Texas 2017 - 85th Regular

Texas House Bill HB3288 Compare Versions

Only one version of the bill is available at this time.

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1	1	By: Klick H.B. No. 3288
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to the reimbursement of prescription drugs under Medicaid
7	7	and the child health plan program.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Section 533.005(a), Government Code, is amended
10	10	to read as follows:
11	11	(a) A contract between a managed care organization and the
12	12	commission for the organization to provide health care services to
13	13	recipients must contain:
14	14	(1) procedures to ensure accountability to the state
15	15	for the provision of health care services, including procedures for
16	16	financial reporting, quality assurance, utilization review, and
17	17	assurance of contract and subcontract compliance;
18	18	(2) capitation rates that ensure the cost-effective
19	19	provision of quality health care;
20	20	(3) a requirement that the managed care organization
21	21	provide ready access to a person who assists recipients in
22	22	resolving issues relating to enrollment, plan administration,
23	23	education and training, access to services, and grievance
24	24	procedures;
25	25	(4) a requirement that the managed care organization
26	26	provide ready access to a person who assists providers in resolving
27	27	issues relating to payment, plan administration, education and
28	28	training, and grievance procedures;
29	29	(5) a requirement that the managed care organization
30	30	provide information and referral about the availability of
31	31	educational, social, and other community services that could
32	32	benefit a recipient;
33	33	(6) procedures for recipient outreach and education;
34	34	(7) a requirement that the managed care organization
35	35	make payment to a physician or provider for health care services
36	36	rendered to a recipient under a managed care plan on any claim for
37	37	payment that is received with documentation reasonably necessary
38	38	for the managed care organization to process the claim:
39	39	(A) not later than:
40	40	(i) the 10th day after the date the claim is
41	41	received if the claim relates to services provided by a nursing
42	42	facility, intermediate care facility, or group home;
43	43	(ii) the 30th day after the date the claim
44	44	is received if the claim relates to the provision of long-term
45	45	services and supports not subject to Subparagraph (i); and
46	46	(iii) the 45th day after the date the claim
47	47	is received if the claim is not subject to Subparagraph (i) or (ii);
48	48	or
49	49	(B) within a period, not to exceed 60 days,
50	50	specified by a written agreement between the physician or provider
51	51	and the managed care organization;
52	52	(7-a) a requirement that the managed care organization
53	53	demonstrate to the commission that the organization pays claims
54	54	described by Subdivision (7)(A)(ii) on average not later than the
55	55	21st day after the date the claim is received by the organization;
56	56	(8) a requirement that the commission, on the date of a
57	57	recipient's enrollment in a managed care plan issued by the managed
58	58	care organization, inform the organization of the recipient's
59	59	Medicaid certification date;
60	60	(9) a requirement that the managed care organization
61	61	comply with Section 533.006 as a condition of contract retention
62	62	and renewal;
63	63	(10) a requirement that the managed care organization
64	64	provide the information required by Section 533.012 and otherwise
65	65	comply and cooperate with the commission's office of inspector
66	66	general and the office of the attorney general;
67	67	(11) a requirement that the managed care
68	68	organization's usages of out-of-network providers or groups of
69	69	out-of-network providers may not exceed limits for those usages
70	70	relating to total inpatient admissions, total outpatient services,
71	71	and emergency room admissions determined by the commission;
72	72	(12) if the commission finds that a managed care
73	73	organization has violated Subdivision (11), a requirement that the
74	74	managed care organization reimburse an out-of-network provider for
75	75	health care services at a rate that is equal to the allowable rate
76	76	for those services, as determined under Sections 32.028 and
77	77	32.0281, Human Resources Code;
78	78	(13) a requirement that, notwithstanding any other
79	79	law, including Sections 843.312 and 1301.052, Insurance Code, the
80	80	organization:
81	81	(A) use advanced practice registered nurses and
82	82	physician assistants in addition to physicians as primary care
83	83	providers to increase the availability of primary care providers in
