GOVERNMENT CODE CHAPTER 531. HEALTH AND HUMAN SERVICES COMMISSION

GOVERNMENT CODE

TITLE 4. EXECUTIVE BRANCH

SUBTITLE I. HEALTH AND HUMAN SERVICES

CHAPTER 531. HEALTH AND HUMAN SERVICES COMMISSION

Text of subchapter effective until April 1, 2025

SUBCHAPTER A. GENERAL PROVISIONS; ORGANIZATION OF COMMISSION

Sec. 531.001. DEFINITIONS. In this subtitle:

Without reference to the amendment of this subdivision, this subchapter was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

(4-a) "Home telemonitoring service" means a health service that requires scheduled remote monitoring of data related to a patient's health and transmission of the data to a licensed home and community support services agency, a federally qualified health center, a rural health clinic, or a hospital, as those terms are defined by Section 531.02164(a). The term is synonymous with "remote patient monitoring."

Added by Acts 1995, 74th Leg., ch. 76, Sec. 8.002(a), eff. Sept. 1, 1995. Amended by Acts 1997, 75th Leg., ch. 165, Sec. 14.01, eff. Sept. 1, 1997; Acts 1997, 75th Leg., ch. 1022, Sec. 97, eff. Sept. 1, 1997; Acts 1999, 76th Leg., ch. 7, Sec. 2, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 899, Sec. 1, eff. Sept. 1, 1999; Acts 1999, 76th Leg., ch. 1460, Sec. 8.01, eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 53, Sec. 1, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 957, Sec. 6, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1429, Sec. 9.007, eff. Sept. 1, 2001; Acts 2003, 78th Leg., ch. 198, Sec. 1.01(a) to 1.01(c), 2.01, eff. Sept. 1, 2003; Acts 2003, 78th Leg., ch. 1276, Sec. 9.009, eff. Sept. 1, 2003.

Amended by:

Acts 2011, 82nd Leg., R.S., Ch. 1205 (S.B. 293), Sec. 1, eff. September 1, 2011.

Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.007, eff. April 2, 2015.

Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 2.01, eff. September 1, 2015.

Acts 2017, 85th Leg., R.S., Ch. 205 (S.B. 1107), Sec. 8, eff. May 27, 2017.

Acts 2017, 85th Leg., R.S., Ch. 316 (H.B. 5), Sec. 22, eff. September 1, 2017.

Acts 2019, 86th Leg., R.S., Ch. 623 (S.B. 1207), Sec. 1, eff. September 1, 2019.

Acts 2019, 86th Leg., R.S., Ch. 964 (S.B. 670), Sec. 1, eff. September 1, 2019.

Acts 2019, 86th Leg., R.S., Ch. 1235 (H.B. 1576), Sec. 1, eff. June 14, 2019.

Acts 2019, 86th Leg., R.S., Ch. 1330 (H.B. 4533), Sec. 1, eff. September 1, 2019.

Acts 2021, 87th Leg., R.S., Ch. 811 (H.B. 2056), Sec. 17, eff. September 1, 2021.

Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(2), eff. April 1, 2025.

Amended by:

Acts 2023, 88th Leg., R.S., Ch. 840 (H.B. 2727), Sec. 1, eff. June 13, 2023.

SUBCHAPTER B. POWERS AND DUTIES

Without reference to the amendment of this section, this section was repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

Sec. 531.02164. MEDICAID SERVICES PROVIDED THROUGH HOME TELEMONITORING SERVICES. (a) In this section:

(1) "Federally qualified health center" has the meaning assigned by 42 U.S.C. Section 1396d(l)(2)(B).

(1-a) "Home and community support services agency" means a person licensed under Chapter 142, Health and Safety Code, to provide home health, hospice, or personal assistance services as defined by Section 142.001, Health and Safety Code.

(2) "Hospital" means a hospital licensed under Chapter 241, Health and Safety Code.

(3) "Rural health clinic" has the meaning assigned by 42 U.S.C. Section 1396d(l)(1).

(b) The executive commissioner shall adopt rules for the provision and reimbursement of home telemonitoring services under Medicaid as provided under this section.

