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A BILL TO BE ENTITLED
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AN ACT
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relating to the Medicaid program, including the administration and |
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operation of the Medicaid managed care program. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 531.024172, Government Code, is amended |
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to read as follows: |
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Sec. 531.024172. ELECTRONIC VISIT VERIFICATION SYSTEM; |
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REIMBURSEMENT OF CERTAIN RELATED CLAIMS. (a) Subject to |
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Subsection (g), [In this section, "acute nursing services" has the
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meaning assigned by Section 531.02417.
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[(b) If it is cost-effective and feasible,] the commission |
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shall, in accordance with federal law, implement an electronic |
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visit verification system to electronically verify [and document,] |
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through a telephone, global positioning, or computer-based system |
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that personal care services or attendant care services provided to |
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recipients under Medicaid, including personal care services or |
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attendant care services provided under the Texas Health Care |
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Transformation and Quality Improvement Program waiver issued under |
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Section 1115 of the federal Social Security Act (42 U.S.C. Section |
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1315) or any other Medicaid waiver program, are provided to |
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recipients in accordance with a prior authorization or plan of |
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care. The electronic visit verification system implemented under |
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this subsection must allow for verification of only the following[,
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basic] information relating to the delivery of Medicaid [acute
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nursing] services[, including]: |
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(1) the type of service provided [the provider's
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name]; |
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(2) the name of the recipient to whom the service is |
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provided [the recipient's name]; [and] |
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(3) the date and times [time] the provider began |
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[begins] and ended the [ends each] service delivery visit; |
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(4) the location, including the address, at which the |
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service was provided; |
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(5) the name of the individual who provided the |
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service; and |
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(6) other information the commission determines is |
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necessary to ensure the accurate adjudication of Medicaid claims. |
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(b) The commission shall establish minimum requirements for |
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third-party entities seeking to provide electronic visit |
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verification system services to health care providers providing |
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Medicaid services and must certify that a third-party entity |
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complies with those minimum requirements before the entity may |
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provide electronic visit verification system services to a health |
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care provider. |
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(c) The commission shall inform each Medicaid recipient who |
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receives personal care services or attendant care services that the |
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health care provider providing the services and the recipient are |
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each required to comply with the electronic visit verification |
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system. A managed care organization that contracts with the |
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commission to provide health care services to Medicaid recipients |
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described by this subsection shall also inform recipients enrolled |
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in a managed care plan offered by the organization of those |
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requirements. |
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(d) In implementing the electronic visit verification |
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system: |
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(1) subject to Subsection (e), the executive |
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commissioner shall adopt compliance standards for health care |
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providers; and |
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(2) the commission shall ensure that: |
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(A) the information required to be reported by |
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health care providers is standardized across managed care |
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organizations that contract with the commission to provide health |
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care services to Medicaid recipients and across commission |
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programs; and |
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(B) time frames for the maintenance of electronic |
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visit verification data by health care providers align with claims |
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payment time frames. |
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(e) In establishing compliance standards for health care |
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providers under this section, the executive commissioner shall |
