83R2471 JSL-D
 
  By: Hinojosa S.B. No. 450
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to prohibiting the delivery of prescription drug benefits
  under the Medicaid program through a managed care delivery model.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 531.069(a), Government Code, is amended
  to read as follows:
         (a)  The commission shall periodically review all purchases
  made under the vendor drug program to determine the
  cost-effectiveness of including a component for prescription drug
  benefits in any capitation rate paid by the state under [a Medicaid
  managed care program or] the child health plan program.
         SECTION 2.  Section 533.005(a), Government Code, is amended
  to read as follows:
         (a)  A contract between a managed care organization and the
  commission for the organization to provide health care services to
  recipients must contain:
               (1)  procedures to ensure accountability to the state
  for the provision of health care services, including procedures for
  financial reporting, quality assurance, utilization review, and
  assurance of contract and subcontract compliance;
               (2)  capitation rates that ensure the cost-effective
  provision of quality health care;
               (3)  a requirement that the managed care organization
  provide ready access to a person who assists recipients in
  resolving issues relating to enrollment, plan administration,
  education and training, access to services, and grievance
  procedures;
               (4)  a requirement that the managed care organization
  provide ready access to a person who assists providers in resolving
  issues relating to payment, plan administration, education and
  training, and grievance procedures;
               (5)  a requirement that the managed care organization
  provide information and referral about the availability of
  educational, social, and other community services that could
  benefit a recipient;
               (6)  procedures for recipient outreach and education;
               (7)  a requirement that the managed care organization
  make payment to a physician or provider for health care services
  rendered to a recipient under a managed care plan not later than the
  45th day after the date a claim for payment is received with
  documentation reasonably necessary for the managed care
  organization to process the claim, or within a period, not to exceed
  60 days, specified by a written agreement between the physician or
  provider and the managed care organization;
               (8)  a requirement that the commission, on the date of a
  recipient's enrollment in a managed care plan issued by the managed
  care organization, inform the organization of the recipient's
  Medicaid certification date;
               (9)  a requirement that the managed care organization
  comply with Section 533.006 as a condition of contract retention
  and renewal;
               (10)  a requirement that the managed care organization
  provide the information required by Section 533.012 and otherwise
  comply and cooperate with the commission's office of inspector
  general and the office of the attorney general;
               (11)  a requirement that the managed care
  organization's usages of out-of-network providers or groups of
  out-of-network providers may not exceed limits for those usages
  relating to total inpatient admissions, total outpatient services,
  and emergency room admissions determined by the commission;
               (12)  if the commission finds that a managed care
  organization has violated Subdivision (11), a requirement that the
  managed care organization reimburse an out-of-network provider for
  health care services at a rate that is equal to the allowable rate
  for those services, as determined under Sections 32.028 and
  32.0281, Human Resources Code;
               (13)  a requirement that the organization use advanced
  practice nurses in addition to physicians as primary care providers
  to increase the availability of primary care providers in the
  organization's provider network;
               (14)  a requirement that the managed care organization
  reimburse a federally qualified health center or rural health
  clinic for health care services provided to a recipient outside of
  regular business hours, including on a weekend day or holiday, at a
  rate that is equal to the allowable rate for those services as
  determined under Section 32.028, Human Resources Code, if the
  recipient does not have a referral from the recipient's primary
  care physician;
               (15)  a requirement that the managed care organization
  develop, implement, and maintain a system for tracking and
  resolving all provider appeals related to claims payment, including
  a process that will require:
                     (A)  a tracking mechanism to document the status
  and final disposition of each provider's claims payment appeal;
                     (B)  the contracting with physicians who are not
  network providers and who are of the same or related specialty as
  the appealing physician to resolve claims disputes related to
  denial on the basis of medical necessity that remain unresolved
  subsequent to a provider appeal; and
                     (C)  the determination of the physician resolving
  the dispute to be binding on the managed care organization and
  provider;
               (16)  a requirement that a medical director who is
  authorized to make medical necessity determinations is available to
  the region where the managed care organization provides health care
  services;
               (17)  a requirement that the managed care organization
  ensure that a medical director and patient care coordinators and
  provider and recipient support services personnel are located in
  the South Texas service region, if the managed care organization
  provides a managed care plan in that region;
               (18)  a requirement that the managed care organization
  provide special programs and materials for recipients with limited
  English proficiency or low literacy skills;
               (19)  a requirement that the managed care organization
  develop and establish a process for responding to provider appeals
  in the region where the organization provides health care services;
               (20)  a requirement that the managed care organization
  develop and submit to the commission, before the organization
  begins to provide health care services to recipients, a
  comprehensive plan that describes how the organization's provider
  network will provide recipients sufficient access to:
                     (A)  preventive care;
                     (B)  primary care;
                     (C)  specialty care;
                     (D)  after-hours urgent care; and
                     (E)  chronic care;
               (21)  a requirement that the managed care organization
  demonstrate to the commission, before the organization begins to
  provide health care services to recipients, that:
                     (A)  the organization's provider network has the
  capacity to serve the number of recipients expected to enroll in a
  managed care plan offered by the organization;
                     (B)  the organization's provider network
  includes:
