TX
Texas Senate Bill SB1283

Texas 2019 - 86th Regular

Texas Senate Bill SB1283 Compare Versions

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1-S.B. No. 1283
1+By: Miles, et al. S.B. No. 1283
2+ (Wu, Klick, Rose)
23
34
5+ A BILL TO BE ENTITLED
46 AN ACT
57 relating to the availability under Medicaid of certain drugs used
68 to treat human immunodeficiency virus or prevent acquired immune
79 deficiency syndrome.
810 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
911 SECTION 1. Section 531.073, Government Code, is amended by
1012 amending Subsection (a) and adding Subsection (j) to read as
1113 follows:
1214 (a) The executive commissioner, in the rules and standards
1315 governing the Medicaid vendor drug program and the child health
1416 plan program, shall require prior authorization for the
1517 reimbursement of a drug that is not included in the appropriate
1618 preferred drug list adopted under Section 531.072, except for any
1719 drug exempted from prior authorization requirements by federal law
1820 and except as provided by Subsection (j). The executive
1921 commissioner may require prior authorization for the reimbursement
2022 of a drug provided through any other state program administered by
2123 the commission or a state health and human services agency,
2224 including a community mental health center and a state mental
2325 health hospital if the commission adopts preferred drug lists under
2426 Section 531.072 that apply to those facilities and the drug is not
2527 included in the appropriate list. The executive commissioner shall
2628 require that the prior authorization be obtained by the prescribing
2729 physician or prescribing practitioner.
2830 (j) The executive commissioner, in the rules and standards
2931 governing the Medicaid vendor drug program, may not require a
30- clinical, nonpreferred, or other prior authorization for any
32+ clinical, nonpreferred, or other prior authorization for an
3133 antiretroviral drug, or a step therapy or other protocol, that
32- could restrict or delay the dispensing of the drug except to
33- minimize fraud, waste, or abuse. In this subsection,
34- "antiretroviral drug" means a drug that treats human
34+ could restrict or delay the dispensing of the drug. In this
35+ subsection, "antiretroviral drug" means a drug that treats human
3536 immunodeficiency virus infection or prevents acquired immune
3637 deficiency syndrome. The term includes:
3738 (1) protease inhibitors;
3839 (2) non-nucleoside reverse transcriptase inhibitors;
3940 (3) nucleoside reverse transcriptase inhibitors;
4041 (4) integrase inhibitors;
4142 (5) fusion inhibitors;
4243 (6) attachment inhibitors;
4344 (7) CD4 post-attachment inhibitors;
4445 (8) CCR5 receptor antagonists; and
4546 (9) other antiretroviral drugs used to treat human
4647 immunodeficiency virus infection or prevent acquired immune
4748 deficiency syndrome.
