section
537A.0351 may receive health care financial assistance under this
subchapter until the first anniversary of the date the commission
disenrolled the participant from a program health benefit plan.
(b) Health care financial assistance the commission makes
available to a participant under this subchapter:
(1) may not exceed the amount described by Section
537A.0353; and
(2) may be used only to pay for eligible services
described by Section 537A.0354.
Sec. 537A.0353. BRIDGE ACCOUNT; FUNDING. (a) The
commission shall establish a bridge account for each participant
eligible to receive health care financial assistance under Section
537A.0351. The account is funded with money the commission
contributes in accordance with this section.
(b) The commission shall enable each participant for whom
the commission establishes a bridge account to access and manage
money in and information regarding the participant's account
through an electronic system. The commission may contract with the
same entity described by Section 537A.0251(b) or another entity
with appropriate experience and expertise to establish, implement,
or administer the electronic system.
(c) The commission shall fund each bridge account in an
amount equal to $1,000 using money the commission retains or
recoups:
(1) during the roll over process described by Section
537A.0256;
(2) following the issuance of a refund as described by
Section 537A.0257; or
(3) under Subsection (e).
(d) The commission may not require a participant to
contribute money to the participant's bridge account.
(e) The commission shall retain or recoup any unexpended
money in a participant's bridge account at the end of the period for
which the participant is eligible to receive health care financial
assistance under this subchapter for the purpose of funding another
participant's POWER account under Subchapter F or bridge account
under this subchapter.
Sec. 537A.0354. USE OF BRIDGE ACCOUNT MONEY. (a) The
commission shall issue to each participant for whom the commission
establishes a bridge account an electronic payment card that allows
the participant to use the card to pay costs for eligible services
described by Subsection (b).
(b) A participant may use money in the participant's bridge
account to pay:
(1) premium costs incurred during the private health
benefit coverage enrollment process and coverage period; and
(2) copayments, deductible costs, and coinsurance
associated with the private health benefit coverage the participant
obtains for health care services that would otherwise be
reimbursable under Medicaid.
(c) Costs described by Subsection (b)(2) associated with
eligible services delivered to a participant may be paid by:
(1) a participant using the electronic payment card
issued under Subsection (a); or
(2) a health care provider directly charging and
receiving payment from the participant's bridge account.
Sec. 537A.0355. ENROLLMENT COUNSELING. The commission
shall provide enrollment counseling to an individual who is seeking
private health benefit coverage and who is otherwise eligible to
receive health care financial assistance under this subchapter.
SECTION 2. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall apply for and actively pursue from the
federal Centers for Medicare and Medicaid Services or another
appropriate federal agency the waiver as required by Section
537A.0051, Government Code, as added by this Act. The commission
may delay implementing other provisions of this Act until the
waiver applied for under that section is granted.
SECTION 3. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2023.