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consider: |
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(1) the administrative burdens placed on health care |
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providers required to comply with the standards; and |
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(2) the benefits of using emerging technologies for |
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ensuring compliance, including Internet-based, mobile |
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telephone-based, and global positioning-based technologies. |
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(f) A health care provider that provides personal care |
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services or attendant care services to Medicaid recipients shall: |
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(1) use an electronic visit verification system to |
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document the provision of those services; |
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(2) comply with all documentation requirements |
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established by the commission; |
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(3) comply with applicable federal and state laws |
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regarding confidentiality of recipients' information; |
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(4) ensure that the commission or the managed care |
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organization with which a claim for reimbursement for a service is |
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filed may review electronic visit verification system |
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documentation related to the claim or obtain a copy of that |
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documentation at no charge to the commission or the organization; |
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and |
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(5) at any time, allow the commission or a managed care |
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organization with which a health care provider contracts to provide |
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health care services to recipients enrolled in the organization's |
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managed care plan to have direct, on-site access to the electronic |
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visit verification system in use by the health care provider. |
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(g) The commission may recognize a health care provider's |
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proprietary electronic visit verification system as complying with |
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this section and allow the health care provider to use that system |
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for a period determined by the commission if the commission |
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determines that the system: |
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(1) complies with all necessary data submission, |
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exchange, and reporting requirements established under this |
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section; |
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(2) meets all other standards and requirements |
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established under this section; and |
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(3) has been in use by the health care provider since |
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at least June 1, 2014. |
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(h) The commission or a managed care organization that |
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contracts with the commission to provide health care services to |
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Medicaid recipients may not pay a claim for reimbursement for |
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personal care services or attendant care services provided to a |
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recipient unless the information from the electronic visit |
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verification system corresponds with the information contained in |
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the claim and the services were provided consistent with a prior |
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authorization or plan of care. A previously paid claim is subject |
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to retrospective review and recoupment if unverified. |
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(i) The commission shall create a stakeholder work group |
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comprised of representatives of affected health care providers, |
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managed care organizations, and Medicaid recipients and |
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periodically solicit from that work group input regarding the |
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ongoing operation of the electronic visit verification system under |
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this section. |
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(j) The executive commissioner may adopt rules necessary to |
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implement this section. |
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SECTION 2. Subchapter C, Chapter 531, Government Code, is |
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amended by adding Section 531.1133 to read as follows: |
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Sec. 531.1133. PROVIDER NOT LIABLE FOR MANAGED CARE |
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ORGANIZATION OVERPAYMENT OR DEBT. (a) If the commission's office |
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of inspector general makes a determination to recoup an overpayment |
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or debt from a managed care organization that contracts with the |
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commission to provide health care services to Medicaid recipients, |
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a provider that contracts with the managed care organization may |
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not be held liable for the good faith provision of services under |
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the provider's contract with the managed care organization that |
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were provided with prior authorization. |
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(b) This section does not: |
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(1) limit the office of inspector general's authority |
