By: Perry S.B. No. 1207
(In the Senate - Filed February 27, 2019; March 7, 2019,
read first time and referred to Committee on Health & Human
Services; April 11, 2019, reported adversely, with favorable
Committee Substitute by the following vote: Yeas 9, Nays 0;
April 11, 2019, sent to printer.)
Click here to see the committee vote
COMMITTEE SUBSTITUTE FOR S.B. No. 1207 By: Perry
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:
(1) the primary health benefit plan issuer will pay at
least $0.01 on the prescription drug claim; or
(2) the prescription drug is covered by the primary
health benefit plan issuer but the primary health benefit plan
issuer will pay nothing on the claim because the recipient has not
met the deductible.
(h) Except as provided by Subsection (g)(2), a prescription
drug prescribed to a recipient with primary health benefit plan
coverage is subject to any applicable Medicaid clinical or
nonpreferred prior authorization requirement if the primary health
benefit plan issuer will pay nothing on the prescription drug
claim.
(i) The commission may include in the Medicaid managed care
eligibility files an indication of whether a recipient has primary
health benefit plan coverage or is enrolled in a group health
benefit plan for which the commission provides premium assistance
under the health insurance premium payment program. For recipients
with that coverage or for whom that premium assistance is provided,
the files may include the following up-to-date, accurate
information related to primary health benefit plan coverage to the
extent the information is available to the commission:
(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; and
(3) the primary health benefit plan coverage benefits,
limits, copayment, and coinsurance information.
(j) The commission shall maintain 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.
(k) 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 a provider outside of the organization's service
delivery area enters into a single-case agreement with the Medicaid
managed care organization to continue providing that care, the
single-case agreement is not considered an out-of-network
agreement.
(l) 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. The Health and Human Services Commission is
required to implement a provision of this Act only if the
legislature appropriates money specifically for that purpose. If
the legislature does not appropriate money specifically for that
purpose, the commission may, but is not required to, implement a
provision of this Act using other appropriations available for that
purpose.
SECTION 4. This Act takes effect September 1, 2019.
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