Texas 2015 - 84th Regular

Texas House Bill HB3464 Compare Versions

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1	1	84R26787 KKR-F
2	2	By: Muñoz, Jr., Guerra H.B. No. 3464
3	3	Substitute the following for H.B. No. 3464:
4	4	By: Crownover C.S.H.B. No. 3464
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the processing and payment of claims for reimbursement
10	10	by providers under Medicaid.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 533.005(a), Government Code, as amended
13	13	by S.B. No. 219, Acts of the 84th Legislature, Regular Session,
14	14	2015, is amended to read as follows:
15	15	(a) A contract between a managed care organization and the
16	16	commission for the organization to provide health care services to
17	17	recipients must contain:
18	18	(1) procedures to ensure accountability to the state
19	19	for the provision of health care services, including procedures for
20	20	financial reporting, quality assurance, utilization review, and
21	21	assurance of contract and subcontract compliance;
22	22	(2) capitation rates that ensure the cost-effective
23	23	provision of quality health care;
24	24	(3) a requirement that the managed care organization
25	25	provide ready access to a person who assists recipients in
26	26	resolving issues relating to enrollment, plan administration,
27	27	education and training, access to services, and grievance
28	28	procedures;
29	29	(4) a requirement that the managed care organization
30	30	provide ready access to a person who assists providers in resolving
31	31	issues relating to payment, plan administration, education and
32	32	training, and grievance procedures;
33	33	(5) a requirement that the managed care organization
34	34	provide information and referral about the availability of
35	35	educational, social, and other community services that could
36	36	benefit a recipient;
37	37	(6) procedures for recipient outreach and education;
38	38	(7) a requirement that the managed care organization
39	39	make payment to a physician or provider for health care services
40	40	rendered to a recipient under a managed care plan on any claim for
41	41	payment that is received with documentation reasonably necessary
42	42	for the managed care organization to process the claim[:
43	43	[(A)] not later than:
44	44	(A) [(i)] the 10th day after the date the claim
45	45	is received if the claim relates to services provided by a nursing
46	46	facility, intermediate care facility, or group home; and
47	47	(B) on average, [(ii)] the 15th [30th] day
48	48	after the date the claim is received if the claim, including a claim
49	49	that relates to the provision of long-term services and supports,
50	50	is not subject to Paragraph (A) [Subparagraph (i); and
51	51	[(iii) the 45th day after the date the claim
52	52	is received if the claim is not subject to Subparagraph (i) or (ii);
53	53	or
54	54	[(B) within a period, not to exceed 60 days,
55	55	specified by a written agreement between the physician or provider
56	56	and the managed care organization];
57	57	(7-a) a requirement that the managed care organization
58	58	demonstrate to the commission that the organization pays claims
59	59	described by Subdivision (7)(B) [(7)(A)(ii)] on average not later
60	60	than the 15th [21st] day after the date the claim is received by the
61	61	organization;
62	62	(7-b) a requirement that the managed care organization
63	63	allow a physician or provider to electronically submit
64	64	documentation necessary for the managed care organization to
65	65	process a claim for payment for health care services rendered to a
66	66	recipient under a managed care plan, including additional
67	67	documentation necessary when the claim is not submitted with
68	68	documentation reasonably necessary for the managed care
69	69	organization to process the claim;
70	70	(8) a requirement that the commission, on the date of a
71	71	recipient's enrollment in a managed care plan issued by the managed
72	72	care organization, inform the organization of the recipient's
73	73	Medicaid certification date;
74	74	(9) a requirement that the managed care organization
75	75	comply with Section 533.006 as a condition of contract retention
76	76	and renewal;
77	77	(10) a requirement that the managed care organization
78	78	provide the information required by Section 533.012 and otherwise
79	79	comply and cooperate with the commission's office of inspector
80	80	general and the office of the attorney general;
81	81	(11) a requirement that the managed care
82	82	organization's usages of out-of-network providers or groups of
83	83	out-of-network providers may not exceed limits for those usages
84	84	relating to total inpatient admissions, total outpatient services,
85	85	and emergency room admissions determined by the commission;
86	86	(12) if the commission finds that a managed care
87	87	organization has violated Subdivision (11), a requirement that the
88	88	managed care organization reimburse an out-of-network provider for
89	89	health care services at a rate that is equal to the allowable rate
90	90	for those services, as determined under Sections 32.028 and
91	91	32.0281, Human Resources Code;
92	92	(13) a requirement that, notwithstanding any other