(1) identify and provide home telemonitoring services to persons diagnosed with conditions for which the commission determines the provision of home telemonitoring services would be cost-effective and clinically effective;

(2) consider providing home telemonitoring services under Subdivision (1) to Medicaid recipients who:

(A) are diagnosed with one or more of the following conditions:

(i) pregnancy;

(ii) diabetes;

(iii) heart disease;

(iv) cancer;

(v) chronic obstructive pulmonary disease;

(vi) hypertension;

(vii) congestive heart failure;

(viii) mental illness or serious emotional disturbance;

(ix) asthma;

(x) myocardial infarction;

(xi) stroke;

(xii) end stage renal disease; or

(xiii) a condition that requires renal dialysis treatment; and

(B) exhibit at least one of the following risk factors:

(i) two or more hospitalizations in the prior 12-month period;

(ii) frequent or recurrent emergency room admissions;

(iii) a documented history of poor adherence to ordered medication regimens;

(iv) a documented risk of falls; and

(v) a documented history of care access challenges;

(3) ensure that clinical information gathered by the following providers while providing home telemonitoring services is shared with the recipient's physician:

(A) a home and community support services agency;

(B) a federally qualified health center;

(D) a hospital;

(4) ensure that the home telemonitoring services provided under this section do not duplicate disease management program services provided under Section 32.057, Human Resources Code; and

(5) require a provider to:

(A) establish a plan of care that includes outcome measures for each recipient who receives home telemonitoring services under this section; and

(B) share the plan and outcome measures with the recipient's physician.

(c-1) Notwithstanding any other provision of this section, the commission shall ensure that home telemonitoring services are available to pediatric persons who:

(1) are diagnosed with end-stage solid organ disease;

(2) have received an organ transplant; or

(3) require mechanical ventilation.

(c-2) In addition to determining whether to provide home telemonitoring services to Medicaid recipients with the conditions described under Subsection (c)(2), the commission shall determine whether high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective. If the commission determines that high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective:

(1) the commission shall, to the extent permitted by state and federal law, provide recipients experiencing a high-risk pregnancy with clinically appropriate home telemonitoring services equipment for temporary use in the recipient's home; and

(2) the executive commissioner by rule shall:

(A) establish criteria to identify recipients experiencing a high-risk pregnancy who would benefit from access to home telemonitoring services equipment;

(B) ensure that, if cost-effective, feasible, and clinically appropriate, the home telemonitoring services equipment provided includes uterine remote monitoring services equipment and pregnancy-induced hypertension remote monitoring services equipment;

(i) prior authorization from the commission before providing home telemonitoring services equipment to a recipient during the first month the equipment is provided to the recipient; and

(ii) an extension of the authorization under Subparagraph (i) from the commission before providing the equipment in a subsequent month based on the ongoing medical need of the recipient; and

(D) prohibit payment or reimbursement for home telemonitoring services equipment during any period that the equipment was not in use because the recipient was hospitalized or away from the recipient's home regardless of whether the equipment remained in the recipient's home while the recipient was hospitalized or away.

(c-3) For purposes of Subsection (c-2), the commission shall require that:

(1) a request for prior authorization under Subsection (c-2)(2)(C)(i) be based on an in-person assessment of the recipient; and

(2) documentation of the recipient's ongoing medical need for the equipment is provided to the commission before the commission grants an extension under Subsection (c-2)(2)(C)(ii).

(d) If, after implementation, the commission determines that a condition for which the commission has authorized the provision and reimbursement of home telemonitoring services under Medicaid under this section is not cost-effective and clinically effective, the commission may discontinue the availability of home telemonitoring services for that condition and stop providing reimbursement under Medicaid for home telemonitoring services for that condition, notwithstanding Section 531.0216 or any other law.

(e) The commission shall determine whether the provision of home telemonitoring services to persons who are eligible to receive benefits under both Medicaid and the Medicare program achieves cost savings for the Medicare program.

