Texas 2019 - 86th Regular

Texas House Bill HB3187 Compare Versions

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

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1	1	86R13385 KKR-F
2	2	By: Muñoz, Jr. H.B. No. 3187
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the processing and payment of claims for reimbursement
8	8	by certain providers under the Medicaid 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) a requirement that the managed care organization
36	36	make payment to a physician or provider for health care services
37	37	rendered to a recipient under a managed care plan on any claim for
38	38	payment that is received with documentation reasonably necessary
39	39	for the managed care organization to process the claim[:
40	40	[(A)] not later than:
41	41	(A) [(i)] the 10th day after the date the claim
42	42	is received if the claim relates to services provided by a nursing
43	43	facility, intermediate care facility, or group home; and
44	44	(B) on average, [(ii)] the 15th [30th] day after
45	45	the date the claim is received if the claim, including a claim that
46	46	relates to the provision of long-term services and supports, is not
47	47	subject to Paragraph (A) [Subparagraph (i); and
48	48	[(iii) the 45th day after the date the claim
49	49	is received if the claim is not subject to Subparagraph (i) or (ii);
50	50	or
51	51	[(B) within a period, not to exceed 60 days,
52	52	specified by a written agreement between the physician or provider
53	53	and the managed care organization];
54	54	(7-a) a requirement that the managed care organization
55	55	demonstrate to the commission that the organization pays claims
56	56	described by Subdivision (7)(B) [(7)(A)(ii)] on average not later
57	57	than the 15th [21st] day after the date the claim is received by the
58	58	organization;
59	59	(7-b) a requirement that the managed care organization
60	60	allow a physician or provider to electronically submit
61	61	documentation necessary for the managed care organization to
62	62	process a claim for payment for health care services rendered to a
63	63	recipient under a managed care plan, including additional
64	64	documentation necessary when the claim is not submitted with
65	65	documentation reasonably necessary for the managed care
66	66	organization to process the claim;
67	67	(8) a requirement that the commission, on the date of a
68	68	recipient's enrollment in a managed care plan issued by the managed
69	69	care organization, inform the organization of the recipient's
70	70	Medicaid certification date;
71	71	(9) a requirement that the managed care organization
72	72	comply with Section 533.006 as a condition of contract retention
73	73	and renewal;
74	74	(10) a requirement that the managed care organization
75	75	provide the information required by Section 533.012 and otherwise
76	76	comply and cooperate with the commission's office of inspector
77	77	general and the office of the attorney general;
78	78	(11) a requirement that the managed care
79	79	organization's usages of out-of-network providers or groups of
80	80	out-of-network providers may not exceed limits for those usages
81	81	relating to total inpatient admissions, total outpatient services,
82	82	and emergency room admissions determined by the commission;
83	83	(12) if the commission finds that a managed care
84	84	organization has violated Subdivision (11), a requirement that the
85	85	managed care organization reimburse an out-of-network provider for
86	86	health care services at a rate that is equal to the allowable rate
87	87	for those services, as determined under Sections 32.028 and
88	88	32.0281, Human Resources Code;
89	89	(13) a requirement that, notwithstanding any other
90	90	law, including Sections 843.312 and 1301.052, Insurance Code, the
91	91	organization:
92	92	(A) use advanced practice registered nurses and
93	93	physician assistants in addition to physicians as primary care
94	94	providers to increase the availability of primary care providers in
95	95	the organization's provider network; and
96	96	(B) treat advanced practice registered nurses
97	97	and physician assistants in the same manner as primary care
98	98	physicians with regard to:
99	99	(i) selection and assignment as primary
100	100	care providers;
101	101	(ii) inclusion as primary care providers in
102	102	the organization's provider network; and
103	103	(iii) inclusion as primary care providers
104	104	in any provider network directory maintained by the organization;
105	105	(14) a requirement that the managed care organization
106	106	reimburse a federally qualified health center or rural health
107	107	clinic for health care services provided to a recipient outside of
108	108	regular business hours, including on a weekend day or holiday, at a
109	109	rate that is equal to the allowable rate for those services as
110	110	determined under Section 32.028, Human Resources Code, if the
111	111	recipient does not have a referral from the recipient's primary
112	112	care physician;
113	113	(15) a requirement that the managed care organization
114	114	develop, implement, and maintain a system for tracking and
115	115	resolving all provider appeals related to claims payment, including
