COMMISSION ON LEGISLATIVE AND PUBLIC AFFAIRS

Thursday, November 9, 2017 Time: 7:00 – 9:00 p.m. Room: Harbor Galveston Island Convention Center Galveston,

AGENDA

1. Call to order by Jorge Duchicela, M.D, Chair. (Vice Chair - Gurjeet S Shokar, MD) 2. Roll call and introduction of guests. (Please have those present sign the attendance report.) 3. Approval of Minutes – April 7, 2017 4 Current Business A. Review and discuss issues likely to be considered during the legislative interim • Hurricane Harvey response – budgetary and health implications • Health insurance coverage – TRS Care • 1115 Medicaid waiver extension • Medicaid – cost containment strategies • GME and workforce B. Federal Update Troy Fiesinger, MD AAFP Commission Government Affairs C. Report from AAFP’s State Legislative Conference Doug Curran, MD 7. Other business 8. Adjourn

If your commission has any items which require financing over $2,000, please meet with the Finance Committee from 3 - 5 p.m. on Thursday, Nov. 9, 2017, in the Clipper Room of The Galveston Island Convention Center, Dallas, Texas, to discuss the cost of the items before going to the Board for approval.

Tom Banning is the staff person responsible for this commission.

Commission on Legislative & Public Affairs, AS17 1 Staff Liaison: HOGUE Robert L MD, FAAFP ...... (325) 646-6568 Tom Banning ...... [email protected] Member (2018) F(325) 646-9199 101 S Park Dr Ste A DUCHICELA Jorge MD, FAAFP ...... (979) 725-8545 Brownwood TX 76801-5959 Chair (2017) F(979) 725-8287 [email protected] 402 Youens Dr HOLBERT Anthony MD, MBA ...... (409) 789-2735 Weimar TX 78962-3680 Member (2018) [email protected] 1316 Tuam St SHOKAR Gurjeet S MD ...... (915) 215-5562 Houston TX 77004-2735 Vice Chair (2017) F(915) 751-4378 [email protected] 9849 Kenworthy St HUNT Farron Cheryl MD, FAAFP ...... El Paso TX 79924-4402 Member (2019) [email protected] Po Box 786 ACKERMAN Lani K MD, FAAFP ...... (979) 575-7708 Port Arthur TX 77641-0786 Member (2019) [email protected] 4836 Rustic Trl JONES Brian D MD, FAAFP ...... (972) 291-7863 Midland TX 79707-1416 Member (2019) F(972) 291-0942 [email protected] 950 E Belt Line Rd Ste 100 ALLISON Jerry A MD, MSHCM, CPE, FAAFP ...... Cedar Hill TX 75104-2423 Member (2017) [email protected] 14361 Olympic Dr KUMAR K Ashok MD, FRCS, FAAFP ...... (210) 567-0428 Farmers Branch TX 75234-3831 Member (2019) F(210) 567-2443 [email protected] 7703 Floyd Curl Dr # Msc7794 ANDERSON Charles Peter MD, FAAFP ...... (512) 396-3663 TX 78229-3900 Member (2017) F(512) 396-3668 [email protected] PO BOX 1804 LASATER Loren S MD, FAAFP ...... (817) 912-8510 San Marcos TX 78667-1804 Member (2017) F(817) 912-8515 [email protected] 2217 Galloway Blvd BALKCOM Ichabod L IV MD, FAAFP ...... (903) 885-3181 Roanoke TX 76262-5495 Member (2019) F(903) 885-1329 [email protected] 482 County Road 1187 MABRY Leah Raye MD, FAAFP ...... (210) 340-5577 Sulphur Springs TX 75482-8492 Member (2019) [email protected] 339 S Presa St BANKS Gerald Clifford MD, MS ...... San Antonio TX 78205-3425 Member (2019) [email protected] 5437 Kitty Hawk Dr MARGO Javier D MD, FAAFP ...... (956) 735-7000 Corpus Christi TX 78414-4183 Member (2017) F(956) 487-6644 [email protected] 110 Hinojosa Cir BAR-ELI Lee Hagar MD ...... (832) 325-6500 Rio Grande City TX 78582-4359 Member (2018) F(832) 325-7260 [email protected] 710 E 7Th 1/2 St MCCRADY William Mike MD ...... (903) 531-4051 Houston TX 77007-1708 Member (2019) F(903) 657-1685 [email protected] 534 S Beckham Ave BARTOS Justin V MD, FAAFP ...... (817) 284-8222 Tyler TX 75702-8310 Member (2018) F(817) 255-1950 [email protected] 4300 City Point Dr Ste 201 MCMURRY Ronnie A MD ...... (409) 384-8171 North Richland Hills TX 76180-8380 Member (2019) F(409) 384-9302 [email protected] 2041 S Wheeler St ELLIOTT Tricia C MD, FAAFP ...... (817) 702-1173 Jasper TX 75951-5603 Member (2018) [email protected] 4626 Hermosa Arroyo Dr MITCHELL Li-Yu Huang MD ...... League City TX 77573-1495 Member (2019) F(903) 526-2871 [email protected] 6120 Brixworth Dr GOERTZ Roland A MD, FAAFP ...... (254) 313-4201 Tyler TX 75703-5516 Member (2019) F(254) 313-4326 [email protected] 1600 Providence Dr MORGAN James MD, FAAFP ...... (817) 693-2520 Waco TX 76707-2261 Member (2019) F(817) 693-2545 [email protected] 2417 Bachman Dr GREER Thomas David MD, FAAFP ...... (940) 538-5321 Flower Mound TX 75028-2380 Member (2018) F(940) 538-5555 [email protected] PO BOX 360 Henrietta TX 76365-0360 [email protected]

Commission on Legislative & Public Affairs, AS17 2 MUELLER Thomas Edwin MD, FAAFP ...... (979) 732-2318 Member (2019) F(979) 732-2310 2122 Highway 71 S # 101 Columbus TX 78934-3011 [email protected] NGUYEN Mary Suzanne MD, FAAFP ...... (830) 538-2254 Member (2018) F(830) 931-2259 PO BOX 960 409 Madrid Street Castroville TX 78009-0960 [email protected] PONCE DE LEON Anne Marie MD ...... (281) 565-2800 Member (2018) 16902 Southwest Fwy Ste 100 Sugar Land TX 77479-2350 [email protected] RAGLE Theron Dale MD ...... (214) 361-0946 Member (2018) F(214) 373-7030 8230 Walnut Hill Ln Ste 600 Dallas TX 75231-4432 [email protected] STOLTZ Steven Michael MD ...... (888) 648-3390 Member (2018) F(888) 648-3390 214 N 16th St # 120 Mcallen TX 78501-4735 [email protected] VAN WINKLE Lloyd MD, FAAFP ...... (830) 538-2254 Member (2019) F(830) 931-2259 409 Madrid St Po Box 960 Castroville TX 78009-4527 [email protected] ANGADICHERIL Tracey Charly DO ...... (409) 772-1044 Resident Member (2017) 301 University Blvd Galveston TX 77555-5302 [email protected] HURLEY Janet L MD ...... (903) 839-2585 TAFP Board Liaison (2017) F(903) 839-3165 1930 Golden Bay Whitehouse TX 75791-5813 [email protected]

Commission on Legislative & Public Affairs, AS17 3 Family medicine in the 85th

By Jonathan Nelson and Perdita Henry

http://www.tafp.org/news/tfp/summer-2017/cover Coming in to the 85th Texas Legislature, Gov. Greg Abbott, Lt. Gov. Dan Patrick, and Speaker laid out their policy priorities for the session. Among them were: sanctuary cities, the transgender bathroom bill, property tax cuts, school finance reform, school choice, shoring up the foster care and child protective services systems, ethics reforms, Gov. Abbott’s desire to call for a convention of states to amend the U.S. Constitution, and of course, passing a balanced budget.

Nowhere in that list are any big-ticket health care items, and that’s no surprise. In the run- up to the session’s start in January 2017, everyone predicted the Affordable Care Act would be the unchallenged law of the land under President Hillary Clinton, fully funded and completely operational. Why consider options for Medicaid reform like block grants, work requirements, co-pays, and the like?

Consequently, when lawmakers arrived in Austin shortly before President Donald Trump was sworn into office, no policy plans were prepared for what might be possible under Republican rule in both Washington, D.C., and the statehouse. So health care policy was low on the priority list this session. Even so, with more than 6,500 bills filed and fewer than 1,200 passed, the Lege took up a number of issues of interest to physicians and their patients.

The 2018-2019 budget First on the docket as always was the state budget, and lawmakers knew coming in the fiscal forecast looked grim. Sagging oil prices and our growing population among other things meant the state faced a $6 billion shortfall. The House and Senate agreed on a budget for the 2018-2019 biennium totaling $216.8 billion in all funds, which included $106.8 billion in state general revenue. The remainder is federal money drawn down by state expenditures for programs like Medicaid and CHIP. Lawmakers also agreed to use $1 billion from the state rainy day fund.

The Legislature funded Medicaid at $62.4 billion, $1.9 billion less than the current biennium, and they appropriated $79.45 billion to Health and Human Services, $1.83 billion less than 2016-2017.

Commission on Legislative & Public Affairs, AS17 4 While many other programs related to public health languished this session, the state followed through on its commitment to increase funding for mental health. The budget spends $300 million for replacement or repair of state mental hospitals or other inpatient mental health facilities, and added $160 million for state hospital deferred maintenance. The Legislature also approved $67 million for community-based crisis service provisions, $30 million to reduce homelessness and recidivism, and $67.6 million to eliminate adult and child mental health waiting lists.

Graduate Medical Education The Legislature continued its recent efforts to expand graduate medical education capacity, increasing GME expansion grants by $44 million and adding $4.3 million to GME formula funding. Throughout the session, lawmakers on committees of jurisdiction over GME made it clear they were concerned that Texas didn’t have enough during a time of medical school expansion. Senate Bill 1066 by Senator Schwertner requires new medical schools to offer new GME positions to keep pace with the number of medical graduates they produce.

In the last weeks of the session, a program near and dear to family physicians suffered a significant blow. The Family Practice Residency Program is a budget strategy administered by the Texas Higher Education Coordinating Board that dedicates funding directly to the state’s family medicine residency training programs. The program had maintained its funding throughout the budget-writing process in both houses, but when budget conferees met to work out the differences in the two versions, they decided to slash the program by 40 percent, dropping its funding from $16.78 million to $10 million.