4849 SECTION 2. Section 533.005(a), Government Code, is amended
4950 to read as follows:
5051 (a) A contract between a managed care organization and the
5152 commission for the organization to provide health care services to
5253 recipients must contain:
5354 (1) procedures to ensure accountability to the state
5455 for the provision of health care services, including procedures for
5556 financial reporting, quality assurance, utilization review, and
5657 assurance of contract and subcontract compliance;
5758 (2) capitation rates that ensure the cost-effective
5859 provision of quality health care;
5960 (3) a requirement that the managed care organization
6061 provide ready access to a person who assists recipients in
6162 resolving issues relating to enrollment, plan administration,
6263 education and training, access to services, and grievance
6364 procedures;
6465 (4) a requirement that the managed care organization
6566 provide ready access to a person who assists providers in resolving
6667 issues relating to payment, plan administration, education and
6768 training, and grievance procedures;
6869 (5) a requirement that the managed care organization
6970 provide information and referral about the availability of
7071 educational, social, and other community services that could
7172 benefit a recipient;
7273 (6) procedures for recipient outreach and education;
7374 (7) a requirement that the managed care organization
7475 make payment to a physician or provider for health care services
7576 rendered to a recipient under a managed care plan on any claim for
7677 payment that is received with documentation reasonably necessary
7778 for the managed care organization to process the claim:
7879 (A) not later than:
7980 (i) the 10th day after the date the claim is
8081 received if the claim relates to services provided by a nursing
8182 facility, intermediate care facility, or group home;
8283 (ii) the 30th day after the date the claim
8384 is received if the claim relates to the provision of long-term
8485 services and supports not subject to Subparagraph (i); and
8586 (iii) the 45th day after the date the claim
8687 is received if the claim is not subject to Subparagraph (i) or (ii);
8788 or
8889 (B) within a period, not to exceed 60 days,
8990 specified by a written agreement between the physician or provider
9091 and the managed care organization;
9192 (7-a) a requirement that the managed care organization
9293 demonstrate to the commission that the organization pays claims
9394 described by Subdivision (7)(A)(ii) on average not later than the
9495 21st day after the date the claim is received by the organization;
9596 (8) a requirement that the commission, on the date of a
9697 recipient's enrollment in a managed care plan issued by the managed
9798 care organization, inform the organization of the recipient's
9899 Medicaid certification date;
99100 (9) a requirement that the managed care organization
100101 comply with Section 533.006 as a condition of contract retention
101102 and renewal;
102103 (10) a requirement that the managed care organization
103104 provide the information required by Section 533.012 and otherwise
104105 comply and cooperate with the commission's office of inspector
105106 general and the office of the attorney general;
106107 (11) a requirement that the managed care
107108 organization's usages of out-of-network providers or groups of
108109 out-of-network providers may not exceed limits for those usages
109110 relating to total inpatient admissions, total outpatient services,
110111 and emergency room admissions determined by the commission;
111112 (12) if the commission finds that a managed care
112113 organization has violated Subdivision (11), a requirement that the
113114 managed care organization reimburse an out-of-network provider for
114115 health care services at a rate that is equal to the allowable rate
115116 for those services, as determined under Sections 32.028 and
116117 32.0281, Human Resources Code;
117118 (13) a requirement that, notwithstanding any other
118119 law, including Sections 843.312 and 1301.052, Insurance Code, the
119120 organization:
120121 (A) use advanced practice registered nurses and
121122 physician assistants in addition to physicians as primary care
122123 providers to increase the availability of primary care providers in
123124 the organization's provider network; and
124125 (B) treat advanced practice registered nurses
125126 and physician assistants in the same manner as primary care
126127 physicians with regard to:
127128 (i) selection and assignment as primary
128129 care providers;
129130 (ii) inclusion as primary care providers in
130131 the organization's provider network; and
131132 (iii) inclusion as primary care providers
132133 in any provider network directory maintained by the organization;
133134 (14) a requirement that the managed care organization
134135 reimburse a federally qualified health center or rural health
135136 clinic for health care services provided to a recipient outside of
136137 regular business hours, including on a weekend day or holiday, at a
