Texas § GV.540.0701 - ACUTE CARE SERVICE DELIVERY THROUGH MOST COST-EFFECTIVE MODEL

§ GV.540.0701. ACUTE CARE SERVICE DELIVERY THROUGH MOST COST-EFFECTIVE MODEL

ACUTE CARE SERVICE DELIVERY THROUGH MOST COST-EFFECTIVE MODEL; MANAGED CARE SERVICE DELIVERY AREAS. (a) Except as otherwise provided by this section and notwithstanding any other law, the commission shall provide Medicaid acute care services through the most cost-effective model of Medicaid capitated managed care as the commission determines. The commission shall require mandatory participation in a Medicaid capitated managed care program for all individuals eligible for Medicaid acute care benefits, but may implement alternative models or arrangements, including a traditional fee-for-service arrangement, if the commission determines the alternative would be more cost-effective or efficient. (b) In determining whether a model or arrangement described by Subsection (a) is more cost-effective, the executive commissioner must consider: (1) the scope, duration, and types of health benefits or services to be provided in a certain part of this state or to a certain recipient population; (2) administrative costs necessary to meet federal and state statutory and regulatory requirements; (3) the anticipated effect of market competition associated with the configuration of Medicaid service delivery models the commission determines; and (4) the gain or loss to this state of a tax collected under Chapter 222 , Insurance Code. (c) If the commission determines that it is not more cost-effective to use a Medicaid managed care model to provide certain types of Medicaid acute care in a certain area or to certain recipients as prescribed by this section, the commission shall provide Medicaid acute care through a traditional fee-for-service arrangement. (d) The commission shall determine the most cost-effective alignment of managed care service delivery areas. The executive commissioner may consider: (1) the number of lives impacted; (2) the usual source of health care services for residents in an area; and (3) other factors that impact health care service delivery in the area. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025.