                           (i)  a sufficient number of primary care
  providers;
                           (ii)  a sufficient variety of provider
  types; and
                           (iii)  providers located throughout the
  region where the organization will provide health care services;
  and
                     (C)  health care services will be accessible to
  recipients through the organization's provider network to a
  comparable extent that health care services would be available to
  recipients under a fee-for-service or primary care case management
  model of Medicaid managed care;
               (22)  a requirement that the managed care organization
  develop a monitoring program for measuring the quality of the
  health care services provided by the organization's provider
  network that:
                     (A)  incorporates the National Committee for
  Quality Assurance's Healthcare Effectiveness Data and Information
  Set (HEDIS) measures;
                     (B)  focuses on measuring outcomes; and
                     (C)  includes the collection and analysis of
  clinical data relating to prenatal care, preventive care, mental
  health care, and the treatment of acute and chronic health
  conditions and substance abuse; and
               (23)  [subject to Subsection (a-1), a requirement that
  the managed care organization develop, implement, and maintain an
  outpatient pharmacy benefit plan for its enrolled recipients:
                     [(A)     that exclusively employs the vendor drug
  program formulary and preserves the state's ability to reduce
  waste, fraud, and abuse under the Medicaid program;
                     [(B)     that adheres to the applicable preferred
  drug list adopted by the commission under Section 531.072;
                     [(C)     that includes the prior authorization
  procedures and requirements prescribed by or implemented under
  Sections 531.073(b), (c), and (g) for the vendor drug program;
                     [(D)     for purposes of which the managed care
  organization:
                           [(i)     may not negotiate or collect rebates
  associated with pharmacy products on the vendor drug program
  formulary; and
                           [(ii)     may not receive drug rebate or
  pricing information that is confidential under Section 531.071;
                     [(E)     that complies with the prohibition under
  Section 531.089;
                     [(F)     under which the managed care organization
  may not 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 under the plan through the
  imposition of different copayments;
                     [(G)     that allows the managed care organization or
  any subcontracted pharmacy benefit manager to contract with a
  pharmacist or pharmacy providers separately for specialty pharmacy
  services, except that:
                           [(i)     the managed care organization and
  pharmacy benefit manager are prohibited from allowing exclusive
  contracts with a specialty pharmacy owned wholly or partly by the
  pharmacy benefit manager responsible for the administration of the
  pharmacy benefit program; and
                           [(ii)     the managed care organization and
  pharmacy benefit manager must adopt policies and procedures for
  reclassifying prescription drugs from retail to specialty drugs,
  and those policies and procedures must be consistent with rules
  adopted by the executive commissioner and include notice to network
  pharmacy providers from the managed care organization;
                     [(H)     under which the managed care organization
  may not prevent a pharmacy or pharmacist from participating as a
  provider if the pharmacy or pharmacist agrees to comply with the
  financial terms and conditions of the contract as well as other
  reasonable administrative and professional terms and conditions of
  the contract;
                     [(I)     under which the managed care organization
  may include mail-order pharmacies in its networks, but may not
  require enrolled recipients to use those pharmacies, and may not
  charge an enrolled recipient who opts to use this service a fee,
  including postage and handling fees; and
                     [(J)     under which the managed care organization or
  pharmacy benefit manager, as applicable, must pay claims in
  accordance with Section 843.339, Insurance Code; and
               [(24)]  a requirement that the managed care
  organization and any entity with which the managed care
  organization contracts for the performance of services under a
  managed care plan disclose, at no cost, to the commission and, on
  request, the office of the attorney general all discounts,
  incentives, rebates, fees, free goods, bundling arrangements, and
  other agreements affecting the net cost of goods or services
  provided under the plan.
         SECTION 3.  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 4.  Section 32.0212, Human Resources Code, is
  amended to read as follows:
         Sec. 32.0212.  DELIVERY OF MEDICAL ASSISTANCE. (a)
  Notwithstanding any other law and subject to Section 533.0025,
  Government Code, the department shall provide medical assistance
  for acute care through the Medicaid managed care system implemented
  under Chapter 533, Government Code.
         (b)  Notwithstanding any other law, the department may not
  provide medical assistance for prescription drug benefits through
  the Medicaid managed care system implemented under Chapter 533,
  Government Code.
         SECTION 5.  The heading to Section 32.046, Human Resources
  Code, is amended to read as follows:
         Sec. 32.046.  VENDOR DRUG PROGRAM; SANCTIONS AND PENALTIES
  [RELATED TO THE PROVISION OF PHARMACY PRODUCTS].
         SECTION 6.  Section 32.046(a), Human Resources Code, is
  amended to read as follows:
         (a)  The executive commissioner of the Health and Human
  Services Commission 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 7.  Sections 533.003(b) and 533.005(a-1),
  Government Code, are repealed.
         SECTION 8.  (a)  The changes in law made by this Act apply
  only to a contract between the Health and Human Services Commission
  and a managed care organization entered into or renewed on or after
  the effective date of this Act.
         (b)  Notwithstanding Section 32.0212(b), Human Resources
  Code, as added by this Act, the Health and Human Services Commission
  may continue providing medical assistance for prescription drug
  benefits under a contract with a managed care organization entered
  into under Chapter 533, Government Code, before the effective date
  of this Act until the earlier of:
               (1)  the termination of the contract; or
               (2)  the effective date of a contract amendment
  excluding prescription drug benefits from the benefits provided
  under the contract.
         (c)  The Health and Human Services Commission shall actively
  seek to amend contracts with managed care organizations entered
  into under Chapter 533, Government Code, before the effective date
  of this Act to exclude prescription drug benefits from the benefits
  provided under the contracts.
         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.  This Act takes effect September 1, 2013.