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Texas House Bill HB1398

Texas 2017 - 85th Regular

Texas House Bill HB1398 Compare Versions

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11 85R3466 KKR-F
22 By: Muñoz, Jr., Guerra H.B. No. 1398
33
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55 A BILL TO BE ENTITLED
66 AN ACT
77 relating to the processing and payment of claims for reimbursement
88 by certain providers under the Medicaid program.
99 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1010 SECTION 1. Section 533.005(a), Government Code, is amended
1111 to read as follows:
1212 (a) A contract between a managed care organization and the
1313 commission for the organization to provide health care services to
1414 recipients must contain:
1515 (1) procedures to ensure accountability to the state
1616 for the provision of health care services, including procedures for
1717 financial reporting, quality assurance, utilization review, and
1818 assurance of contract and subcontract compliance;
1919 (2) capitation rates that ensure the cost-effective
2020 provision of quality health care;
2121 (3) a requirement that the managed care organization
2222 provide ready access to a person who assists recipients in
2323 resolving issues relating to enrollment, plan administration,
2424 education and training, access to services, and grievance
2525 procedures;
2626 (4) a requirement that the managed care organization
2727 provide ready access to a person who assists providers in resolving
2828 issues relating to payment, plan administration, education and
2929 training, and grievance procedures;
3030 (5) a requirement that the managed care organization
3131 provide information and referral about the availability of
3232 educational, social, and other community services that could
3333 benefit a recipient;
3434 (6) procedures for recipient outreach and education;
3535 (7) a requirement that the managed care organization
3636 make payment to a physician or provider for health care services
3737 rendered to a recipient under a managed care plan on any claim for
3838 payment that is received with documentation reasonably necessary
3939 for the managed care organization to process the claim[:
4040 [(A)] not later than:
4141 (A) [(i)] the 10th day after the date the claim
4242 is received if the claim relates to services provided by a nursing
4343 facility, intermediate care facility, or group home; and
4444 (B) on average, [(ii)] the 15th [30th] day
4545 after the date the claim is received if the claim, including a claim
4646 that relates to the provision of long-term services and supports,
4747 is not subject to Paragraph (A) [Subparagraph (i); and
4848 [(iii) the 45th day after the date the claim
4949 is received if the claim is not subject to Subparagraph (i) or (ii);
5050 or
5151 [(B) within a period, not to exceed 60 days,
5252 specified by a written agreement between the physician or provider
5353 and the managed care organization];
5454 (7-a) a requirement that the managed care organization
5555 demonstrate to the commission that the organization pays claims
5656 described by Subdivision (7)(B) [(7)(A)(ii)] on average not later
5757 than the 15th [21st] day after the date the claim is received by the
5858 organization;
5959 (7-b) a requirement that the managed care organization
6060 allow a physician or provider to electronically submit
6161 documentation necessary for the managed care organization to
6262 process a claim for payment for health care services rendered to a
6363 recipient under a managed care plan, including additional
6464 documentation necessary when the claim is not submitted with
6565 documentation reasonably necessary for the managed care
6666 organization to process the claim;
6767 (8) a requirement that the commission, on the date of a
6868 recipient's enrollment in a managed care plan issued by the managed
6969 care organization, inform the organization of the recipient's
7070 Medicaid certification date;
7171 (9) a requirement that the managed care organization
7272 comply with Section 533.006 as a condition of contract retention
7373 and renewal;
7474 (10) a requirement that the managed care organization
7575 provide the information required by Section 533.012 and otherwise
7676 comply and cooperate with the commission's office of inspector
7777 general and the office of the attorney general;
7878 (11) a requirement that the managed care
7979 organization's usages of out-of-network providers or groups of
8080 out-of-network providers may not exceed limits for those usages
8181 relating to total inpatient admissions, total outpatient services,
8282 and emergency room admissions determined by the commission;
8383 (12) if the commission finds that a managed care
8484 organization has violated Subdivision (11), a requirement that the
8585 managed care organization reimburse an out-of-network provider for
8686 health care services at a rate that is equal to the allowable rate
8787 for those services, as determined under Sections 32.028 and
8888 32.0281, Human Resources Code;
8989 (13) a requirement that, notwithstanding any other
9090 law, including Sections 843.312 and 1301.052, Insurance Code, the
9191 organization:
9292 (A) use advanced practice registered nurses and
9393 physician assistants in addition to physicians as primary care
9494 providers to increase the availability of primary care providers in
9595 the organization's provider network; and
9696 (B) treat advanced practice registered nurses
9797 and physician assistants in the same manner as primary care
9898 physicians with regard to:
9999 (i) selection and assignment as primary
100100 care providers;
