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A BILL TO BE ENTITLED
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AN ACT
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relating to consumer protection provisions applicable to Medicaid |
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managed care contracts. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 533.003(a), Government Code, is amended |
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to read as follows: |
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(a) In awarding contracts to managed care organizations, |
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the commission shall: |
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(1) give preference to organizations that have |
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significant participation in the organization's provider network |
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from each health care provider in the region who has traditionally |
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provided care to Medicaid and charity care patients; |
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(2) give extra consideration to organizations that |
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agree to assure continuity of care for at least three months beyond |
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the period of Medicaid eligibility for recipients; |
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(3) consider the need to use different managed care |
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plans to meet the needs of different populations; |
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(4) consider the ability of organizations to process |
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Medicaid claims electronically; [and] |
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(5) in the initial implementation of managed care in |
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the South Texas service region, give extra consideration to an |
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organization that either: |
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(A) is locally owned, managed, and operated, if |
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one exists; or |
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(B) is in compliance with the requirements of |
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Section 533.004; and |
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(6) require an organization to provide the commission |
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with a history of reductions in reimbursement rates and covered |
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health care services made by the organization, and consider this |
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history in determining the quality of the proposal for a contract. |
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SECTION 2. Section 533.005(a), Government Code, is amended |
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to read as follows: |
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(a) A contract between a managed care organization and the |
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commission for the organization to provide health care services to |
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recipients must contain: |
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(1) procedures to ensure accountability to the state |
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for the provision of health care services, including procedures for |
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financial reporting, quality assurance, utilization review, and |
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assurance of contract and subcontract compliance; |
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(2) capitation rates that ensure the cost-effective |
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provision of quality health care; |
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(3) a requirement that the managed care organization |
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provide ready access to a person who assists recipients in |
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resolving issues relating to enrollment, plan administration, |
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education and training, access to services, and grievance |
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procedures; |
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(4) a requirement that the managed care organization |
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provide ready access to a person who assists providers in resolving |
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issues relating to payment, plan administration, education and |
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training, and grievance procedures; |
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(5) a requirement that the managed care organization |
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provide information and referral about the availability of |
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educational, social, and other community services that could |
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benefit a recipient; |
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(6) procedures for recipient outreach and education; |
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(7) a requirement that the managed care organization |
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make payment to a physician or provider for health care services |
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rendered to a recipient under a managed care plan not later than the |
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45th day after the date a claim for payment is received with |
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documentation reasonably necessary for the managed care |
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organization to process the claim, or within a period, not to exceed |
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60 days, specified by a written agreement between the physician or |
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provider and the managed care organization; |
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(8) a requirement that the commission, on the date of a |
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recipient's enrollment in a managed care plan issued by the managed |
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care organization, inform the organization of the recipient's |
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Medicaid certification date; |
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(9) a requirement that the managed care organization |
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comply with Section 533.006 as a condition of contract retention |
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and renewal; |
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(10) a requirement that the managed care organization |
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provide the information required by Section 533.012 and otherwise |
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comply and cooperate with the commission's office of inspector |
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general and the office of the attorney general; |
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(11) a requirement that the managed care |
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organization's usages of out-of-network providers or groups of |
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out-of-network providers may not exceed limits for those usages |
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relating to total inpatient admissions, total outpatient services, |
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and emergency room admissions determined by the commission; |
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(12) if the commission finds that a managed care |
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organization has violated Subdivision (11), a requirement that the |
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managed care organization reimburse an out-of-network provider for |
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health care services at a rate that is equal to the allowable rate |
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for those services, as determined under Sections 32.028 and |
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32.0281, Human Resources Code; |
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(13) a requirement that the organization use advanced |
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practice nurses in addition to physicians as primary care providers |
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to increase the availability of primary care providers in the |
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organization's provider network; |
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(14) a requirement that the managed care organization |
