Texas 2019 - 86th Regular

Texas House Bill HB2933 Compare Versions

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

Old	New	Differences
1	1	86R10176 LED-D
2	2	By: Hinojosa H.B. No. 2933
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to timely claims payments in the Medicaid managed care
8	8	program.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 533.005(a), Government Code, is amended
11	11	to read as follows:
12	12	(a) A contract between a managed care organization and the
13	13	commission for the organization to provide health care services to
14	14	recipients must contain:
15	15	(1) procedures to ensure accountability to the state
16	16	for the provision of health care services, including procedures for
17	17	financial reporting, quality assurance, utilization review, and
18	18	assurance of contract and subcontract compliance;
19	19	(2) capitation rates that ensure the cost-effective
20	20	provision of quality health care;
21	21	(3) a requirement that the managed care organization
22	22	provide ready access to a person who assists recipients in
23	23	resolving issues relating to enrollment, plan administration,
24	24	education and training, access to services, and grievance
25	25	procedures;
26	26	(4) a requirement that the managed care organization
27	27	provide ready access to a person who assists providers in resolving
28	28	issues relating to payment, plan administration, education and
29	29	training, and grievance procedures;
30	30	(5) a requirement that the managed care organization
31	31	provide information and referral about the availability of
32	32	educational, social, and other community services that could
33	33	benefit a recipient;
34	34	(6) procedures for recipient outreach and education;
35	35	(7) subject to Subdivision (7-b), a requirement that
36	36	the managed care organization make payment to a physician or
37	37	provider for health care services rendered to a recipient under a
38	38	managed care plan offered by the managed care organization on any
39	39	claim for payment that is received with documentation reasonably
40	40	necessary for the managed care organization to process the claim:
41	41	(A) not later than[:
42	42	[(i)] the 10th day after the date the claim
43	43	is received if the claim relates to services provided by a nursing
44	44	facility, intermediate care facility, or group home; and
45	45	(B) on average, not later than [(ii)] the 15th
46	46	[30th] day after the date the claim is received if the claim,
47	47	including a claim that relates to the provision of long-term
48	48	services and supports, is not subject to Paragraph (A)
49	49	[Subparagraph (i); and
50	50	[(iii) the 45th day after the date the claim
51	51	is received if the claim is not subject to Subparagraph (i) or (ii);
52	52	or
53	53	[(B) within a period, not to exceed 60 days,
54	54	specified by a written agreement between the physician or provider
55	55	and the managed care organization];
56	56	(7-a) a requirement that the managed care organization
57	57	demonstrate to the commission that the organization pays claims to
58	58	which [described by] Subdivision (7)(B) applies [(7)(A)(ii)] on
59	59	average not later than the 15th [21st] day after the date the claim
60	60	is received by the organization;
61	61	(7-b) a requirement that the managed care organization
62	62	demonstrate to the commission that, within each provider category
63	63	and service delivery area designated by the commission, the
64	64	organization pays at least 98 percent of claims within the times
65	65	prescribed by Subdivision (7);
66	66	(7-c) a requirement that, on any claim for payment that
67	67	is received without documentation reasonably necessary for the
68	68	managed care organization to process the claim, the managed care
69	69	organization make payment to a physician or provider for health
70	70	care services rendered to a recipient under a managed care plan
71	71	offered by the managed care organization not later than the 15th day
72	72	after the date the organization receives the documentation
73	73	necessary to process the claim;
74	74	(7-d) a requirement that a project to fix the managed
75	75	care organization's claims processing system last not longer than
76	76	60 days and that the organization make payment on a claim that is
77	77	pending because of the project not later than the 30th day after the
78	78	date the project is completed;
79	79	(8) a requirement that the commission, on the date of a
80	80	recipient's enrollment in a managed care plan issued by the managed
81	81	care organization, inform the organization of the recipient's
82	82	Medicaid certification date;
83	83	(9) a requirement that the managed care organization
84	84	comply with Section 533.006 as a condition of contract retention
85	85	and renewal;
86	86	(10) a requirement that the managed care organization
87	87	provide the information required by Section 533.012 and otherwise
88	88	comply and cooperate with the commission's office of inspector
89	89	general and the office of the attorney general;
90	90	(11) a requirement that the managed care
91	91	organization's usages of out-of-network providers or groups of
92	92	out-of-network providers may not exceed limits for those usages
93	93	relating to total inpatient admissions, total outpatient services,
94	94	and emergency room admissions determined by the commission;