TAFP will maintain close communication with the state’s residency programs, studying the effects of this funding cut and making those effects known to the Legislature.

First, do no harm Once again this session, organized medicine won important legislative battles by ensuring many bad bills didn’t become law. Sometimes the best defense is just a really good defense. Nurse practitioner organizations were back in force this session with a raft of bills designed to allow advanced practice registered nurses to practice medicine independently. None of those bills succeeded in either the House or the Senate.

On April 25, TAFP member Emily Briggs, MD, MPH, of New Braunfels, testified before the House Committee on Public Health in opposition to House Bill 3395, which would have allowed advanced practice registered nurses to practice medicine independently in counties having no physicians. Briggs told the committee that she shared their goal to expand access to care in rural communities, granting nurses the authority to diagnose and prescribe is not the solution.

Commission on Legislative & Public Affairs, AS17 5 She described the complexity and the variance of problems rural physicians treat on a daily basis. “Patients with chest pain, lacerations, burns, broken bones, or a woman in labor. Even highly trained primary care physicians who may have done an extra year of training in rural practice many times do not feel prepared for rural practice. If we want to improve access to care in rural areas, we should strengthen our efforts to recruit physicians from rural communities to medicine. We need to continue to provide loan repayment as a recruitment strategy and we need competitive reimbursement for our Medicaid patients.” The bill didn’t make it out of the committee.

Clearing the way for telemedicine in Texas After years of lawsuits and friction between large telemedicine providers and the Texas Medical Board, the advancement of telemedicine in the state had reached an impasse. National direct-to-consumer telemedicine firms wanted free rein to sell their services outside of the state’s regulatory oversight and without regard for patients’ existing relationships with their physicians. The medical board rules held that a physician couldn’t treat a patient via telemedicine unless the physician had established a relationship with the patient in a previous face-to-face visit, a stipulation companies like Dallas-based Teladoc found unworkable. In the months leading up to the start of the legislative session, TAFP, TMA, and the Texas e-Health Alliance drew together a diverse group of stakeholders and over the course of many meetings, brokered an improbable agreement in which all sides could claim victory.

In the end, Gov. Abbott signed into law a measure passed unanimously by both the Senate and House that protects the standard of care for patients, defines the responsibilities physicians must maintain when providing telemedicine services, and allows for innovation and progress in the market.

Senate Bill 1107 by Sen. Charles Schwertner, MD, R-Georgetown, establishes a statutory definition for telemedicine and clarifies that the standard of care for a traditional, in- person medical setting also applies to telemedicine services. In the House, Rep. added language making it clearer that telemedicine is not a distinct service but a tool physicians can use. The bill also prohibits health plans from excluding telemedicine from coverage just because the care isn’t provided in person.

Under the new law, TAFP fully expects that family physicians in the state can offer telemedicine services to their patients in a safe and efficacious manner and that they will be able to compete with large companies like Teladoc and American Well.

Public health In a session without much focus on health care and no extra money to spend, public health initiatives gained little momentum, except in the case of a few important mental health

Commission on Legislative & Public Affairs, AS17 6 issues like the $300 million investment in our state hospitals and other state-funded inpatient mental health facilities mentioned above. H.B. 2561 by Rep. , D-Houston, seeks to address people’s misuse of, and addiction to, opioid pain medicines. It includes Physician Drug Monitoring Program initiatives to identify potentially harmful prescribing or dispensing patterns or practices that might suggest drug diversion or “doctor shopping.” The prescribing amendment calls for physicians and all other prescribers and dispensers to check the PDMP before prescribing any of the listed classes of medications after Sept. 1, 2019.

To help alleviate Texas’ shortage of psychiatrists, S.B. 674 by Sen. Schwertner creates an expedited licensing process for psychiatrists who are licensed to practice medicine in another state and are board certified.

H.B. 3576 by Rep. Bobby Guerra, D-McAllen, will improve the state’s testing and screening capabilities for infectious diseases, such as the Zika virus.

Women’s health In a 2016 study published in the journal Obstetrics & Gynecology, researchers found that from 2011 to 2015, 537 Texas women died while pregnant or within 42 days of delivery, compared to 296 from 2007 to 2010. This doubling of maternal deaths made Texas the most dangerous place to give birth in the developed world. Maternal mortality was on the agenda for the 85th Legislature but many of the bills that would help us understand and identify the dangers facing new and expectant mothers failed to pass. The issue of maternal mortality is a concern all over the country but Texas unfortunately has the distinction of being the worst. In fact, Janet Realini, MD, MPH, president of Healthy Futures of Texas and chair of Texas Women’s Healthcare Coalition, spoke about her concerns during her TAFP Member of the Month interview. “Texas women have the highest maternal mortality rate of any state — higher than many third-world countries,” she said. “Preventive care and contraception are incredibly important in addressing this issue in two ways: preventing unplanned pregnancies that can stress women with health issues and serving as an entry to health care for women with health risks.”

Several representatives arrived at the Capitol with the intention of finding out why Texas women are dying at a higher rate, ensuring they have access to the care needed, and finding out why African-American women — who give birth to 11 percent of babies born but account for almost 29 percent of all maternal deaths — die at higher rates than other women in the state.

Two specific bills aimed to do just that were House Bill 2403 by Rep. , D- Houston, and Senate Bill 1929 by Sen. Lois Kolkhorst R-Brenham. H.B. 2403 would have required the Maternal Mortality and Morbidity Task Force to conduct a study of the causes of death in African-American women and S.B. 1929 would have extended the Maternal

Commission on Legislative & Public Affairs, AS17 7 Mortality and Morbidity Task Force through 2023. Both bills were killed in what has become known as the Mother’s Day Massacre, when more than 100 bills were allowed to expire due to political push-back from the House Freedom Caucus.

At the end of the regular legislative session, only two bills addressing maternal mortality passed. H.B. 1158 by Rep. Sarah Davis, R-West University Place, will make postpartum screenings available to women on Medicaid but will not offer treatment to those diagnosed. Senate Bill 1599 by Sen. Borris L. Miles, D-Houston, requires the Department of State Health Services to post protocol for pregnancy-related death investigations and best practices for reporting those deaths to the medical examiner or justice of the peace of each county.

When lawmakers returned to the Capitol for a 30-day special session, Rep. Kolkhorst filed S.B. 17 to extend the work of the Task Force on Maternal Mortality and Morbidity until 2023. The bill passed and the governor signed it into law.

Funding for Healthy Texas Women and the Family Planning Program remained level for the next biennium, which is a major victory considering the cuts many public health programs sustained this time around.

A rider in the budget directs HHSC to seek a Medicaid 1115 waiver to provide a 90/10 federal match for the Health Texas Women’s program. If the federal government approves the waiver, funding for the program would start in 2019, which could have a significant impact on the budget and structure for women’s health programs in the state.

Your Academy in action Despite a tough political climate and a difficult budget process, strong physician leadership in TAFP and a well-respected advocacy team represented the specialty well this session, standing in support of family physicians and their patients. Great appreciation goes out to all those members who served as Physician of the Day during the regular session and the special session, and to those members who provided testimony, contacted their representatives and state officials, served as Key Contacts, and supported the Academy’s efforts.

Commission on Legislative & Public Affairs, AS17 8 Medicine’s Big Winners as Legislature Wraps Up Regular Session

www.texmed.org /2017LegislativeWrapup/

The 2017 regular session of the Texas Legislature gaveled to a close May 29. For medicine, the session was a mosaic of many richly colored tiles with some dark spots and quite a few shades of grey. The artists were shifting alliances and divisions of senators and representatives, Democrats and Republicans, and various factions of the GOP.

The final product includes one obvious empty space. Thanks to a long-brewing, House-Senate feud over unrelated issues, the legislature adjourned without passing a bill to reauthorize the Texas Medical Board (TMB) and the Medical Practice Act beyond their scheduled Aug. 31, 2017, demise.

"This is a fight that has nothing to do with the physicians or with the TMB, and everyone at the Capitol knows that," said TMA President Carlos J. Cardenas, MD. "The TMB serves a critical state function, licensing physicians and protecting the health and safety of Texans. We have no reason to believe that any of our state leaders want the TMB to go away, and we have every expectation that they will find a way to make sure that doesn’t happen."

Gov. Greg Abbott is calling the legislature back for a special session beginning July 18. While his "call" for the session includes 20 different items, the governor clearly stated that lawmakers must reauthorize TMB and the Medical Practice Act -- and similar legislation regarding a number of other state agencies -- before moving on to the other 19 topics. "That will be the only legislation on the special session [agenda] until they pass out of the Senate in full," he said at a June 6 news conference.

Below is a comprehensive look at the bills that were of interest to TMA and its members.

Medicine's Bills Signed by the Governor

Senate Bill 507 by Sen. Kelly Hancock (R-North Richland Hills) and Rep. (R-Lubbock) will expand the billing mediation process to all physicians and others providing out-of-network services at certain in-network facilities. It also expands mediation to out-of-network situations for emergency care.

Senate Bill 680 by Senator Hancock empowers physicians to override health plans’ step therapy protocols, allowing them to continue prescribing an effective medication even if the insurer’s step therapy plan calls for a change in medication.

Senate Bill 1107 by Sen. Charles Schwertner, MD (R-Georgetown), establishes a statutory definition for telemedicine and clarifies that the standard of care for a traditional, in-person medical setting also applies to telemedicine services. In the House, Rep. Four Price (R-Amarillo) added language making it clearer that telemedicine is not a distinct service but a tool physicians can use. The bill also prohibits health plans from excluding telemedicine from coverage just because the care isn’t provided in person.

House Bill 62 by Rep. (R-Midland) to ban texting while driving statewide is on Gov. Greg Abbott’s desk. After a 10-year journey and a nearly unanimous vote, hopefully the governor will sign it into law. Sen. Judith Zaffirini (D-Laredo) was the bill’s Senate sponsor. The measure was a TMA and Texas Public Health Coalition (TPHC) priority. During the July special session, Governor Abbott wants lawmakers to explore this issue further and enact "legislation that fully pre-empts cities and counties from any regulation of mobile devices in vehicles."

Commission on Legislative & Public Affairs, AS17 9 House Bill 2561 by Rep. Senfronia Thompson (D-Houston) finally passed, amended by lawmakers to include Physician Drug Monitoring Program (PDMP) initiatives to identify potentially harmful prescribing or dispensing patterns or practices that might suggest drug diversion or “doctor shopping.” The idea is to address people’s misuse of, and addiction to, opioid pain medicines. The prescribing amendment calls for physicians and all other prescribers and dispensers to check the PDMP before prescribing any of the listed classes of medications after Sept. 1, 2019. The implementation date provides TMA with the opportunity to request possible revisions during the 2019 Texas Legislature.

