86R9886 LED-D
By: Perry S.B. No. 1207
A BILL TO BE ENTITLED
AN ACT
relating to the coordination of private health benefits with
Medicaid benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.038 to read as follows:
Sec. 533.038. COORDINATION OF BENEFITS. (a) In this
section:
(1) "Medicaid managed care organization" means a
managed care organization that contracts with the commission under
this chapter to provide health care services to recipients.
(2) "Medicaid wrap-around benefit" means a
Medicaid-covered service, including a pharmacy or medical benefit,
that is provided to a recipient with both Medicaid and primary
health benefit plan coverage when the recipient has exceeded the
primary health benefit plan coverage limit or when the service is
not covered by the primary health benefit plan issuer.
(b) The commission, in coordination with Medicaid managed
care organizations, shall develop and adopt a clear policy for a
Medicaid managed care organization to ensure the coordination and
timely delivery of Medicaid wrap-around benefits for recipients
with both primary health benefit plan coverage and Medicaid
coverage.
(c) To further assist with the coordination of benefits, the
commission, in coordination with Medicaid managed care
organizations, shall develop and maintain a list of services that
are not traditionally covered by primary health benefit plan
coverage that a Medicaid managed care organization may approve
without having to coordinate with the primary health benefit plan
issuer and that can be resolved through third-party liability
resolution processes. The commission shall review and update the
list quarterly.
(d) A Medicaid managed care organization that in good faith
and following commission policies provides coverage for a Medicaid
wrap-around benefit shall include the cost of providing the benefit
in the organization's financial reports. The commission shall
include the reported costs in computing capitation rates for the
managed care organization.
(e) If the commission determines that a recipient's primary
health benefit plan issuer should have been the primary payor of a
claim, the Medicaid managed care organization that paid the claim
shall work with the commission on the recovery process and make
every attempt to reduce health care provider and recipient
abrasion.
(f) The executive commissioner may seek a waiver from the
federal government as needed to:
(1) address federal policies related to coordination
of benefits and third-party liability; and
(2) maximize federal financial participation for
recipients with both primary health benefit plan coverage and
Medicaid coverage.
(g) Notwithstanding Sections 531.073 and 533.005(a)(23) or
any other law, the commission shall ensure that a prescription drug
that is covered under the Medicaid vendor drug program or other
applicable formulary and is prescribed to a recipient with primary
health benefit plan coverage is not subject to any prior
authorization requirement if the primary health benefit plan issuer
will pay at least $0.01 on the prescription drug claim. If the
primary insurer will pay nothing on a prescription drug claim, the
prescription drug is subject to any applicable Medicaid clinical or
nonpreferred prior authorization requirement.
(h) The commission shall ensure that the daily Medicaid
managed care eligibility files indicate whether a recipient has
primary health benefit plan coverage or health insurance premium
payment coverage. For a recipient who has that coverage, the files
must include the following up-to-date, accurate information
related to primary health benefit plan coverage:
(1) the health benefit plan issuer's name and address
and the recipient's policy number;
(2) the primary health benefit plan coverage start and
end dates;
(3) the primary health benefit plan coverage benefits,
limits, copayment, and coinsurance information; and
(4) any additional information that would be useful to
ensure the coordination of benefits.
(i) The commission shall develop and implement processes
and policies to allow a health care provider who is primarily
providing services to a recipient through primary health benefit
plan coverage to receive Medicaid reimbursement for services
ordered, referred, prescribed, or delivered, regardless of whether
the provider is enrolled as a Medicaid provider. The commission
shall allow a provider who is not enrolled as a Medicaid provider to
order, refer, prescribe, or deliver services to a recipient based
on the provider's national provider identifier number and may not
require an additional state provider identifier number to receive
reimbursement for the services. The commission may seek a waiver of
Medicaid provider enrollment requirements for providers of
recipients with primary health benefit plan coverage to implement
this subsection.
(j) The commission shall develop and implement a clear and
easy process to allow a recipient with complex medical needs who has
established a relationship with a specialty provider in an area
outside of the recipient's Medicaid managed care organization's
service delivery area to continue receiving care from that provider
if the provider will enter into a single-case agreement with the
Medicaid managed care organization. A single-case agreement with a
provider outside of the organization's service delivery area in
accordance with this subsection is not considered an
out-of-network agreement and must be included in the organization's
network adequacy determination.
(k) The commission shall develop and implement processes
to:
(1) reimburse a recipient with primary health benefit
plan coverage who pays a copayment or coinsurance amount out of
pocket because the primary health benefit plan issuer refuses to
enroll in Medicaid, enter into a single-case agreement, or bill the
recipient's Medicaid managed care organization; and
(2) capture encounter data for the Medicaid
wrap-around benefits provided by the Medicaid managed care
organization under this subsection.
SECTION 2. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 3. This Act takes effect September 1, 2019.