|
SECTION 1. (a) 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 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:
(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;
(ii) the 30th day after the
date the claim is received if the claim relates to the provision of
long-term services and supports not subject to 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)(A)(ii) on average not
later than the 21st day after the date the claim is received by the
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,
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)(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 complies with the provider access standards
established under Section 533.0061, as added by Chapter 1272 (S.B. 760),
Acts of the 84th Legislature, Regular Session, 2015;
(B) as a condition of
contract retention and renewal:
(i) continue to comply with
the provider access standards established under Section 533.0061, as
added by Chapter 1272 (S.B. 760), Acts of the 84th Legislature, Regular
Session, 2015; and
(ii) make substantial
efforts, as determined by the commission, to mitigate or remedy any
noncompliance with the provider access standards established under Section
533.0061, as added by Chapter 1272 (S.B. 760), Acts of the 84th
Legislature, Regular Session, 2015;
(C) pay liquidated damages
for each failure, as determined by the commission, to comply with the
provider access standards established under Section 533.0061, as added
by Chapter 1272 (S.B. 760), Acts of the 84th Legislature, Regular Session,
2015, in amounts that are reasonably related to the noncompliance; and
(D) 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 Section 533.0061(a), as added by Chapter 1272 (S.B. 760), Acts of
the 84th Legislature, Regular Session, 2015, and specific data with
respect to access to primary care, specialty care, long-term services and
supports, nursing services, and therapy services on the average length of
time between:
(i) the date a provider
requests prior authorization for the care or service and the date the
organization approves or denies the request; and
(ii) the date the
organization approves a request for prior authorization 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,
subject to the provider access standards established under Section 533.0061,
as added by Chapter 1272 (S.B. 760), Acts of the 84th Legislature, Regular
Session, 2015:
(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 with and [or] collect rebates from labelers and
manufacturers, as those terms are defined by Section 531.070, that are
associated with pharmacy products on the managed care organization's
[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 in accordance with 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;
(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; and
(26) a requirement that the
managed care organization make initial and subsequent primary care provider
assignments and changes.
(b) This section takes
effect September 1, 2018.
|