86R31958 LED-D
By: Perry, et al. S.B. No. 1207
(Krause, Parker, Leach, Davis of Harris)
Substitute the following for S.B. No. 1207: No.
A BILL TO BE ENTITLED
AN ACT
relating to the operation and administration of Medicaid, including
the Medicaid managed care program and the medically dependent
children (MDCP) waiver program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 531.001, Government Code, is amended by
adding Subdivision (4-c) to read as follows:
(4-c) "Medicaid managed care organization" means a
managed care organization as defined by Section 533.001 that
contracts with the commission under Chapter 533 to provide health
care services to Medicaid recipients.
SECTION 2. Section 531.02444, Government Code, is amended
by amending Subsection (a) and adding Subsections (d) and (e) to
read as follows:
(a) The executive commissioner shall develop and implement:
(1) a Medicaid buy-in program for persons with
disabilities as authorized by the Ticket to Work and Work
Incentives Improvement Act of 1999 (Pub. L. No. 106-170) or the
Balanced Budget Act of 1997 (Pub. L. No. 105-33); and
(2) subject to Subsection (d) as authorized by the
Deficit Reduction Act of 2005 (Pub. L. No. 109-171), a Medicaid
buy-in program for children with disabilities that are [is]
described by 42 U.S.C. Section 1396a(cc)(1) and whose family
incomes do not exceed 300 percent of the applicable federal poverty
level.
(d) The executive commissioner by rule shall increase the
maximum family income prescribed by Subsection (a)(2) for
determining eligibility of children with disabilities for the
buy-in program under that subdivision to the maximum family income
amount for which federal matching funds are available, considering
available appropriations for that purpose.
(e) The commission shall, at the request of a child's
legally authorized representative, conduct a disability
determination assessment of the child to determine the child's
eligibility for the buy-in program under Subsection (a)(2). The
commission shall directly conduct the disability determination
assessment and may not contract with a Medicaid managed care
organization or other entity to conduct the assessment.
SECTION 3. Subchapter B, Chapter 531, Government Code, is
amended by adding Sections 531.024162, 531.024163, 531.024164,
531.0601, 531.0602, and 531.06021 to read as follows:
Sec. 531.024162. NOTICE REQUIREMENTS REGARDING MEDICAID
COVERAGE OR PRIOR AUTHORIZATION DENIAL AND INCOMPLETE REQUESTS.
(a) The commission shall ensure that notice sent by the commission
or a Medicaid managed care organization to a Medicaid recipient or
provider regarding the denial of coverage or prior authorization
for a service includes:
(1) information required by federal and state law and
applicable regulations;
(2) for the recipient, a clear and easy-to-understand
explanation of the reason for the denial; and
(3) for the provider, a thorough and detailed clinical
explanation of the reason for the denial, including, as applicable,
information required under Subsection (b).
(b) The commission or a Medicaid managed care organization
that receives from a provider a coverage or prior authorization
request that contains insufficient or inadequate documentation to
approve the request shall issue a notice to the provider and the
Medicaid recipient on whose behalf the request was submitted. The
notice issued under this subsection must:
(1) include a section specifically for the provider
that contains:
(A) a clear and specific list and description of
the documentation necessary for the commission or organization to
make a final determination on the request;
(B) the applicable timeline, based on the
requested service, for the provider to submit the documentation and
a description of the reconsideration process described by Section
533.00284, if applicable; and
(C) information on the manner through which a
provider may contact a Medicaid managed care organization or other
entity as required by Section 531.024163; and
(2) be sent to the provider:
(A) using the provider's preferred method of
contact most recently provided to the commission or the Medicaid
managed care organization and using any alternative and known
methods of contact; and
(B) as applicable, through an electronic
notification on an Internet portal.
Sec. 531.024163. ACCESSIBILITY OF INFORMATION REGARDING
MEDICAID PRIOR AUTHORIZATION REQUIREMENTS. (a) The executive
commissioner by rule shall require each Medicaid managed care
organization or other entity responsible for authorizing coverage
for health care services under Medicaid to ensure that the
organization or entity maintains on the organization's or entity's
Internet website in an easily searchable and accessible format:
(1) the applicable timelines for prior authorization
requirements, including:
(A) the time within which the organization or
entity must make a determination on a prior authorization request;
(B) a description of the notice the organization
or entity provides to a provider and Medicaid recipient on whose
behalf the request was submitted regarding the documentation
required to complete a determination on a prior authorization
request; and
(C) the deadline by which the organization or
entity is required to submit the notice described by Paragraph (B);
and
(2) an accurate and up-to-date catalogue of coverage
criteria and prior authorization requirements, including:
(A) for a prior authorization requirement first
imposed on or after September 1, 2019, the effective date of the
requirement;
(B) a list or description of any supporting or
other documentation necessary to obtain prior authorization for a
specified service; and
(C) the date and results of each review of the
prior authorization requirement conducted under Section 533.00283,
if applicable.
