TX
Texas House Bill HB4055

Texas 2019 - 86th Regular

Texas House Bill HB4055 Compare Versions

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1-86R22071 JG-F
2- By: Wu, Klick H.B. No. 4055
3- Substitute the following for H.B. No. 4055:
4- By: Thompson of Harris C.S.H.B. No. 4055
1+86R11658 JG-F
2+ By: Wu H.B. No. 4055
53
64
75 A BILL TO BE ENTITLED
86 AN ACT
97 relating to the availability under Medicaid of certain drugs used
10- to treat human immunodeficiency virus or prevent acquired immune
8+ to treat human immunodeficiency virus and prevent acquired immune
119 deficiency syndrome.
1210 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1311 SECTION 1. Section 531.073, Government Code, is amended by
1412 amending Subsection (a) and adding Subsection (j) to read as
1513 follows:
1614 (a) The executive commissioner, in the rules and standards
1715 governing the Medicaid vendor drug program and the child health
1816 plan program, shall require prior authorization for the
1917 reimbursement of a drug that is not included in the appropriate
2018 preferred drug list adopted under Section 531.072, except for any
2119 drug exempted from prior authorization requirements by federal law
2220 and except as provided by Subsection (j). The executive
2321 commissioner may require prior authorization for the reimbursement
2422 of a drug provided through any other state program administered by
2523 the commission or a state health and human services agency,
2624 including a community mental health center and a state mental
2725 health hospital if the commission adopts preferred drug lists under
2826 Section 531.072 that apply to those facilities and the drug is not
2927 included in the appropriate list. The executive commissioner shall
3028 require that the prior authorization be obtained by the prescribing
3129 physician or prescribing practitioner.
3230 (j) The executive commissioner, in the rules and standards
3331 governing the Medicaid vendor drug program, may not require a
3432 clinical, nonpreferred, or other prior authorization for an
3533 antiretroviral drug, or a step therapy or other protocol, that
3634 could restrict or delay the dispensing of the drug. In this
3735 subsection, "antiretroviral drug" means a drug that treats human
38- immunodeficiency virus infection or prevents acquired immune
36+ immunodeficiency virus infection and prevents acquired immune
3937 deficiency syndrome. The term includes:
4038 (1) protease inhibitors;
4139 (2) non-nucleoside reverse transcriptase inhibitors;
4240 (3) nucleoside reverse transcriptase inhibitors;
4341 (4) integrase inhibitors;
44- (5) fusion inhibitors;
45- (6) attachment inhibitors;
46- (7) CD4 post-attachment inhibitors;
47- (8) CCR5 receptor antagonists; and
48- (9) other antiretroviral drugs used to treat human
49- immunodeficiency virus infection or prevent acquired immune
50- deficiency syndrome.
42+ (5) fusion inhibitors; and
43+ (6) antivirals.
5144 SECTION 2. Section 533.005(a), Government Code, is amended
5245 to read as follows:
5346 (a) A contract between a managed care organization and the
5447 commission for the organization to provide health care services to
5548 recipients must contain:
5649 (1) procedures to ensure accountability to the state
5750 for the provision of health care services, including procedures for
5851 financial reporting, quality assurance, utilization review, and
5952 assurance of contract and subcontract compliance;
6053 (2) capitation rates that ensure the cost-effective
6154 provision of quality health care;
6255 (3) a requirement that the managed care organization
6356 provide ready access to a person who assists recipients in
6457 resolving issues relating to enrollment, plan administration,
6558 education and training, access to services, and grievance
6659 procedures;
6760 (4) a requirement that the managed care organization
6861 provide ready access to a person who assists providers in resolving
6962 issues relating to payment, plan administration, education and
7063 training, and grievance procedures;
7164 (5) a requirement that the managed care organization
7265 provide information and referral about the availability of
7366 educational, social, and other community services that could
7467 benefit a recipient;
7568 (6) procedures for recipient outreach and education;
7669 (7) a requirement that the managed care organization
7770 make payment to a physician or provider for health care services
7871 rendered to a recipient under a managed care plan on any claim for
7972 payment that is received with documentation reasonably necessary
8073 for the managed care organization to process the claim:
8174 (A) not later than:
8275 (i) the 10th day after the date the claim is
8376 received if the claim relates to services provided by a nursing
8477 facility, intermediate care facility, or group home;
8578 (ii) the 30th day after the date the claim
8679 is received if the claim relates to the provision of long-term
8780 services and supports not subject to Subparagraph (i); and
8881 (iii) the 45th day after the date the claim
8982 is received if the claim is not subject to Subparagraph (i) or (ii);
9083 or
9184 (B) within a period, not to exceed 60 days,
9285 specified by a written agreement between the physician or provider
9386 and the managed care organization;
9487 (7-a) a requirement that the managed care organization
9588 demonstrate to the commission that the organization pays claims
9689 described by Subdivision (7)(A)(ii) on average not later than the
9790 21st day after the date the claim is received by the organization;
9891 (8) a requirement that the commission, on the date of a