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to recoup an overpayment or debt from a provider that is owed by the |
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provider as a result of the provider's failure to comply with |
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applicable law or a contract provision, notwithstanding any prior |
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authorization for a service provided; or |
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(2) apply to an action brought under Chapter 36, Human |
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Resources Code. |
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SECTION 3. Section 531.120, Government Code, is amended by |
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adding Subsection (c) to read as follows: |
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(c) The commission shall provide the notice required by |
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Subsection (a) to a provider that is a hospital not later than the |
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90th day before the date the overpayment or debt that is the subject |
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of the notice must be paid. |
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SECTION 4. Section 533.00281, Government Code, is |
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redesignated as Section 533.0121, Government Code, and amended to |
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read as follows: |
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Sec. 533.0121 [533.00281]. UTILIZATION REVIEW AND |
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FINANCIAL AUDIT PROCESS FOR [STAR + PLUS] MEDICAID MANAGED CARE |
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ORGANIZATIONS CONDUCTED BY OFFICE OF CONTRACT MANAGEMENT. (a) The |
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commission's office of contract management shall establish an |
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annual utilization review and financial audit process for managed |
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care organizations participating in the [STAR + PLUS] Medicaid |
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managed care program. The commission shall determine the topics to |
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be examined in a [the] review [process], except that with respect to |
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a managed care organization participating in the STAR + PLUS |
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Medicaid managed care program, the review [process] must include a |
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thorough investigation of the [each managed care] organization's |
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procedures for determining whether a recipient should be enrolled |
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in the STAR + PLUS home and community-based services and supports |
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(HCBS) program, including the conduct of functional assessments for |
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that purpose and records relating to those assessments. |
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(b) The office of contract management shall use the |
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utilization review and financial audit process established under |
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this section to review each fiscal year: |
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(1) each managed care organization [every managed care
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organization] participating in the [STAR + PLUS] Medicaid managed |
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care program in this state for that organization's first five years |
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of participation; [or] |
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(2) each managed care organization providing health |
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care services to a population of recipients new to receiving those |
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services through a Medicaid [only the] managed care delivery model |
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for the first three years that organization provides those services |
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to that population; or |
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(3) managed care organizations that, using a |
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risk-based assessment process and evaluation of prior history, the |
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office determines have a higher likelihood of contract or financial |
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noncompliance [inappropriate client placement in the STAR + PLUS
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home and community-based services and supports (HCBS) program]. |
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(c) In addition to the reviews required by Subsection (b), |
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the office of contract management shall use the utilization review |
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and financial audit process established under this section to |
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review each managed care organization participating in the Medicaid |
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managed care program at least once every five years. |
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(d) In conjunction with the commission's office of contract |
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management, the commission shall provide a report to the standing |
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committees of the senate and house of representatives with |
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jurisdiction over Medicaid not later than December 1 of each year. |
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The report must: |
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(1) summarize the results of the [utilization] reviews |
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conducted under this section during the preceding fiscal year; |
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(2) provide analysis of errors committed by each |
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reviewed managed care organization; and |
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(3) extrapolate those findings and make |
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recommendations for improving the efficiency of the Medicaid |
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managed care program. |
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(e) If a [utilization] review conducted under this section |