101101 (ii) inclusion as primary care providers in
102102 the organization's provider network; and
103103 (iii) inclusion as primary care providers
104104 in any provider network directory maintained by the organization;
105105 (14) a requirement that the managed care organization
106106 reimburse a federally qualified health center or rural health
107107 clinic for health care services provided to a recipient outside of
108108 regular business hours, including on a weekend day or holiday, at a
109109 rate that is equal to the allowable rate for those services as
110110 determined under Section 32.028, Human Resources Code, if the
111111 recipient does not have a referral from the recipient's primary
112112 care physician;
113113 (15) a requirement that the managed care organization
114114 develop, implement, and maintain a system for tracking and
115115 resolving all provider appeals related to claims payment, including
116116 a process that will require:
117117 (A) a tracking mechanism to document the status
118118 and final disposition of each provider's claims payment appeal;
119119 (B) the contracting with physicians who are not
120120 network providers and who are of the same or related specialty as
121121 the appealing physician to resolve claims disputes related to
122122 denial on the basis of medical necessity that remain unresolved
123123 subsequent to a provider appeal;
124124 (C) the determination of the physician resolving
125125 the dispute to be binding on the managed care organization and
126126 provider; and
127127 (D) the managed care organization to allow a
128128 provider with a claim that has not been paid before the time
129129 prescribed by Subdivision (7)(B) [(7)(A)(ii)] to initiate an appeal
130130 of that claim;
131131 (16) a requirement that a medical director who is
132132 authorized to make medical necessity determinations is available to
133133 the region where the managed care organization provides health care
134134 services;
135135 (17) a requirement that the managed care organization
136136 ensure that a medical director and patient care coordinators and
137137 provider and recipient support services personnel are located in
138138 the South Texas service region, if the managed care organization
139139 provides a managed care plan in that region;
140140 (18) a requirement that the managed care organization
141141 provide special programs and materials for recipients with limited
142142 English proficiency or low literacy skills;
143143 (19) a requirement that the managed care organization
144144 develop and establish a process for responding to provider appeals
145145 in the region where the organization provides health care services;
146146 (20) a requirement that the managed care organization:
147147 (A) develop and submit to the commission, before
148148 the organization begins to provide health care services to
149149 recipients, a comprehensive plan that describes how the
150150 organization's provider network complies with the provider access
151151 standards established under Section 533.0061, as added by Chapter
152152 1272 (S.B. 760), Acts of the 84th Legislature, Regular Session,
153153 2015;
154154 (B) as a condition of contract retention and
155155 renewal:
156156 (i) continue to comply with the provider
157157 access standards established under Section 533.0061, as added by
158158 Chapter 1272 (S.B. 760), Acts of the 84th Legislature, Regular
159159 Session, 2015; and
160160 (ii) make substantial efforts, as
161161 determined by the commission, to mitigate or remedy any
162162 noncompliance with the provider access standards established under
163163 Section 533.0061, as added by Chapter 1272 (S.B. 760), Acts of the
164164 84th Legislature, Regular Session, 2015;
165165 (C) pay liquidated damages for each failure, as
166166 determined by the commission, to comply with the provider access
167167 standards established under Section 533.0061, as added by Chapter
168168 1272 (S.B. 760), Acts of the 84th Legislature, Regular Session,
169169 2015, in amounts that are reasonably related to the noncompliance;
170170 and
171171 (D) regularly, as determined by the commission,
172172 submit to the commission and make available to the public a report
173173 containing data on the sufficiency of the organization's provider
174174 network with regard to providing the care and services described
175175 under Section 533.0061(a), as added by Chapter 1272 (S.B. 760),
176176 Acts of the 84th Legislature, Regular Session, 2015, and specific
177177 data with respect to access to primary care, specialty care,
178178 long-term services and supports, nursing services, and therapy
179179 services on the average length of time between:
180180 (i) the date a provider requests prior
181181 authorization for the care or service and the date the organization
182182 approves or denies the request; and
183183 (ii) the date the organization approves a
184184 request for prior authorization for the care or service and the date
185185 the care or service is initiated;
186186 (21) a requirement that the managed care organization
187187 demonstrate to the commission, before the organization begins to
188188 provide health care services to recipients, that, subject to the
189189 provider access standards established under Section 533.0061, as
190190 added by Chapter 1272 (S.B. 760), Acts of the 84th Legislature,
191191 Regular Session, 2015:
192192 (A) the organization's provider network has the
193193 capacity to serve the number of recipients expected to enroll in a
194194 managed care plan offered by the organization;
195195 (B) the organization's provider network
196196 includes:
197197 (i) a sufficient number of primary care
198198 providers;
199199 (ii) a sufficient variety of provider
200200 types;
201201 (iii) a sufficient number of providers of
202202 long-term services and supports and specialty pediatric care
203203 providers of home and community-based services; and
204204 (iv) providers located throughout the
205205 region where the organization will provide health care services;
206206 and
207207 (C) health care services will be accessible to
208208 recipients through the organization's provider network to a
209209 comparable extent that health care services would be available to
210210 recipients under a fee-for-service or primary care case management
211211 model of Medicaid managed care;
212212 (22) a requirement that the managed care organization
213213 develop a monitoring program for measuring the quality of the
214214 health care services provided by the organization's provider
215215 network that:
216216 (A) incorporates the National Committee for
217217 Quality Assurance's Healthcare Effectiveness Data and Information
218218 Set (HEDIS) measures;
219219 (B) focuses on measuring outcomes; and
220220 (C) includes the collection and analysis of
221221 clinical data relating to prenatal care, preventive care, mental
222222 health care, and the treatment of acute and chronic health
223223 conditions and substance abuse;
224224 (23) subject to Subsection (a-1), a requirement that
225225 the managed care organization develop, implement, and maintain an
226226 outpatient pharmacy benefit plan for its enrolled recipients:
227227 (A) that exclusively employs the vendor drug
228228 program formulary and preserves the state's ability to reduce
229229 waste, fraud, and abuse under Medicaid;
230230 (B) that adheres to the applicable preferred drug
231231 list adopted by the commission under Section 531.072;
232232 (C) that includes the prior authorization
233233 procedures and requirements prescribed by or implemented under
234234 Sections 531.073(b), (c), and (g) for the vendor drug program;
235235 (D) for purposes of which the managed care
236236 organization:
237237 (i) may not negotiate or collect rebates
238238 associated with pharmacy products on the vendor drug program
239239 formulary; and
240240 (ii) may not receive drug rebate or pricing
241241 information that is confidential under Section 531.071;
242242 (E) that complies with the prohibition under
243243 Section 531.089;
244244 (F) under which the managed care organization may
245245 not prohibit, limit, or interfere with a recipient's selection of a
246246 pharmacy or pharmacist of the recipient's choice for the provision
247247 of pharmaceutical services under the plan through the imposition of
248248 different copayments;
249249 (G) that allows the managed care organization or
250250 any subcontracted pharmacy benefit manager to contract with a
251251 pharmacist or pharmacy providers separately for specialty pharmacy
252252 services, except that:
253253 (i) the managed care organization and
254254 pharmacy benefit manager are prohibited from allowing exclusive
255255 contracts with a specialty pharmacy owned wholly or partly by the
256256 pharmacy benefit manager responsible for the administration of the
257257 pharmacy benefit program; and
258258 (ii) the managed care organization and
259259 pharmacy benefit manager must adopt policies and procedures for
260260 reclassifying prescription drugs from retail to specialty drugs,
261261 and those policies and procedures must be consistent with rules
262262 adopted by the executive commissioner and include notice to network
263263 pharmacy providers from the managed care organization;
264264 (H) under which the managed care organization may
265265 not prevent a pharmacy or pharmacist from participating as a
266266 provider if the pharmacy or pharmacist agrees to comply with the
267267 financial terms and conditions of the contract as well as other
268268 reasonable administrative and professional terms and conditions of
269269 the contract;
270270 (I) under which the managed care organization may
271271 include mail-order pharmacies in its networks, but may not require
272272 enrolled recipients to use those pharmacies, and may not charge an
273273 enrolled recipient who opts to use this service a fee, including
274274 postage and handling fees;
275275 (J) under which the managed care organization or
276276 pharmacy benefit manager, as applicable, must pay claims and allow
277277 the electronic submission of claims documentation in accordance
278278 with Subdivisions (7) and (7-b) [Section 843.339, Insurance Code];
279279 and
280280 (K) under which the managed care organization or
281281 pharmacy benefit manager, as applicable:
282282 (i) to place a drug on a maximum allowable
283283 cost list, must ensure that:
284284 (a) the drug is listed as "A" or "B"
285285 rated in the most recent version of the United States Food and Drug
286286 Administration's Approved Drug Products with Therapeutic
287287 Equivalence Evaluations, also known as the Orange Book, has an "NR"
288288 or "NA" rating or a similar rating by a nationally recognized
289289 reference; and
290290 (b) the drug is generally available
291291 for purchase by pharmacies in the state from national or regional
292292 wholesalers and is not obsolete;
293293 (ii) must provide to a network pharmacy
294294 provider, at the time a contract is entered into or renewed with the
295295 network pharmacy provider, the sources used to determine the
296296 maximum allowable cost pricing for the maximum allowable cost list
297297 specific to that provider;
298298 (iii) must review and update maximum