95	95	(12) if the commission finds that a managed care
96	96	organization has violated Subdivision (11), a requirement that the
97	97	managed care organization reimburse an out-of-network provider for
98	98	health care services at a rate that is equal to the allowable rate
99	99	for those services, as determined under Sections 32.028 and
100	100	32.0281, Human Resources Code;
101	101	(13) a requirement that, notwithstanding any other
102	102	law, including Sections 843.312 and 1301.052, Insurance Code, the
103	103	organization:
104	104	(A) use advanced practice registered nurses and
105	105	physician assistants in addition to physicians as primary care
106	106	providers to increase the availability of primary care providers in
107	107	the organization's provider network; and
108	108	(B) treat advanced practice registered nurses
109	109	and physician assistants in the same manner as primary care
110	110	physicians with regard to:
111	111	(i) selection and assignment as primary
112	112	care providers;
113	113	(ii) inclusion as primary care providers in
114	114	the organization's provider network; and
115	115	(iii) inclusion as primary care providers
116	116	in any provider network directory maintained by the organization;
117	117	(14) a requirement that the managed care organization
118	118	reimburse a federally qualified health center or rural health
119	119	clinic for health care services provided to a recipient outside of
120	120	regular business hours, including on a weekend day or holiday, at a
121	121	rate that is equal to the allowable rate for those services as
122	122	determined under Section 32.028, Human Resources Code, if the
123	123	recipient does not have a referral from the recipient's primary
124	124	care physician;
125	125	(15) a requirement that the managed care organization
126	126	develop, implement, and maintain a system for tracking and
127	127	resolving all provider appeals related to claims payment, including
128	128	a process that will require:
129	129	(A) a tracking mechanism to document the status
130	130	and final disposition of each provider's claims payment appeal;
131	131	(B) the contracting with physicians who are not
132	132	network providers and who are of the same or related specialty as
133	133	the appealing physician to resolve claims disputes related to
134	134	denial on the basis of medical necessity that remain unresolved
135	135	subsequent to a provider appeal;
136	136	(C) the determination of the physician resolving
137	137	the dispute to be binding on the managed care organization and
138	138	provider; and
139	139	(D) the managed care organization to allow a
140	140	provider with a claim that has not been paid before the time
141	141	prescribed by Subdivision (7)(B) [(7)(A)(ii)] to initiate an appeal
142	142	of that claim;
143	143	(16) a requirement that a medical director who is
144	144	authorized to make medical necessity determinations is available to
145	145	the region where the managed care organization provides health care
146	146	services;
147	147	(17) a requirement that the managed care organization
148	148	ensure that a medical director and patient care coordinators and
149	149	provider and recipient support services personnel are located in
150	150	the South Texas service region, if the managed care organization
151	151	provides a managed care plan in that region;
152	152	(18) a requirement that the managed care organization
153	153	provide special programs and materials for recipients with limited
154	154	English proficiency or low literacy skills;
155	155	(19) a requirement that the managed care organization
156	156	develop and establish a process for responding to provider appeals
157	157	in the region where the organization provides health care services;
158	158	(20) a requirement that the managed care organization:
159	159	(A) develop and submit to the commission, before
160	160	the organization begins to provide health care services to
161	161	recipients, a comprehensive plan that describes how the
162	162	organization's provider network complies with the provider access
163	163	standards established under Section 533.0061;
164	164	(B) as a condition of contract retention and
165	165	renewal:
166	166	(i) continue to comply with the provider
167	167	access standards established under Section 533.0061; and
168	168	(ii) make substantial efforts, as
169	169	determined by the commission, to mitigate or remedy any
170	170	noncompliance with the provider access standards established under
171	171	Section 533.0061;
172	172	(C) pay liquidated damages for each failure, as
173	173	determined by the commission, to comply with the provider access
174	174	standards established under Section 533.0061 in amounts that are
175	175	reasonably related to the noncompliance; and
176	176	(D) regularly, as determined by the commission,
177	177	submit to the commission and make available to the public a report
178	178	containing data on the sufficiency of the organization's provider
179	179	network with regard to providing the care and services described
180	180	under Section 533.0061(a) and specific data with respect to access
181	181	to primary care, specialty care, long-term services and supports,
182	182	nursing services, and therapy services on the average length of
183	183	time between:
184	184	(i) the date a provider requests prior
185	185	authorization for the care or service and the date the organization
186	186	approves or denies the request; and
187	187	(ii) the date the organization approves a
188	188	request for prior authorization for the care or service and the date
189	189	the care or service is initiated;
190	190	(21) a requirement that the managed care organization
191	191	demonstrate to the commission, before the organization begins to
192	192	provide health care services to recipients, that, subject to the
193	193	provider access standards established under Section 533.0061:
194	194	(A) the organization's provider network has the
195	195	capacity to serve the number of recipients expected to enroll in a
196	196	managed care plan offered by the organization;
197	197	(B) the organization's provider network
198	198	includes:
199	199	(i) a sufficient number of primary care
200	200	providers;
201	201	(ii) a sufficient variety of provider
202	202	types;
203	203	(iii) a sufficient number of providers of
204	204	long-term services and supports and specialty pediatric care
205	205	providers of home and community-based services; and
206	206	(iv) providers located throughout the
207	207	region where the organization will provide health care services;
208	208	and
209	209	(C) health care services will be accessible to
210	210	recipients through the organization's provider network to a
211	211	comparable extent that health care services would be available to
212	212	recipients under a fee-for-service or primary care case management
213	213	model of Medicaid managed care;
214	214	(22) a requirement that the managed care organization
215	215	develop a monitoring program for measuring the quality of the
216	216	health care services provided by the organization's provider
217	217	network that:
218	218	(A) incorporates the National Committee for
219	219	Quality Assurance's Healthcare Effectiveness Data and Information
220	220	Set (HEDIS) measures;
221	221	(B) focuses on measuring outcomes; and
222	222	(C) includes the collection and analysis of
223	223	clinical data relating to prenatal care, preventive care, mental
224	224	health care, and the treatment of acute and chronic health
225	225	conditions and substance abuse;
226	226	(23) subject to Subsection (a-1), a requirement that
227	227	the managed care organization develop, implement, and maintain an
228	228	outpatient pharmacy benefit plan for its enrolled recipients:
229	229	(A) that exclusively employs the vendor drug
230	230	program formulary and preserves the state's ability to reduce
231	231	waste, fraud, and abuse under Medicaid;
232	232	(B) that adheres to the applicable preferred drug
233	233	list adopted by the commission under Section 531.072;
234	234	(C) that includes the prior authorization
235	235	procedures and requirements prescribed by or implemented under
236	236	Sections 531.073(b), (c), and (g) for the vendor drug program;
237	237	(D) for purposes of which the managed care
238	238	organization:
239	239	(i) may not negotiate or collect rebates
240	240	associated with pharmacy products on the vendor drug program
241	241	formulary; and
242	242	(ii) may not receive drug rebate or pricing
243	243	information that is confidential under Section 531.071;
244	244	(E) that complies with the prohibition under
245	245	Section 531.089;
246	246	(F) under which the managed care organization may
247	247	not prohibit, limit, or interfere with a recipient's selection of a
248	248	pharmacy or pharmacist of the recipient's choice for the provision
249	249	of pharmaceutical services under the plan through the imposition of
250	250	different copayments;
251	251	(G) that allows the managed care organization or
252	252	any subcontracted pharmacy benefit manager to contract with a
253	253	pharmacist or pharmacy providers separately for specialty pharmacy
254	254	services, except that:
255	255	(i) the managed care organization and
256	256	pharmacy benefit manager are prohibited from allowing exclusive
257	257	contracts with a specialty pharmacy owned wholly or partly by the
258	258	pharmacy benefit manager responsible for the administration of the
259	259	pharmacy benefit program; and
260	260	(ii) the managed care organization and
261	261	pharmacy benefit manager must adopt policies and procedures for
262	262	reclassifying prescription drugs from retail to specialty drugs,
263	263	and those policies and procedures must be consistent with rules
264	264	adopted by the executive commissioner and include notice to network
265	265	pharmacy providers from the managed care organization;
266	266	(H) under which the managed care organization may
267	267	not prevent a pharmacy or pharmacist from participating as a
268	268	provider if the pharmacy or pharmacist agrees to comply with the
269	269	financial terms and conditions of the contract as well as other
270	270	reasonable administrative and professional terms and conditions of
271	271	the contract;
272	272	(I) under which the managed care organization may
273	273	include mail-order pharmacies in its networks, but may not require
274	274	enrolled recipients to use those pharmacies, and may not charge an
275	275	enrolled recipient who opts to use this service a fee, including
276	276	postage and handling fees;
277	277	(J) under which the managed care organization or