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reimburse a federally qualified health center or rural health |
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clinic for health care services provided to a recipient outside of |
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regular business hours, including on a weekend day or holiday, at a |
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rate that is equal to the allowable rate for those services as |
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determined under Section 32.028, Human Resources Code, if the |
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recipient does not have a referral from the recipient's primary |
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care physician; |
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(15) a requirement that the managed care organization |
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develop, implement, and maintain a system for tracking and |
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resolving all provider appeals related to claims payment, including |
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a process that will require: |
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(A) a tracking mechanism to document the status |
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and final disposition of each provider's claims payment appeal; |
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(B) the contracting with physicians who are not |
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network providers and who are of the same or related specialty as |
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the appealing physician to resolve claims disputes related to |
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denial on the basis of medical necessity that remain unresolved |
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subsequent to a provider appeal; and |
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(C) the determination of the physician resolving |
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the dispute to be binding on the managed care organization and |
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provider; |
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(16) a requirement that a medical director who is |
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authorized to make medical necessity determinations is available to |
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the region where the managed care organization provides health care |
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services; |
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(17) a requirement that the managed care organization |
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ensure that a medical director and patient care coordinators and |
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provider and recipient support services personnel are located in |
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the South Texas service region, if the managed care organization |
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provides a managed care plan in that region; |
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(18) a requirement that the managed care organization |
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provide special programs and materials for recipients with limited |
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English proficiency or low literacy skills; |
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(19) a requirement that the managed care organization |
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develop and establish a process for responding to provider appeals |
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in the region where the organization provides health care services; |
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(20) a requirement that the managed care organization |
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develop and submit to the commission, before the organization |
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begins to provide health care services to recipients, a |
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comprehensive plan that describes how the organization's provider |
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network will provide recipients sufficient access to: |
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(A) preventive care; |
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(B) primary care; |
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(C) specialty care; |
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(D) after-hours urgent care; and |
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(E) chronic care; |
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(21) a requirement that the managed care organization |
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demonstrate to the commission, before the organization begins to |
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provide health care services to recipients, that: |
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(A) the organization's provider network has the |
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capacity to serve the number of recipients expected to enroll in a |
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managed care plan offered by the organization; |
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(B) the organization's provider network |
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includes: |
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(i) a sufficient number of primary care |
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providers; |
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(ii) a sufficient variety of provider |
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types; and |
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(iii) providers located throughout the |
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region where the organization will provide health care services; |
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and |
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(C) health care services will be accessible to |
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recipients through the organization's provider network to a |
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comparable extent that health care services would be available to |
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recipients under a fee-for-service or primary care case management |
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model of Medicaid managed care; |
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(22) a requirement that the managed care organization |
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develop a monitoring program for measuring the quality of the |
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health care services provided by the organization's provider |
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network that: |
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(A) incorporates the National Committee for |
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Quality Assurance's Healthcare Effectiveness Data and Information |
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Set (HEDIS) measures; |
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(B) focuses on measuring outcomes; and |
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(C) includes the collection and analysis of |
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clinical data relating to prenatal care, preventive care, mental |
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health care, and the treatment of acute and chronic health |
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conditions and substance abuse; |
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(23) subject to Subsection (a-1), a requirement that |
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the managed care organization develop, implement, and maintain an |
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outpatient pharmacy benefit plan for its enrolled recipients: |
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(A) that exclusively employs the vendor drug |
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program formulary and preserves the state's ability to reduce |
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waste, fraud, and abuse under the Medicaid program; |
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(B) that adheres to the applicable preferred drug |
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list adopted by the commission under Section 531.072; |
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(C) that includes the prior authorization |
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procedures and requirements prescribed by or implemented under |
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Sections 531.073(b), (c), and (g) for the vendor drug program; |
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(D) for purposes of which the managed care |
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organization: |
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(i) may not negotiate or collect rebates |
