GOVERNMENT CODE CHAPTER 543. CLINICAL INITIATIVES TO IMPROVE MEDICAID QUALITY OF CARE AND COST-EFFECTIVENESS

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

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.

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.

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.

SUBCHAPTER B. ASSESSMENT OF CLINICAL INITIATIVES

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.

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.

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.

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

(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

(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.

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

(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.

Text of section effective on April 01, 2025

Sec. 543.0056. COMMISSION ACTION ON CLINICAL INITIATIVE. After the commission analyzes a clinical initiative under Section 543.0054:

(1) if the commission determined that the initiative is cost-effective and will improve the quality of care under Medicaid, the commission may:

(A) implement the initiative if implementing the initiative is not otherwise prohibited by law; or

(B) if implementation requires a change in law, submit a copy of the final report together with recommendations relating to the initiative's implementation to the standing committees of the senate and house of representatives with jurisdiction over Medicaid; and

(2) if the commission determined that the initiative is not cost-effective or will not improve quality of care under Medicaid, the commission may not implement the initiative.

Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.