The commission must make sure a managed care organization in the pilot program provides specified Medicaid and waiver benefits, and the commission must evaluate, choose, and provide the most cost-effective dental benefits.
Sec. 542.0109. REQUIRED BENEFITS. (a) The commission shall ensure that a managed care organization participating in the pilot program provides: (1) all Medicaid state plan acute care benefits available under the STAR+PLUS Medicaid managed care program; (2) long-term services and supports under the Medicaid state plan, including: (A) Community First Choice services; (B) personal assistance services; (C) day activity health services; and (D) habilitation services; (3) long-term services and supports under the STAR+PLUS home and community-based services (HCBS) waiver program, including: (A) assisted living services; (B) personal assistance services; (C) employment assistance; (D) supported employment; (E) adult foster care; (F) dental care; (G) nursing care; (H) respite care; (I) home-delivered meals; (J) cognitive rehabilitative therapy; (K) physical therapy; (L) occupational therapy; (M) speech-language pathology; (N) medical supplies; (O) minor home modifications; and (P) adaptive aids; (4) the following long-term services and supports under a Medicaid waiver program: (A) enhanced behavioral health services; (B) behavioral supports; (C) day habilitation; and (D) community support transportation; (5) the following additional long-term services and supports: (A) housing supports; (B) behavioral health crisis intervention services; and (C) high medical needs services; (6) other nonresidential long-term services and supports that the commission, in collaboration with the advisory committee and pilot program work group, determines are appropriate and consistent with requirements governing the Medicaid waiver programs, person-centered approaches, home and community-based setting requirements, and achievement of the most integrated and least restrictive setting based on an individual's needs and preferences; and (7) dental services benefits in accordance with Subsection (b). (b) In developing the pilot program, the commission shall: (1) evaluate dental services benefits provided through Medicaid waiver programs and dental services benefits provided as a value-added service under the Medicaid managed care delivery model; (2) determine which dental services benefits are the most cost-effective in reducing emergency room and inpatient hospital admissions resulting from poor oral health; and (3) based on the determination made under Subdivision (2), provide the most cost-effective dental services benefits to pilot program participants. (c) Before implementing the pilot program, the commission, in collaboration with the advisory committee and pilot program work group, shall: (1) for pilot program purposes only, develop recommendations to modify adult foster care and supported employment and employment assistance benefits to increase access to and availability of those services; and (2) as necessary, define services listed under Subsections (a)(4) and (5) and any other services the commission determines to be appropriate under Subsection (a)(6). Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025.