137138 rate that is equal to the allowable rate for those services as
138139 determined under Section 32.028, Human Resources Code, if the
139140 recipient does not have a referral from the recipient's primary
140141 care physician;
141142 (15) a requirement that the managed care organization
142143 develop, implement, and maintain a system for tracking and
143144 resolving all provider appeals related to claims payment, including
144145 a process that will require:
145146 (A) a tracking mechanism to document the status
146147 and final disposition of each provider's claims payment appeal;
147148 (B) the contracting with physicians who are not
148149 network providers and who are of the same or related specialty as
149150 the appealing physician to resolve claims disputes related to
150151 denial on the basis of medical necessity that remain unresolved
151152 subsequent to a provider appeal;
152153 (C) the determination of the physician resolving
153154 the dispute to be binding on the managed care organization and
154155 provider; and
155156 (D) the managed care organization to allow a
156157 provider with a claim that has not been paid before the time
157158 prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
158159 claim;
159160 (16) a requirement that a medical director who is
160161 authorized to make medical necessity determinations is available to
161162 the region where the managed care organization provides health care
162163 services;
163164 (17) a requirement that the managed care organization
164165 ensure that a medical director and patient care coordinators and
165166 provider and recipient support services personnel are located in
166167 the South Texas service region, if the managed care organization
167168 provides a managed care plan in that region;
168169 (18) a requirement that the managed care organization
169170 provide special programs and materials for recipients with limited
170171 English proficiency or low literacy skills;
171172 (19) a requirement that the managed care organization
172173 develop and establish a process for responding to provider appeals
173174 in the region where the organization provides health care services;
174175 (20) a requirement that the managed care organization:
175176 (A) develop and submit to the commission, before
176177 the organization begins to provide health care services to
177178 recipients, a comprehensive plan that describes how the
178179 organization's provider network complies with the provider access
179180 standards established under Section 533.0061;
180181 (B) as a condition of contract retention and
181182 renewal:
182183 (i) continue to comply with the provider
183184 access standards established under Section 533.0061; and
184185 (ii) make substantial efforts, as
185186 determined by the commission, to mitigate or remedy any
186187 noncompliance with the provider access standards established under
187188 Section 533.0061;
188189 (C) pay liquidated damages for each failure, as
189190 determined by the commission, to comply with the provider access
190191 standards established under Section 533.0061 in amounts that are
191192 reasonably related to the noncompliance; and
192193 (D) regularly, as determined by the commission,
193194 submit to the commission and make available to the public a report
194195 containing data on the sufficiency of the organization's provider
195196 network with regard to providing the care and services described
196197 under Section 533.0061(a) and specific data with respect to access
197198 to primary care, specialty care, long-term services and supports,
198199 nursing services, and therapy services on the average length of
199200 time between:
200201 (i) the date a provider requests prior
201202 authorization for the care or service and the date the organization
202203 approves or denies the request; and
203204 (ii) the date the organization approves a
204205 request for prior authorization for the care or service and the date
205206 the care or service is initiated;
206207 (21) a requirement that the managed care organization
207208 demonstrate to the commission, before the organization begins to
208209 provide health care services to recipients, that, subject to the
209210 provider access standards established under Section 533.0061:
210211 (A) the organization's provider network has the
211212 capacity to serve the number of recipients expected to enroll in a
212213 managed care plan offered by the organization;
213214 (B) the organization's provider network
214215 includes:
215216 (i) a sufficient number of primary care
216217 providers;
217218 (ii) a sufficient variety of provider
218219 types;
219220 (iii) a sufficient number of providers of
220221 long-term services and supports and specialty pediatric care
221222 providers of home and community-based services; and
222223 (iv) providers located throughout the
223224 region where the organization will provide health care services;
224225 and
225226 (C) health care services will be accessible to
226227 recipients through the organization's provider network to a
227228 comparable extent that health care services would be available to