(b) The executive commissioner by rule shall require each
Medicaid managed care organization or other entity responsible for
authorizing coverage for health care services under Medicaid to:
(1) adopt and maintain a process for a provider or
Medicaid recipient to contact the organization or entity to clarify
prior authorization requirements or to assist the provider in
submitting a prior authorization request; and
(2) ensure that the process described by Subdivision
(1) is not arduous or overly burdensome to a provider or recipient.
Sec. 531.024164. EXTERNAL MEDICAL REVIEW. (a) In this
section, "external medical reviewer" and "reviewer" mean a
third-party medical review organization that provides objective,
unbiased medical necessity determinations conducted by clinical
staff with education and practice in the same or similar practice
area as the procedure for which an independent determination of
medical necessity is sought in accordance with applicable state law
and rules.
(b) The commission shall contract with an independent
external medical reviewer to conduct external medical reviews and
review:
(1) the resolution of a Medicaid recipient appeal
related to a reduction in or denial of services on the basis of
medical necessity in the Medicaid managed care program; or
(2) a denial by the commission of eligibility for a
Medicaid program in which eligibility is based on a Medicaid
recipient's medical and functional needs.
(c) A Medicaid managed care organization may not have a
financial relationship with or ownership interest in the external
medical reviewer with which the commission contracts.
(d) The external medical reviewer with which the commission
contracts must:
(1) be overseen by a medical director who is a
physician licensed in this state; and
(2) employ or be able to consult with staff with
experience in providing private duty nursing services and long-term
services and supports.
(e) The commission shall establish a common procedure for
reviews. Medical necessity under the procedure must be based on
publicly available, up-to-date, evidence-based, and peer-reviewed
clinical criteria. The reviewer shall conduct the review within a
period specified by the commission. The commission shall also
establish a procedure for expedited reviews that allows the
reviewer to identify an appeal that requires an expedited
resolution.
(f) An external medical review described by Subsection
(b)(1) occurs after the internal Medicaid managed care organization
appeal and before the Medicaid fair hearing and is granted when a
Medicaid recipient contests the internal appeal decision of the
Medicaid managed care organization. An external medical review
described by Subsection (b)(2) occurs after the eligibility denial
and before the Medicaid fair hearing. The Medicaid recipient or
applicant, or the recipient's or applicant's parent or legally
authorized representative, must affirmatively opt out of the
external medical review to proceed to a Medicaid fair hearing
without first participating in the external medical review.
(g) The external medical reviewer's determination of
medical necessity establishes the minimum level of services a
Medicaid recipient must receive, except that the level of services
may not exceed the level identified as medically necessary by the
ordering health care provider.
(h) The external medical reviewer shall require a Medicaid
managed care organization, in an external medical review relating
to a reduction in services, to submit a detailed reason for the
reduction and supporting documents.
Sec. 531.0601. LONG-TERM CARE SERVICES WAIVER PROGRAM
INTEREST LISTS. (a) This section applies only to a child who is
enrolled in the medically dependent children (MDCP) waiver program
but becomes ineligible for services under the program because the
child no longer meets:
(1) the level of care criteria for medical necessity
for nursing facility care; or
(2) the age requirement for the program.
(b) A legally authorized representative of a child who is
notified by the commission that the child is no longer eligible for
the medically dependent children (MDCP) waiver program following a
Medicaid fair hearing, or without a Medicaid fair hearing if the
representative opted in writing to forego the hearing, may request
that the commission:
(1) return the child to the interest list for the
program unless the child is ineligible due to the child's age; or
(2) place the child on the interest list for another
Section 1915(c) waiver program.
