(a) Clinical initiative evaluation process. This process
consists of the submission, preliminary review, analysis, and approval
of a clinical initiative.
(1) Authorized submitters may submit suggestions of
clinical initiatives in written form sent via postal mail, in electronic
form via email, or using the designated online form available via
the HHSC Internet website required under this subchapter.
(2) Each suggestion for a clinical initiative will
be submitted to the state Medicaid director.
(3) Designated HHSC staff will review each suggestion
and determine if it warrants a full analysis. Suggestions selected
for full analysis will be posted on HHSC Internet website for public
comment within 30 days of receipt by the state Medicaid director.
(4) HHSC will determine the number of selected suggestions
to undergo full analysis depending on available staff resources. If
sufficient staff resources are available, the full analysis will be
completed within 180 days of receipt of the suggestion by the state
Medicaid director.
(5) HHSC staff will consult appropriate subject matter
experts both internally and externally for determination of whether
a clinical initiative suggestion warrants full analysis. Subject matter
experts will also be consulted during full analysis and report development
of the clinical initiative, if additional input is needed.
(b) Number of clinical initiatives selected for full
analysis. HHSC is authorized by statute to determine the number of
clinical initiatives that will receive full analysis. This determination
will be based on staff resources and external contractor availability
and whether a clinical initiative is already a Texas Medicaid benefit.
(c) Preliminary review of clinical initiatives suggestions.
HHSC staff will consult with the appropriate advisory committees to
determine whether a clinical initiative suggestion warrants full analysis.
A suggestion of a clinical initiative will be reviewed and the determination
as to whether it warrants a full analysis will be based on the following
criteria:
(1) Suggestion is not currently a benefit under the
Medicaid program;
(2) There is evidence that the suggestion will improve
quality of care under Medicaid;
(3) There is evidence that the suggestion will improve
the cost-effectiveness of Medicaid;
(4) Suggestion is not undergoing clinical trials; and
(5) Suggestion will not expand a health care provider's
scope of practice beyond the law governing the provider's practice.
(d) Analysis of clinical initiative.
(1) HHSC staff will consult with the appropriate internal
and external stakeholders and subject matter experts during the full
analysis. These sources can include:
(A) Advisory committees that advise HHSC on quality-related
issues and policies;
(B) Internal HHSC business and clinical units, including
but not limited to, the Office of Medical Director and the Office
of Medicaid/CHIP Policy; and
(C) External contractors as designated by HHSC.
(2) A full analysis of selected clinical initiatives
is based on the following sources relating to the initiative (where
applicable and if available):
(A) Public comments and submitted research;
(B) Available clinical research and historical utilization
information;
(C) Published medical literature;
(D) Any adoption of the initiative by medical societies
or other clinical groups;
(E) Implementation by Medicare, another state Medicaid
program or the Children's Health Insurance Program;
(F) Results of reports, research, pilot programs, or
clinical studies relating to the initiative conducted by institutions
of higher education, governmental entities and agencies, private and
nonprofit think tanks and research groups;
(G) Impact the initiative would have on the Medicaid
program if implemented in Texas, including an estimated number of
recipients under Medicaid and potential cost savings to the state;
and
(H) Any statutory barriers to implement the approved
clinical initiative.
(e) Final reports.
(1) HHSC staff will consult with the appropriate internal
and external clinical experts on developing the final reports, including:
(A) Internal HHSC business and clinical units, such
as the Office of Medical Director and the Office of Medicaid/CHIP
Policy; and
(B) External contractors as determined by HHSC.
(2) A final report of an approved clinical initiative
will include the following information:
(A) The feasibility of implementing the initiative;
(B) The likely impact on quality of care provided under
the Medicaid program;
(C) Any anticipated cost savings to the state;
(D) A summary of public comments, including a description
of any opposition to implementing the initiative;
(E) The identification of any statutory barriers; and
(F) If the initiative is not implemented, an explanation
of why.
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