228229 recipients under a fee-for-service or primary care case management
229230 model of Medicaid managed care;
230231 (22) a requirement that the managed care organization
231232 develop a monitoring program for measuring the quality of the
232233 health care services provided by the organization's provider
233234 network that:
234235 (A) incorporates the National Committee for
235236 Quality Assurance's Healthcare Effectiveness Data and Information
236237 Set (HEDIS) measures;
237238 (B) focuses on measuring outcomes; and
238239 (C) includes the collection and analysis of
239240 clinical data relating to prenatal care, preventive care, mental
240241 health care, and the treatment of acute and chronic health
241242 conditions and substance abuse;
242243 (23) subject to Subsection (a-1), a requirement that
243244 the managed care organization develop, implement, and maintain an
244245 outpatient pharmacy benefit plan for its enrolled recipients:
245246 (A) that exclusively employs the vendor drug
246247 program formulary and preserves the state's ability to reduce
247248 waste, fraud, and abuse under Medicaid;
248249 (B) that adheres to the applicable preferred drug
249250 list adopted by the commission under Section 531.072;
250251 (C) that includes the prior authorization
251252 procedures and requirements prescribed by or implemented under
252253 Sections 531.073(b), (c), and (g) for the vendor drug program;
253254 (C-1) that does not require a clinical,
254- nonpreferred, or other prior authorization for any antiretroviral
255+ nonpreferred, or other prior authorization for an antiretroviral
255256 drug, as defined by Section 531.073, or a step therapy or other
256- protocol, that could restrict or delay the dispensing of the drug
257- except to minimize fraud, waste, or abuse;
257+ protocol, that could restrict or delay the dispensing of the drug;
258258 (D) for purposes of which the managed care
259259 organization:
260260 (i) may not negotiate or collect rebates
261261 associated with pharmacy products on the vendor drug program
262262 formulary; and
263263 (ii) may not receive drug rebate or pricing
264264 information that is confidential under Section 531.071;
265265 (E) that complies with the prohibition under
266266 Section 531.089;
267267 (F) under which the managed care organization may
268268 not prohibit, limit, or interfere with a recipient's selection of a
269269 pharmacy or pharmacist of the recipient's choice for the provision
270270 of pharmaceutical services under the plan through the imposition of
271271 different copayments;
272272 (G) that allows the managed care organization or
273273 any subcontracted pharmacy benefit manager to contract with a
274274 pharmacist or pharmacy providers separately for specialty pharmacy
275275 services, except that:
276276 (i) the managed care organization and
277277 pharmacy benefit manager are prohibited from allowing exclusive
278278 contracts with a specialty pharmacy owned wholly or partly by the
279279 pharmacy benefit manager responsible for the administration of the
280280 pharmacy benefit program; and
281281 (ii) the managed care organization and
282282 pharmacy benefit manager must adopt policies and procedures for
283283 reclassifying prescription drugs from retail to specialty drugs,
284284 and those policies and procedures must be consistent with rules
285285 adopted by the executive commissioner and include notice to network
286286 pharmacy providers from the managed care organization;
287287 (H) under which the managed care organization may
288288 not prevent a pharmacy or pharmacist from participating as a
289289 provider if the pharmacy or pharmacist agrees to comply with the
290290 financial terms and conditions of the contract as well as other
291291 reasonable administrative and professional terms and conditions of
292292 the contract;
293293 (I) under which the managed care organization may
294294 include mail-order pharmacies in its networks, but may not require
295295 enrolled recipients to use those pharmacies, and may not charge an
296296 enrolled recipient who opts to use this service a fee, including
297297 postage and handling fees;
298298 (J) under which the managed care organization or
299299 pharmacy benefit manager, as applicable, must pay claims in
300300 accordance with Section 843.339, Insurance Code; and
301301 (K) under which the managed care organization or
302302 pharmacy benefit manager, as applicable:
303303 (i) to place a drug on a maximum allowable
304304 cost list, must ensure that:
305305 (a) the drug is listed as "A" or "B"
306306 rated in the most recent version of the United States Food and Drug
307307 Administration's Approved Drug Products with Therapeutic
308308 Equivalence Evaluations, also known as the Orange Book, has an "NR"
309309 or "NA" rating or a similar rating by a nationally recognized
310310 reference; and
311311 (b) the drug is generally available
312312 for purchase by pharmacies in the state from national or regional
313313 wholesalers and is not obsolete;
314314 (ii) must provide to a network pharmacy
