Texas 2019 - 86th Regular

Texas House Bill HB3748 Compare Versions

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

Old	New	Differences
1	1	86R9886 LED-D
2	2	By: Krause H.B. No. 3748
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the coordination of private health benefits with
8	8	Medicaid benefits.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subchapter A, Chapter 533, Government Code, is
11	11	amended by adding Section 533.038 to read as follows:
12	12	Sec. 533.038. COORDINATION OF BENEFITS. (a) In this
13	13	section:
14	14	(1) "Medicaid managed care organization" means a
15	15	managed care organization that contracts with the commission under
16	16	this chapter to provide health care services to recipients.
17	17	(2) "Medicaid wrap-around benefit" means a
18	18	Medicaid-covered service, including a pharmacy or medical benefit,
19	19	that is provided to a recipient with both Medicaid and primary
20	20	health benefit plan coverage when the recipient has exceeded the
21	21	primary health benefit plan coverage limit or when the service is
22	22	not covered by the primary health benefit plan issuer.
23	23	(b) The commission, in coordination with Medicaid managed
24	24	care organizations, shall develop and adopt a clear policy for a
25	25	Medicaid managed care organization to ensure the coordination and
26	26	timely delivery of Medicaid wrap-around benefits for recipients
27	27	with both primary health benefit plan coverage and Medicaid
28	28	coverage.
29	29	(c) To further assist with the coordination of benefits, the
30	30	commission, in coordination with Medicaid managed care
31	31	organizations, shall develop and maintain a list of services that
32	32	are not traditionally covered by primary health benefit plan
33	33	coverage that a Medicaid managed care organization may approve
34	34	without having to coordinate with the primary health benefit plan
35	35	issuer and that can be resolved through third-party liability
36	36	resolution processes. The commission shall review and update the
37	37	list quarterly.
38	38	(d) A Medicaid managed care organization that in good faith
39	39	and following commission policies provides coverage for a Medicaid
40	40	wrap-around benefit shall include the cost of providing the benefit
41	41	in the organization's financial reports. The commission shall
42	42	include the reported costs in computing capitation rates for the
43	43	managed care organization.
44	44	(e) If the commission determines that a recipient's primary
45	45	health benefit plan issuer should have been the primary payor of a
46	46	claim, the Medicaid managed care organization that paid the claim
47	47	shall work with the commission on the recovery process and make
48	48	every attempt to reduce health care provider and recipient
49	49	abrasion.
50	50	(f) The executive commissioner may seek a waiver from the
51	51	federal government as needed to:
52	52	(1) address federal policies related to coordination
53	53	of benefits and third-party liability; and
54	54	(2) maximize federal financial participation for
55	55	recipients with both primary health benefit plan coverage and
56	56	Medicaid coverage.
57	57	(g) Notwithstanding Sections 531.073 and 533.005(a)(23) or
58	58	any other law, the commission shall ensure that a prescription drug
59	59	that is covered under the Medicaid vendor drug program or other
60	60	applicable formulary and is prescribed to a recipient with primary
61	61	health benefit plan coverage is not subject to any prior
62	62	authorization requirement if the primary health benefit plan issuer
63	63	will pay at least $0.01 on the prescription drug claim. If the
64	64	primary insurer will pay nothing on a prescription drug claim, the
65	65	prescription drug is subject to any applicable Medicaid clinical or
66	66	nonpreferred prior authorization requirement.
67	67	(h) The commission shall ensure that the daily Medicaid
68	68	managed care eligibility files indicate whether a recipient has
69	69	primary health benefit plan coverage or health insurance premium
70	70	payment coverage. For a recipient who has that coverage, the files
71	71	must include the following up-to-date, accurate information
72	72	related to primary health benefit plan coverage:
73	73	(1) the health benefit plan issuer's name and address
74	74	and the recipient's policy number;
75	75	(2) the primary health benefit plan coverage start and
76	76	end dates;
77	77	(3) the primary health benefit plan coverage benefits,
78	78	limits, copayment, and coinsurance information; and
79	79	(4) any additional information that would be useful to
80	80	ensure the coordination of benefits.
81	81	(i) The commission shall develop and implement processes
82	82	and policies to allow a health care provider who is primarily
83	83	providing services to a recipient through primary health benefit
84	84	plan coverage to receive Medicaid reimbursement for services
85	85	ordered, referred, prescribed, or delivered, regardless of whether
86	86	the provider is enrolled as a Medicaid provider. The commission
87	87	shall allow a provider who is not enrolled as a Medicaid provider to
88	88	order, refer, prescribe, or deliver services to a recipient based
89	89	on the provider's national provider identifier number and may not
90	90	require an additional state provider identifier number to receive
91	91	reimbursement for the services. The commission may seek a waiver of
92	92	Medicaid provider enrollment requirements for providers of
93	93	recipients with primary health benefit plan coverage to implement
94	94	this subsection.
95	95	(j) The commission shall develop and implement a clear and
96	96	easy process to allow a recipient with complex medical needs who has
97	97	established a relationship with a specialty provider in an area
98	98	outside of the recipient's Medicaid managed care organization's
99	99	service delivery area to continue receiving care from that provider
100	100	if the provider will enter into a single-case agreement with the
101	101	Medicaid managed care organization. A single-case agreement with a
102	102	provider outside of the organization's service delivery area in
103	103	accordance with this subsection is not considered an
104	104	out-of-network agreement and must be included in the organization's
105	105	network adequacy determination.
106	106	(k) The commission shall develop and implement processes
107	107	to:
108	108	(1) reimburse a recipient with primary health benefit
109	109	plan coverage who pays a copayment or coinsurance amount out of
110	110	pocket because the primary health benefit plan issuer refuses to
111	111	enroll in Medicaid, enter into a single-case agreement, or bill the
112	112	recipient's Medicaid managed care organization; and
113	113	(2) capture encounter data for the Medicaid
114	114	wrap-around benefits provided by the Medicaid managed care
115	115	organization under this subsection.
116	116	SECTION 2. If before implementing any provision of this Act
117	117	a state agency determines that a waiver or authorization from a
118	118	federal agency is necessary for implementation of that provision,
119	119	the agency affected by the provision shall request the waiver or
120	120	authorization and may delay implementing that provision until the
121	121	waiver or authorization is granted.
122	122	SECTION 3. This Act takes effect September 1, 2019.