Senate Bill 674 by Senator Schwertner created an expedited licensing process for psychiatrists who are licensed to practice medicine in another state and board certified.

Senate Bill 922 by Senator Buckingham will allow Medicaid to reimburse school districts and open-enrollment charter schools for telehealth services provided to students.

Senate Bill 81, Sen. Jane Nelson’s (R-Flower Mound) Cancer Prevention Research Institute of Texas sunset bill, extends the sunset date of the cancer research organization from 2021 to 2023, while also adding two years to its eligibility to allocate funds, to 2022. Its House sponsor was Rep. Sarah Davis (R-West University Place).

Medicine's Bills Sent to the Governor

Thanks to the more than 1,250 Texas physicians who rallied to support this bill during the final weekend of the session, Senate Bill 1148 by Sen. Dawn Buckingham, MD (R-Lakeway), finally passed. As originally written, SB 1148 would have prohibited health plans and hospitals from using maintenance of certification (MOC) to differentiate among physicians for payment, contracting, or credentialing. It also would have required TMB to certify alternative MOC programs. In the final compromise version, the bill still prohibits the state from using MOC as a requirement for state licensure or renewal, or insurance participation — but permits health facilities to use MOC if hospital medical staffs vote it is appropriate for their own hospital. Rep. , MD (R-Friendswood), was the House sponsor.

House Bill 10 by Representative Price will establish a state mental health parity work group, designate an ombudsman as an advocacy resource, and clarify benefit terms and coverage for mental health and substance use. TMA hopes the legislation also will improve Texas Department of Insurance mental health parity oversight; increase physician, health care provider, and patient engagement toward achieving true mental health parity; and identify areas to improve historic parity challenges.

House Bill 1917 by Rep. Richard Raymond (D-Laredo) will keep the Medicaid Preferred Drug List (PDL) under Texas Health and Human Commission (HHSC) oversight. The bill places the PDL under HHSC auspices until 2023, after which managed care organizations would manage the formulary and the PDL. The bill's Senate sponsor was Senator Schwertner.

House Bill 3576 by Rep. Bobby Guerra (D-McAllen) will shore up the state’s testing and screening capabilities for infectious diseases, such as the Zika virus. TMA told lawmakers physicians support the bill because it upholds a core function of public health. Disease surveillance allows for the implementation of prevention and treatment activities, TMA said.

Senate Bill 570 by Sen. Jose Rodriguez (D-El Paso) “relating to the regulation of the retention, storage, transportation, and disposal of used or scrap tires” was successfully reconsidered after initially failing on a tight vote, thanks in part to Representative Davis’ floor explanation that the bill could help mitigate the spread of infectious diseases such as the Zika and West Nile viruses by reducing the standing rainwater in old tires (thereby keeping disease-carrying mosquitoes from breeding in the stagnant water). She drew from points provided by TPHC, of which TMA is a member. Boom — the bill was saved and passed and is on Governor Abbott’s desk.

Senate Bill 894 by Senator Buckingham relates to HHSC’s strategy for managing audit resources, including proceduresCommission for auditing on Legislative and collecting & Public Affairs, payments AS17 from Medicaid managed care organizations (MCOs). The 10bill requires HHSC to adopt risk-based audit procedures for MCOs, making the process transparent.

Senate Bill 1066 by Senator Schwertner requires new medical schools to offer new GME positions to keep pace with their medical graduates. TMA testified in February in support of the bill.

House Bill 435 by Rep. (R-Canadian) became the host vehicle for House Bill 14 by Andrew Murr (R- Junction), which will allow the Texas Department of State Health Services (DSHS) to post signs prohibiting handguns at Texas’ 10 state mental health hospitals.

House Bill 1600 by Representative Thompson will allow Medicaid to pay physicians to conduct mental health screenings during each annual well-child exam, under the Texas Health Steps program. TMA explained in committee testimony that this bill improves the current scenario in which designated Medicaid procedure codes for this screening may be used only once in a young patient’s lifetime (between ages 12 and 18).

House Bill 2466 by Representative Davis will require children’s Medicaid and the Children’s Health Insurance Program (CHIP) to cover maternal depression screening for an enrolled child’s mother during a covered well-baby visit or other office visit to a pediatrician or pediatric provider. Sen. Joan Huffman (R-Houston), the Senate sponsor, added an amendment allowing pregnant women enrolling in Medicaid to sign up for texts, emails, or phone calls from their Medicaid HMO to receive appointment reminders, as well as health information to maintain a healthy pregnancy.

The governor has 21 days to sign bills, veto them, or let them become law without his signature. TMA will be reporting what happens.

Bills TMA Opposed That Died

House Bill 1415 by Rep. (R-Fort Worth) and its companion, Senate Bill 681 by Senator Hancock, would have granted advanced practice registered nurses full, independent practice and prescribing authority without physician supervision.

Senate Bill 728 by Sen. Van Taylor (R-Plano) and its companion, House Bill 2118 by Representative Klick, would have allowed patients 30 days of direct access to treatment by physical therapists without being seen first by a physician.

House Bill 719 by Rep. (D-Houston) would have indexed the caps established in the 2003 tort reform law according to changes in the Consumer Price Index.

House Bill 593 by Rep. (R–Lubbock) and its companion, Senate Bill 1240 by Senator Rodriguez, would have allowed psychologists prescribing authority, a practice reserved for medical school-trained physicians.

House Bill 4011 by Representative Burrows would have amounted to unnecessary overregulation of the business of medicine by requiring physicians to receive from patients a signed disclosure form with an itemized statement of the amounts to be billed for nonemergency medical services before those services were even provided. Thanks to hundreds of calls and emails from TMA member physicians to the Capitol, HB 4011 was voted down on the House floor, 97 to 34.

Senate Bill 2127 by Sen. Larry Taylor (R-Galveston) would have prohibited a credit reporting agency from including on a credit report a collection account for certain health care services provided by out-of-network physicians. Narrow insurance networks cause this problem by creating balance-billing circumstances, which was addressed in other legislation.

House Bill 1675 by Rep. (R-Van) would have allowed health plans to require physicians to accept virtual credit cards for payment for services rendered. Commission on Legislative & Public Affairs, AS17 11 House Bill 1070 by Rep. (R-Plano) would have prohibited physicians from refusing to care for a patient based on his or her immunization status.

House Bill 1124 by Rep. Matt Krause (R-Fort Worth) and its companion, Senate Bill 2008 by Sen. Van Taylor, would have made it easier to parents to opt out of vaccinating their children.

Senate Bill 95 by Sen. Bob Hall (R-Edgewood) would have expanded the lawful sale of raw, unpasteurized milk and cheese at farmers markets.

House Bill 2962 by Rep. (R-Southlake) would have required physicians and health facilities to file a form to report any medical complications following an abortion. TMA noted earlier in opposing the measure that it would require a physician who diagnoses a complication following an abortion and/or initiates treatment of a woman following an abortion to report that information to the state — and imposes a penalty for not doing so. This requirement would include an emergency physician with no prior history about the patient. (TMA’s concerns have nothing to do with the issue of abortion, but instead the bill’s intrusion into the patient-physician relationship.)

House Bill 3476 by Rep. (R-Houston) would have required preparticipation electrocardiograms for all school student athletes, a test that not every student athlete needs and one that could result in false positives, which could ultimately harm students and their parents.

The Budget Compromise

The final compromise state budget for the 2018-19 biennium totals $216.7 billion in all funds and $106.8 billion in state general revenue dollars. It also draws $1 billion from the rainy day fund, an idea embraced by the House Appropriations Committee. The final budget also uses some of the Senate’s accounting idea of delaying payment of transportation dollars until the start of the next biennium, to credit this budget that amount.

A breakdown of what the conference committee did follows.

Medicaid

It approved $427 million general revenue in Medicaid cost containment (technically the rider applies to all HHSC agencies, but most of the savings will come from Medicaid); $77 million is anticipated to come from reducing the risk margins to Medicaid and CHIP plans. It eliminated a separate rider asking HHSC to achieve $1 billion in savings by pursuing federal Medicaid flexibility.

Maternal and Child Health

It adopted a Senate rider directing HHSC to pursue a Medicaid 1115 women's health waiver, which if approved will provide a 90/10 federal funding match for the Healthy Texas Women’s program, effective 2019. It also adopted riders to decrease Medicaid neonatal intensive care unit costs, prevent maternal mortality, screen and treat women for perinatal depression, report postpartum depression screening and treatment, and collaborate with the Maternal Mortality and Morbidity Task Force to study maternal mortality to reduce the incidence.

Mental Health

It adopted $300 million for replacement or repair of state hospitals or other inpatient mental health facilities, and added $160 million for state hospital deferred maintenance. It also approved $67 million for community-based crisis service provisions, $30 million to reduce homelessness and recidivism, and $67.6 million to eliminate adult and child mental health waiting lists.

GME Commission on Legislative & Public Affairs, AS17 12 Lawmakers added $44 million for graduate medical education (GME) expansion grants, and increased GME formula funding by $4.3 million. The Family Medicine Residency Program was cut by $6 million, and the Physician Education Loan Repayment Program was reduced by $8.4 million.

Department of State Health Services

Conferees approved Senate funding levels, $131 million, and directed $219,000 in federal funds to local health departments. The bill imposes a roughly $30 million cut in public health preparedness. It also reduces funding for immunizations, HIV/AIDS, infectious diseases, chronic disease prevention, and the Children with Special Health Care Needs program. On the bright side, the compromise plan requires HHSC and the comptroller to study how increasing the legal age for buying tobacco products from 18 to 21 could result in Medicaid savings by reducing the rates of preterm and low-birth-weight births. TMA and TPHC strongly supported a bill to raise the tobacco-use age from 18 to 21, but that bill was one of many that died this session.

Supplemental Budget Passes: The Senate unanimously passed the supplemental budget bill for the current two- year cycle on Tuesday. House Bill 2 totals $2.6 billion and adds about $800 million in state funds plus $1.6 billion in federal funds to cover the current budget's Medicaid shortfall. Another $158 million in combined state/federal funds pays for Texas Department of Family and Protective Services needs, largely for hiring new Child Protective Services caseworkers. HB 2 also covers repairs at state mental hospitals as well as gaps in public education and the state teachers' pension program. The House concurred in the Senate’s changes later in the week and sent the bill to Governor Abbott.