84	84	the organization's provider network; and
85	85	(B) treat advanced practice registered nurses
86	86	and physician assistants in the same manner as primary care
87	87	physicians with regard to:
88	88	(i) selection and assignment as primary
89	89	care providers;
90	90	(ii) inclusion as primary care providers in
91	91	the organization's provider network; and
92	92	(iii) inclusion as primary care providers
93	93	in any provider network directory maintained by the organization;
94	94	(14) a requirement that the managed care organization
95	95	reimburse a federally qualified health center or rural health
96	96	clinic for health care services provided to a recipient outside of
97	97	regular business hours, including on a weekend day or holiday, at a
98	98	rate that is equal to the allowable rate for those services as
99	99	determined under Section 32.028, Human Resources Code, if the
100	100	recipient does not have a referral from the recipient's primary
101	101	care physician;
102	102	(15) a requirement that the managed care organization
103	103	develop, implement, and maintain a system for tracking and
104	104	resolving all provider appeals related to claims payment, including
105	105	a process that will require:
106	106	(A) a tracking mechanism to document the status
107	107	and final disposition of each provider's claims payment appeal;
108	108	(B) the contracting with physicians who are not
109	109	network providers and who are of the same or related specialty as
110	110	the appealing physician to resolve claims disputes related to
111	111	denial on the basis of medical necessity that remain unresolved
112	112	subsequent to a provider appeal;
113	113	(C) the determination of the physician resolving
114	114	the dispute to be binding on the managed care organization and
115	115	provider; and
116	116	(D) the managed care organization to allow a
117	117	provider with a claim that has not been paid before the time
118	118	prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
119	119	claim;
120	120	(16) a requirement that a medical director who is
121	121	authorized to make medical necessity determinations is available to
122	122	the region where the managed care organization provides health care
123	123	services;
124	124	(17) a requirement that the managed care organization
125	125	ensure that a medical director and patient care coordinators and
126	126	provider and recipient support services personnel are located in
127	127	the South Texas service region, if the managed care organization
128	128	provides a managed care plan in that region;
129	129	(18) a requirement that the managed care organization
130	130	provide special programs and materials for recipients with limited
131	131	English proficiency or low literacy skills;
132	132	(19) a requirement that the managed care organization
133	133	develop and establish a process for responding to provider appeals
134	134	in the region where the organization provides health care services;
135	135	(20) a requirement that the managed care organization:
136	136	(A) develop and submit to the commission, before
137	137	the organization begins to provide health care services to
138	138	recipients, a comprehensive plan that describes how the
139	139	organization's provider network complies with the provider access
140	140	standards established under Section 533.0061;
141	141	(B) as a condition of contract retention and
142	142	renewal:
143	143	(i) continue to comply with the provider
144	144	access standards established under Section 533.0061; and
145	145	(ii) make substantial efforts, as
146	146	determined by the commission, to mitigate or remedy any
147	147	noncompliance with the provider access standards established under
148	148	Section 533.0061;
149	149	(C) pay liquidated damages for each failure, as
150	150	determined by the commission, to comply with the provider access
151	151	standards established under Section 533.0061 in amounts that are
152	152	reasonably related to the noncompliance; and
153	153	(D) regularly, as determined by the commission,
154	154	submit to the commission and make available to the public a report
155	155	containing data on the sufficiency of the organization's provider
156	156	network with regard to providing the care and services described
157	157	under Section 533.0061(a) and specific data with respect to access
158	158	to primary care, specialty care, long-term services and supports,
159	159	nursing services, and therapy services on the average length of
160	160	time between:
161	161	(i) the date a provider requests prior
162	162	authorization for the care or service and the date the organization
163	163	approves or denies the request; and
164	164	(ii) the date the organization approves a