9992 recipient's enrollment in a managed care plan issued by the managed
10093 care organization, inform the organization of the recipient's
10194 Medicaid certification date;
10295 (9) a requirement that the managed care organization
10396 comply with Section 533.006 as a condition of contract retention
10497 and renewal;
10598 (10) a requirement that the managed care organization
10699 provide the information required by Section 533.012 and otherwise
107100 comply and cooperate with the commission's office of inspector
108101 general and the office of the attorney general;
109102 (11) a requirement that the managed care
110103 organization's usages of out-of-network providers or groups of
111104 out-of-network providers may not exceed limits for those usages
112105 relating to total inpatient admissions, total outpatient services,
113106 and emergency room admissions determined by the commission;
114107 (12) if the commission finds that a managed care
115108 organization has violated Subdivision (11), a requirement that the
116109 managed care organization reimburse an out-of-network provider for
117110 health care services at a rate that is equal to the allowable rate
118111 for those services, as determined under Sections 32.028 and
119112 32.0281, Human Resources Code;
120113 (13) a requirement that, notwithstanding any other
121114 law, including Sections 843.312 and 1301.052, Insurance Code, the
122115 organization:
123116 (A) use advanced practice registered nurses and
124117 physician assistants in addition to physicians as primary care
125118 providers to increase the availability of primary care providers in
126119 the organization's provider network; and
127120 (B) treat advanced practice registered nurses
128121 and physician assistants in the same manner as primary care
129122 physicians with regard to:
130123 (i) selection and assignment as primary
131124 care providers;
132125 (ii) inclusion as primary care providers in
133126 the organization's provider network; and
134127 (iii) inclusion as primary care providers
135128 in any provider network directory maintained by the organization;
136129 (14) a requirement that the managed care organization
137130 reimburse a federally qualified health center or rural health
138131 clinic for health care services provided to a recipient outside of
139132 regular business hours, including on a weekend day or holiday, at a
140133 rate that is equal to the allowable rate for those services as
141134 determined under Section 32.028, Human Resources Code, if the
142135 recipient does not have a referral from the recipient's primary
143136 care physician;
144137 (15) a requirement that the managed care organization
145138 develop, implement, and maintain a system for tracking and
146139 resolving all provider appeals related to claims payment, including
147140 a process that will require:
148141 (A) a tracking mechanism to document the status
149142 and final disposition of each provider's claims payment appeal;
150143 (B) the contracting with physicians who are not
151144 network providers and who are of the same or related specialty as
152145 the appealing physician to resolve claims disputes related to
153146 denial on the basis of medical necessity that remain unresolved
154147 subsequent to a provider appeal;
155148 (C) the determination of the physician resolving
156149 the dispute to be binding on the managed care organization and
157150 provider; and
158151 (D) the managed care organization to allow a
159152 provider with a claim that has not been paid before the time
160153 prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
161154 claim;
162155 (16) a requirement that a medical director who is
163156 authorized to make medical necessity determinations is available to
164157 the region where the managed care organization provides health care
165158 services;
166159 (17) a requirement that the managed care organization
167160 ensure that a medical director and patient care coordinators and
168161 provider and recipient support services personnel are located in
169162 the South Texas service region, if the managed care organization
170163 provides a managed care plan in that region;
171164 (18) a requirement that the managed care organization
172165 provide special programs and materials for recipients with limited
173166 English proficiency or low literacy skills;
174167 (19) a requirement that the managed care organization
175168 develop and establish a process for responding to provider appeals
176169 in the region where the organization provides health care services;
177170 (20) a requirement that the managed care organization:
178171 (A) develop and submit to the commission, before
179172 the organization begins to provide health care services to
180173 recipients, a comprehensive plan that describes how the
181174 organization's provider network complies with the provider access
182175 standards established under Section 533.0061;
183176 (B) as a condition of contract retention and
184177 renewal:
185178 (i) continue to comply with the provider
186179 access standards established under Section 533.0061; and
187180 (ii) make substantial efforts, as
188181 determined by the commission, to mitigate or remedy any
189182 noncompliance with the provider access standards established under
190183 Section 533.0061;
191184 (C) pay liquidated damages for each failure, as
192185 determined by the commission, to comply with the provider access
193186 standards established under Section 533.0061 in amounts that are
194187 reasonably related to the noncompliance; and