Bills TMA Supported That Did Not Pass

Senate Bill 80 by Sen. Jane Nelson (R-Flower Mound) was one of several versions of the Texas Medical Board sunset bill. TMA is hopeful a version of this bill will be revisited should the governor call a special session, as TMB needs to be continued by Sept. 1, 2017, or its authority to license and credential physicians in Texas expires.

Senate Bill 833 by Sen. Bryan Hughes (R-Mineola) and its companion, House Bill 752 by Rep. Morgan Meyer (R- Dallas), would protect employed physicians who act as whistleblowers against corporate employers over patient health care quality issues. The bill would have required TMB to investigate complaints against the entities it certifies (like nonprofit health corporations [NPHCs]), just as it must do for licensees. The bill changes nothing about NPHCs that are operating properly, but it will address the NPHCs that retaliate against whistleblowing physicians.

Senate Bill 1929 by Sen. Lois Kolkhorst (R-Brenham) would continue the Maternal Mortality and Morbidity Task Force at DSHS, which is helping the state identify the causes of Texas’ high and growing rates of maternal mortality and morbidity. TMA urged support of the bill to combat maternal deaths and their root causes, which include mental health issues and opioid abuse.

House Bill 477 by Rep. (D-Fort Worth) would have required health coverage providers to educate consumers purchasing individual health benefit coverage.

House Bill 1908 by Rep. , MD (R-Richmond), would have raised the age to purchase tobacco products from 18 to 21. A compromise in the budget will require HHSC and the comptroller to study how increasing the legal age for purchasing and using tobacco could result in Medicaid savings due to fewer preterm and low-birth-weight births.

House Bill 2249 by Rep. J.D. Sheffield, DO (R-Gatesville), the “Parents’ Right to Know” bill, would have required the state to report vaccination exemption-rate data at the more-precise school level rather than at the school district level. Commission on Legislative & Public Affairs, AS17 13 House Bill 2760 by Representative Bonnen and its companion, Senate Bill 2210 by Senator Hancock, would have required daily updates of health plan network directories.

House Bill 3124 by Rep. Lance Gooden (R-Terrell) would have allowed doctors in physician-led accountable care organizations to receive and share physician-specific comparison data and information.

Action, June 1, 2017

Updated June 7, 2017

TMA Testimonies and Letters

TMA Texas Legislature main page

Commission on Legislative & Public Affairs, AS17 14 Analysis: The line for money at the Texas Capitol just got longer

The Texas Legislature's list of things to do in 2019 is already piling up, and it was an expensive set of chores before anyone ever heard of Hurricane Harvey.

BY ROSS RAMSEY OCT. 9, 2017

The Senate chamber at the Texas Capitol on Aug. 16, 2017, the morning after the end of the special session.

Legislative sessions are almost always about the money — how much is available, and who is going to get it. The next session of the Texas Legislature will have the usual suspects in line —school finance, border security, pensions, etc. — but a new entry will be at the front of the line.

His name is Harvey.

This year’s regular and special legislative sessions were marked by financial wrangling, and by some analysts’ reckoning, lawmakers dug their successors a deep hole. The Texas Taxpayers and Research Association recently estimated that the starting point for the next budget — the one lawmakers will write in 2019 — is a negative $7.9 billion. And that was before Harvey.

On the plus side, the state’s direct storm costs won’t be huge, if the past is a guide. The Center for Public Policy Priorities looked back at other recent storms that caused catastrophic damage. The Legislature’s supplemental appropriation for Hurricane Ike, for instance, was $312 million. The federal tab for that 2009 storm was $35 billion.

So it’s possible Harvey won’t be the gnarliest piece of budget math when Texas lawmakers get back to Austin in January 2019. But it will probably be the easiest-to- grasp of a set of big-dollar demands.

Gov. Greg Abbott and Texas A&M Chancellor John Sharp, the governor’s choice to oversee the state end of the Harvey recovery, have both said the state will put up millions of dollars from the current two-year budget to help with the cleanup and rebuilding from the storm.

It’s a cash-flow thing; spend money set aside for future use by state government and then cover those costs in the next session with money from the Rainy Day Fund, federal reimbursements and other sources.

Accountants are used to that kind of stuff. But the state already short-sheeted the budget they’re now planning to borrow from. Budget-writers put about $2 billion less than they know they’ll need in the 2018-19 budget for Medicaid. They also have to make

Commission on Legislative & Public Affairs, AS17 15 up for a deferral of sales taxes — proposed by the Legislature and approved by voters — of $3.6 billion for roads and highways.

And that’s before the supplicants with the regular list of expensive ideas line up at the Capitol. The Legislature has been shorting public education for years, spending less per student on schools than it did a decade ago. That’s been a good deal for budget-writers, at least in the short term, because the money the state didn’t spend on schools was raised from local school property taxpayers.

Those taxpayers aren’t likely to stop squawking about recurring property tax increases, leaving lawmakers in a familiar fix in 2019 when it comes to school finance: They can lower overall spending on education, raise local property taxes, spend more state money, or some combination of the three.

Nobody said the job was going to be easy.

As it stands, the state’s share of public education is around 38 percent — down from 45 percent the last time lawmakers made serious changes just over a decade ago. The state government would have to spend roughly $3.3 billion more every year to bring its share in line with what local districts pay. On the other hand, that would mean a $3.3 billion annual cut in school property taxes.

But there are plenty of other things in that line, and everyone has different priorities. Voters themselves made that expensive decision on transportation.

In 2015, a year when the state budget outlook was much rosier than now, the Legislature decided to spend $400 million on border security every year — a decision they stuck with, more or less, in the current, harder-to-write budget.

The state’s massive pension systems are in much better shape than their troubled counterparts in other states, but they still require expensive attention. Put the Employees Retirement System and the Teachers’ Retirement System in the 2019 money line.

Don’t forget the Medicaid money and the persistently rising costs of the state’s health and human services network. Higher education has been pinched hard, too. Put them in line.

The numbers will firm up over the next year; at this time 12 months from now, lawmakers will be working on the next budget — a two-year plan for 2020-21. Harvey will be at the front of the queue.

Disclosure: The Center for Public Policy Priorities, the Texas Taxpayers and Research Association and the Texas A&M University System have been financial supporters of The Texas Tribune. A complete list of Tribune donors and sponsors is available here.

Commission on Legislative & Public Affairs, AS17 16 Retired Texas teachers are worried about health insurance costs and counting on lawmakers to help

TEXAS LEGISLATURE AT AUG 4

Robert T. Garrett, Austin Bureau reporter

Dallas News.com

Connect with Robert T. Garrett

AUSTIN — Waves of panic are spreading among tens of thousands of retired Texas teachers and other former school employees over rising health care costs they'll soon be shouldering. Some have gone back to work. Others plan to borrow money from relatives.

If the Legislature's two GOP-led chambers don't end their warring over how to pay for a bill to offer some relief within the next few days, retired educators could seek vengeance in next March's primaries, some have warned.

"The days of sitting back and relying on people in the Legislature to take care of these issues need to end," said retired Denton County school administrator Clint Mosely.

He and others have said they'll reconsider support of Republican incumbents based on whether they act to dial back the increased cost-sharing scheduled to begin Jan. 1.

Retired Spanish teacher Deborah Woosley of Waxahachie, who's gone back to work because she has diabetes and can't afford the bills, said she and her husband usually vote and are conservative.

"But we will change who we vote for if they don't do something to make this right for all the teachers," she said.

The House insists the state should pay for relieving some of the squeeze of people on the Teacher Retirement System's health care plan by dipping into a savings account called the rainy day fund. Lt. Gov. Dan Patrick and the Senate, though, want to deploy an accounting maneuver. It involves delaying payments to Medicaid insurers and making up the difference later.

If the chambers deadlock, very few of the 268,000 people who rely on "TRS-Care," as the insolvent health plan is known, would escape financial pain. More than 50,000 plan members live in Dallas, Collin and 11 other North Texas counties.

Commission on Legislative & Public Affairs, AS17 17 "I'm getting a little more nervous every day," said Tim Lee, who heads the Texas Retired Teachers Association, which has 82,000 members. "With the time running out, it's getting harder to see that agreement is on the horizon."

Lee and others say a human — and possible political — crisis began building in June, when Gov. Greg Abbott signed legislation slapping a $1 billion patch on the plan's expected deficit in the two-year budget cycle that begins Sept. 1.

For the first time, managers of TRS, best known for its $143 billion pension fund, were allowed to stop offering a no-cost plan and received broad power to impose higher financial burdens on retirees and their families.

The move ended a 12-year freeze on premiums. It was lawmakers' tiny olive branch to retired teachers. It barely assuaged the fixed-income pensioners' anger, though, over the Legislature's continuing failure to add the billions needed to make their future retirement checks safe. Until pension reserves meet actuarial standards, state law forbids awarding cost-of-living increases. They've been granted only once in the past 15 years.

Increased health care costs could be "devastating economically," said former Irving principal María Elena Coronado, who has lupus and lives with her mother.

"I'm responsible for my 91-year-old mom so any extra expenses — it's going to be pretty drastic," said Coronado, 57.

Next year, she faces a $1,750 increase in her maximum out-of-pocket health expenses — to $6,650.

"Everything is budgeted," she said. "That's going to hurt."

Because about 95 percent of Texas' retired school employees haven't paid into Social Security, many rely on TRS pension checks as their sole source of income. Some retired teachers make as little as $24,000 a year, and janitors, $12,000.

During this year's regular session, as lawmakers discussed changes to health care, news reached many plan members very slowly if at all, according to TRS executive director Brian Guthrie and Lee of the retired teachers' group.

Starting in June, though, beneficiaries grasped the situation and protested in calls, letters and emails to lawmakers and Abbott. The Republican governor responded by adding retired teacher health care to the agenda of the special session that ends early next week.

How the bills would help

Both chambers have approved bills to spend $212 million more in the next cycle on TRS-Care. Separate bills by GOP Sens. Jane Nelson of Flower Mound and Joan Huffman of Houston and

Commission on Legislative & Public Affairs, AS17 18 Rep. , R-Lufkin, would dial back big premium increases facing a small group of retirees caring for adult disabled children. There are 570 of those, TRS estimates.