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results in a determination to recoup money from a managed care |
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organization, the provider protections from liability under |
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Section 531.1133 apply [a service provider who contracts with the
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managed care organization may not be held liable for the good faith
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provision of services based on an authorization from the managed
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care organization]. |
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SECTION 5. Section 533.005, Government Code, is amended by |
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amending Subsection (a) and adding Subsection (d) to read as |
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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 access to and the |
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cost-effective 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) subject to Subdivision (7-b), a requirement that |
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the managed care organization make payment to a physician or |
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provider for health care services rendered to a recipient under a |
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managed care plan offered by the managed care organization on any |
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claim for payment that is received with documentation reasonably |
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necessary for the managed care organization to process the claim: |
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(A) not later than[:
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[(i)] the 10th day after the date the claim |
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is received if the claim relates to services provided by a nursing |
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facility, intermediate care facility, or group home; and |
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(B) on average, not later than [(ii)] the 15th |
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[30th] day after the date the claim is received if the claim, |
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including a claim that relates to the provision of long-term |
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services and supports, is not subject to Paragraph (A) |
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[Subparagraph (i); and
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[(iii)
the 45th day after the date the claim
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is received if the claim is not subject to Subparagraph (i) or (ii);
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or
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[(B)
within a period, not to exceed 60 days,
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specified by a written agreement between the physician or provider
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and the managed care organization]; |
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(7-a) a requirement that the managed care organization |
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demonstrate to the commission that the organization pays claims to |
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which [described by] Subdivision (7)(B) applies [(7)(A)(ii)] on |
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average not later than the 15th [21st] day after the date the claim |
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is received by the organization; |
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(7-b) a requirement that the managed care organization |
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demonstrate to the commission that, within each provider category |
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and service delivery area designated by the commission, the |
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organization pays at least 98 percent of claims within the times |
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prescribed by Subdivision (7); |
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(7-c) a requirement that the managed care organization |
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establish an electronic process for use by providers in submitting |
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claims documentation that complies with Section 533.0055(b)(6) and |
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allows providers to submit additional documentation on a claim when |
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the organization determines the claim was not submitted with |
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documentation reasonably necessary to process the claim; |
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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 |
|
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 utilization [usages] of out-of-network providers or |
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groups of out-of-network providers may not exceed limits determined |
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by the commission, including limits [for those usages] relating to: |
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(A) total inpatient admissions, total outpatient |
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services, and emergency room admissions [determined by the
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commission]; |
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(B) acute care services not described by |
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Paragraph (A); and |
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(C) long-term services and supports; |
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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, notwithstanding any other |
|
law, including Sections 843.312 and 1301.052, Insurance Code, the |
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organization: |
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(A) use advanced practice registered nurses and |
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physician assistants in addition to physicians as primary care |
|
providers to increase the availability of primary care providers in |
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the organization's provider network; and |
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(B) treat advanced practice registered nurses |
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and physician assistants in the same manner as primary care |
|
physicians with regard to: |
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(i) selection and assignment as primary |
|
care providers; |
