PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 353. MEDICAID MANAGED CARE
SUBCHAPTER E. STANDARDS FOR MEDICAID MANAGED CARE
The Texas Health and Human Services Commission (HHSC) adopts an amendment to §353.421, concerning Special Disease Management for Health Care MCOs.
The amendment to §353.421 is adopted with changes to the proposed text as published in the July 19, 2024, issue of the Texas Register (49 TexReg 5221). This rule will be republished.
BACKGROUND AND JUSTIFICATION
The adopted amendment implements Texas Government Code, §533.009(c) as amended by House Bill (H.B.) 2658, 87th Legislature, Regular Session, 2021. The adopted amendment relates to managed care organization (MCO) requirements for special disease management (DM) programs. The purpose of the DM programs is to improve health outcomes for Medicaid members diagnosed with a disease or chronic health condition. The Texas Health and Human Services Commission (HHSC) identifies the diseases and chronic conditions for a member to be eligible for the MCO's DM program in HHSC's Uniform Managed Care Manual Chapter 9: Disease Management.
The adopted amendment organizes the definition of "special disease management" with the new definitions "active participation" and "high-risk member" into one rule. These definitions identify what these terms mean when used in the section.
The adopted amendment to implement Texas Government Code §533.009(c)(3), added by H.B. 2658, requires a health care MCO to include mechanisms to identify low active participation rates in the MCO's special DM program, the reason for the low rates, and to increase active participation in the program for high-risk members.
The adopted amendment also corrects formatting, uses consistent terminology, and corrects the use of acronyms to improve the readability of the section.
COMMENTS
The 31-day comment period ended August 19, 2024. During this period, HHSC did not receive any comments regarding the proposed rule.
HHSC revised references to the Texas Government Code citations in proposed §353.421(a)(1) and subsection (d) to implement H.B. 4611, 88th Legislature, Regular Session, 2023, which makes non-substantive revisions to the Texas Government Code that make the statute more accessible, understandable, and usable.
STATUTORY AUTHORITY
The amendment is adopted under Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §533.009, which requires the Executive Commissioner of HHSC, by rule, to prescribe the minimum standards that a managed care organization must meet in providing special disease management.
§353.421.Special Disease Management for a Health Care Managed Care Organization.
(a) Definitions. The following words and terms, when used in this section have the following meanings, unless the context clearly indicates otherwise.
(1) Active participation--One or more encounters in a calendar year, either face-to-face or by an approved telehealth modality, between the disease management staff of a health care managed care organization (MCO) and a member or the member's representative. In determining active participation, a member who is assessed and provided supports and services that address a chronic disease, but is not participating in the MCO's special disease management program as described in Texas Government Code §540.0708 should not be counted as participating in the disease management program.
(2) High-risk member--A member at high-risk for non-adherence to the member's plan of care that addresses the member's disease or other chronic health condition, such as heart disease; chronic kidney disease and its medical complications; respiratory illness, including asthma; diabetes; end-stage renal disease; human immunodeficiency virus infection (HIV), or acquired immunodeficiency syndrome (AIDS). A high risk member has multiple or complex medical or behavioral health conditions, or both, with clinical instability undergoing active treatment and at risk of avoidable emergency room visits or hospitalizations.
(3) Special disease management--Coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.
(b) A health care MCO must provide special disease management services. A health care MCO must:
(1) implement policies and procedures to ensure that a member who requires special disease management services are identified and enrolled into the MCO's special disease management program;
(2) develop and maintain screening and evaluation procedures for the early detection, prevention, treatment, or referral of a member at risk for or diagnosed with chronic conditions such as heart disease; chronic kidney disease and its medical complications; respiratory illness, including asthma; diabetes; HIV infection; or AIDS;
(3) ensure a member who is enrolled in the MCO's special disease management program has the opportunity to disenroll from the program within 30 days while still maintaining access to all other covered services;
(4) show evidence of the ability to manage complex diseases in the Medicaid population by demonstrating the health care MCO's ability to comply with this section; and
(5) include mechanisms to:
(A) identify:
(i) low active participation rates in the MCO's special disease management program; and
(ii) the reason for the low rates; and
(B) increase active participation in the disease management program for high-risk members.