Both bills would target $115 million to cut in half the scheduled higher deductibles for about 55,000 "non-Medicare-eligible retirees" — many, though not all of them, under 65. Their policies cover 23,000 dependents. Instead of being $3,000 for an individual and $6,000 for a family, the deductibles would be $1,500 and $3,000, respectively.

Each bill also would reduce premiums for the 153,000 TRS-Care retirees who are on Medicare and their nearly 37,000 dependents.

Huffman and Ashby took "a slightly different approach" to those reductions, though, said TRS spokesman Howard Goldman.

What if the bills fail?

If neither bill passes, it will force current and former teachers to reconsider how they vote in state elections, said Mosely, the retired Denton County educator.

"This will be a great incentive for teachers to become more politically active — to protect themselves," he said.

Mosely, who retired as The Colony's associate principal after 33 years as a teacher and administrator, said disrespect for educators' financial security will cause "a tremendous fall-off in how many young people want to get into the profession."

Lee said the Legislature gave TRS-Care a shaky financial footing when it created the health plan in 1985. The plan gets most of its money in legally prescribed contributions from the state, school districts and active teachers. Amounts are set at a percentage of districts' payrolls, and they grow much more slowly than medical inflation, he said.

Also swelling the plan's deficit is a trend toward earlier retirements, he said. They result in a smaller share of members qualifying for Medicare, the federal health program for seniors. Without federal dollars, the cost to TRS-Care can run nearly $14,000 per beneficiary per year, compared with less than $3,000 per person per year for the Medicare Advantage plan it offers.

Woosley, 61, has diabetes and is one of the high-cost, non-Medicare-eligible retirees. Her medications will cost more starting Jan. 1. They'll hit the new $3,000 annual deductible within the first two months of next year, she said.

And the cap on her yearly out-of-pocket expenses, not counting premiums, is increasing by 36 percent.

"It's all going to have a huge impact on me and my husband," she said, referring to spouse Richard Woosley, 70. A 36-year science teacher, he qualifies for TRS-Care's more generous Medicare Advantage plan. But its costs are going up, too.

Commission on Legislative & Public Affairs, AS17 19 The Woosleys are worried they'll run through their savings. Because of that, he's going to ramp up his substitute teaching to three days a week if possible, she said.

For Deborah, though, substitute teaching is too stressful. Despite fear she'll hurt her health, she's taken a full-time office job at a storage facility. It pays just $10 an hour.

"I'd rather do that than take a handout from anyone," she said.

The fine print

Here are links to the Teacher Retirement System's descriptions of next year's TRS-Care plans:

Non-Medicare-eligible retirees

Medicare-eligible retirees

Commission on Legislative & Public Affairs, AS17 20 With retired teachers' health care at stake, legislators clash on fixes

The House and the Senate are figuring out whether they can compromise on exactly how to put $212 million into an underfunded health insurance program for retired teachers. Teachers say they'll take their frustration to the polls.

BY ALIYYA SWABY AUG. 3, 2017 12 AM

David Hatcher is one of thousands of retired teachers poised to see large increases in state-run health care costs next January.

When David Hatcher got a blood test at his oncologist's office two summers ago, the doctor spelled out his results decisively: “The bad news is you’ve got leukemia. The good news: It’s the kind we can treat with a pill.”

A retired public school history teacher, Hatcher might soon be unable to afford the tablets that keep his chronic myeloid leukemia in check — his health care costs are set to rise, whether or not the Texas Legislature can agree in the next two weeks on a temporary fix for the retired teachers’ health insurance plan.

"After working for 31 years for the state of Texas, being very successful at teaching kids and giving all my time to kids, I'm going to be rewarded ... with them taking basically 25 percent or more of my [monthly pension payment] from me just to pay health care," he said. "That to me is a travesty."

As of Tuesday afternoon, the House and the Senate had each voted out bills that would put $212 million into the Teacher Retirement System to make the TRS-CARE health insurance more affordable for retired teachers over the next two years, lowering their deductibles and premiums. The one-time influx of money would temporarily bolster a state-run program that has been faltering for years, with the state keeping base funding stagnant despite the rising costs of health care.

Legislators are considering a long list of education issues this special session — including school finance reform and "private school choice" — but many have said providing relief for these retirees is among the most pressing.

The problem: The chambers want to take the $212 million from different places in the budget and so far have been unwilling to compromise during the July-August special session. The House wants to take millions from the state's savings, while the Senate wants to employ an accounting maneuver in another part of the budget and make up the difference later.

Another problem: For the retired teachers like Hatcher, who need insurance to cover expensive medicine, even $212 million isn't enough.

Commission on Legislative & Public Affairs, AS17 21 And teachers say they'll take their anger with them to the polls for the March primaries.

Legislators are considering the $212 million patch to fix a problem they created during the regular session. Back in the spring, they increased funding for TRS-CARE by $483 million over the next two years. But they also changed the structure of the program to dial back benefits, in order to keep the system running, leading to higher deductibles and out-of-pocket costs, especially for retired teachers younger than 65. Those changes go into effect in January 2018.

"A lot of retirees knew those were coming, but a lot of them did not," said Brian Guthrie, executive director of the Teacher Retirement System, which broke the news to the teachers as the regular session concluded in May. Many were surprised to find out they would have fewer options and less extensive benefit packages.

Hatcher, 63, found out in June that he would soon have to pay 10 times his current deductible before his insurance would pay any portion of his medical care costs. He might have to spend more than $600 on his leukemia medication each month, up from around $30 to $65. No fix the Legislature is seriously considering this month would significantly reduce the cost of his pills.

"We gotta use some common sense here. It's quite obvious that a person cannot pay that kind of money for their medicine," he said.

A staunch Republican, Hatcher was one of thousands of current and retired teachers who called their state representatives, explaining the effects the changes would have on them — prompting legislators to file bills to help them in the special session. Gov. Greg Abbott then put the issue on his list of priorities for the 30 days.

Hatcher's state representative, , a Fort Worth Republican, joined 129 other House members Tuesday in voting to take $212.7 million from the state's Rainy Day Fund — a savings account largely fed by oil and gas production taxes — to put toward temporary relief for retired teachers.

The Senate voted to put $212 million into the health insurance plan, instead using an accounting maneuver to borrow money intended to pay health care companies that provide Medicaid, and make it up in a later payment.

Sen. Jane Nelson, R-Flower Mound, who wrote her chamber's bill, called the House's method of dipping into its savings a "false promise" for long-term relief. Rep. Trent Ashby, R-Lufkin, author of the House's version, likened the Senate's method to charging hundreds of millions on a state credit card, not a "fiscally prudent thing to do."

Many retirees, like Hatcher, would still fall through the cracks and get little to no relief. But both plans would cut deductibles in half and reduce premiums for some retirees.

Now the House and Senate have to figure out a compromise, or end up doing nothing for more than 1 million current and retired teachers who make up a strong voting bloc.

Commission on Legislative & Public Affairs, AS17 22 "If things go poorly and they feel like they can't afford to live, they're probably going to be more conscientious about who they're voting for," said Tim Lee, executive director of the Texas Retired Teachers Association, which lobbies for the retirees. He has testified before House and Senate committees in the past few weeks begging them to put aside their differences to fund the legislation. "Whatever the Legislature doesn't push forward as additional funding is going to be paid for out of the pockets of retired teachers," he said.

New Braunfels ISD educator Stephanie Quinn, 39, comes from a family of teachers and strong Republicans. For the first time this year, she is considering voting for state leaders not based on whether they are Republican, but based on whether they support teachers — even if it means voting for a Democrat.

She started a petition last Saturday demanding Abbott and state elected officials make state health care affordable for both current and retired teachers. By Wednesday evening, it had received more than 50,000 signatures.

"If this movement keeps growing the way it is, it could definitely affect the way people vote in March," she said.

Quinn's mother, Debbie Coleman, 63, retired in June after teaching for 35 years. When she first decided to retire, she chose a plan where she would pay just $400 before her insurance started to cover her medical costs. Now, just months later, she's expecting that amount to balloon to about $3,000, or $1,500 if legislators figure out a compromise.

"When I first started looking into [retirement], it looked like a much safer situation than it is now," Coleman said. She was a Democrat as a young woman and switched to the Republican Party when she got older. "We have to look at our futures. You have to be loyal to your family and sometimes not loyal to the party."

Experts and advocates say the shortfall in the health care program will continue to increase, unless the state creates a funding structure to pay for a higher percentage of health care costs as they rise each year.

"We were clear and upfront with the Legislature that even the changes they made this session, although welcome, would not be a long-term fix," said Guthrie said. Over the next four years, legislators will see a TRS-CARE funding gap of $300 million to $500 million, meaning retired teachers could be facing the exact same fight.

Disclosure: The Texas Retired Teachers Association has been a financial supporter of The Texas Tribune. A complete list of Tribune donors and sponsors can be viewed here.

Clarification: This story has been updated to more precisely describe the state's Rainy Day Fund.

Commission on Legislative & Public Affairs, AS17 23 Texas Requests Medicaid Waiver Extension for $6.2 Billion Texas rejected the 2014 Affordable Care Act (ACA) Medicaid expansion, but has asked again for a Medicaid waiver extension and $6.2 billion in funding.

By Jesse Migneault healthpayerintelligence.com

June 29, 2017 - Although Texas refused federal funds in the 2014 ACA Medicaid expansion, it has recently submitted documents requesting its second Medicaid waiver extension for $6.2 billion.

Originally approved in 2011, the 1115 Medicaid Waiver was already extended in 2016, and is set to expire at the end of 2017. If the second waiver extension is approved, it would provide federal funding until September 30, 2019.

If the waiver extension is not granted, officials are alarmed at the prospect of shuttering three main programs: Medicaid managed care, Uncompensated Care (UC), and the Delivery System Reform Incentive Payment (DSRIP) pools. Dig Deeper

• HHS Offers Waivers for Health Insurance Exchange Stability • Texas Wrongly Claimed $3.8M in Medicaid Reimbursements • One-third of Hispanic Texans Lack Medical Insurance in 2016

“We believe this extension is necessary to allow the new administration and the 115th Congress to make changes to the nation's health care system, and the Medicaid program specifically, during 2017,” said Texas Health and Human Services in their waiver request letter. “This extension would provide financial and operational certainty for Texas providers to continue serving Medicaid and low-income uninsured populations that benefit from the waiver.”

Commission on Legislative & Public Affairs, AS17 24 The total expenditures for the Texas Medicaid program currently sit at $29 billion. The program provides coverage to approximately 4.8 million residents.

