Sec. 534.104. MANAGED CARE STRATEGY PROPOSALS; PILOT PROGRAM SERVICE PROVIDERS. (a) The department, in consultation and collaboration with the advisory committee, shall identify private services providers or managed care organizations that are good candidates to develop a service delivery model involving a managed care strategy based on capitation and to test the model in the provision of long-term services and supports under Medicaid to individuals with an intellectual or developmental disability through a pilot program established under this subchapter.
(b) The department shall solicit managed care strategy proposals from the private services providers and managed care organizations identified under Subsection (a). In addition, the department may accept and approve a managed care strategy proposal from any qualified entity that is a private services provider or managed care organization if the proposal provides for a comprehensive array of long-term services and supports, including case management and service coordination.
(c) A managed care strategy based on capitation developed for implementation through a pilot program under this subchapter must be designed to:
(1) increase access to long-term services and supports;
(2) improve quality of acute care services and long-term services and supports;
(3) promote meaningful outcomes by using person-centered planning, individualized budgeting, and self-determination, and promote community inclusion;
(4) promote integrated service coordination of acute care services and long-term services and supports;
(5) promote efficiency and the best use of funding;
(6) promote the placement of an individual in housing that is the least restrictive setting appropriate to the individual's needs;
(7) promote employment assistance and customized, integrated, and competitive employment;
(8) provide fair hearing and appeals processes in accordance with applicable federal law; and
(9) promote sufficient flexibility to achieve the goals listed in this section through the pilot program.
(d) The department, in consultation and collaboration with the advisory committee, shall evaluate each submitted managed care strategy proposal and determine whether:
(1) the proposed strategy satisfies the requirements of this section; and
(2) the private services provider or managed care organization that submitted the proposal has a demonstrated ability to provide the long-term services and supports appropriate to the individuals who will receive services through the pilot program based on the proposed strategy, if implemented.
(e) Based on the evaluation performed under Subsection (d), the department may select as pilot program service providers one or more private services providers or managed care organizations with whom the commission will contract.
(f) For each pilot program service provider, the department shall develop and implement a pilot program. Under a pilot program, the pilot program service provider shall provide long-term services and supports under Medicaid to persons with an intellectual or developmental disability to test its managed care strategy based on capitation.
(g) The department, in consultation and collaboration with the advisory committee, shall analyze information provided by the pilot program service providers and any information collected by the department during the operation of the pilot programs for purposes of making a recommendation about a system of programs and services for implementation through future state legislation or rules.
(h) The analysis under Subsection (g) must include an assessment of the effect of the managed care strategies implemented in the pilot programs on:
(1) access to long-term services and supports;
(2) the quality of acute care services and long-term services and supports;
(3) meaningful outcomes using person-centered planning, individualized budgeting, and self-determination, including a person's inclusion in the community;
(4) the integration of service coordination of acute care services and long-term services and supports;
(5) the efficiency and use of funding;
(6) the placement of individuals in housing that is the least restrictive setting appropriate to an individual's needs;
(7) employment assistance and customized, integrated, competitive employment options; and
(8) the number and types of fair hearing and appeals processes in accordance with applicable federal law.
Added by Acts 2013, 83rd Leg., R.S., Ch. 1310 (S.B. 7), Sec. 1.01, eff. September 1, 2013.
Amended by:
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.249, eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 1117 (H.B. 3523), Sec. 5, eff. June 19, 2015.
Section: Previous 534.051 534.052 534.053 534.054 534.101 534.102 534.103 534.104 534.105 534.106 534.1065 534.107 534.108 534.109 534.110 NextLast modified: September 28, 2016