(c) A special disease management program must include:
(1) patient self-management education;
(2) patient education regarding the role of the provider;
(3) evidence-supported models, standards of care in the medical community, and clinical outcomes;
(4) standardized protocols and participation criteria;
(5) physician-directed or physician-supervised care;
(6) implementation of interventions that address the continuum of care;
(7) mechanisms to modify or change interventions that have not been proven effective;
(8) mechanisms to monitor the impact of the special disease management program over time, including both the clinical and the financial impact;
(9) a system to track and monitor all members enrolled in a special disease management program for clinical, utilization, and cost measures;
(10) designated staff to implement and maintain the program and assist members in accessing program services;
(11) a system that enables providers to request specific special disease management interventions; and
(12) provider information, including:
(A) the differences between recommended prevention and treatment and actual care received by a member enrolled in a special disease management program;
(B) information concerning the member's adherence to a service plan; and
(C) reports on changes in each member's health status.
(d) A health care MCO's special disease management program must have performance measures for particular diseases. HHSC reviews the performance measures submitted by a special disease management program for comparability with the relevant performance measures in Texas Government Code §540.0708, relating to contracts for disease management programs.
(e) A health care MCO implementing a special disease management program for chronic kidney disease and its medical complications that includes screening for and diagnosis and treatment of this disease and its medical complications, must, for the screening, diagnosis and treatment, use generally recognized clinical practice guidelines and laboratory assessments that identify chronic kidney disease on the basis of impaired kidney function or the presence of kidney damage.
(f) A health care MCO that develops and implements a special disease management program must coordinate participant care with a provider of a disease management program under Texas Human Resources Code §32.057, during a transition period for patients that move from one disease management program to another program.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on November 8, 2024.
TRD-202405460
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: November 28, 2024
Proposal publication date: July 19, 2024
For further information, please call: (512) 438-2910
SUBCHAPTER J. PURCHASED HEALTH SERVICES
DIVISION 28. PHARMACY SERVICES: REIMBURSEMENT
The Texas Health and Human Services Commission (HHSC) adopts an amendment to §355.8549, concerning Medicaid Coverage and Reimbursement for Non-Opioid Treatments.
Section 355.8549 is adopted without changes to the proposed text as published in the August 2, 2024, issue of the Texas Register (49 TexReg 5614). This rule will not be republished.
BACKGROUND AND JUSTIFICATION
The amendment is necessary to comply with Texas Human Resources Code §32.03117, which requires HHSC to reimburse a Medicaid hospital provider who provides a non-opioid treatment to a Medicaid recipient. Section 32.03117 also requires HHSC by rule to ensure that, to the extent permitted by federal law, a hospital provider who provides outpatient department (OPD) services to a Medicaid recipient is reimbursed separately under Medicaid for any non-opioid treatment provided as part of those services. The adoption of the amendment codifies the current process HHSC follows that separately reimburses Medicaid providers who provide non-opioid treatment to Medicaid recipients as part of an OPD service.
COMMENTS
The 31-day comment period ended September 3, 2024. During this period, HHSC did not receive any comments regarding the proposed rule.
STATUTORY AUTHORITY
The amendment is adopted under Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Government Code §531.033, which requires the Executive Commissioner of HHSC to adopt rules necessary to carry out the commission's duties under Chapter 531; Texas Human Resources Code §32.021(c), which requires the executive commissioner to adopt rules necessary for the proper and efficient operation of the medical assistance program; and Texas Human Resources Code §32.03117, which requires the executive commissioner by rule to ensure that, to the extent permitted by federal law, a hospital provider that provides outpatient department services to a medical assistance recipient is reimbursed separately under the medical assistance program for any non-opioid treatment provided as part of those services.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on November 8, 2024.
TRD-202405472
Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Effective date: November 28, 2024
Proposal publication date: August 2, 2024
For further information, please call: (512) 438-2910