The commission may give managed care organizations flexibility and contract incentives, and it must develop benchmarks and prefer organizations that meet quality goals when awarding contracts.
Sec. 543A.0052. FINANCIAL INCENTIVES AND CONTRACT AWARD PREFERENCES. (a) The commission may allow a managed care organization participating in the child health plan program or Medicaid increased flexibility to implement quality initiatives in a managed care plan offered by the organization, including flexibility with respect to financial arrangements, to: (1) achieve high-quality, cost-effective health care; (2) increase the use of high-quality, cost-effective delivery models; (3) reduce the incidence of unnecessary institutionalization and potentially preventable events; and (4) in collaboration with physicians and other health care providers, increase the use of alternative payment systems, including shared savings models. (b) The commission shall develop quality-of-care and cost-efficiency benchmarks, including benchmarks based on a managed care organization's performance with respect to: (1) reducing potentially preventable events; and (2) containing the growth rate of health care costs. (c) The commission may include in a contract between a managed care organization and the commission financial incentives that are based on the organization's successful implementation of quality initiatives under Subsection (a) or success in achieving quality-of-care and cost-efficiency benchmarks under Subsection (b). The commission may implement the financial incentives only if implementing the incentives would be cost-effective. (d) In awarding contracts to managed care organizations under the child health plan program and Medicaid, the commission shall, in addition to considerations under Section 540.0204 of this code and Section 62.155, Health and Safety Code, give preference to an organization that offers a managed care plan that: (1) successfully implements quality initiatives under Subsection (a) as the commission determines based on data or other evidence the organization provides; or (2) meets quality-of-care and cost-efficiency benchmarks under Subsection (b). Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025. SUBCHAPTER C. QUALITY-BASED HEALTH HOME PAYMENT SYSTEMS