93	93	law, including Sections 843.312 and 1301.052, Insurance Code, the
94	94	organization:
95	95	(A) use advanced practice registered nurses and
96	96	physician assistants in addition to physicians as primary care
97	97	providers to increase the availability of primary care providers in
98	98	the organization's provider network; and
99	99	(B) treat advanced practice registered nurses
100	100	and physician assistants in the same manner as primary care
101	101	physicians with regard to:
102	102	(i) selection and assignment as primary
103	103	care providers;
104	104	(ii) inclusion as primary care providers in
105	105	the organization's provider network; and
106	106	(iii) inclusion as primary care providers
107	107	in any provider network directory maintained by the organization;
108	108	(14) a requirement that the managed care organization
109	109	reimburse a federally qualified health center or rural health
110	110	clinic for health care services provided to a recipient outside of
111	111	regular business hours, including on a weekend day or holiday, at a
112	112	rate that is equal to the allowable rate for those services as
113	113	determined under Section 32.028, Human Resources Code, if the
114	114	recipient does not have a referral from the recipient's primary
115	115	care physician;
116	116	(15) a requirement that the managed care organization
117	117	develop, implement, and maintain a system for tracking and
118	118	resolving all provider appeals related to claims payment, including
119	119	a process that will require:
120	120	(A) a tracking mechanism to document the status
121	121	and final disposition of each provider's claims payment appeal;
122	122	(B) the contracting with physicians who are not
123	123	network providers and who are of the same or related specialty as
124	124	the appealing physician to resolve claims disputes related to
125	125	denial on the basis of medical necessity that remain unresolved
126	126	subsequent to a provider appeal;
127	127	(C) the determination of the physician resolving
128	128	the dispute to be binding on the managed care organization and
129	129	provider; and
130	130	(D) the managed care organization to allow a
131	131	provider with a claim that has not been paid before the time
132	132	prescribed by Subdivision (7)(B) [(7)(A)(ii)] to initiate an appeal
133	133	of that claim;
134	134	(16) a requirement that a medical director who is
135	135	authorized to make medical necessity determinations is available to
136	136	the region where the managed care organization provides health care
137	137	services;
138	138	(17) a requirement that the managed care organization
139	139	ensure that a medical director and patient care coordinators and
140	140	provider and recipient support services personnel are located in
141	141	the South Texas service region, if the managed care organization
142	142	provides a managed care plan in that region;
143	143	(18) a requirement that the managed care organization
144	144	provide special programs and materials for recipients with limited
145	145	English proficiency or low literacy skills;
146	146	(19) a requirement that the managed care organization
147	147	develop and establish a process for responding to provider appeals
148	148	in the region where the organization provides health care services;
149	149	(20) a requirement that the managed care organization:
150	150	(A) develop and submit to the commission, before
151	151	the organization begins to provide health care services to
152	152	recipients, a comprehensive plan that describes how the
153	153	organization's provider network will provide recipients sufficient
154	154	access to:
155	155	(i) preventive care;
156	156	(ii) primary care;
157	157	(iii) specialty care;
158	158	(iv) after-hours urgent care;
159	159	(v) chronic care;
160	160	(vi) long-term services and supports;
161	161	(vii) nursing services; and
162	162	(viii) therapy services, including
163	163	services provided in a clinical setting or in a home or
164	164	community-based setting; and
165	165	(B) regularly, as determined by the commission,
166	166	submit to the commission and make available to the public a report
167	167	containing data on the sufficiency of the organization's provider
168	168	network with regard to providing the care and services described
169	169	under Paragraph (A) and specific data with respect to Paragraphs
170	170	(A)(iii), (vi), (vii), and (viii) on the average length of time
171	171	between:
172	172	(i) the date a provider makes a referral for
173	173	the care or service and the date the organization approves or denies
174	174	the referral; and
175	175	(ii) the date the organization approves a
176	176	referral for the care or service and the date the care or service is
177	177	initiated;
178	178	(21) a requirement that the managed care organization
179	179	demonstrate to the commission, before the organization begins to
180	180	provide health care services to recipients, that:
181	181	(A) the organization's provider network has the
182	182	capacity to serve the number of recipients expected to enroll in a
183	183	managed care plan offered by the organization;
184	184	(B) the organization's provider network
185	185	includes:
186	186	(i) a sufficient number of primary care