315315 provider, at the time a contract is entered into or renewed with the
316316 network pharmacy provider, the sources used to determine the
317317 maximum allowable cost pricing for the maximum allowable cost list
318318 specific to that provider;
319319 (iii) must review and update maximum
320320 allowable cost price information at least once every seven days to
321321 reflect any modification of maximum allowable cost pricing;
322322 (iv) must, in formulating the maximum
323323 allowable cost price for a drug, use only the price of the drug and
324324 drugs listed as therapeutically equivalent in the most recent
325325 version of the United States Food and Drug Administration's
326326 Approved Drug Products with Therapeutic Equivalence Evaluations,
327327 also known as the Orange Book;
328328 (v) must establish a process for
329329 eliminating products from the maximum allowable cost list or
330330 modifying maximum allowable cost prices in a timely manner to
331331 remain consistent with pricing changes and product availability in
332332 the marketplace;
333333 (vi) must:
334334 (a) provide a procedure under which a
335335 network pharmacy provider may challenge a listed maximum allowable
336336 cost price for a drug;
337337 (b) respond to a challenge not later
338338 than the 15th day after the date the challenge is made;
339339 (c) if the challenge is successful,
340340 make an adjustment in the drug price effective on the date the
341341 challenge is resolved[,] and make the adjustment applicable to all
342342 similarly situated network pharmacy providers, as determined by the
343343 managed care organization or pharmacy benefit manager, as
344344 appropriate;
345345 (d) if the challenge is denied,
346346 provide the reason for the denial; and
347347 (e) report to the commission every 90
348348 days the total number of challenges that were made and denied in the
349349 preceding 90-day period for each maximum allowable cost list drug
350350 for which a challenge was denied during the period;
351351 (vii) must notify the commission not later
352352 than the 21st day after implementing a practice of using a maximum
353353 allowable cost list for drugs dispensed at retail but not by mail;
354354 and
355355 (viii) must provide a process for each of
356356 its network pharmacy providers to readily access the maximum
357357 allowable cost list specific to that provider;
358358 (24) a requirement that the managed care organization
359359 and any entity with which the managed care organization contracts
360360 for the performance of services under a managed care plan disclose,
361361 at no cost, to the commission and, on request, the office of the
362362 attorney general all discounts, incentives, rebates, fees, free
363363 goods, bundling arrangements, and other agreements affecting the
364364 net cost of goods or services provided under the plan;
365365 (25) a requirement that the managed care organization
366366 not implement significant, nonnegotiated, across-the-board
367367 provider reimbursement rate reductions unless:
368368 (A) subject to Subsection (a-3), the
369369 organization has the prior approval of the commission to make the
370370 reductions [reduction]; or
371371 (B) the rate reductions are based on changes to
372372 the Medicaid fee schedule or cost containment initiatives
373373 implemented by the commission; and
374374 (26) a requirement that the managed care organization
375375 make initial and subsequent primary care provider assignments and
376376 changes.
377377 SECTION 3. Section 533.005, Government Code, as amended by
378378 this Act, applies to a contract entered into or renewed on or after
379379 the effective date of this Act. A contract entered into or renewed
380380 before that date is governed by the law in effect on the date the
381381 contract was entered into or renewed, and that law is continued in
382382 effect for that purpose.
383383 SECTION 4. If before implementing any provision of this Act
384384 a state agency determines that a waiver or authorization from a
385385 federal agency is necessary for implementation of that provision,
386386 the agency affected by the provision shall request the waiver or
387387 authorization and may delay implementing that provision until the
388388 waiver or authorization is granted.
389389 SECTION 5. This Act takes effect September 1, 2019.
390- ______________________________ ______________________________
391- President of the Senate Speaker of the House
392- I hereby certify that S.B. No. 1283 passed the Senate on
393- April 17, 2019, by the following vote: Yeas 31, Nays 0; and that
394- the Senate concurred in House amendment on May 23, 2019, by the
395- following vote: Yeas 31, Nays 0.
396- ______________________________
397- Secretary of the Senate
398- I hereby certify that S.B. No. 1283 passed the House, with
399- amendment, on May 17, 2019, by the following vote: Yeas 141,
400- Nays 5, one present not voting.
401- ______________________________
402- Chief Clerk of the House
403- Approved:
404- ______________________________
405- Date
406- ______________________________
407- Governor