(f) To comply with state and federal requirements to provide access to medically necessary services under Medicaid, including the Medicaid managed care program, and if the commission determines it is cost-effective and clinically effective, the commission or a Medicaid managed care organization, as applicable, may reimburse providers for home telemonitoring services provided to persons who have conditions and exhibit risk factors other than those expressly authorized by this section.

Added by Acts 2011, 82nd Leg., R.S., Ch. 1205 (S.B. 293), Sec. 5, eff. September 1, 2011.

Amended by:

Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.033, eff. April 2, 2015.

Acts 2019, 86th Leg., R.S., Ch. 1061 (H.B. 1063), Sec. 2, eff. September 1, 2019.

Acts 2021, 87th Leg., R.S., Ch. 624 (H.B. 4), Sec. 3, eff. June 15, 2021.

Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01, eff. April 1, 2025.

Amended by:

Acts 2023, 88th Leg., R.S., Ch. 840 (H.B. 2727), Sec. 2, eff. June 13, 2023.

Sec. 531.084. MEDICAID LONG-TERM CARE COST CONTAINMENT STRATEGIES. (a) The commission shall make every effort to achieve cost efficiencies within the Medicaid long-term care program. To achieve those efficiencies, the commission shall:

(1) establish a fee schedule for reimbursable incurred medical expenses for dental services controlled in long-term care facilities;

(2) implement a fee schedule for reimbursable incurred medical expenses for durable medical equipment in nursing facilities and ICF-IID facilities;

(3) implement a durable medical equipment fee schedule action plan;

(4) establish a system for private contractors to secure and coordinate the collection of Medicare funds for recipients who are dually eligible for Medicare and Medicaid;

(5) create additional partnerships with pharmaceutical companies to obtain discounted prescription drugs for Medicaid recipients; and

(6) develop and implement a system for auditing the Medicaid hospice care system that provides services in long-term care facilities to ensure correct billing for pharmaceuticals.

(b) The executive commissioner and the commissioner of aging and disability services shall jointly appoint persons to serve on a work group to assist the commission in developing the fee schedule required by Subsection (a)(1). The work group must consist of providers of long-term care services, including dentists and long-term care advocates.

(1) the need to ensure access to dental services for residents of long-term care facilities who are unable to travel to a dental office to obtain care;

(2) the most recent Comprehensive Fee Report published by the National Dental Advisory Service;

(3) the difficulty of providing dental services in long-term care facilities;

(4) the complexity of treating medically compromised patients; and

(5) time-related and travel-related costs incurred by dentists providing dental services in long-term care facilities.

(d) The commission shall annually update the fee schedule required by Subsection (a)(1).

Added by Acts 2005, 79th Leg., Ch. 349 (S.B. 1188), Sec. 5(a), eff. September 1, 2005.

Amended by:

Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.117, eff. April 2, 2015.

For expiration of this section, see Subsection (d).

Sec. 531.09991. PLAN FOR THE TRANSITION OF CARE OF CERTAIN INDIVIDUALS. (a) Not later than January 1, 2025, the commission shall, in consultation with nursing facilities licensed under Chapter 242, Health and Safety Code, develop a plan for transitioning from a hospital that primarily provides behavioral health services to a nursing facility individuals who require:

(1) a level of care provided by nursing facilities; and

(2) a high level of behavioral health supports and services.

(b) The plan must include:

(1) recommendations for providing incentives to providers for the provision of services to individuals described by Subsection (a), including an assessment of the feasibility of including incentive payments under the Quality Incentive Payment Program (QIPP) for those providers;

(2) recommendations for methods to create bed capacity, including reserving specific beds; and

(3) a fiscal estimate, including estimated costs to nursing facilities and savings to hospitals that will result from transitioning individuals under Subsection (a).

(c) The commission may implement the plan, including recommendations under the plan, only if the commission determines that implementing the plan would increase the amount of available state general revenue.

(d) This section expires September 1, 2025.

Added by Acts 2023, 88th Leg., R.S., Ch. 1035 (S.B. 26), Sec. 4, eff. September 1, 2023.

SUBCHAPTER C. MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD, ABUSE, OR OVERCHARGES