165	165	request for prior authorization for the care or service and the date
166	166	the care or service is initiated;
167	167	(21) a requirement that the managed care organization
168	168	demonstrate to the commission, before the organization begins to
169	169	provide health care services to recipients, that, subject to the
170	170	provider access standards established under Section 533.0061:
171	171	(A) the organization's provider network has the
172	172	capacity to serve the number of recipients expected to enroll in a
173	173	managed care plan offered by the organization;
174	174	(B) the organization's provider network
175	175	includes:
176	176	(i) a sufficient number of primary care
177	177	providers;
178	178	(ii) a sufficient variety of provider
179	179	types;
180	180	(iii) a sufficient number of providers of
181	181	long-term services and supports and specialty pediatric care
182	182	providers of home and community-based services; and
183	183	(iv) providers located throughout the
184	184	region where the organization will provide health care services;
185	185	and
186	186	(C) health care services will be accessible to
187	187	recipients through the organization's provider network to a
188	188	comparable extent that health care services would be available to
189	189	recipients under a fee-for-service or primary care case management
190	190	model of Medicaid managed care;
191	191	(22) a requirement that the managed care organization
192	192	develop a monitoring program for measuring the quality of the
193	193	health care services provided by the organization's provider
194	194	network that:
195	195	(A) incorporates the National Committee for
196	196	Quality Assurance's Healthcare Effectiveness Data and Information
197	197	Set (HEDIS) measures;
198	198	(B) focuses on measuring outcomes; and
199	199	(C) includes the collection and analysis of
200	200	clinical data relating to prenatal care, preventive care, mental
201	201	health care, and the treatment of acute and chronic health
202	202	conditions and substance abuse;
203	203	(23) subject to Subsection (a-1), a requirement that
204	204	the managed care organization develop, implement, and maintain an
205	205	outpatient pharmacy benefit plan for its enrolled recipients:
206	206	(A) that exclusively employs the vendor drug
207	207	program formulary and preserves the state's ability to reduce
208	208	waste, fraud, and abuse under Medicaid;
209	209	(B) that adheres to the applicable preferred drug
210	210	list adopted by the commission under Section 531.072;
211	211	(C) that includes the prior authorization
212	212	procedures and requirements prescribed by or implemented under
213	213	Sections 531.073(b), (c), and (g) for the vendor drug program;
214	214	(D) for purposes of which the managed care
215	215	organization:
216	216	(i) may not negotiate or collect rebates
217	217	associated with pharmacy products on the vendor drug program
218	218	formulary; and
219	219	(ii) may not receive drug rebate or pricing
220	220	information that is confidential under Section 531.071;
221	221	(E) that complies with the prohibition under
222	222	Section 531.089;
223	223	(F) under which the managed care organization may
224	224	not prohibit, limit, or interfere with a recipient's selection of a
225	225	pharmacy or pharmacist of the recipient's choice for the provision
226	226	of pharmaceutical services under the plan through the imposition of
227	227	different copayments;
228	228	(G) under which a contract between the managed
229	229	care organization or any subcontracted pharmacy benefit manager and
230	230	a pharmacist or pharmacy provider shall indicate the reimbursement
231	231	methodology to be used, and must, at a minimum, indicate:
232	232	(i) the amount to be paid for each claim for
233	233	ingredient cost as a percentage of the amount that would be paid
234	234	under Medicaid fee-for-service; and
235	235	(ii) the amount to be paid for each claim
236	236	for the professional dispensing fee as a percentage of the amount
237	237	that would be paid under Medicaid fee-for-service;
238	238	(HG) 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	(IH) under which the managed care organization
254	254	may 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	(JI) under which the managed care organization
260	260	may include mail-order pharmacies in its networks, but may not
261	261	require enrolled recipients to use those pharmacies, and may not
262	262	charge an enrolled recipient who opts to use this service a fee,
263	263	including postage and handling fees;
264	264	(KJ) under which the managed care organization or
265	265	pharmacy benefit manager, as applicable, must pay claims in
266	266	accordance with Section 843.339, Insurance Code; and
267	267	(LK) under which the managed care organization or