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(ii) inclusion as primary care providers in |
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the organization's provider network; and |
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(iii) inclusion as primary care providers |
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in any provider network directory maintained by the organization; |
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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 |
|
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 |
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recipient does not have a referral from the recipient's primary |
|
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 |
|
resolving all provider complaints and appeals related to claims |
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payment and prior authorization and service denials, including a |
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system [process] that will [require]: |
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(A) allow providers to electronically track and |
|
determine [a tracking mechanism to document] the status and final |
|
disposition of the [each] provider's [claims payment] appeal or |
|
complaint, as applicable; |
|
(B) require the contracting with physicians or |
|
other health care providers who are not network providers and who |
|
are of the same or related specialty as the appealing physician or |
|
other provider, as appropriate, to resolve claims disputes related |
|
to denial on the basis of medical necessity that remain unresolved |
|
subsequent to a provider appeal; and |
|
(C) require the determination of the physician or |
|
other health care provider resolving the dispute to be binding on |
|
the managed care organization and the appealing provider; [and
|
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[(D)
the managed care organization to allow a
|
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provider with a claim that has not been paid before the time
|
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prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that
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claim;] |
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(15-a) a requirement that the managed care |
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organization make available on the organization's Internet website |
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summary information that is accessible to the public regarding the |
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number of provider appeals and the disposition of those appeals, |
|
organized by provider and service types; |
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(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 |
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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 |
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the South Texas service region, if the managed care organization |
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provides Medicaid services to recipients [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 |
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(D) annually [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: |
|
(i) 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 average length of time between the |
|
date the organization approves a request for prior authorization |
|
for the care or service and the date the care or service is |
|
initiated; and |
|
(iii) the number of providers who are |
|
accepting new patients; |
|
(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 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 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; 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; and
|
|
[(26)
a requirement that the managed care
|
|
organization] make initial and subsequent primary care provider |
|
assignments and changes. |
|
(d) In addition to the requirements specified by Subsection |
|
(a), a contract described by that subsection must provide that if |
|
the managed care organization has an ownership interest in a health |
|
care provider in the organization's provider network, the |
|
organization: |
|
(1) must include in the provider network at least one |
|
other health care provider of the same type in which the |
|
organization does not have an ownership interest unless the |
|
organization is able to demonstrate to the commission that the |
|
provider included in the provider network is the only provider |
|
located in an area that meets requirements established by the |
|
commission relating to the time and distance a recipient is |
|
expected to travel to receive services; and |
|
(2) may not give preference in authorizing referrals |
|
to the provider in which the organization has an ownership interest |
|
as compared to other providers of the same or similar services |
|
participating in the organization's provider network. |
|
SECTION 6. Subchapter A, Chapter 533, Government Code, is |
|
amended by adding Section 533.00541 to read as follows: |
|
Sec. 533.00541. PRIOR AUTHORIZATION REQUIREMENTS FOR |
|
CERTAIN POST-ACUTE CARE SERVICES. Notwithstanding any other law |
|
and except as otherwise provided by a settlement agreement filed |
|
with and approved by a court, the commission shall require a managed |
|
care organization that contracts with the commission to provide |
|
health care services to recipients to: |
|
(1) approve or pend a request from a provider of acute |
|
care inpatient services for prior authorization for the following |
|
services or equipment not later than 72 hours after receiving the |
|
request to allow for a safe and timely discharge of a patient from |
|
an inpatient facility: |
|
(A) home health services; |
|
(B) long-term services and supports, including |
|
care provided through a nursing facility; |
|
(C) private-duty nursing; |
|
(D) therapy services; and |
|
(E) durable medical equipment; |
|
(2) ensure that a provider described by Subdivision |
|
(1) has an opportunity to engage in direct discussions with the |
|
organization regarding the appropriate level of post-acute care |
|
while a request for prior authorization is pending; |
|
(3) contact, notify, and negotiate with a provider |
|
described by Subdivision (1) before approving a prior authorization |
|
request for personal care services or attendant care services with |
|
an expiration date different from the expiration date requested by |
|
the provider; |
|
(4) submit to a provider of personal care services or |
|
attendant care services any change to a recipient's service plan |
|
relating to personal care services or attendant care services not |
|
later than the fifth day before the date the plan is to be effective |
|
for purposes of giving the provider time to initiate the change and |
|
the recipient an opportunity to agree to the change, unless the |
|
organization is changing the plan in order to meet an emerging need |
|
for personal care services or attendant care services; |
|
(5) include on subsequent prior authorization |
|