(c) At the time a child's legally authorized representative
makes a request under Subsection (b), the commission shall:
(1) for a child who becomes ineligible for the reason
described by Subsection (a)(1), place the child:
(A) on the interest list for the medically
dependent children (MDCP) waiver program in the first position on
the list; or
(B) except as provided by Subdivision (3), on the
interest list for another Section 1915(c) waiver program in a
position relative to other persons on the list that is based on the
date the child was initially placed on the interest list for the
medically dependent children (MDCP) waiver program;
(2) except as provided by Subdivision (3), for a child
who becomes ineligible for the reason described by Subsection
(a)(2), place the child on the interest list for another Section
1915(c) waiver program in a position relative to other persons on
the list that is based on the date the child was initially placed on
the interest list for the medically dependent children (MDCP)
waiver program; or
(3) for a child who becomes ineligible for a reason
described by Subsection (a) and who is already on an interest list
for another Section 1915(c) waiver program, move the child to a
position on the interest list relative to other persons on the list
that is based on the date the child was initially placed on the
interest list for the medically dependent children (MDCP) waiver
program, if that date is earlier than the date the child was
initially placed on the interest list for the other waiver program.
(d) At the time the commission provides notice to a legally
authorized representative that a child is no longer eligible for
the medically dependent children (MDCP) waiver program following a
Medicaid fair hearing, or without a Medicaid fair hearing if the
representative opted in writing to forego the hearing, the
commission shall inform the representative in writing about the
options under this section for placing the child on an interest
list.
Sec. 531.0602. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
PROGRAM REASSESSMENTS. (a) The commission shall ensure that the
care coordinator for a Medicaid managed care organization under the
STAR Kids managed care program provides the results of the annual
medical necessity determination reassessment to the parent or
legally authorized representative of a recipient receiving
benefits under the medically dependent children (MDCP) waiver
program for review. The commission shall ensure the provision of
the results does not delay the determination of the services to be
provided to the recipient or the ability to authorize and initiate
services.
(b) The commission shall require the parent's or
representative's signature to verify the parent or representative
received the results of the reassessment from the care coordinator
under Subsection (a). A Medicaid managed care organization may not
delay the delivery of care pending the signature.
(c) The commission shall provide a parent or representative
who disagrees with the results of the reassessment an opportunity
to dispute the reassessment with the Medicaid managed care
organization through a peer-to-peer review with the treating
physician of choice.
(d) This section does not affect any rights of a recipient
to appeal a reassessment determination through the Medicaid managed
care organization's internal appeal process or through the Medicaid
fair hearing process.
Sec. 531.06021. MEDICALLY DEPENDENT CHILDREN (MDCP) WAIVER
PROGRAM QUALITY MONITORING; REPORT. (a) The commission, through
the state's external quality review organization, shall:
(1) conduct annual surveys of Medicaid recipients
receiving benefits under the medically dependent children (MDCP)
waiver program, or their representatives, using the Consumer
Assessment of Healthcare Providers and Systems;
(2) conduct annual focus groups with recipients
described by Subdivision (1) or their representatives on issues
identified through:
(A) the Consumer Assessment of Healthcare
Providers and Systems;
(B) other external quality review organization
activities; or
(C) stakeholders, including the STAR Kids
Managed Care Advisory Committee described by Section 533.00254; and
(3) as frequently as feasible but not less frequently
than annually, calculate Medicaid managed care organizations'
performance on performance measures using available data sources
such as the STAR Kids Screening and Assessment Instrument or the
National Committee for Quality Assurance's Healthcare
Effectiveness Data and Information Set (HEDIS) measures.
(b) Not later than the 30th day after the last day of each
state fiscal quarter, the commission shall submit to the governor,
the lieutenant governor, the speaker of the house of
representatives, the Legislative Budget Board, and each standing
legislative committee with primary jurisdiction over Medicaid a
report containing, for the most recent state fiscal quarter, the
following information and data related to access to care for
Medicaid recipients receiving benefits under the medically
dependent children (MDCP) waiver program:
(1) enrollment in the Medicaid buy-in for children
program implemented under Section 531.02444;
(2) requests relating to interest list placements
under Section 531.0601;
(3) use of the Medicaid escalation help line
established under Section 533.00253;
(4) use, requests to opt out, and outcomes of the
external medical review procedure established under Section
531.024164; and
(5) complaints relating to the medically dependent
children (MDCP) waiver program, categorized by disposition.
SECTION 4. Section 533.00253(a)(1), Government Code, is
amended to read as follows:
(1) "Advisory committee" means the STAR Kids Managed
Care Advisory Committee described by [established under] Section
533.00254.
