Texas 2023 - 88th Regular

Texas House Bill HB1701 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	88R6189 BDP-F
2	2	By: Collier H.B. No. 1701
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to administrative and judicial review of certain Medicaid
8	8	reimbursement disputes; authorizing a fee.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subchapter A, Chapter 533, Government Code, is
11	11	amended by adding Section 533.0057 to read as follows:
12	12	Sec. 533.0057. CONFISCATORY REIMBURSEMENT RATES
13	13	PROHIBITED; ADMINISTRATIVE AND JUDICIAL REVIEW OF CERTAIN
14	14	REIMBURSEMENT DISPUTES. (a) In this section, "confiscatory"
15	15	means, with respect to the reimbursement rate paid by a managed care
16	16	organization to a provider, a rate that is below the rate necessary
17	17	to:
18	18	(1) recover the provider's reasonable operating
19	19	expenses;
20	20	(2) realize a reasonable return on the provider's
21	21	costs; and
22	22	(3) ensure confidence in the provider's continued:
23	23	(A) financial integrity; and
24	24	(B) participation in Medicaid.
25	25	(b) A managed care organization may not pay a confiscatory
26	26	reimbursement rate to a provider under a Medicaid managed care
27	27	model or arrangement implemented under this chapter.
28	28	(c) Notwithstanding any other law, a provider, including a
29	29	pharmacy provider, has the right to a contested case hearing under
30	30	Chapter 2001 to dispute the amount of a reimbursement rate paid to
31	31	the provider by a managed care organization or the organization's
32	32	pharmacy benefit manager if, subject to Subsection (f), the
33	33	provider believes the rate is confiscatory in violation of
34	34	Subsection (b), except that the decision of the hearing officer or
35	35	the administrative law judge, as applicable, is not subject to
36	36	judicial review under Chapter 2001. Solely for purposes of this
37	37	section, a managed care organization is to be treated as a state
38	38	agency under Chapter 2001.
39	39	(d) A contested case hearing under Subsection (c) shall be
40	40	conducted by an administrative law judge, unless the commission's
41	41	appeals division employs at least one full-time hearing officer
42	42	whose sole duty is to preside over contested cases. If the
43	43	commission's appeals division employs a hearing officer described
44	44	by this subsection, that officer shall conduct the contested case
45	45	hearing under Subsection (c).
46	46	(e) Parties to a contested case brought under this section:
47	47	(1) must include:
48	48	(A) the provider; and
49	49	(B) the managed care organization and any
50	50	appropriate agent of the organization, including a pharmacy benefit
51	51	manager; and
52	52	(2) may not include the commission.
53	53	(f) If the provider's contract with the managed care
54	54	organization or the organization's agent contains a process for
55	55	handling disputes relating to provider reimbursement, the provider
56	56	may request a contested case hearing under Subsection (c) only if:
57	57	(1) the provider first submits the dispute for
58	58	resolution through the contractual process; and
59	59	(2) the managed care organization or the
60	60	organization's agent, as appropriate, fails to resolve the dispute
61	61	through the contractual process not later than the 45th day after
62	62	the day the dispute is submitted, or if the provider is dissatisfied
63	63	with the resolution of the contractual process.
64	64	(g) In a contested case brought under this section, the
65	65	hearing officer or administrative law judge, as applicable, shall
66	66	determine whether the reimbursement rate is confiscatory and may
67	67	order the managed care organization or the organization's agent to
68	68	pay a rate that is not confiscatory. A hearing officer or
69	69	administrative law judge, as applicable, may not award an amount:
70	70	(1) to any one provider that, as a percentage of the
71	71	provider's average net income before taxes, exceeds the managed
72	72	care organization's percentage of net income before taxes that is
73	73	computed in accordance with the contract between the organization
74	74	and the commission and is authorized to be retained by the
75	75	organization under that contract, averaged over all financial
76	76	statistical reporting periods; or
77	77	(2) that, in the aggregate, exceeds the amount of
78	78	resources maintained by the managed care organization to reasonably
79	79	accommodate program changes at no additional cost to the commission
80	80	in accordance with the contract between the organization and the
81	81	commission.
82	82	(h) In a contested case brought under this section, the
83	83	hearing officer or administrative law judge, as applicable, has the
84	84	discretion:
85	85	(1) considering the interest of judicial economy and
86	86	efficiency, to combine cases wholly or partly that involve the same
87	87	type of provider and the same or substantially similar
88	88	reimbursement issues; or
89	89	(2) to impose part or all of the costs for the hearing
90	90	against the party or parties that do not substantially prevail.
91	91	(i) In awarding costs in a contested case brought under this
92	92	section, the hearing officer or administrative law judge, as
93	93	applicable:
94	94	(1) shall consider whether the position of the party
95	95	was taken in good faith and had a reasonable basis in fact and law;
96	96	and
97	97	(2) may not award attorney's fees.
98	98	(j) The commission or the State Office of Administrative
99	99	Hearings may impose a fee in an amount not to exceed $500 on each
100	100	party to a contested case brought under this section for the purpose
101	101	of offsetting the costs of the hearing.
102	102	SECTION 2. The change in law made by this Act applies only
103	103	to a reimbursement paid to a Medicaid provider on or after the
104	104	effective date of this Act.
105	105	SECTION 3. If before implementing any provision of this Act
106	106	a state agency determines that a waiver or authorization from a
107	107	federal agency is necessary for implementation of that provision,
108	108	the agency affected by the provision shall request the waiver or
109	109	authorization and may delay implementing that provision until the
110	110	waiver or authorization is granted.
111	111	SECTION 4. This Act takes effect immediately if it receives
112	112	a vote of two-thirds of all the members elected to each house, as
113	113	provided by Section 39, Article III, Texas Constitution. If this
114	114	Act does not receive the vote necessary for immediate effect, this
115	115	Act takes effect September 1, 2023.