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Texas Statutes (Last Updated: January 4, 2014) |
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GOVERNMENT CODE |
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Title 4. EXECUTIVE BRANCH |
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Subtitle I. HEALTH AND HUMAN SERVICES |
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Chapter 533. IMPLEMENTATION OF MEDICAID MANAGED CARE PROGRAM |
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Subchapter A. GENERAL PROVISIONS |
Sec. 533.0025. DELIVERY OF SERVICES
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(a) In this section, "medical assistance" has the meaning assigned by Section 32.003, Human Resources Code.
(b) Except as otherwise provided by this section and notwithstanding any other law, the commission shall provide medical assistance for acute care through the most cost-effective model of Medicaid managed care as determined by the commission. If the commission determines that it is more cost-effective, the commission may provide medical assistance for acute care in a certain part of this state or to a certain population of recipients using:
(1) a health maintenance organization model, including the acute care portion of Medicaid Star + Plus pilot programs;
(2) a primary care case management model;
(3) a prepaid health plan model;
(4) an exclusive provider organization model; or
(5) another Medicaid managed care model or arrangement.
(c) In determining whether a model or arrangement described by Subsection (b) is more cost-effective, the commissioner must consider:
(1) the scope, duration, and types of health benefits or services to be provided in a certain part of this state or to a certain population of recipients;
(2) administrative costs necessary to meet federal and state statutory and regulatory requirements;
(3) the anticipated effect of market competition associated with the configuration of Medicaid service delivery models determined by the commission; and
(4) the gain or loss to this state of a tax collected under Chapter 222, Insurance Code.
(d) If the commission determines that it is not more cost-effective to use a Medicaid managed care model to provide certain types of medical assistance for acute care in a certain area or to certain medical assistance recipients as prescribed by this section, the commission shall provide medical assistance for acute care through a traditional fee-for-service arrangement.
(e) The commission shall determine the most cost-effective alignment of managed care service delivery areas. The commissioner may consider the number of lives impacted, the usual source of health care services for residents in an area, and other factors that impact the delivery of health care services in the area.