Texas 2015 - 84th Regular

Texas House Bill HB1041 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	84R26130 KFF-F
2	2	By: Collier H.B. No. 1041
3	3	Substitute the following for H.B. No. 1041:
4	4	By: Raymond C.S.H.B. No. 1041
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to administrative and judicial review of certain Medicaid
10	10	reimbursement disputes; authorizing a fee.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subchapter A, Chapter 533, Government Code, is
13	13	amended by adding Section 533.0057 to read as follows:
14	14	Sec. 533.0057. CONFISCATORY REIMBURSEMENT RATES
15	15	PROHIBITED; ADMINISTRATIVE AND JUDICIAL REVIEW OF CERTAIN
16	16	REIMBURSEMENT DISPUTES. (a) In this section, "confiscatory"
17	17	means, with respect to the reimbursement rate paid by a managed care
18	18	organization to a provider, a rate that is below the rate necessary
19	19	to:
20	20	(1) recover the provider's reasonable operating
21	21	expenses;
22	22	(2) realize a reasonable return on the provider's
23	23	costs; and
24	24	(3) ensure confidence in the provider's continued:
25	25	(A) financial integrity; and
26	26	(B) participation in Medicaid.
27	27	(b) A managed care organization may not pay a confiscatory
28	28	reimbursement rate to a provider under a Medicaid managed care
29	29	model or arrangement implemented under this chapter.
30	30	(c) Notwithstanding any other law, a provider, including a
31	31	pharmacy provider, has the right to a contested case hearing under
32	32	Chapter 2001 to dispute the amount of a reimbursement rate paid to
33	33	the provider by a managed care organization or the organization's
34	34	pharmacy benefit manager if, subject to Subsection (f), the
35	35	provider believes the rate is confiscatory in violation of
36	36	Subsection (b), except that the decision of the hearing officer or
37	37	the administrative law judge, as applicable, is not subject to
38	38	judicial review under Chapter 2001. Solely for purposes of this
39	39	section, a managed care organization is to be treated as a state
40	40	agency under Chapter 2001.
41	41	(d) A contested case hearing under Subsection (c) shall be
42	42	conducted by an administrative law judge, unless the commission's
43	43	appeals division employs at least one full-time hearing officer
44	44	whose sole duty is to preside over contested cases. If the
45	45	commission's appeals division employs a hearing officer described
46	46	by this subsection, that officer shall conduct the contested case
47	47	hearing under Subsection (c).
48	48	(e) Parties to a contested case brought under this section:
49	49	(1) must include:
50	50	(A) the provider; and
51	51	(B) the managed care organization and any
52	52	appropriate agent of the organization, including a pharmacy benefit
53	53	manager; and
54	54	(2) may not include the commission.
55	55	(f) If the provider's contract with the managed care
56	56	organization or the organization's agent contains a process for
57	57	handling disputes relating to provider reimbursement, the provider
58	58	may request a contested case hearing under Subsection (c) only if:
59	59	(1) the provider first submits the dispute for
60	60	resolution through the contractual process; and
61	61	(2) the managed care organization or the
62	62	organization's agent, as appropriate, fails to resolve the dispute
63	63	through the contractual process not later than the 45th day after
64	64	the day the dispute is submitted, or if the provider is dissatisfied
65	65	with the resolution of the contractual process.
66	66	(g) In a contested case brought under this section, the
67	67	hearing officer or administrative law judge, as applicable, shall
68	68	determine whether the reimbursement rate is confiscatory and may
69	69	order the managed care organization or the organization's agent to
70	70	pay a rate that is not confiscatory. A hearing officer or
71	71	administrative law judge, as applicable, may not award an amount:
72	72	(1) to any one provider that, as a percentage of the
73	73	provider's average net income before taxes, exceeds the managed
74	74	care organization's percentage of net income before taxes that is
75	75	computed in accordance with the contract between the organization
76	76	and the commission and is authorized to be retained by the
77	77	organization under that contract, averaged over all financial
78	78	statistical report reporting periods; or
79	79	(2) that in the aggregate exceeds the amount of
80	80	resources maintained by the managed care organization to reasonably
81	81	accommodate program changes at no additional cost to the commission
82	82	in accordance with the contract between the organization and the
83	83	commission.
84	84	(h) In a contested case brought under this section, the
85	85	hearing officer or administrative law judge, as applicable, has the
86	86	discretion:
87	87	(1) considering the interest of judicial economy and
88	88	efficiency, to combine cases wholly or partly that involve the same
89	89	type of provider and the same or substantially similar
90	90	reimbursement issues; or
91	91	(2) to impose part or all of the costs for the hearing
92	92	against the party or parties that do not substantially prevail.
93	93	(i) In awarding costs in a contested case brought under this
94	94	section, the hearing officer or administrative law judge, as
95	95	applicable:
96	96	(1) shall consider whether the position of the party
97	97	was taken in good faith and had a reasonable basis in fact and law;
98	98	and
99	99	(2) may not award attorney's fees.
100	100	(j) The commission or the State Office of Administrative
101	101	Hearings may impose a fee in an amount not to exceed $500 on each
102	102	party to a contested case brought under this section for the purpose
103	103	of offsetting the costs of the hearing.
104	104	SECTION 2. The change in law made by this Act applies only
105	105	to a reimbursement paid to a Medicaid provider on or after the
106	106	effective date of this Act.
107	107	SECTION 3. If before implementing any provision of this Act
108	108	a state agency determines that a waiver or authorization from a
109	109	federal agency is necessary for implementation of that provision,
110	110	the agency affected by the provision shall request the waiver or
111	111	authorization and may delay implementing that provision until the
112	112	waiver or authorization is granted.
113	113	SECTION 4. This Act takes effect immediately if it receives
114	114	a vote of two-thirds of all the members elected to each house, as
115	115	provided by Section 39, Article III, Texas Constitution. If this
116	116	Act does not receive the vote necessary for immediate effect, this
117	117	Act takes effect September 1, 2015.