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SECTION 1. 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 15th [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];
(7-a) a requirement that
the managed care organization allow a physician or provider to
electronically submit documentation necessary for the managed care
organization to process a claim for payment for health care services
rendered to a recipient under a managed care plan, including additional
documentation necessary when the claim is not submitted with documentation
reasonably necessary for the managed care organization to process the
claim;
(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;
(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 and allow the electronic submission of claims documentation
in accordance with Subdivisions (7) and (7-a)
[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.
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SECTION 1. Section
533.005(a), Government Code, as amended by S.B. No. 219, Acts of the 84th
Legislature, Regular Session, 2015, 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 on any claim for payment that is received with
documentation reasonably necessary for the managed care organization to
process the claim[:
[(A)]
not later than:
(A) [(i)] the
10th day after the date the claim is received if the claim relates to
services provided by a nursing facility, intermediate care facility, or
group home; and
(B) on average, [(ii)]
the 15th [30th] day after the date the claim is received if
the claim, including a claim that relates to the provision of
long-term services and supports, is not subject to Paragraph (A)
[Subparagraph (i); and
[(iii)
the 45th day after the date the claim is received if the claim is not
subject to Subparagraph (i) or (ii); or
[(B) within a period, not
to exceed 60 days, specified by a written agreement between the physician
or provider and the managed care organization];
(7-a) a requirement that the
managed care organization demonstrate to the commission that the
organization pays claims described by Subdivision
(7)(B) [(7)(A)(ii)] on average not later than the 15th [21st]
day after the date the claim is received by the organization;
(7-b) a requirement that
the managed care organization allow a physician or provider to
electronically submit documentation necessary for the managed care
organization to process a claim for payment for health care services
rendered to a recipient under a managed care plan, including additional
documentation necessary when the claim is not submitted with documentation
reasonably necessary for the managed care organization to process the
claim;
(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,
notwithstanding any other law, including Sections 843.312 and 1301.052,
Insurance Code, the organization:
(A) use advanced practice
registered nurses and physician assistants in addition to physicians as
primary care providers to increase the availability of primary care
providers in the organization's provider network; and
(B) treat advanced practice
registered nurses and physician assistants in the same manner as primary
care physicians with regard to:
(i) selection and assignment
as primary care providers;
(ii) inclusion as primary
care providers in the organization's provider network; and
(iii) inclusion as primary
care providers in any provider network directory maintained by the
organization;
(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;
(C) the determination of the
physician resolving the dispute to be binding on the managed care
organization and provider; and
(D) the managed care
organization to allow a provider with a claim that has not been paid before
the time prescribed by Subdivision (7)(B)
[(7)(A)(ii)] to initiate an appeal of that claim;
(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:
(A) 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:
(i) preventive care;
(ii) primary care;
(iii) specialty care;
(iv) after-hours urgent
care;
(v) chronic care;
(vi) long-term services and
supports;
(vii) nursing services; and
(viii) therapy services,
including services provided in a clinical setting or in a home or
community-based setting; and
(B) regularly, as determined
by the commission, submit to the commission and make available to the
public a report containing data on the sufficiency of the organization's
provider network with regard to providing the care and services described
under Paragraph (A) and specific data with respect to Paragraphs (A)(iii),
(vi), (vii), and (viii) on the average length of time between:
(i) the date a provider
makes a referral for the care or service and the date the organization
approves or denies the referral; and
(ii) the date the
organization approves a referral for the care or service and the date the
care or service is initiated;
(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;
(iii) a sufficient number of
providers of long-term services and supports and specialty pediatric care
providers of home and community-based services; and
(iv) 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;
(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 Medicaid;
(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;
(J) under which the managed
care organization or pharmacy benefit manager, as applicable, must pay
claims and allow the electronic submission of claims documentation
in accordance with Subdivisions (7) and (7-b)
[Section 843.339, Insurance Code]; and
(K) under which the managed
care organization or pharmacy benefit manager, as applicable:
(i) to place a drug on a
maximum allowable cost list, must ensure that:
(a) the drug is listed as
"A" or "B" rated in the most recent version of the
United States Food and Drug Administration's Approved Drug Products with
Therapeutic Equivalence Evaluations, also known as the Orange Book, has an
"NR" or "NA" rating or a similar rating by a nationally
recognized reference; and
(b) the drug is generally
available for purchase by pharmacies in the state from national or regional
wholesalers and is not obsolete;
(ii) must provide to a
network pharmacy provider, at the time a contract is entered into or
renewed with the network pharmacy provider, the sources used to determine
the maximum allowable cost pricing for the maximum allowable cost list
specific to that provider;
(iii) must review and update
maximum allowable cost price information at least once every seven days to
reflect any modification of maximum allowable cost pricing;
(iv) must, in formulating
the maximum allowable cost price for a drug, use only the price of the drug
and drugs listed as therapeutically equivalent in the most recent version
of the United States Food and Drug Administration's Approved Drug Products
with Therapeutic Equivalence Evaluations, also known as the Orange Book;
(v) must establish a process
for eliminating products from the maximum allowable cost list or modifying
maximum allowable cost prices in a timely manner to remain consistent with
pricing changes and product availability in the marketplace;
(vi) must:
(a) provide a procedure
under which a network pharmacy provider may challenge a listed maximum
allowable cost price for a drug;
(b) respond to a challenge
not later than the 15th day after the date the challenge is made;
(c) if the challenge is
successful, make an adjustment in the drug price effective on the date the
challenge is resolved, and make the adjustment applicable to all similarly
situated network pharmacy providers, as determined by the managed care
organization or pharmacy benefit manager, as appropriate;
(d) if the challenge is
denied, provide the reason for the denial; and
(e) report to the commission
every 90 days the total number of challenges that were made and denied in
the preceding 90-day period for each maximum allowable cost list drug for
which a challenge was denied during the period;
(vii) must notify the
commission not later than the 21st day after implementing a practice of
using a maximum allowable cost list for drugs dispensed at retail but not
by mail; and
(viii) must provide a process
for each of its network pharmacy providers to readily access the maximum
allowable cost list specific to that provider;
(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; and
(25) a requirement that the
managed care organization not implement significant, nonnegotiated,
across-the-board provider reimbursement rate reductions unless:
(A) subject to Subsection
(a-3), the organization has the prior approval of the commission to make
the reduction; or
(B) the rate reductions are
based on changes to the Medicaid fee schedule or cost containment
initiatives implemented by the commission.
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