187	187	providers;
188	188	(ii) a sufficient variety of provider
189	189	types;
190	190	(iii) a sufficient number of providers of
191	191	long-term services and supports and specialty pediatric care
192	192	providers of home and community-based services; and
193	193	(iv) providers located throughout the
194	194	region where the organization will provide health care services;
195	195	and
196	196	(C) health care services will be accessible to
197	197	recipients through the organization's provider network to a
198	198	comparable extent that health care services would be available to
199	199	recipients under a fee-for-service or primary care case management
200	200	model of Medicaid managed care;
201	201	(22) a requirement that the managed care organization
202	202	develop a monitoring program for measuring the quality of the
203	203	health care services provided by the organization's provider
204	204	network that:
205	205	(A) incorporates the National Committee for
206	206	Quality Assurance's Healthcare Effectiveness Data and Information
207	207	Set (HEDIS) measures;
208	208	(B) focuses on measuring outcomes; and
209	209	(C) includes the collection and analysis of
210	210	clinical data relating to prenatal care, preventive care, mental
211	211	health care, and the treatment of acute and chronic health
212	212	conditions and substance abuse;
213	213	(23) subject to Subsection (a-1), a requirement that
214	214	the managed care organization develop, implement, and maintain an
215	215	outpatient pharmacy benefit plan for its enrolled recipients:
216	216	(A) that exclusively employs the vendor drug
217	217	program formulary and preserves the state's ability to reduce
218	218	waste, fraud, and abuse under Medicaid;
219	219	(B) that adheres to the applicable preferred drug
220	220	list adopted by the commission under Section 531.072;
221	221	(C) that includes the prior authorization
222	222	procedures and requirements prescribed by or implemented under
223	223	Sections 531.073(b), (c), and (g) for the vendor drug program;
224	224	(D) for purposes of which the managed care
225	225	organization:
226	226	(i) may not negotiate or collect rebates
227	227	associated with pharmacy products on the vendor drug program
228	228	formulary; and
229	229	(ii) may not receive drug rebate or pricing
230	230	information that is confidential under Section 531.071;
231	231	(E) that complies with the prohibition under
232	232	Section 531.089;
233	233	(F) under which the managed care organization may
234	234	not prohibit, limit, or interfere with a recipient's selection of a
235	235	pharmacy or pharmacist of the recipient's choice for the provision
236	236	of pharmaceutical services under the plan through the imposition of
237	237	different copayments;
238	238	(G) that allows the managed care organization or
239	239	any subcontracted pharmacy benefit manager to contract with a
240	240	pharmacist or pharmacy providers separately for specialty pharmacy
241	241	services, except that:
242	242	(i) the managed care organization and
243	243	pharmacy benefit manager are prohibited from allowing exclusive
244	244	contracts with a specialty pharmacy owned wholly or partly by the
245	245	pharmacy benefit manager responsible for the administration of the
246	246	pharmacy benefit program; and
247	247	(ii) the managed care organization and
248	248	pharmacy benefit manager must adopt policies and procedures for
249	249	reclassifying prescription drugs from retail to specialty drugs,
250	250	and those policies and procedures must be consistent with rules
251	251	adopted by the executive commissioner and include notice to network
252	252	pharmacy providers from the managed care organization;
253	253	(H) under which the managed care organization may
254	254	not prevent a pharmacy or pharmacist from participating as a
255	255	provider if the pharmacy or pharmacist agrees to comply with the
256	256	financial terms and conditions of the contract as well as other
257	257	reasonable administrative and professional terms and conditions of
258	258	the contract;
259	259	(I) under which the managed care organization may
260	260	include mail-order pharmacies in its networks, but may not require
261	261	enrolled recipients to use those pharmacies, and may not charge an
262	262	enrolled recipient who opts to use this service a fee, including
263	263	postage and handling fees;
264	264	(J) under which the managed care organization or
265	265	pharmacy benefit manager, as applicable, must pay claims and allow
266	266	the electronic submission of claims documentation in accordance
267	267	with Subdivisions (7) and (7-b) [Section 843.339, Insurance Code];
268	268	and
269	269	(K) under which the managed care organization or
270	270	pharmacy benefit manager, as applicable:
271	271	(i) to place a drug on a maximum allowable
272	272	cost list, must ensure that:
273	273	(a) the drug is listed as "A" or "B"
274	274	rated in the most recent version of the United States Food and Drug
275	275	Administration's Approved Drug Products with Therapeutic
276	276	Equivalence Evaluations, also known as the Orange Book, has an "NR"
277	277	or "NA" rating or a similar rating by a nationally recognized
278	278	reference; and
279	279	(b) the drug is generally available
