86R13164 KFF-F
By: Kolkhorst S.B. No. 2262
A BILL TO BE ENTITLED
AN ACT
relating to delivery of outpatient prescription drug benefits under
certain public benefit programs, including Medicaid and the child
health plan program.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. DELIVERY OF OUTPATIENT PRESCRIPTION DRUG BENEFITS USING
FEE-FOR-SERVICE DELIVERY MODEL UNDER CERTAIN PUBLIC BENEFIT
PROGRAMS
SECTION 1.01. Subchapter B, Chapter 531, Government Code,
is amended by adding Section 531.068 to read as follows:
Sec. 531.068. DELIVERY OF OUTPATIENT PRESCRIPTION DRUG
BENEFITS UNDER CERTAIN PROGRAMS. (a) In this section, "recipient"
means a person receiving benefits under a program described by
Subsection (b).
(b) Notwithstanding any other law, beginning January 1,
2020, the commission shall provide outpatient prescription drug
benefits through the vendor drug program using a transparent
fee-for-service delivery model to persons, including persons
enrolled in a managed care program, receiving benefits under:
(1) Medicaid;
(2) the child health plan program;
(3) the kidney health care program; and
(4) any other benefits program administered by the
commission that provides an outpatient prescription drug benefit.
(c) In providing outpatient prescription drug benefits
under this section, the commission shall:
(1) eliminate any obligation to pay fees included in
the capitation rate or other amounts paid to managed care
organizations that are associated with the provision of outpatient
prescription drug benefits, including:
(A) the guaranteed risk margin; and
(B) the health insurance providers fee imposed
under Section 9010 of the federal Patient Protection and Affordable
Care Act (Pub. L. No. 111-148), as amended by the Health Care and
Education Reconciliation Act of 2010 (Pub. L. No. 111-152), and the
associated effects of that fee on federal income taxes;
(2) pay claims in accordance with the deadlines
imposed by Section 843.339, Insurance Code;
(3) if the commission contracts with a claims
processor for purposes of this section, pay the processor only for
reimbursement of any prescribed drug and a contracted
administrative fee; and
(4) in accordance with the findings of the study
conducted by the commission in response to Section 60 following the
Article II appropriations to the commission in Chapter 605
(S.B. 1), Acts of the 85th Legislature, Regular Session, 2017 (the
General Appropriations Act):
(A) consistently apply clinical prior
authorization requirements statewide and use prior authorizations
to control unnecessary utilization;
(B) ensure the preferred drug list is not
disadvantaged;
(C) maintain drug utilization review; and
(D) coordinate data exchange under existing data
warehouse and enterprise data resources.
(d) In providing outpatient prescription drug benefits
under this section, the commission may not:
(1) prohibit, limit, or interfere with a recipient's
selection of a pharmacy or pharmacist of the recipient's choice for
the provision of pharmaceutical services by imposing different
copayments associated with a pharmacy or pharmacist; and
(2) prevent a pharmacy or pharmacist from
participating as a provider if the pharmacy or pharmacist agrees to
comply with the financial terms of the program and any contract
required under the program.
(e) In providing outpatient prescription drug benefits
under this section, the commission may include mail-order
pharmacies in the commission's network of pharmacy providers,
except the commission may not:
(1) require recipients to use a mail-order pharmacy;
or
(2) charge a recipient who elects to use a mail-order
pharmacy a fee for using the mail order service, including a postage
or handling fee.
(f) Notwithstanding any other law, a managed care
organization providing health care services under a benefit program
described by Subsection (b) may not develop, implement, or
maintain an outpatient pharmacy benefit plan for recipients
beginning on the 180th day after the date the commission begins
providing outpatient prescription drug benefits under this
section.
SECTION 1.02. As soon as practicable after the effective
date of this article, but not later than December 31, 2019, the
Health and Human Services Commission shall amend each contract with
a managed care organization entered into before the effective date
of this article to prohibit the organization from providing
outpatient prescription drug benefits to recipients under a public
benefits program subject to Section 531.068, Government Code, as
added by this Act, beginning on the 180th day after the date the
commission begins providing outpatient prescription drug benefits
in the manner required by that section.
ARTICLE 2. CESSATION OF DELIVERY OF OUTPATIENT PRESCRIPTION DRUG
BENEFITS BY MANAGED CARE ORGANIZATIONS
SECTION 2.01. Section 533.012(a), Government Code, is
amended to read as follows:
(a) Each managed care organization contracting with the
commission under this chapter shall submit the following, at no
cost, to the commission and, on request, the office of the attorney
general:
(1) a description of any financial or other business
relationship between the organization and any subcontractor
providing health care services under the contract;
(2) a copy of each type of contract between the
organization and a subcontractor relating to the delivery of or
payment for health care services;
(3) a description of the fraud control program used by
any subcontractor that delivers health care services; and
(4) a description and breakdown of all funds paid to or
by the managed care organization, including a health maintenance
organization, primary care case management provider, [pharmacy
benefit manager,] and exclusive provider organization, necessary
for the commission to determine the actual cost of administering
the managed care plan.
SECTION 2.02. Section 32.046(a), Human Resources Code, is
amended to read as follows:
(a) The executive commissioner shall adopt rules governing
sanctions and penalties that apply to a provider [who participates]
in the vendor drug program [or is enrolled as a network pharmacy
provider of a managed care organization contracting with the
commission under Chapter 533, Government Code, or its subcontractor
and] who submits an improper claim for reimbursement under the
program.
SECTION 2.03. The following provisions are repealed:
(1) Sections 531.0697, 533.003(b), and 533.056,
Government Code; and
(2) Section 32.073(c), Human Resources Code.
SECTION 2.04. The changes in law made by this article apply
beginning on the 180th day after the date the Health and Human
Services Commission begins providing outpatient prescription drug
benefits in the manner required by Section 531.068, Government
Code, as added by this Act. Until the changes in law made by this
article apply, the law as it existed on the day immediately before
the effective date of this article governs, and the former law is
continued in effect for that purpose.
ARTICLE 3. FEDERAL AUTHORIZATION AND EFFECTIVE DATE
SECTION 3.01. 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 3.02. This Act takes effect September 1, 2019.