195188 (D) regularly, as determined by the commission,
196189 submit to the commission and make available to the public a report
197190 containing data on the sufficiency of the organization's provider
198191 network with regard to providing the care and services described
199192 under Section 533.0061(a) and specific data with respect to access
200193 to primary care, specialty care, long-term services and supports,
201194 nursing services, and therapy services on the average length of
202195 time between:
203196 (i) the date a provider requests prior
204197 authorization for the care or service and the date the organization
205198 approves or denies the request; and
206199 (ii) the date the organization approves a
207200 request for prior authorization for the care or service and the date
208201 the care or service is initiated;
209202 (21) a requirement that the managed care organization
210203 demonstrate to the commission, before the organization begins to
211204 provide health care services to recipients, that, subject to the
212205 provider access standards established under Section 533.0061:
213206 (A) the organization's provider network has the
214207 capacity to serve the number of recipients expected to enroll in a
215208 managed care plan offered by the organization;
216209 (B) the organization's provider network
217210 includes:
218211 (i) a sufficient number of primary care
219212 providers;
220213 (ii) a sufficient variety of provider
221214 types;
222215 (iii) a sufficient number of providers of
223216 long-term services and supports and specialty pediatric care
224217 providers of home and community-based services; and
225218 (iv) providers located throughout the
226219 region where the organization will provide health care services;
227220 and
228221 (C) health care services will be accessible to
229222 recipients through the organization's provider network to a
230223 comparable extent that health care services would be available to
231224 recipients under a fee-for-service or primary care case management
232225 model of Medicaid managed care;
233226 (22) a requirement that the managed care organization
234227 develop a monitoring program for measuring the quality of the
235228 health care services provided by the organization's provider
236229 network that:
237230 (A) incorporates the National Committee for
238231 Quality Assurance's Healthcare Effectiveness Data and Information
239232 Set (HEDIS) measures;
240233 (B) focuses on measuring outcomes; and
241234 (C) includes the collection and analysis of
242235 clinical data relating to prenatal care, preventive care, mental
243236 health care, and the treatment of acute and chronic health
244237 conditions and substance abuse;
245238 (23) subject to Subsection (a-1), a requirement that
246239 the managed care organization develop, implement, and maintain an
247240 outpatient pharmacy benefit plan for its enrolled recipients:
248241 (A) that exclusively employs the vendor drug
249242 program formulary and preserves the state's ability to reduce
250243 waste, fraud, and abuse under Medicaid;
251244 (B) that adheres to the applicable preferred drug
252245 list adopted by the commission under Section 531.072;
253246 (C) that includes the prior authorization
254247 procedures and requirements prescribed by or implemented under
255248 Sections 531.073(b), (c), and (g) for the vendor drug program;
256249 (C-1) that does not require a clinical,
257250 nonpreferred, or other prior authorization for an antiretroviral
258251 drug, as defined by Section 531.073, or a step therapy or other
259252 protocol, that could restrict or delay the dispensing of the drug;
260253 (D) for purposes of which the managed care
261254 organization:
262255 (i) may not negotiate or collect rebates
263256 associated with pharmacy products on the vendor drug program
264257 formulary; and
265258 (ii) may not receive drug rebate or pricing
266259 information that is confidential under Section 531.071;
267260 (E) that complies with the prohibition under
268261 Section 531.089;
269262 (F) under which the managed care organization may
270263 not prohibit, limit, or interfere with a recipient's selection of a
271264 pharmacy or pharmacist of the recipient's choice for the provision
272265 of pharmaceutical services under the plan through the imposition of
273266 different copayments;
274267 (G) that allows the managed care organization or
275268 any subcontracted pharmacy benefit manager to contract with a
276269 pharmacist or pharmacy providers separately for specialty pharmacy
277270 services, except that:
278271 (i) the managed care organization and
279272 pharmacy benefit manager are prohibited from allowing exclusive
280273 contracts with a specialty pharmacy owned wholly or partly by the
281274 pharmacy benefit manager responsible for the administration of the
282275 pharmacy benefit program; and
283276 (ii) the managed care organization and
284277 pharmacy benefit manager must adopt policies and procedures for
285278 reclassifying prescription drugs from retail to specialty drugs,
286279 and those policies and procedures must be consistent with rules
287280 adopted by the executive commissioner and include notice to network
288281 pharmacy providers from the managed care organization;
289282 (H) under which the managed care organization may
290283 not prevent a pharmacy or pharmacist from participating as a
291284 provider if the pharmacy or pharmacist agrees to comply with the
292285 financial terms and conditions of the contract as well as other
293286 reasonable administrative and professional terms and conditions of