280	280	for purchase by pharmacies in the state from national or regional
281	281	wholesalers and is not obsolete;
282	282	(ii) must provide to a network pharmacy
283	283	provider, at the time a contract is entered into or renewed with the
284	284	network pharmacy provider, the sources used to determine the
285	285	maximum allowable cost pricing for the maximum allowable cost list
286	286	specific to that provider;
287	287	(iii) must review and update maximum
288	288	allowable cost price information at least once every seven days to
289	289	reflect any modification of maximum allowable cost pricing;
290	290	(iv) must, in formulating the maximum
291	291	allowable cost price for a drug, use only the price of the drug and
292	292	drugs listed as therapeutically equivalent in the most recent
293	293	version of the United States Food and Drug Administration's
294	294	Approved Drug Products with Therapeutic Equivalence Evaluations,
295	295	also known as the Orange Book;
296	296	(v) must establish a process for
297	297	eliminating products from the maximum allowable cost list or
298	298	modifying maximum allowable cost prices in a timely manner to
299	299	remain consistent with pricing changes and product availability in
300	300	the marketplace;
301	301	(vi) must:
302	302	(a) provide a procedure under which a
303	303	network pharmacy provider may challenge a listed maximum allowable
304	304	cost price for a drug;
305	305	(b) respond to a challenge not later
306	306	than the 15th day after the date the challenge is made;
307	307	(c) if the challenge is successful,
308	308	make an adjustment in the drug price effective on the date the
309	309	challenge is resolved, and make the adjustment applicable to all
310	310	similarly situated network pharmacy providers, as determined by the
311	311	managed care organization or pharmacy benefit manager, as
312	312	appropriate;
313	313	(d) if the challenge is denied,
314	314	provide the reason for the denial; and
315	315	(e) report to the commission every 90
316	316	days the total number of challenges that were made and denied in the
317	317	preceding 90-day period for each maximum allowable cost list drug
318	318	for which a challenge was denied during the period;
319	319	(vii) must notify the commission not later
320	320	than the 21st day after implementing a practice of using a maximum
321	321	allowable cost list for drugs dispensed at retail but not by mail;
322	322	and
323	323	(viii) must provide a process for each of
324	324	its network pharmacy providers to readily access the maximum
325	325	allowable cost list specific to that provider;
326	326	(24) a requirement that the managed care organization
327	327	and any entity with which the managed care organization contracts
328	328	for the performance of services under a managed care plan disclose,
329	329	at no cost, to the commission and, on request, the office of the
330	330	attorney general all discounts, incentives, rebates, fees, free
331	331	goods, bundling arrangements, and other agreements affecting the
332	332	net cost of goods or services provided under the plan; and
333	333	(25) a requirement that the managed care organization
334	334	not implement significant, nonnegotiated, across-the-board
335	335	provider reimbursement rate reductions unless:
336	336	(A) subject to Subsection (a-3), the
337	337	organization has the prior approval of the commission to make the
338	338	reduction; or
339	339	(B) the rate reductions are based on changes to
340	340	the Medicaid fee schedule or cost containment initiatives
341	341	implemented by the commission.
342	342	SECTION 2. (a) The Health and Human Services Commission, in
343	343	a contract between the commission and a managed care organization
344	344	under Chapter 533, Government Code, that is entered into or renewed
345	345	on or after the effective date of this Act, shall require that the
346	346	managed care organization comply with Sections 533.005(a)(7),
347	347	(7-a), and (23)(J), Government Code, as amended by this Act, and
348	348	Section 533.005(a)(7-b), Government Code, as added by this Act.
349	349	(b) The Health and Human Services Commission shall seek to
350	350	amend contracts entered into with managed care organizations under
351	351	Chapter 533, Government Code, before the effective date of this Act
352	352	to require that those managed care organizations comply with
353	353	Sections 533.005(a)(7), (7-a), and (23)(J), Government Code, as
354	354	amended by this Act, and Section 533.005(a)(7-b), Government Code,
355	355	as added by this Act. To the extent of a conflict between those
356	356	provisions and a provision of a contract with a managed care
357	357	organization entered into before the effective date of this Act,
358	358	the contract provision prevails.
359	359	SECTION 3. If before implementing any provision of this Act
360	360	a state agency determines that a waiver or authorization from a
361	361	federal agency is necessary for implementation of that provision,
362	362	the agency affected by the provision shall request the waiver or
363	363	authorization and may delay implementing that provision until the
364	364	waiver or authorization is granted.
365	365	SECTION 4. This Act takes effect September 1, 2015.