268	268	pharmacy benefit manager, as applicable:
269	269	(i) to place a drug on a maximum allowable
270	270	cost list, must ensure that:
271	271	(a) the drug is listed as "A" or "B"
272	272	rated in the most recent version of the United States Food and Drug
273	273	Administration's Approved Drug Products with Therapeutic
274	274	Equivalence Evaluations, also known as the Orange Book, has an "NR"
275	275	or "NA" rating or a similar rating by a nationally recognized
276	276	reference; and
277	277	(b) the drug is generally available
278	278	for purchase by pharmacies in the state from national or regional
279	279	wholesalers and is not obsolete;
280	280	(ii) must provide to a network pharmacy
281	281	provider, at the time a contract is entered into or renewed with the
282	282	network pharmacy provider, the sources used to determine the
283	283	maximum allowable cost pricing for the maximum allowable cost list
284	284	specific to that provider;
285	285	(iii) must review and update maximum
286	286	allowable cost price information at least once every seven days to
287	287	reflect any modification of maximum allowable cost pricing;
288	288	(iv) must, in formulating the maximum
289	289	allowable cost price for a drug, use only the price of the drug and
290	290	drugs listed as therapeutically equivalent in the most recent
291	291	version of the United States Food and Drug Administration's
292	292	Approved Drug Products with Therapeutic Equivalence Evaluations,
293	293	also known as the Orange Book;
294	294	(v) must establish a process for
295	295	eliminating products from the maximum allowable cost list or
296	296	modifying maximum allowable cost prices in a timely manner to
297	297	remain consistent with pricing changes and product availability in
298	298	the marketplace;
299	299	(vi) must:
300	300	(a) provide a procedure under which a
301	301	network pharmacy provider may challenge a listed maximum allowable
302	302	cost price for a drug;
303	303	(b) respond to a challenge not later
304	304	than the 15th day after the date the challenge is made;
305	305	(c) if the challenge is successful,
306	306	make an adjustment in the drug price effective on the date the
307	307	challenge is resolved, and make the adjustment applicable to all
308	308	similarly situated network pharmacy providers, as determined by the
309	309	managed care organization or pharmacy benefit manager, as
310	310	appropriate;
311	311	(d) if the challenge is denied,
312	312	provide the reason for the denial; and
313	313	(e) report to the commission every 90
314	314	days the total number of challenges that were made and denied in the
315	315	preceding 90-day period for each maximum allowable cost list drug
316	316	for which a challenge was denied during the period;
317	317	(vii) must notify the commission not later
318	318	than the 21st day after implementing a practice of using a maximum
319	319	allowable cost list for drugs dispensed at retail but not by mail;
320	320	and
321	321	(viii) must provide a process for each of
322	322	its network pharmacy providers to readily access the maximum
323	323	allowable cost list specific to that provider;
324	324	(24) a requirement that the managed care organization
325	325	and any entity with which the managed care organization contracts
326	326	for the performance of services under a managed care plan disclose,
327	327	at no cost, to the commission and, on request, the office of the
328	328	attorney general all discounts, incentives, rebates, fees, free
329	329	goods, bundling arrangements, and other agreements affecting the
330	330	net cost of goods or services provided under the plan;
331	331	(25) a requirement that the managed care organization
332	332	not implement significant, nonnegotiated, across-the-board
333	333	provider reimbursement rate reductions unless:
334	334	(A) subject to Subsection (a-3), the
335	335	organization has the prior approval of the commission to make the
336	336	reduction; or
337	337	(B) the rate reductions are based on changes to
338	338	the Medicaid fee schedule or cost containment initiatives
339	339	implemented by the commission; and
340	340	(26) a requirement that the managed care organization
341	341	make initial and subsequent primary care provider assignments and
342	342	changes.
343	343	SECTION 2. If before implementing any provision of this Act
344	344	a state agency determines that a waiver or authorization from a
345	345	federal agency is necessary for implementation of that provision,
346	346	the agency affected by the provision shall request the waiver or
347	347	authorization and may delay implementing that provision until the
348	348	waiver or authorization is granted.
349	349	SECTION 3. This Act takes effect March 1, 2018.