GOVERNMENT CODE

TITLE 4. EXECUTIVE BRANCH

SUBTITLE I. HEALTH AND HUMAN SERVICES

CHAPTER 536. MEDICAID AND THE CHILD HEALTH PLAN PROGRAM: QUALITY-BASED OUTCOMES AND PAYMENTS

SUBCHAPTER A.  GENERAL PROVISIONS


Text of section effective until April 01, 2025

Sec. 536.001.  DEFINITIONS.  In this chapter:
(1)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 837, Sec. 3.40(a)(21), and Ch. 946, Sec. 2.37(b)(20), eff. January 1, 2016.
(2)  "Alternative payment system" includes:
(A)  a global payment system;
(B)  an episode-based bundled payment system; and
(C)  a blended payment system.
(3)  "Blended payment system" means a system for compensating a physician or other health care provider that includes at least one or more features of a global payment system and an episode-based bundled payment system, but that may also include a system under which a portion of the compensation paid to a physician or other health care provider is based on a fee-for-service payment arrangement.
(4)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, Sec. 2.287(18), eff. April 2, 2015.
(5)  "Episode-based bundled payment system" means a system for compensating a physician or other health care provider for arranging for or providing health care services to child health plan program enrollees or Medicaid recipients that is based on a flat payment for all services provided in connection with a single episode of medical care.
(6)  "Exclusive provider benefit plan" means a managed care plan subject to 28 T.A.C. Part 1, Chapter 3, Subchapter KK.
(7)  "Freestanding emergency medical care facility" means a facility licensed under Chapter 254, Health and Safety Code.
(8)  "Global payment system" means a system for compensating a physician or other health care provider for arranging for or providing a defined set of covered health care services to child health plan program enrollees or Medicaid recipients for a specified period that is based on a predetermined payment per enrollee or recipient, as applicable, for the specified period, without regard to the quantity of services actually provided.
(9)  "Health care provider" means any person, partnership, professional association, corporation, facility, or institution licensed, certified, registered, or chartered by this state to provide health care.  The term includes an employee, independent contractor, or agent of a health care provider acting in the course and scope of the employment or contractual relationship.
(10)  "Hospital" means a public or private institution licensed under Chapter 241 or 577, Health and Safety Code, including a general or special hospital as defined by Section 241.003, Health and Safety Code.
(11)  "Managed care organization" means a person that is authorized or otherwise permitted by law to arrange for or provide a managed care plan.  The term includes health maintenance organizations and exclusive provider organizations.
(12)  "Managed care plan" means a plan, including an exclusive provider benefit plan, under which a person undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services.  A part of the plan must consist of arranging for or providing health care services as distinguished from indemnification against the cost of those services on a prepaid basis through insurance or otherwise.  The term does not include a plan that indemnifies a person for the cost of health care services through insurance.
(13)  Repealed by Acts 2015, 84th Leg., R.S., Ch. 1, Sec. 2.287(18), eff. April 2, 2015.
(14)  "Physician" means a person licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code.
(15)  "Potentially preventable admission" means an admission of a person to a hospital or long-term care facility that may have reasonably been prevented with adequate access to ambulatory care or health care coordination.
(16)  "Potentially preventable ancillary service" means a health care service provided or ordered by a physician or other health care provider to supplement or support the evaluation or treatment of a patient, including a diagnostic test, laboratory test, therapy service, or radiology service, that may not be reasonably necessary for the provision of quality health care or treatment.
(17)  "Potentially preventable complication" means a harmful event or negative outcome with respect to a person, including an infection or surgical complication, that:
(A)  occurs after the person's admission to a hospital or long-term care facility; and
(B)  may have resulted from the care, lack of care, or treatment provided during the hospital or long-term care facility stay rather than from a natural progression of an underlying disease.
(18)  "Potentially preventable event" means a potentially preventable admission, a potentially preventable ancillary service, a potentially preventable complication, a potentially preventable emergency room visit, a potentially preventable readmission, or a combination of those events.
(19)  "Potentially preventable emergency room visit" means treatment of a person in a hospital emergency room or freestanding emergency medical care facility for a condition that may not require emergency medical attention because the condition could be, or could have been, treated or prevented by a physician or other health care provider in a nonemergency setting.
(20)  "Potentially preventable readmission" means a return hospitalization of a person within a period specified by the commission that may have resulted from deficiencies in the care or treatment provided to the person during a previous hospital stay or from deficiencies in post-hospital discharge follow-up.  The term does not include a hospital readmission necessitated by the occurrence of unrelated events after the discharge.  The term includes the readmission of a person to a hospital for:
(A)  the same condition or procedure for which the person was previously admitted;
(B)  an infection or other complication resulting from care previously provided;
(C)  a condition or procedure that indicates that a surgical intervention performed during a previous admission was unsuccessful in achieving the anticipated outcome; or
(D)  another condition or procedure of a similar nature, as determined by the executive commissioner.
(21)  "Quality-based payment system" means a system for compensating a physician or other health care provider, including an alternative payment system, that provides incentives to the physician or other health care provider for providing high-quality, cost-effective care and bases some portion of the payment made to the physician or other health care provider on quality of care outcomes, which may include the extent to which the physician or other health care provider reduces potentially preventable events.
Added by Acts 2011, 82nd Leg., 1st C.S., Ch. 7 (S.B. 7), Sec. 1.12(a), eff. September 28, 2011.
Amended by: 
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 2.287(18), eff. April 2, 2015.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.21, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 837 (S.B. 200), Sec. 3.40(a)(21), eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.21, eff. January 1, 2016.
Acts 2015, 84th Leg., R.S., Ch. 946 (S.B. 277), Sec. 2.37(b)(20), eff. January 1, 2016.
Repealed by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 3.01(3), eff. April 1, 2025.