116	116	a process that will require:
117	117	(A) a tracking mechanism to document the status
118	118	and final disposition of each provider's claims payment appeal;
119	119	(B) the contracting with physicians who are not
120	120	network providers and who are of the same or related specialty as
121	121	the appealing physician to resolve claims disputes related to
122	122	denial on the basis of medical necessity that remain unresolved
123	123	subsequent to a provider appeal;
124	124	(C) the determination of the physician resolving
125	125	the dispute to be binding on the managed care organization and
126	126	provider; and
127	127	(D) the managed care organization to allow a
128	128	provider with a claim that has not been paid before the time
129	129	prescribed by Subdivision (7)(B) [(7)(A)(ii)] to initiate an appeal
130	130	of that claim;
131	131	(16) a requirement that a medical director who is
132	132	authorized to make medical necessity determinations is available to
133	133	the region where the managed care organization provides health care
134	134	services;
135	135	(17) a requirement that the managed care organization
136	136	ensure that a medical director and patient care coordinators and
137	137	provider and recipient support services personnel are located in
138	138	the South Texas service region, if the managed care organization
139	139	provides a managed care plan in that region;
140	140	(18) a requirement that the managed care organization
141	141	provide special programs and materials for recipients with limited
142	142	English proficiency or low literacy skills;
143	143	(19) a requirement that the managed care organization
144	144	develop and establish a process for responding to provider appeals
145	145	in the region where the organization provides health care services;
146	146	(20) a requirement that the managed care organization:
147	147	(A) develop and submit to the commission, before
148	148	the organization begins to provide health care services to
149	149	recipients, a comprehensive plan that describes how the
150	150	organization's provider network complies with the provider access
151	151	standards established under Section 533.0061;
152	152	(B) as a condition of contract retention and
153	153	renewal:
154	154	(i) continue to comply with the provider
155	155	access standards established under Section 533.0061; and
156	156	(ii) make substantial efforts, as
157	157	determined by the commission, to mitigate or remedy any
158	158	noncompliance with the provider access standards established under
159	159	Section 533.0061;
160	160	(C) pay liquidated damages for each failure, as
161	161	determined by the commission, to comply with the provider access
162	162	standards established under Section 533.0061 in amounts that are
163	163	reasonably related to the noncompliance; and
164	164	(D) regularly, as determined by the commission,
165	165	submit to the commission and make available to the public a report
166	166	containing data on the sufficiency of the organization's provider
167	167	network with regard to providing the care and services described
168	168	under Section 533.0061(a) and specific data with respect to access
169	169	to primary care, specialty care, long-term services and supports,
170	170	nursing services, and therapy services on the average length of
171	171	time between:
172	172	(i) the date a provider requests prior
173	173	authorization for the care or service and the date the organization
174	174	approves or denies the request; and
175	175	(ii) the date the organization approves a
176	176	request for prior authorization for the care or service and the date
177	177	the care or service is 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, subject to the
181	181	provider access standards established under Section 533.0061:
182	182	(A) the organization's provider network has the
183	183	capacity to serve the number of recipients expected to enroll in a
184	184	managed care plan offered by the organization;
185	185	(B) the organization's provider network
186	186	includes:
187	187	(i) a sufficient number of primary care
188	188	providers;
189	189	(ii) a sufficient variety of provider
190	190	types;
191	191	(iii) a sufficient number of providers of
192	192	long-term services and supports and specialty pediatric care
193	193	providers of home and community-based services; and
194	194	(iv) providers located throughout the
195	195	region where the organization will provide health care services;
196	196	and
197	197	(C) health care services will be accessible to
198	198	recipients through the organization's provider network to a
199	199	comparable extent that health care services would be available to
200	200	recipients under a fee-for-service or primary care case management
201	201	model of Medicaid managed care;
202	202	(22) a requirement that the managed care organization
203	203	develop a monitoring program for measuring the quality of the
204	204	health care services provided by the organization's provider
205	205	network that:
206	206	(A) incorporates the National Committee for
207	207	Quality Assurance's Healthcare Effectiveness Data and Information
208	208	Set (HEDIS) measures;
209	209	(B) focuses on measuring outcomes; and