requests approved with a retroactive effective date an expiration |
|
date that takes into account the date the service change described |
|
by Subdivision (4) was implemented by the provider; and |
|
(6) provide complete electronic access to prior |
|
authorizations through the organization's process required under |
|
Section 533.005(a)(7-c). |
|
SECTION 7. Section 533.0055(b), Government Code, is amended |
|
to read as follows: |
|
(b) The provider protection plan required under this |
|
section must provide for: |
|
(1) prompt payment and proper reimbursement of |
|
providers by managed care organizations; |
|
(2) prompt and accurate adjudication of claims |
|
through: |
|
(A) provider education on the proper submission |
|
of clean claims and on appeals; |
|
(B) acceptance of uniform forms, including HCFA |
|
Forms 1500 and UB-92 and subsequent versions of those forms, |
|
through an electronic portal; and |
|
(C) the establishment of standards for claims |
|
payments in accordance with a provider's contract; |
|
(3) adequate and clearly defined provider network |
|
standards that are specific to provider type, including physicians, |
|
general acute care facilities, and other provider types defined in |
|
the commission's network adequacy standards [in effect on January
|
|
1, 2013], and that ensure choice among multiple providers to the |
|
greatest extent possible; |
|
(4) a prompt credentialing process for providers; |
|
(5) uniform efficiency standards and requirements for |
|
managed care organizations for the submission and electronic |
|
tracking of prior authorization [preauthorization] requests for |
|
services provided under Medicaid; |
|
(6) establishment of an electronic process, including |
|
the use of an Internet portal, through which providers in any |
|
managed care organization's provider network may: |
|
(A) submit electronic claims, prior |
|
authorization request forms and attachments [requests], claims |
|
appeals and reconsiderations, clinical data, and other |
|
documentation that the managed care organization requests for prior |
|
authorization and claims processing, including an electronic |
|
process that allows for the resubmission of a claim without a |
|
requirement that the resubmitted claim be submitted in paper form |
|
in order to avoid treatment of the resubmitted claim as a duplicate |
|
claim; and |
|
(B) obtain electronic remittance advice |
|
documents, explanation of benefits statements, service plans under |
|
the STAR Kids Medicaid managed care program, and other standardized |
|
reports; |
|
(7) the measurement of the rates of retention by |
|
managed care organizations of significant traditional providers; |
|
(8) the creation of a work group to review and make |
|
recommendations to the commission concerning any requirement under |
|
this subsection for which immediate implementation is not feasible |
|
at the time the plan is otherwise implemented, including the |
|
required process for submission and acceptance of attachments for |
|
claims processing and prior authorization requests through an |
|
electronic process under Subdivision (6) and, for any requirement |
|
that is not implemented immediately, recommendations regarding the |
|
expected: |
|
(A) fiscal impact of implementing the |
|
requirement; and |
|
(B) timeline for implementation of the |
|
requirement; and |
|
(9) any other provision that the commission determines |
|
will ensure efficiency or reduce administrative burdens on |
|
providers participating in a Medicaid managed care model or |
|
arrangement. |
|
SECTION 8. Subchapter A, Chapter 533, Government Code, is |
|
amended by adding Section 533.0058 to read as follows: |
|
Sec. 533.0058. RESTRICTIONS ON CERTAIN REIMBURSEMENT RATE |
|
REDUCTIONS. (a) In this section, "across-the-board provider |
|
reimbursement rate reduction" means a provider reimbursement rate |
|
reduction proposed by a managed care organization that the |
|
commission determines is likely to affect more than 50 percent of a |
|
particular type of provider participating in the organization's |
|
provider network during the 12-month period following |
|
implementation of the proposed reduction, regardless of whether: |
|
(1) the organization limits the proposed reduction to |
|
specific service areas or provider types; or |
|
(2) the affected providers are likely to experience |
|
differing percentages of rate reductions or amounts of lost revenue |
|
as a result of the proposed reduction. |
|
(b) Except as provided by Subsection (e), a managed care |
|
organization that contracts with the commission to provide health |
|
care services to recipients may not implement a significant, as |
|
determined by the commission, across-the-board provider |
|
reimbursement rate reduction unless the organization: |
|
(1) at least 90 days before the proposed rate |
|
reduction is to take effect: |
|
(A) provides the commission and affected |
|
providers with written notice of the proposed rate reduction; and |
|
(B) makes a good faith effort to negotiate the |
|
reduction with the affected providers; and |
|
(2) receives prior approval from the commission, |
|
subject to Subsection (c). |
|
(c) An across-the-board provider reimbursement rate |
|
reduction is considered to have received the commission's prior |
|
approval for purposes of Subsection (b)(2) unless the commission |
|
issues a written statement of disapproval not later than the 45th |
|
day after the date the commission receives notice of the proposed |
|
rate reduction from the managed care organization under Subsection |
|
(b)(1)(A). |
|
(d) If a managed care organization proposes an |
|
across-the-board provider reimbursement rate reduction in |
|
accordance with this section and subsequently rejects alternative |
|
rate reductions suggested by an affected provider, the organization |
|
must provide the provider with written notice of that rejection, |
|
including an explanation of the grounds for the rejection, before |
|
implementing any rate reduction. |
|
(e) This section does not apply to rate reductions that are |
|
implemented because of reductions to the Medicaid fee schedule or |
|
cost containment initiatives that are specifically directed by the |
|
legislature and implemented by the commission. |
|
SECTION 9. Subchapter A, Chapter 533, Government Code, is |
|
amended by adding Section 533.00611 to read as follows: |
|
Sec. 533.00611. STANDARDS FOR DETERMINING MEDICAL |
|
NECESSITY. (a) Except as provided by Subsection (b), the |
|
commission shall establish standards that govern the processes, |
|
criteria, and guidelines under which managed care organizations |
|
determine the medical necessity of a health care service covered by |
|
Medicaid. In establishing standards under this section, the |
|
commission shall: |
|
(1) ensure that each recipient has equal access in |
|
scope and duration to the same covered health care services for |
|
which the recipient is eligible, regardless of the managed care |
|
organization with which the recipient is enrolled; |
|
(2) provide managed care organizations with |
|
flexibility to approve covered medically necessary services for |
|
recipients that may not be within prescribed criteria and |