SECTION 5. Section 533.00253, Government Code, is amended
by adding Subsections (c-1), (c-2), (f), (g), and (h) to read as
follows:
(c-1) To improve the care needs assessment tool used for
purposes of a care needs assessment provided as a component of care
management services and to improve the initial assessment and
reassessment processes, the commission in consultation and
collaboration with the advisory committee shall consider changes
that will:
(1) reduce the amount of time needed to complete the
care needs assessment initially and at reassessment; and
(2) improve training and consistency in the completion
of the care needs assessment using the tool and in the initial
assessment and reassessment processes across different Medicaid
managed care organizations and different service coordinators
within the same Medicaid managed care organization.
(c-2) To the extent feasible and allowed by federal law, the
commission shall streamline the STAR Kids managed care program
annual care needs reassessment process for a child who has not had a
significant change in function that may affect medical necessity.
(f) The commission shall operate a Medicaid escalation help
line through which Medicaid recipients receiving benefits under the
medically dependent children (MDCP) waiver program and their
legally authorized representatives, parents, guardians, or other
representatives have access to assistance. The escalation help
line must be:
(1) dedicated to assisting families of Medicaid
recipients receiving benefits under the medically dependent
children (MDCP) waiver program in navigating and resolving issues
related to the STAR Kids managed care program; and
(2) operational at all times, including evenings,
weekends, and holidays.
(g) The commission shall ensure staff operating the
Medicaid escalation help line:
(1) return a telephone call not later than two hours
after receiving the call during standard business hours; and
(2) return a telephone call not later than four hours
after receiving the call during evenings, weekends, and holidays.
(h) The commission shall require a Medicaid managed care
organization participating in the STAR Kids managed care program
to:
(1) designate an individual as a single point of
contact for the Medicaid escalation help line; and
(2) authorize that individual to take action to
resolve escalated issues.
SECTION 6. Subchapter A, Chapter 533, Government Code, is
amended by adding Sections 533.00254, 533.00282, 533.00283,
533.00284, and 533.038 to read as follows:
Sec. 533.00254. STAR KIDS MANAGED CARE ADVISORY COMMITTEE.
(a) The STAR Kids Managed Care Advisory Committee established by
the executive commissioner under Section 531.012 shall:
(1) advise the commission on the operation of the STAR
Kids managed care program under Section 533.00253; and
(2) make recommendations for improvements to that
program.
(b) On September 1, 2023:
(1) the advisory committee is abolished; and
(2) this section expires.
Sec. 533.00282. UTILIZATION REVIEW AND PRIOR AUTHORIZATION
PROCEDURES. (a) Section 4201.304(a)(2), Insurance Code, does not
apply to a Medicaid managed care organization or a utilization
review agent who conducts utilization reviews for a Medicaid
managed care organization.
(b) In addition to the requirements of Section 533.005, a
contract between a Medicaid managed care organization and the
commission must require that:
(1) before issuing an adverse determination on a prior
authorization request, the organization provide the physician
requesting the prior authorization with a reasonable opportunity to
discuss the request with another physician who practices in the
same or a similar specialty, but not necessarily the same
subspecialty, and has experience in treating the same category of
population as the recipient on whose behalf the request is
submitted; and
(2) the organization review and issue determinations
on prior authorization requests with respect to a recipient who is
not hospitalized at the time of the request according to the
following time frames:
(A) within three business days after receiving
the request; or
(B) within the time frame and following the
process established by the commission if the organization receives
a request for prior authorization that does not include sufficient
or adequate documentation.
(c) The commission shall establish a process consistent
with 42 C.F.R. Section 438.210 for use by a Medicaid managed care
organization that receives a prior authorization request, with
respect to a recipient who is not hospitalized at the time of the
request, that does not include sufficient or adequate
documentation. The process must provide a time frame within which a
provider may submit the necessary documentation.
Sec. 533.00283. ANNUAL REVIEW OF PRIOR AUTHORIZATION
REQUIREMENTS. (a) Each Medicaid managed care organization shall
develop and implement a process to conduct an annual review of the
organization's prior authorization requirements, other than a
prior authorization requirement prescribed by or implemented under
Section 531.073 for the vendor drug program. In conducting a
review, the organization must:
(1) solicit, receive, and consider input from
providers in the organization's provider network; and
(2) ensure that each prior authorization requirement
is based on accurate, up-to-date, evidence-based, and
peer-reviewed clinical criteria that distinguish, as appropriate,
between categories, including age, of recipients for whom prior
authorization requests are submitted.
(b) A Medicaid managed care organization may not impose a
prior authorization requirement, other than a prior authorization
requirement prescribed by or implemented under Section 531.073 for
the vendor drug program, unless the organization has reviewed the
requirement during the most recent annual review required under
this section.