210	210	(C) includes the collection and analysis of
211	211	clinical data relating to prenatal care, preventive care, mental
212	212	health care, and the treatment of acute and chronic health
213	213	conditions and substance abuse;
214	214	(23) subject to Subsection (a-1), a requirement that
215	215	the managed care organization develop, implement, and maintain an
216	216	outpatient pharmacy benefit plan for its enrolled recipients:
217	217	(A) that exclusively employs the vendor drug
218	218	program formulary and preserves the state's ability to reduce
219	219	waste, fraud, and abuse under Medicaid;
220	220	(B) that adheres to the applicable preferred drug
221	221	list adopted by the commission under Section 531.072;
222	222	(C) that includes the prior authorization
223	223	procedures and requirements prescribed by or implemented under
224	224	Sections 531.073(b), (c), and (g) for the vendor drug program;
225	225	(D) for purposes of which the managed care
226	226	organization:
227	227	(i) may not negotiate or collect rebates
228	228	associated with pharmacy products on the vendor drug program
229	229	formulary; and
230	230	(ii) may not receive drug rebate or pricing
231	231	information that is confidential under Section 531.071;
232	232	(E) that complies with the prohibition under
233	233	Section 531.089;
234	234	(F) under which the managed care organization may
235	235	not prohibit, limit, or interfere with a recipient's selection of a
236	236	pharmacy or pharmacist of the recipient's choice for the provision
237	237	of pharmaceutical services under the plan through the imposition of
238	238	different copayments;
239	239	(G) that allows the managed care organization or
240	240	any subcontracted pharmacy benefit manager to contract with a
241	241	pharmacist or pharmacy providers separately for specialty pharmacy
242	242	services, except that:
243	243	(i) the managed care organization and
244	244	pharmacy benefit manager are prohibited from allowing exclusive
245	245	contracts with a specialty pharmacy owned wholly or partly by the
246	246	pharmacy benefit manager responsible for the administration of the
247	247	pharmacy benefit program; and
248	248	(ii) the managed care organization and
249	249	pharmacy benefit manager must adopt policies and procedures for
250	250	reclassifying prescription drugs from retail to specialty drugs,
251	251	and those policies and procedures must be consistent with rules
252	252	adopted by the executive commissioner and include notice to network
253	253	pharmacy providers from the managed care organization;
254	254	(H) under which the managed care organization may
255	255	not prevent a pharmacy or pharmacist from participating as a
256	256	provider if the pharmacy or pharmacist agrees to comply with the
257	257	financial terms and conditions of the contract as well as other
258	258	reasonable administrative and professional terms and conditions of
259	259	the contract;
260	260	(I) under which the managed care organization may
261	261	include mail-order pharmacies in its networks, but may not require
262	262	enrolled recipients to use those pharmacies, and may not charge an
263	263	enrolled recipient who opts to use this service a fee, including
264	264	postage and handling fees;
265	265	(J) under which the managed care organization or
266	266	pharmacy benefit manager, as applicable, must pay claims and allow
267	267	the electronic submission of claims documentation in accordance
268	268	with Subdivisions (7) and (7-b) [Section 843.339, Insurance Code];
269	269	and
270	270	(K) under which the managed care organization or
271	271	pharmacy benefit manager, as applicable:
272	272	(i) to place a drug on a maximum allowable
273	273	cost list, must ensure that:
274	274	(a) the drug is listed as "A" or "B"
275	275	rated in the most recent version of the United States Food and Drug
276	276	Administration's Approved Drug Products with Therapeutic
277	277	Equivalence Evaluations, also known as the Orange Book, has an "NR"
278	278	or "NA" rating or a similar rating by a nationally recognized
279	279	reference; and
280	280	(b) the drug is generally available
281	281	for purchase by pharmacies in the state from national or regional
282	282	wholesalers and is not obsolete;
283	283	(ii) must provide to a network pharmacy
284	284	provider, at the time a contract is entered into or renewed with the
285	285	network pharmacy provider, the sources used to determine the
286	286	maximum allowable cost pricing for the maximum allowable cost list
287	287	specific to that provider;
288	288	(iii) must review and update maximum
289	289	allowable cost price information at least once every seven days to
290	290	reflect any modification of maximum allowable cost pricing;
291	291	(iv) must, in formulating the maximum
292	292	allowable cost price for a drug, use only the price of the drug and
293	293	drugs listed as therapeutically equivalent in the most recent
294	294	version of the United States Food and Drug Administration's
295	295	Approved Drug Products with Therapeutic Equivalence Evaluations,
296	296	also known as the Orange Book;
297	297	(v) must establish a process for
298	298	eliminating products from the maximum allowable cost list or