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associated with pharmacy products on the vendor drug program |
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formulary; and |
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(ii) may not receive drug rebate or pricing |
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information that is confidential under Section 531.071; |
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(E) that complies with the prohibition under |
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Section 531.089; |
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(F) under which the managed care organization may |
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not prohibit, limit, or interfere with a recipient's selection of a |
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pharmacy or pharmacist of the recipient's choice for the provision |
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of pharmaceutical services under the plan through the imposition of |
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different copayments; |
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(G) that allows the managed care organization or |
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any subcontracted pharmacy benefit manager to contract with a |
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pharmacist or pharmacy providers separately for specialty pharmacy |
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services, except that: |
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(i) the managed care organization and |
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pharmacy benefit manager are prohibited from allowing exclusive |
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contracts with a specialty pharmacy owned wholly or partly by the |
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pharmacy benefit manager responsible for the administration of the |
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pharmacy benefit program; and |
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(ii) the managed care organization and |
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pharmacy benefit manager must adopt policies and procedures for |
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reclassifying prescription drugs from retail to specialty drugs, |
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and those policies and procedures must be consistent with rules |
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adopted by the executive commissioner and include notice to network |
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pharmacy providers from the managed care organization; |
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(H) under which the managed care organization may |
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not prevent a pharmacy or pharmacist from participating as a |
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provider if the pharmacy or pharmacist agrees to comply with the |
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financial terms and conditions of the contract as well as other |
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reasonable administrative and professional terms and conditions of |
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the contract; |
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(I) under which the managed care organization may |
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include mail-order pharmacies in its networks, but may not require |
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enrolled recipients to use those pharmacies, and may not charge an |
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enrolled recipient who opts to use this service a fee, including |
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postage and handling fees; and |
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(J) under which the managed care organization or |
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pharmacy benefit manager, as applicable, must pay claims in |
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accordance with Section 843.339, Insurance Code; [and] |
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(24) a requirement that the managed care organization |
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and any entity with which the managed care organization contracts |
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for the performance of services under a managed care plan disclose, |
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at no cost, to the commission and, on request, the office of the |
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attorney general all discounts, incentives, rebates, fees, free |
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goods, bundling arrangements, and other agreements affecting the |
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net cost of goods or services provided under the plan; |
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(25) a requirement that the managed care organization |
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not reduce reimbursement rates or covered services, including |
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value-added services, during the first year that the managed care |
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organization begins providing health care services to enrollees |
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under the contract; |
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(26) a requirement that the managed care organization |
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notify enrollees by certified mail of any reimbursement rate or |
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covered service reduction not later than the 61st day before the |
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date the reduction will take effect and advise those enrollees of |
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the right to change to a different managed care plan, subject to |
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Section 533.0076, and the necessary steps to do so; and |
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(27) a requirement that a managed care organization |
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restore reimbursement rates and services to the levels in effect at |
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the beginning of the contract term before the managed care |
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organization will be permitted to expand to other areas of the state |
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or receive any state-paid capitation rate or other premium |
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increases. |
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SECTION 3. Section 533.003(a), Government Code, as amended |
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by this Act, applies only to a proposal for a contract submitted by |
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a managed care organization on or after September 1, 2013. A |
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proposal for a contract submitted before that date is governed by |
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the law in effect on the date the proposal was submitted, and that |
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law is continued in effect for that purpose. |
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SECTION 4. (a) The Health and Human Services Commission |
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shall, in a contract between the commission and a managed care |
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organization under Chapter 533, Government Code, that is entered |
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into or renewed on or after the effective date of this Act, require |
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that the managed care organization comply with Section 533.005(a), |
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Government Code, as amended by this Act. |
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(b) The Health and Human Services Commission shall seek to |
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amend contracts entered into with managed care organizations under |
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Chapter 533, Government Code, before the effective date of this Act |
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to require those managed care organizations to comply with Section |
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533.005(a), Government Code, as amended by this Act. To the extent |
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of a conflict between that section and a provision of a contract |
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with a managed care organization entered into before the effective |
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date of this Act, the contract provision prevails. |
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SECTION 5. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 6. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2013. |