299299 allowable cost price information at least once every seven days to
300300 reflect any modification of maximum allowable cost pricing;
301301 (iv) must, in formulating the maximum
302302 allowable cost price for a drug, use only the price of the drug and
303303 drugs listed as therapeutically equivalent in the most recent
304304 version of the United States Food and Drug Administration's
305305 Approved Drug Products with Therapeutic Equivalence Evaluations,
306306 also known as the Orange Book;
307307 (v) must establish a process for
308308 eliminating products from the maximum allowable cost list or
309309 modifying maximum allowable cost prices in a timely manner to
310310 remain consistent with pricing changes and product availability in
311311 the marketplace;
312312 (vi) must:
313313 (a) provide a procedure under which a
314314 network pharmacy provider may challenge a listed maximum allowable
315315 cost price for a drug;
316316 (b) respond to a challenge not later
317317 than the 15th day after the date the challenge is made;
318318 (c) if the challenge is successful,
319319 make an adjustment in the drug price effective on the date the
320320 challenge is resolved, and make the adjustment applicable to all
321321 similarly situated network pharmacy providers, as determined by the
322322 managed care organization or pharmacy benefit manager, as
323323 appropriate;
324324 (d) if the challenge is denied,
325325 provide the reason for the denial; and
326326 (e) report to the commission every 90
327327 days the total number of challenges that were made and denied in the
328328 preceding 90-day period for each maximum allowable cost list drug
329329 for which a challenge was denied during the period;
330330 (vii) must notify the commission not later
331331 than the 21st day after implementing a practice of using a maximum
332332 allowable cost list for drugs dispensed at retail but not by mail;
333333 and
334334 (viii) must provide a process for each of
335335 its network pharmacy providers to readily access the maximum
336336 allowable cost list specific to that provider;
337337 (24) a requirement that the managed care organization
338338 and any entity with which the managed care organization contracts
339339 for the performance of services under a managed care plan disclose,
340340 at no cost, to the commission and, on request, the office of the
341341 attorney general all discounts, incentives, rebates, fees, free
342342 goods, bundling arrangements, and other agreements affecting the
343343 net cost of goods or services provided under the plan;
344344 (25) a requirement that the managed care organization
345345 not implement significant, nonnegotiated, across-the-board
346346 provider reimbursement rate reductions unless:
347347 (A) subject to Subsection (a-3), the
348348 organization has the prior approval of the commission to make the
349349 reduction; or
350350 (B) the rate reductions are based on changes to
351351 the Medicaid fee schedule or cost containment initiatives
352352 implemented by the commission; and
353353 (26) a requirement that the managed care organization
354354 make initial and subsequent primary care provider assignments and
355355 changes.
356356 SECTION 2. Subchapter B, Chapter 32, Human Resources Code,
357357 is amended by adding Section 32.0292 to read as follows:
358358 Sec. 32.0292. PAYMENT OF CERTAIN TRANSPORTATION CLAIMS.
359359 The executive commissioner shall adopt rules to ensure the
360360 commission or the commission's designee pays a claim for
361361 nonemergency ambulance services provided to a recipient of medical
362362 assistance under this chapter not later than the 15th day after the
363363 date the claim for payment is received with documentation
364364 reasonably necessary for the commission or the designee to process
365365 the claim.
366366 SECTION 3. The executive commissioner of the Health and
367367 Human Services Commission shall adopt the rules necessary to
368368 implement Section 32.0292, Human Resources Code, as added by this
369369 Act, not later than October 1, 2017.
370370 SECTION 4. (a) The Health and Human Services Commission, in
371371 a contract between the commission and a managed care organization
372372 under Chapter 533, Government Code, that is entered into or renewed
373373 on or after the effective date of this Act, shall require that the
374374 managed care organization comply with Sections 533.005(a)(7),
375375 (7-a), and (23)(J), Government Code, as amended by this Act, and
376376 Section 533.005(a)(7-b), Government Code, as added by this Act.
377377 (b) The Health and Human Services Commission shall seek to
378378 amend contracts entered into with managed care organizations under
379379 Chapter 533, Government Code, before the effective date of this Act
380380 to require that those managed care organizations comply with
381381 Sections 533.005(a)(7), (7-a), and (23)(J), Government Code, as
382382 amended by this Act, and Section 533.005(a)(7-b), Government Code,
383383 as added by this Act. To the extent of a conflict between those
384384 provisions and a provision of a contract with a managed care
385385 organization entered into before the effective date of this Act,
386386 the contract provision prevails.
387387 SECTION 5. If before implementing any provision of this Act
388388 a state agency determines that a waiver or authorization from a
389389 federal agency is necessary for implementation of that provision,
390390 the agency affected by the provision shall request the waiver or
391391 authorization and may delay implementing that provision until the
392392 waiver or authorization is granted.
393393 SECTION 6. This Act takes effect September 1, 2017.