Sec. 533.00284. RECONSIDERATION FOLLOWING ADVERSE
DETERMINATIONS ON CERTAIN PRIOR AUTHORIZATION REQUESTS. (a) In
addition to the requirements of Section 533.005, a contract between
a Medicaid managed care organization and the commission must
include a requirement that the organization establish a process for
reconsidering an adverse determination on a prior authorization
request that resulted solely from the submission of insufficient or
inadequate documentation.
(b) The process for reconsidering an adverse determination
on a prior authorization request under this section must:
(1) allow a provider to, not later than the seventh
business day following the date of the determination, submit any
documentation that was identified as insufficient or inadequate in
the notice provided under Section 531.024162;
(2) allow the provider requesting the prior
authorization to discuss the request with another provider who
practices in the same or a similar specialty, but not necessarily
the same subspecialty, and has experience in treating the same
category of population as the recipient on whose behalf the request
is submitted;
(3) require the Medicaid managed care organization to,
not later than the first business day following the date the
provider submits sufficient and adequate documentation under
Subdivision (1), amend the determination on the prior authorization
request as necessary, considering the additional documentation;
and
(4) comply with 42 C.F.R. Section 438.210.
(c) An adverse determination on a prior authorization
request is considered a denial of services in an evaluation of the
Medicaid managed care organization only if the determination is not
amended under Subsection (b)(3) to approve the request.
(d) The process for reconsidering an adverse determination
on a prior authorization request under this section does not
affect:
(1) any related timelines, including the timeline for
an internal appeal, a Medicaid fair hearing, or a review conducted
by an independent review organization; or
(2) any rights of a recipient to appeal a
determination on a prior authorization request.
Sec. 533.038. COORDINATION OF BENEFITS. (a) In this
section, "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. In developing the policy, the commission shall consider
requiring a Medicaid managed care organization to allow,
notwithstanding Sections 531.073 and 533.005(a)(23) or any other
law, a recipient using a prescription drug for which the
recipient's primary health benefit plan issuer previously provided
coverage to continue receiving the prescription drug without
requiring additional prior authorization.
(c) To further assist with the coordination of benefits and
to the extent allowed under federal requirements for third-party
liability, 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 periodically review and
update the list.
(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) 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.
(h) To the extent allowed by federal law, 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, or prescribed,
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, or prescribe 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.
(i) The commission shall develop a clear and easy process,
to be implemented through a contract, that allows a recipient with
complex medical needs who has established a relationship with a
specialty provider to continue receiving care from that provider.
SECTION 7. (a) Section 531.02444(e), Government Code, as
added by this Act, applies to a request for a disability
determination assessment to determine eligibility for the Medicaid
buy-in for children program made on or after the effective date of
this Act.
(b) Section 531.0601, Government Code, as added by this Act,
applies only to a child who becomes ineligible for the medically
dependent children (MDCP) waiver program on or after December 1,
2019.
(c) Section 531.0602, Government Code, as added by this Act,
applies only to a reassessment of a child's eligibility for the
medically dependent children (MDCP) waiver program made on or after
December 1, 2019.
(d) Notwithstanding Section 531.06021, Government Code, as
added by this Act, the Health and Human Services Commission shall
submit the first report required by that section not later than
September 30, 2020, for the state fiscal quarter ending August 31,
2020.
(e) Not later than March 1, 2020, the Health and Human
Services Commission shall:
(1) develop a plan to improve the care needs
assessment tool and the initial assessment and reassessment
processes as required by Sections 533.00253(c-1) and (c-2),
Government Code, as added by this Act; and
(2) post the plan on the commission's Internet
website.
(f) Sections 533.00282 and 533.00284, Government Code, as
added by this Act, apply only to a contract between the Health and
Human Services Commission and a Medicaid managed care organization
under Chapter 533, Government Code, that is entered into or renewed
on or after the effective date of this Act.
(g) The Health and Human Services Commission shall seek to
amend contracts entered into with Medicaid managed care
organizations under Chapter 533, Government Code, before the
effective date of this Act to include the provisions required by
Sections 533.00282 and 533.00284, Government Code, as added by this
Act.
SECTION 8. As soon as practicable after the effective date
of this Act, the executive commissioner of the Health and Human
Services Commission shall adopt rules necessary to implement the
changes in law made by this Act.
SECTION 9. 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 10. 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 11. This Act takes effect September 1, 2019.