299	299	modifying maximum allowable cost prices in a timely manner to
300	300	remain consistent with pricing changes and product availability in
301	301	the marketplace;
302	302	(vi) must:
303	303	(a) provide a procedure under which a
304	304	network pharmacy provider may challenge a listed maximum allowable
305	305	cost price for a drug;
306	306	(b) respond to a challenge not later
307	307	than the 15th day after the date the challenge is made;
308	308	(c) if the challenge is successful,
309	309	make an adjustment in the drug price effective on the date the
310	310	challenge is resolved[,] and make the adjustment applicable to all
311	311	similarly situated network pharmacy providers, as determined by the
312	312	managed care organization or pharmacy benefit manager, as
313	313	appropriate;
314	314	(d) if the challenge is denied,
315	315	provide the reason for the denial; and
316	316	(e) report to the commission every 90
317	317	days the total number of challenges that were made and denied in the
318	318	preceding 90-day period for each maximum allowable cost list drug
319	319	for which a challenge was denied during the period;
320	320	(vii) must notify the commission not later
321	321	than the 21st day after implementing a practice of using a maximum
322	322	allowable cost list for drugs dispensed at retail but not by mail;
323	323	and
324	324	(viii) must provide a process for each of
325	325	its network pharmacy providers to readily access the maximum
326	326	allowable cost list specific to that provider;
327	327	(24) a requirement that the managed care organization
328	328	and any entity with which the managed care organization contracts
329	329	for the performance of services under a managed care plan disclose,
330	330	at no cost, to the commission and, on request, the office of the
331	331	attorney general all discounts, incentives, rebates, fees, free
332	332	goods, bundling arrangements, and other agreements affecting the
333	333	net cost of goods or services provided under the plan;
334	334	(25) a requirement that the managed care organization
335	335	not implement significant, nonnegotiated, across-the-board
336	336	provider reimbursement rate reductions unless:
337	337	(A) subject to Subsection (a-3), the
338	338	organization has the prior approval of the commission to make the
339	339	reductions [reduction]; or
340	340	(B) the rate reductions are based on changes to
341	341	the Medicaid fee schedule or cost containment initiatives
342	342	implemented by the commission; and
343	343	(26) a requirement that the managed care organization
344	344	make initial and subsequent primary care provider assignments and
345	345	changes.
346	346	SECTION 2. Subchapter B, Chapter 32, Human Resources Code,
347	347	is amended by adding Section 32.0292 to read as follows:
348	348	Sec. 32.0292. PAYMENT OF CERTAIN TRANSPORTATION CLAIMS.
349	349	The executive commissioner shall adopt rules to ensure the
350	350	commission or the commission's designee pays a claim for
351	351	nonemergency ambulance services provided to a recipient of medical
352	352	assistance under this chapter not later than the 15th day after the
353	353	date the claim for payment is received with documentation
354	354	reasonably necessary for the commission or the designee to process
355	355	the claim.
356	356	SECTION 3. The executive commissioner of the Health and
357	357	Human Services Commission shall adopt the rules necessary to
358	358	implement Section 32.0292, Human Resources Code, as added by this
359	359	Act, not later than October 1, 2019.
360	360	SECTION 4. (a) The Health and Human Services Commission, in
361	361	a contract between the commission and a managed care organization
362	362	under Chapter 533, Government Code, that is entered into or renewed
363	363	on or after the effective date of this Act, shall require that the
364	364	managed care organization comply with Sections 533.005(a)(7),
365	365	(7-a), and (23)(J), Government Code, as amended by this Act, and
366	366	Section 533.005(a)(7-b), Government Code, as added by this Act.
367	367	(b) The Health and Human Services Commission shall seek to
368	368	amend contracts entered into with managed care organizations under
369	369	Chapter 533, Government Code, before the effective date of this Act
370	370	to require that those managed care organizations comply with
371	371	Sections 533.005(a)(7), (7-a), and (23)(J), Government Code, as
372	372	amended by this Act, and Section 533.005(a)(7-b), Government Code,
373	373	as added by this Act. To the extent of a conflict between those
374	374	provisions and a provision of a contract with a managed care
375	375	organization entered into before the effective date of this Act,
376	376	the contract provision prevails.
377	377	SECTION 5. If before implementing any provision of this Act
378	378	a state agency determines that a waiver or authorization from a
379	379	federal agency is necessary for implementation of that provision,
380	380	the agency affected by the provision shall request the waiver or
381	381	authorization and may delay implementing that provision until the
382	382	waiver or authorization is granted.
383	383	SECTION 6. This Act takes effect September 1, 2019.