“This funding would provide time for Texas to develop a new, comprehensive waiver or block grant proposal to achieve increased program flexibility and efficiency,” said the extension request letter. “Texas providers require a level of financial and operational certainty to continue serving Medicaid and low-income uninsured populations that benefit from the waiver.”

Texas currently leads the nation in having the largest percentage of uninsured residents at 20.5 percent, although that figure does represent a 6.5- percent reduction from 2013 levels.

When the waiver was first approved in 2011, it came with several healthcare requirements, such as benchmarking quality outcomes for providers. Some observers at the time thought this would be a catalyst to move the state towards a full Medicaid expansion in 2014. It was not.

Instead of using the funds to increase Medicaid coverage for uninsured adults, the state placed its existing Medicaid fee-for-service enrollees into managed care programs.

In total, Texas transferred close to one million Medicaid enrollees into private-payer managed care plans while still receiving federal matching funds.

According to a state of Texas HHS evaluation, the waiver funding has reaped mixed results for both Medicaid managed care, Uncompensated Care (UC), and the Delivery System Reform Incentive Payment (DSRIP) pools.

“In expanding Medicaid managed care statewide as well as transitioning much of the funding historically allocated for uncompensated hospital care into an incentive payment pool, the state has transitioned to much more accountable uses of public dollars,” said the evaluation report.

A driving force behind the waiver extension request has been the increase in uncompensated care costs across the state. Approximately half of the money from the waiver goes to the state’s UC fund.

The DSRIP program, which has established 20 regional healthcare partnerships and hundreds of pilot community health programs, is focused on improving healthcare for the poor. Despite its innovative approach and flexibility with patient outreach, the state evaluation determined the program lacked sufficient data to determine its effectiveness.

Commission on Legislative & Public Affairs, AS17 25 Across the state, providers remain uncertain as to how the projects would be funded without the continued Medicaid waiver funding. The evaluation concluded that without waiver funding the programs would likely not continue.

Commission on Legislative & Public Affairs, AS17 26 Texas Budget and Health Care Legislation Summary – 2017

June 8, 2017 by Andrew Fairgrieve Health Management Associates This week, our In Focus section comes to us from HMA Principal Dianne Longley, of our Austin, Texas, office. Dianne provides an update on and summary of the Texas Legislature’s adoption of a state fiscal year (SFY) 2018- 2019 budget, as well as a review of health care legislation passed by the Legislature this session. Texas Legislature Adopts SFY 2018-2019 Budget The Texas Legislature adjourned May 29, 2017, after adopting a $217 billion (all funds) two-year budget, reflecting a 0.2 percent increase over the current 2016- 17 biennial budget. The budget includes $106.7 billion in general revenue, which must be certified by the State Comptroller. Legislative budget leaders estimate the legislature will face a $1 billion shortfall when they reconvene in 2019. The budget is estimated to be as much as six percent lower than the prior biennium when considering inflation costs and population growth. The Texas state fiscal year (SFY) begins September 1 and ends August 31. Funding for Medicaid includes $62.4 billion in all funds, a reduction of $1.9 billion from SFY 2016-2017 (including a reduction of $0.4 billion in GR funds). Funding includes:

DECREASE FROM FUNDING CATEGORY SFY 2017-18 SFY 2016-17

Medicaid Client Services $57.4 billion $1.3 billion

Other Programs supported by $1.7 billion $0.1 billion Medicaid Funding

Medicaid Program Administration $3.3 billion $0.6 billion

Total $62.4 billion One of the biggest Medicaid compromises resolves differences between the Senate and House versions of the budget for funding to reinstate pediatric therapy rate cuts for services for children with developmental disabilities. The final budget restores 25 percent of the Medicaid pediatric therapy rate cuts which were enacted earlier this year as required by the 2015 Legislature. The House budget had included funds for a 50 percent rate restoration, and the Senate

Commission on Legislative & Public Affairs, AS17 27 version included no rate increase. HHSC is required to monitor changes in the availability of therapy providers and notify the Legislature if covered children are unable to access covered services as a result of the rate cut. Following is additional information on funding details:

• The budget includes funds for Medicaid caseload growth in 2018, but provides no funds for FY 2019 caseload growth. While the Legislative Budget Board (LBB) has not yet released projections for unfunded amounts, earlier projections estimated costs associated with caseload growth at $700 million in General Revenue (state funds) for the biennium. HHSC previously estimated the two-year cost of enrollment growth plus inflation could be as high as $1.9 billion. The budget is based on a projection that full-benefit Medicaid caseloads will increase by approximately 80,000 enrollees over the two-year period. • The budget includes no funding for projected cost growth per Medicaid participant for 2018 or 2019. • Funding for CHIP client services includes 2.0 billion in All Funds, an increase of $156.3 million in funding due to projected caseload growth and maintenance of FY 2017 premium levels without any increase in per enrollee costs. • The budget includes funding for an additional 735 enrollees in the Home and Community-based Services (HCS) waiver by the end of 2019. An additional 276 enrollment slots are included for children in Child Protective Services custody who are expected to require Long Term Supports and Services (LTSS). All other funding for long term care waivers is maintained at the August 2017 level, which is the first time in 10 years the legislature has failed to appropriate funds to reduce waiver “interest” (i.e., wait) lists. • Funding for the Texas Integrated Eligibility Redesign System (TIERS) includes $392.6 million (all funds), reflecting an increase of $0.6 million in total spending from 2016-17. Note: Rider 152 specifies that of these budgeted funds, $114.4 million must be spent for capital enhancements and maintenance; HHSC must also provide a quarterly report detailing spending and progress towards implementing the TIERS project. Behavioral Health Funding • Spending for behavioral health (BH) services for the biennium is estimated at $3.5 billion for Medicaid, and $48.7 million for CHIP. • Funding for non-Medicaid/CHIP behavioral health totals $4.0 billion. This includes funding for programs across 18 agencies, and includes inpatient client services at state hospitals and community hospitals; outpatient services provided through Local Mental Health Authorities; Substance Abuse prevention, intervention, and treatment services, mental health care and substance abuse treatment for incarcerated individuals; mental health care for veterans, and other services.

Commission on Legislative & Public Affairs, AS17 28 • Funding includes $62.6 million for the biennium to address waitlists for community mental health services for adults and children, and an additional $69.0 million in General Revenue contingency funding for several bills that would provide grants to community organizations for BH services and peer supports. The budget also includes $10.3 million to increase maximum security forensic bed capacity, and $366 million for new construction and maintenance at state hospitals and other inpatient mental health facilities. The Legislature also enacted separate supplemental legislation (House Bill 2) to close the gap for unmet costs expected for the current fiscal year. HB 2 funding includes $794 million to address the Medicaid shortfall, which will bring in an additional $1.6 billion in federal funds. Based on estimated growth projections and funding, the Center for Public Policy Priorities estimates the 2018-19 Medicaid shortfall will be at least $1.2 billion when the Legislature returns in 2019.

Budget Riders The Appropriations legislation for the Health and Human Services Commission also includes more than 230 “riders” that address additional requirements related to program operations, funding, and budget guidance. For example, budgeted Medicaid funding levels assume $1 billion in cost containment for Medicaid client services based on budget riders that reduce the risk margin for Medicaid managed care organizations and that direct HHSC to contain costs through a variety of specific actions. Following is a summary of some of the more significant Medicaid riders.

• Rider 5 – Cost Comparison Report: requires HHSC to analyze and report on residential and nonresidential services in HCS, Texas Home Living, and Intermediate Care Facilities for Individuals with Intellectual Disabilities and Related Conditions. The report must include detailed cost analysis across facilities and based on types of coverage and services. The report is due no later than August 31, 2018. • Rider 8 – Additional Funding Sources, Medicaid: if the appropriations for Medicaid are insufficient to meet mandated services, the LBB and Governor are authorized to transfer funds as necessary to HHSC. • Rider 13 – Local reporting on DSH, Uncompensated Care, DSRIP, and Indigent Care Expenditures: requires HHSC to develop a report that non- state public hospitals, private hospitals, hospital districts, physician and private administrators use to describe any expenditures they make through the Disproportionate Share Hospital (DSH) program, the Uncompensated Care (UC) Pool, the Delivery System Reform Incentive Payment (DSRIP) Pool and the Indigent Care Program. The report must include expenditures

Commission on Legislative & Public Affairs, AS17 29 by method of finance per year. HHSC also shall require contracted hospital providers to report payments to entities who provide consultative services regarding revenue maximization under the medical assistance program, UC, DSRIP and DSH. • Rider 16 – Dental and Orthodontia Providers in the Texas Medicaid Program: requires HHSC to strengthen the capacity of the HHSC Office of Inspector General to investigate and prosecute abuse by dentists and orthodontists, and conduct more extensive reviews of medical necessity for orthodontia services in the Medicaid program. • Rider 21 – Report on Pay for Quality Measures: requires HHSC to evaluate how Managed Care Organizations (MCOs) use pay for quality measures to improve health care and whether these initiatives are successful. A report is due to the Legislature no later than October 1, 2018 and must include recommendations for improving current pay for quality measures, areas requiring additional studies, and how the findings could be used to expand pay for quality measures into outpatient settings. • Rider 29 – Medicaid Substance Abuse Treatment: requires HHSC to evaluate spending on substance abuse services and submit a report by December 1, 2017. • Rider 34 – Medicaid Funding Reduction and Cost Containment: requires HHSC to implement cost containment measures that will reduce Medicaid spending by $830 million from all funds ($350 million in General Revenue). The Rider includes 18 initiatives that can be used, including increasing Fraud, Waste, and Abuse collections; evaluating reimbursement for dual eligibles; reviewing utilization and rates for durable medical equipment; strengthening and expanding prior authorization and utilization reviews; and implementing fee-for-service payment and MCO premium adjustments that incentivize the most appropriate and effective use of services. It also includes an option to identify and execute savings by conducting an independent audit of MCO premiums every two years; evaluating trend factors; and using a competitive procurement process with price as one component of the procurement evaluations. HHSC is required to submit a plan to the LBB to implement cost containment initiatives by December 1, 2017. The plan must include an analysis of initiatives determined not to be cost effective. • Rider 157 – Medicaid Provider Enrollment Portal: contingent upon submitting a plan to the LBB and the Governor, HHSC will receive an additional $30 million in SFY 2019 to develop a centralized Medicaid provider enrollment portal. • Rider 158 – Managed Care Risk Margin: the approved budget includes a reduction of $182.6 million based on HHSC reducing the risk margin in managed care premiums from 2.0 percent to 1.5 percent for STAR and STAR Health, and from 2.0 to 1.75 percent for STAR+PLUS and STAR