278	278	pharmacy benefit manager, as applicable, must pay claims in
279	279	accordance with Section 843.339, Insurance Code; and
280	280	(K) under which the managed care organization or
281	281	pharmacy benefit manager, as applicable:
282	282	(i) to place a drug on a maximum allowable
283	283	cost list, must ensure that:
284	284	(a) the drug is listed as "A" or "B"
285	285	rated in the most recent version of the United States Food and Drug
286	286	Administration's Approved Drug Products with Therapeutic
287	287	Equivalence Evaluations, also known as the Orange Book, has an "NR"
288	288	or "NA" rating or a similar rating by a nationally recognized
289	289	reference; and
290	290	(b) the drug is generally available
291	291	for purchase by pharmacies in the state from national or regional
292	292	wholesalers and is not obsolete;
293	293	(ii) must provide to a network pharmacy
294	294	provider, at the time a contract is entered into or renewed with the
295	295	network pharmacy provider, the sources used to determine the
296	296	maximum allowable cost pricing for the maximum allowable cost list
297	297	specific to that provider;
298	298	(iii) must review and update maximum
299	299	allowable cost price information at least once every seven days to
300	300	reflect any modification of maximum allowable cost pricing;
301	301	(iv) must, in formulating the maximum
302	302	allowable cost price for a drug, use only the price of the drug and
303	303	drugs listed as therapeutically equivalent in the most recent
304	304	version of the United States Food and Drug Administration's
305	305	Approved Drug Products with Therapeutic Equivalence Evaluations,
306	306	also known as the Orange Book;
307	307	(v) must establish a process for
308	308	eliminating products from the maximum allowable cost list or
309	309	modifying maximum allowable cost prices in a timely manner to
310	310	remain consistent with pricing changes and product availability in
311	311	the marketplace;
312	312	(vi) must:
313	313	(a) provide a procedure under which a
314	314	network pharmacy provider may challenge a listed maximum allowable
315	315	cost price for a drug;
316	316	(b) respond to a challenge not later
317	317	than the 15th day after the date the challenge is made;
318	318	(c) if the challenge is successful,
319	319	make an adjustment in the drug price effective on the date the
320	320	challenge is resolved[,] and make the adjustment applicable to all
321	321	similarly situated network pharmacy providers, as determined by the
322	322	managed care organization or pharmacy benefit manager, as
323	323	appropriate;
324	324	(d) if the challenge is denied,
325	325	provide the reason for the denial; and
326	326	(e) report to the commission every 90
327	327	days the total number of challenges that were made and denied in the
328	328	preceding 90-day period for each maximum allowable cost list drug
329	329	for which a challenge was denied during the period;
330	330	(vii) must notify the commission not later
331	331	than the 21st day after implementing a practice of using a maximum
332	332	allowable cost list for drugs dispensed at retail but not by mail;
333	333	and
334	334	(viii) must provide a process for each of
335	335	its network pharmacy providers to readily access the maximum
336	336	allowable cost list specific to that provider;
337	337	(24) a requirement that the managed care organization
338	338	and any entity with which the managed care organization contracts
339	339	for the performance of services under a managed care plan disclose,
340	340	at no cost, to the commission and, on request, the office of the
341	341	attorney general all discounts, incentives, rebates, fees, free
342	342	goods, bundling arrangements, and other agreements affecting the
343	343	net cost of goods or services provided under the plan;
344	344	(25) a requirement that the managed care organization
345	345	not implement significant, nonnegotiated, across-the-board
346	346	provider reimbursement rate reductions unless:
347	347	(A) subject to Subsection (a-3), the
348	348	organization has the prior approval of the commission to make the
349	349	reductions [reduction]; or
350	350	(B) the rate reductions are based on changes to
351	351	the Medicaid fee schedule or cost containment initiatives
352	352	implemented by the commission; and
353	353	(26) a requirement that the managed care organization
354	354	make initial and subsequent primary care provider assignments and
355	355	changes.
356	356	SECTION 2. Section 533.005, Government Code, as amended by
357	357	this Act, applies to a contract entered into or renewed on or after
358	358	the effective date of this Act. A contract entered into or renewed
359	359	before that date is governed by the law in effect on the date the
360	360	contract was entered into or renewed, and that law is continued in
361	361	effect for that purpose.
362	362	SECTION 3. If before implementing any provision of this Act
363	363	a state agency determines that a waiver or authorization from a
364	364	federal agency is necessary for implementation of that provision,
365	365	the agency affected by the provision shall request the waiver or
366	366	authorization and may delay implementing that provision until the
367	367	waiver or authorization is granted.
368	368	SECTION 4. This Act takes effect September 1, 2019.