294287 the contract;
295288 (I) under which the managed care organization may
296289 include mail-order pharmacies in its networks, but may not require
297290 enrolled recipients to use those pharmacies, and may not charge an
298291 enrolled recipient who opts to use this service a fee, including
299292 postage and handling fees;
300293 (J) under which the managed care organization or
301294 pharmacy benefit manager, as applicable, must pay claims in
302295 accordance with Section 843.339, Insurance Code; and
303296 (K) under which the managed care organization or
304297 pharmacy benefit manager, as applicable:
305298 (i) to place a drug on a maximum allowable
306299 cost list, must ensure that:
307300 (a) the drug is listed as "A" or "B"
308301 rated in the most recent version of the United States Food and Drug
309302 Administration's Approved Drug Products with Therapeutic
310303 Equivalence Evaluations, also known as the Orange Book, has an "NR"
311304 or "NA" rating or a similar rating by a nationally recognized
312305 reference; and
313306 (b) the drug is generally available
314307 for purchase by pharmacies in the state from national or regional
315308 wholesalers and is not obsolete;
316309 (ii) must provide to a network pharmacy
317310 provider, at the time a contract is entered into or renewed with the
318311 network pharmacy provider, the sources used to determine the
319312 maximum allowable cost pricing for the maximum allowable cost list
320313 specific to that provider;
321314 (iii) must review and update maximum
322315 allowable cost price information at least once every seven days to
323316 reflect any modification of maximum allowable cost pricing;
324317 (iv) must, in formulating the maximum
325318 allowable cost price for a drug, use only the price of the drug and
326319 drugs listed as therapeutically equivalent in the most recent
327320 version of the United States Food and Drug Administration's
328321 Approved Drug Products with Therapeutic Equivalence Evaluations,
329322 also known as the Orange Book;
330323 (v) must establish a process for
331324 eliminating products from the maximum allowable cost list or
332325 modifying maximum allowable cost prices in a timely manner to
333326 remain consistent with pricing changes and product availability in
334327 the marketplace;
335328 (vi) must:
336329 (a) provide a procedure under which a
337330 network pharmacy provider may challenge a listed maximum allowable
338331 cost price for a drug;
339332 (b) respond to a challenge not later
340333 than the 15th day after the date the challenge is made;
341334 (c) if the challenge is successful,
342335 make an adjustment in the drug price effective on the date the
343336 challenge is resolved[,] and make the adjustment applicable to all
344337 similarly situated network pharmacy providers, as determined by the
345338 managed care organization or pharmacy benefit manager, as
346339 appropriate;
347340 (d) if the challenge is denied,
348341 provide the reason for the denial; and
349342 (e) report to the commission every 90
350343 days the total number of challenges that were made and denied in the
351344 preceding 90-day period for each maximum allowable cost list drug
352345 for which a challenge was denied during the period;
353346 (vii) must notify the commission not later
354347 than the 21st day after implementing a practice of using a maximum
355348 allowable cost list for drugs dispensed at retail but not by mail;
356349 and
357350 (viii) must provide a process for each of
358351 its network pharmacy providers to readily access the maximum
359352 allowable cost list specific to that provider;
360353 (24) a requirement that the managed care organization
361354 and any entity with which the managed care organization contracts
362355 for the performance of services under a managed care plan disclose,
363356 at no cost, to the commission and, on request, the office of the
364357 attorney general all discounts, incentives, rebates, fees, free
365358 goods, bundling arrangements, and other agreements affecting the
366359 net cost of goods or services provided under the plan;
367360 (25) a requirement that the managed care organization
368361 not implement significant, nonnegotiated, across-the-board
369362 provider reimbursement rate reductions unless:
370363 (A) subject to Subsection (a-3), the
371364 organization has the prior approval of the commission to make the
372365 reductions [reduction]; or
373366 (B) the rate reductions are based on changes to
374367 the Medicaid fee schedule or cost containment initiatives
375368 implemented by the commission; and
376369 (26) a requirement that the managed care organization
377370 make initial and subsequent primary care provider assignments and
378371 changes.
379372 SECTION 3. Section 533.005, Government Code, as amended by
380373 this Act, applies to a contract entered into or renewed on or after
381374 the effective date of this Act. A contract entered into or renewed
382375 before that date is governed by the law in effect on the date the
383376 contract was entered into or renewed, and that law is continued in
384377 effect for that purpose.
385378 SECTION 4. If before implementing any provision of this Act
386379 a state agency determines that a waiver or authorization from a
387380 federal agency is necessary for implementation of that provision,
388381 the agency affected by the provision shall request the waiver or
389382 authorization and may delay implementing that provision until the
390383 waiver or authorization is granted.
391384 SECTION 5. This Act takes effect September 1, 2019.