Commission on Legislative & Public Affairs, AS17 30 Kids. An additional reduction of $11 million is included based on HHSC reducing the risk margin in CHIP managed care premiums from 2.0 percent to 1.5 percent. • Rider 167 – Office of Inspector General: Managed Care Organization Performance, Reporting Requirement: requires the Office of Inspector General (OIG) to review cost avoidance and waste prevention activities used by MCOs to prevent waste; the OIG must submit a report on its findings to the LBB and Governor by March 2, 2018, and provide recommendations for performance measures related to cost avoidance and waste prevention activities that should be applicable to all MCOs. • Rider 175 – Managed Care Organization Services for Individuals with Serious Mental Illness: requires HHSC to develop performance metrics to hold MCOs accountable for care of enrollees with serious mental illness. Metrics should include performance measures for integrated care, jail and emergency department diversion, integration of care and enhanced cost control HHSC must submit a report no later than November 1, 208 detailing performance metrics. • Rider 180 – Hospital payments: the budget includes $356.9 million in SFY 2018 and $357.7 million in SFY 2019 to provide Medicaid hospital add-on payments for trauma care, safety net hospitals and rural hospitals. To the extent possible, HHSC shall ensure any funds identified in the rider that are included in Medicaid managed care capitation rates are distributed by the MCOs to the hospitals. • Rider 202 – Evaluation of Rural Hospital Funding Initiatives: requires HHSC to evaluate Medicaid funding initiatives for rural hospital services and submit a progress report by August 1, 2018, and a final report by August 1, 2019. The study must include determining the percentage of estimated allowable hospital costs reimbursed by payments for services providers provided to managed care clients; the percentage of wrongful denials; the average wait tine for final payment; and any remedies taken by HHSC to improve vendor compliance. • Rider 205 – Operational and Administrative Efficiencies related to Technology and Electronic Visit Verification: requires HHSC to review technology usage and Electronic Visit Verification (EVV), including opportunities to improve operational efficiencies and general cost savings; strategies to improve collection and maintenance of accurate contact information for individuals receiving services; and strategies to streamline the administrative requirements imposed on health providers using EVV. HHSC must submit a report no later than March 31, 2018. • Rider 212 – Texas Medicaid Pre-term Births and Low Birthweight Births: requires HHSC to work with the Comptroller of Public Accounts and the Legislative Budget Board to study opportunities for Medicaid savings from

Commission on Legislative & Public Affairs, AS17 31 increasing the minimum legal age for access to tobacco products from 18 to 21. • Rider 214 – Exemption from waiver Rate Reduction: exempts providers of consumer directed services from rate reductions for supported home living services in the HCS waiver and Community Support Services in the Texas Home Living waiver. • Rider 215 – Medicaid Therapy Services Reporting: requires HHSC to track and report information related to access to pediatric therapy services. Information must include complaint data received by HHSC and by MCOs, the number of therapy provider terminations, the utilization of therapy services, the number of members on wait lists due to an insufficient network, and the number of providers no longer accepting new clients and the reason. Reports are due quarterly to the LBB and the Governor beginning December 1, 2018. • Rider 218 – Adjustment of Therapy Rate Reductions: provides funds to restore 25 percent of the reductions made to reimbursement rates for acute care therapy services during the 2016-17 biennium. Also includes funds to phase in and delay the planned reduction of rates for therapy assistants. Reductions will not begin until December 1, 2017 and rates will remain at 85 percent of the rate paid to a licensed therapist until September 1, 2018, when rates will be reduced to 70 percent of the rate paid to a licensed therapist. • Rider 219 – Prescription Drug Benefit Administration in Medicaid, CHIP, and Other Health-Related Services: requires HHSC to study potential cost savings achieved from a single statewide claims processor to deliver drug benefits in the Medicaid, CHIP, Women’s Health, Children with Special Health Care Needs (CSHCN), and Kidney Health Care programs; reduction of the Affordable Care Act Health Providers Fee, guaranteed risk margin, and administrative services fees from decreasing capitation related to pharmacy benefits; and transitioning to a pricing methodology based on National Average Drug Acquisition Cost with a professional dispensing fee. • Rider 220 – Evaluation of Medicaid Managed care: 1) requires HHSC to contract with an independent organization to conduct a comprehensive evaluation of Medicaid managed care. The evaluation must include a review of the delivery system, assessment of the performance of managed care including analysis of costs, cost savings, cost trends, the impact of caseload growth, cost containment initiatives, and contractual mandates, and how cost trends in Texas compare to other states. The report must include recommendations on additional operational efficiencies, delivery system reforms, and cost containment initiatives. 2) Requires HHSC to evaluate the contract management and oversight function for Medicaid and CHIP managed care contracts and consider existing contract requirements and enforcement, including penalties, and the need for additional training

Commission on Legislative & Public Affairs, AS17 32 and resources for effective contract management. 3) Requires HHSC to conduct a study of Medicaid managed care rate setting processes and methodologies in other states. 4) requires HHSC to conduct an audit of administrative expenditures made by managed care organizations in Medicaid and CHIP, and use the audit to identify opportunities for savings. Findings are to be reported to the Governor, LBB, and legislative committees not late than September 1, 2018. Links to applicable budget documents used in developing this summary are available at: http://www.lbb.state.tx.us/budget.aspx

Texas State Legislation Summary In addition to the state biennial budget, the Legislature enacted numerous legislative proposals that impact public and private insurance plans. Not all enacted bills have been signed by the governor. The Governor has 10 days after receipt of a bill to sign or veto a bill, or allow it to become law without signature. For bills sent to the governor within 10 days of final adjournment (May 29th), the governor has until 20 days after adjournment (June 18th) to sign or veto a bill, or allow it to become law without signature. Links to all legislation are available at: http://www.legis.state.tx.us/MnuLegislation.aspx Enacted Senate Legislation: • SB 74 – BH Services Access: Expands the authorization of a Medicaid/CHIP provider enrolled in a managed care organization to provide behavioral health services to provide targeted case management and psychiatric rehabilitative services to children, adolescents, and their families, as a means of expanding access to certain services. • SB 507 – Balance Billing: Expands the balance billing mediation process for commercial health plans to include all physicians and other providers that provide out-of-network services at certain in-network facilities. • SB 680 – Medicaid Step Therapy: Authorizes physicians to override health plans’ step therapy protocols, enabling patients to continue receiving effective medication. • SB 894 –MCO Audit Oversight: Imposes several requirements intended to improve HHSC’s oversight and use of audit resources for monitoring MCO compliance and operations. Includes changes to the electronic visit verification system and strategies for verifying the accuracy of program and financial information reported by Medicaid managed care organizations. • SB 922 – Telemedicine: requires HHSC to ensure that Medicaid reimbursement is provided to a public-school district or open-enrollment charter school for telehealth services provided through the district or charter school by a health professional, even if the health professional is not the patient’s primary care provider.

Commission on Legislative & Public Affairs, AS17 33 • SB 1107 – Telemedicine: Establishes a statutory definition for telemedicine and provides that the standard of care for a traditional, in-person medical setting also applies for telemedicine services. Clarifies that telemedicine is not a distinct service but a tool physicians can use. Prohibits health plans from excluding telemedicine from coverage solely because it isn’t provided in-person. • SB 1148 – Maintenance of Certification: With a few exceptions, prohibits the state from using Maintenance of Certification (MOC) as a requirement for state licensure or renewal, or insurance participation; prohibits certain hospitals and health facilities, and managed care plans from using MOC to differentiate among physicians for payment, contracting or credentialing. • SB 1462 – Local Health Care Funding Programs: Enacts several provisions related to the funding of local health care districts, county healthcare provider participation programs, and municipal health care provider participation programs, including requirements related to the funding of intergovernmental transfers and funding of Medicaid supplemental payment program payments. • SB 2087 – Temporary Health Risk Pool: Authorizes the Commissioner of Insurance to establish and administer a temporary health insurance risk pool with federal funds, to the extent those funds become available. Enacted House Legislation • HB 10 – Access to Behavioral Health Services: Increases the Texas Department of Insurance’s authority to enforce existing mental health parity law and creates a BH ombudsman to help consumers and providers navigate the BH health care system and benefits. Establishes a state mental health parity work group and clarifies benefits for mental health and substance use. • HB 490 – Cochlear Implant Coverage: amends the Insurance Code to require certain commercial health benefit plans to cover hearing aids and cochlear implants for individuals who are 18 years of age or younger. • HB 1036 –Mammography Benefits: Requires certain commercial insurance plans to include digital mammography and breast tomosynthesis coverage under annual breast cancer screenings for females 35 years of age or older • HB 1296 – Medication Synchronization: Requires certain commercial insurance plans to provide coverage for medications in cases where physicians, working in conjunction with the patient’s health plan and the pharmacy, determine which medications should be aligned to properly treat chronic diseases. Eliminates barriers to medication synchronization by requiring health plans to prorate any cost-sharing amount charged for a prescription drug dispensed in a quantity that is less than the full amount as part of a recommended medication synchronization program, resulting in reduced upfront costs for patients.

Commission on Legislative & Public Affairs, AS17 34 • HB 1600 – Mental Health Screenings for Adolescents: Authorizes Medicaid/CHIP payment for mental health screenings during each annual well-child exam. Currently, payment for applicable screening medical codes is authorized only once between the ages of 12 and 18 for each adolescent. • HB 1629 – HIV Viral Loads Quality Oversight: Requires HHSC to adopt Medicaid/CHIP quality measures related to ensuring persons with HIV maintain a low viral load, thus improving the health of individuals with HIV and reducing the transmission of HIV. • HB 1917 – Medicaid Vendor Drug Program: Retains the Medicaid Preferred Drug List (PDL) under HHSC oversight, delaying until 2023 previous plans to put the PDL under the oversight of managed care organizations. • HB 2379 – Fraud, Waste and Abuse: Enacts numerous changes to the FWA program oversight and penalty payments. • HB 2590 – LTSS Administrative Amendments: Amends the appeal process for LTSS providers, to be consistent with the process for other providers participating in Medicaid waiver programs. Includes establishing an informal dispute resolution process for HCS and Texas Home Living (TxHmL). Grants HHSC the authority to use amelioration as a tool to assist providers with compliance, and allows a provider to use a portion of an administrative penalty toward compliance and program improvement. • HB 2466 – Maternal Depression Screening: Requires Medicaid/CHIP coverage of maternal depression screening for an enrolled child’s mother during a covered well-baby visit or other office visit to a pediatric provider. Also allows pregnant women enrolled in Medicaid to sign up for texts, emails, or phone calls from their MCO to receive appointment reminders and health information to maintain a healthy pregnancy. • HB 3295 – LTSS Pilot Programs: Extends the statutory deadline by one year for pilot programs intended to test one or more service delivery models for long term services and supports under Medicaid managed care. The new expiration date is moved from September 1, 2018 to September 1, 2019, and is necessary to provide consistency with the 24-month period state law allows for program operations. • HB 3675 – Ophthalmology benefits: clarifies that patients covered by a Medicaid MCO have direct access to ophthalmologists and optometrists for non-surgical eye care services, without a requirement that the provider or the patient obtain prior authorization for those services. Clarifies that an ophthalmologist or an optometrist who joins an established practice may become a network provider for the MCOs with which the practice already has a valid contract. Allows institutions of higher learning with accredited ophthalmology or optometry training programs to contract with MCOs as network providers. Amends current law relating to the provision of eye

Commission on Legislative & Public Affairs, AS17 35 health care by certain professionals and institutions as providers in the Medicaid managed care program. Special Legislative Session Likely Due to the failure to pass several key legislative proposals (including the Sunset legislation that authorizes continuation of the Texas Medical Board, the licensing agency for medical providers), the Governor is expected to call a special session sometime this summer. Governor Abbot was expected to announce his decision last week, but has not yet done so. The special session will be limited to only those items specifically identified by the Governor.

Commission on Legislative & Public Affairs, AS17 36 Senate State Affairs Committee Health Insurance Market Stability: Study the factors affecting health insurance markets in Texas, particularly the individual market, including federal and state law. Make recommendations that would result in increased stability in the markets and enhance value and affordability for individual consumers and businesses. Examine what steps the state needs to take to allow out-of-state health insurance sales. In developing its recommendations, the committee should consider the flexibility afforded to states by 1332 "state innovation" waivers, which allow states to modify or eliminate tax penalties associated with individual and employer coverage mandates; modify requirements for benefits and subsidies; and find alternative ways to provide benefit plan choices, determine eligibility for subsidies, and enroll consumers.

Senate Health & Human Services Committee

Substance Abuse/Opioids: Review substance use prevention, intervention, and recovery programs operated or funded by the state and make recommendations to enhance services, outreach, and agency coordination. Examine the adequacy of substance use, services for pregnant and postpartum women enrolled in Medicaid or the Healthy Texas Women Program and recommend ways to improve substance use related health outcomes for these women and their newborns. Examine the impact of recent legislative efforts to curb overprescribing and doctor shopping via the prescription monitoring program and recommend ways to expand on current efforts.

Medicaid Managed Care Quality and Compliance: Review the Health and Human Services Commission’s efforts to improve quality and efficiency in the Medicaid program, including pay-for-quality initiatives in Medicaid managed care. Compare alternative payment models and value-based payment arrangements with providers in Medicaid managed care, the Employees Retirement System, and the Teachers Retirement System, and identify areas for cross-collaboration and coordination among these entities. Evaluate the commission's efforts to ensure Medicaid managed care organizations' compliance with contractual obligations and the use of incentives and sanctions to enforce compliance. Assess the commission's progress in implementing competitive bidding practices for Medicaid managed care contracts and other initiatives to ensure the best value for taxpayer dollars used in Medicaid managed care contracts.

Health Care Cost Transparency: Study efforts by the Department of State Health Services and the Texas Department of Insurance to increase health care cost transparency, including a review of the Texas Health Care Information Collection (THCIC) system, and the consumer Guide to Healthcare. Recommend ways to make provider and facility fees more accessible to consumers to improve health care cost transparency, increase quality of care, and create a more informed health care consumer base.

House Committee on Appropriations

Monitor the implementation of Employee Retirement System (ERS) Rider 18 of the General Appropriations Act. Evaluate the impact of obtaining savings through reduced contracted provider rates and innovative value-based plan design models with Health Related Institutions (HRIs). Examine the impact to HRIs of providing patient care at discounted rates, as well as potential free market implications, the methodology used to determine each HRI’s savings obligation, and progress on initiating innovative plan redesign based on HRI proposals.

Monitor Congressional action on federal healthcare reform and CHIP reauthorization. Identify potential impacts of any proposed federal changes. Identify short- and long-term benefits and challenges related to converting Texas Medicaid funding to a block grant or per capita cap methodology. Determine how Texas should best prepare for federal changes, including statutory and regulatory revisions, as well as any new administrative functions that may be needed. Explore opportunities to increase the state's flexibility in administering its Medicaid program, including but not limited to the use of 1115 and 1332 waivers.

Study the sustainability of TRS-Care and consider options for funding retired teacher health care in Texas, especially as it pertains to contributions being based on active employee payroll rather than the cost of health care. Monitor the implementation of H.B. 3976 (85R) and H.B. 30 (85(1)).

House Committee on Human Services

Review the history and any future roll-out of Medicaid Managed Care in Texas. Determine the impact managed care has had on the quality and cost of care. In the review, determine: initiatives that managed care organizations (MCOs) have implemented to improve quality of care; whether access to care and network adequacy contractual requirements are sufficient; and whether MCOs have improved the coordination of care. Also determine provider and Medicaid participants’ satisfaction within STAR, STAR Health, Star Kids, and STAR+Plus managed care programs. In addition, review the Health and Human Services Commission's (HHSC) oversight of managed care organizations, and make recommendations for any needed improvement.

House Committee on Insurance

Assess the status of the health insurance market in Texas and opportunities to improve this market through waivers of federal law or other mechanisms. Monitor any changes in federal law that may affect these options.

Evaluate recent efforts by the Legislature and the Texas Department of Insurance to minimize instances of surprise medical billing and to ensure the adequacy of health insurance networks. Identify instances in which surprise billing most often occurs and ways to decrease its frequency through enhanced transparency or other methods.

Examine the impacts of changes in prescription drug coverage and drug formularies on patients, particularly those with chronic conditions.

Evaluate recent efforts in Texas and in other states to enhance transparency regarding the practices of pharmacy benefit managers.

House Committee on Public Health

Review state programs that provide women’s health services and recommend solutions to increase access to effective and timely care. During the review, identify services provided in each program, the number of providers and clients participating in the programs, and the enrollment and transition process between programs. Monitor the work of the Maternal Mortality and Morbidity Task Force and recommend solutions to reduce maternal deaths and morbidity. In addition, review the correlation between pre-term and low birth weight births and the use of alcohol and tobacco. Consider options to increase treatment options and deter usage of these substances.

Review opportunities to improve population health and health care delivery in rural and urban medically underserved areas. Identify potential opportunities to improve access to care, including the role of telemedicine. In the review, identify the challenges facing rural hospitals and the impact of rural hospital closures.In PROCLAMATION

APPOINTMENT OF SELECT COMMI'I-I'EE ON OPIOIDS AND SUBSTANCE ABUSE

Pursuant to Rule 1, Section 16, House Rules, I, Joe Straus, Speaker of the Texas House of Representatives, create the House Select Committee on Opioids and Substance Abuse.

The House Select Committee on Opioids and Substance Abuse will, not later than November 1, 2018, develop and present concrete principles and action items to reduce the scourge of opioids in Texas and to provide legislative solutions to address these issues, as well as examine other issues related to substance abuse in Texas.

In developing these principles and action items, The House Select Committee on Opioids and Substance Abuse shall:

1. Study the prevalence and impact of substance use and substance use disorders in Texas, including co-occurring mental illness. Study the prevalence and impact of opioids and synthetic drugs in Texas. Review the history of overdoses and deaths due to overdoses. Also review other health-related impacts due to substance abuse. Identify substances that are contributing to overdoses, related deaths and health impacts, and compare the data to other states. During the review, identify effective and efficient prevention and treatment responses by health care systems, including hospital districts and coordination across state and local governments. Recommend solutions to prevent overdoses and related health impacts and deaths in Texas.

2. Review the prevalence of substance abuse and substance use disorders in pregnant women, veterans, homeless individuals, and people with co-occurring mental illness. In the review, study the impact of opioids and identify available programs specifically targeted to these populations and the number of people served. Consider whether the programs have the capacity to meet the needs of Texans. In addition, research innovative programs from other states that have reduced substance abuse and substance use disorders, and determine if these programs would meet the needs of Texans. Recommend strategies to increase the capacity to provide effective services.

3. Review policies and guidelines used by state agencies to monitor for and prevent abuse of prescription drugs in state- funded or state-administered programs. Include in this review policies implemented by the Texas Medicaid Program, the Division of Workers' Compensation of the Texas Department of Insurance, the Teacher Retirement System, and the Employee Retirement System. Make recommendations regarding best practices.

4. Monitor and evaluate the implementation of legislation passed by the 85th Legislature regarding the Prescription Monitoring Program. In addition, review the prescribing of addictive drugs by physicians and other health care providers within various geographic regions of this state. Determine the role of health care professionals in preventing overutilization and diversion of addictive prescriptions. Provide recommendations that will improve efforts to prevent overutilization and diversion of addictive prescriptions.

5. Identify how opioids have impacted the normal scope of work for law enforcement, first responders, and hospital emergency department personnel.

6. Examine the impact of substance abuse and substance use disorders on Texans who are involved in the adult or juvenile criminal justice system and/or the Child Protective Services system. Identify barriers to treatment and the availability of treatment in various areas of the state. Recommend solutions to improve state and local policy, including alternatives to justice system involvement, and ways to increase access to effective treatment and recovery options.

7. Examine the impact of overdose reporting defense laws known as "Good Samaritan" laws.

8. Identify the specialty courts in Texas that specialize in substance use disorders. Determine the effectiveness of these courts and consider solutions to increase the number of courts in Texas.

The committee shall have 13 members. The following members are hereby appointed to the House Select Committee on Opioids and Substance Abuse:

Rep. Four Price, Chair Rep. , Vice Chair Rep. Carol Alvarado Rep. Rep. Rep. Rep. Andy Murr Rep. Poncho Nevarez Rep. Kevin Roberts Rep. Rep. J.D. Sheffield Rep. Gary VanDeaver Rep. James White

This committee may request the assistance of other committees and other legislative service agencies in obtaining information.

The committee shall file a final report in the manner provided by Rule 4, Section 61, House Rules, not later than November 1, 2018.