|
guidelines; |
|
(3) require managed care organizations to make |
|
available to providers all criteria and guidelines used to |
|
determine medical necessity through an Internet portal accessible |
|
by the providers; |
|
(4) ensure that managed care organizations |
|
consistently apply the same medical necessity criteria and |
|
guidelines for the approval of services and in retrospective |
|
utilization reviews; and |
|
(5) ensure that managed care organizations include in |
|
any service or prior authorization denial specific information |
|
about the medical necessity criteria or guidelines that were not |
|
met. |
|
(b) This section does not apply to or affect the |
|
commission's authority to: |
|
(1) determine medical necessity for home and |
|
community-based services provided under the STAR + PLUS Medicaid |
|
managed care program; or |
|
(2) conduct utilization reviews of those services. |
|
SECTION 10. Section 533.0071, Government Code, is amended |
|
to read as follows: |
|
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The |
|
commission shall make every effort to improve the administration of |
|
contracts with managed care organizations. To improve the |
|
administration of these contracts, the commission shall: |
|
(1) ensure that the commission has appropriate |
|
expertise and qualified staff to effectively manage contracts with |
|
managed care organizations under the Medicaid managed care program; |
|
(2) evaluate options for Medicaid payment recovery |
|
from managed care organizations if the enrollee dies or is |
|
incarcerated or if an enrollee is enrolled in more than one state |
|
program or is covered by another liable third party insurer; |
|
(3) maximize Medicaid payment recovery options by |
|
contracting with private vendors to assist in the recovery of |
|
capitation payments, payments from other liable third parties, and |
|
other payments made to managed care organizations with respect to |
|
enrollees who leave the managed care program; |
|
(4) decrease the administrative burdens of managed |
|
care for the state, the managed care organizations, and the |
|
providers under managed care networks to the extent that those |
|
changes are compatible with state law and existing Medicaid managed |
|
care contracts, including decreasing those burdens by: |
|
(A) where possible, decreasing the duplication |
|
of administrative reporting and process requirements for the |
|
managed care organizations and providers, such as requirements for |
|
the submission of encounter data, quality reports, historically |
|
underutilized business reports, and claims payment summary |
|
reports; |
|
(B) allowing managed care organizations to |
|
provide updated address and other contact information directly to |
|
the commission for correction in the state eligibility system; |
|
(C) promoting consistency and uniformity among |
|
managed care organization policies, including policies relating to |
|
the prior authorization processes [preauthorization process], |
|
lengths of hospital stays, filing deadlines, levels of care, and |
|
case management services; and |
|
(D) [reviewing the appropriateness of primary
|
|
care case management requirements in the admission and clinical
|
|
criteria process, such as requirements relating to including a
|
|
separate cover sheet for all communications, submitting
|
|
handwritten communications instead of electronic or typed review
|
|
processes, and admitting patients listed on separate
|
|
notifications; and
|
|
[(E)] providing a portal that complies with |
|
Section 533.0055(b)(6) through which providers in any managed care |
|
organization's provider network may submit acute care services and |
|
long-term services and supports claims; and |
|
(5) reserve the right to amend the managed care |
|
organization's process for resolving provider appeals of denials |
|
based on medical necessity to include an independent review process |
|
established by the commission for final determination of these |
|
disputes. |
|
SECTION 11. Section 533.0076, Government Code, is amended |
|
by amending Subsection (c) and adding Subsection (d) to read as |
|
follows: |
|
(c) The commission shall allow a recipient who is enrolled |
|
in a managed care plan under this chapter to disenroll from that |
|
plan and enroll in another managed care plan[:
|
|
[(1)] at any time for cause in accordance with federal |
|
law, including because: |
|
(1) the recipient moves out of the managed care |
|
organization's service area; |
|
(2) the plan does not, on the basis of moral or |
|
religious objections, cover the service the recipient seeks; |
|
(3) the recipient needs related services to be |
|
performed at the same time, not all related services are available |
|
within the organization's provider network, and the recipient's |
|
primary care provider or another provider determines that receiving |
|
the services separately would subject the recipient to unnecessary |
|
risk; |
|
(4) for recipients of long-term services or supports, |
|
the recipient would have to change the recipient's residential, |
|
institutional, or employment supports provider based on that |
|
provider's change in status from an in-network to an out-of-network |
|
provider with the managed care organization and, as a result, would |
|
experience a disruption in the recipient's residence or employment; |
|
or |
|
(5) of another reason permitted under federal law, |
|
including poor quality of care, lack of access to services covered |
|
under the contract, or lack of access to providers experienced in |
|
dealing with the recipient's care needs[; and
|
|
[(2)
once for any reason after the periods described
|
|
by Subsections (a) and (b)]. |
|
(d) The commission shall implement a process by which the |
|
commission verifies that a recipient is permitted to disenroll from |
|
one managed care plan offered by a managed care organization and |
|
enroll in another managed care plan, including a plan offered by |
|
another managed care organization, before the disenrollment |
|
occurs. |
|
SECTION 12. Subchapter A, Chapter 533, Government Code, is |
|
amended by adding Section 533.0091 to read as follows: |
|
Sec. 533.0091. CARE COORDINATION SERVICES. A managed care |
|
organization that contracts with the commission to provide health |
|
care services to recipients shall ensure that persons providing |
|
care coordination services through the organization coordinate |
|
with hospital discharge planners, who must notify the organization |
|
of an inpatient admission of a recipient, to facilitate the timely |
|
discharge of the recipient to the appropriate level of care and |
|
minimize potentially preventable readmissions. |
|
SECTION 13. Subchapter A, Chapter 533, Government Code, is |
|
amended by adding Section 533.0122 to read as follows: |
|
Sec. 533.0122. UTILIZATION REVIEW AUDITS CONDUCTED BY |
|
OFFICE OF INSPECTOR GENERAL. (a) If the commission's office of |
|
inspector general intends to conduct a utilization review audit of |
|
a provider of services under a Medicaid managed care delivery |
|
model, the office shall inform both the provider and the managed |
|
care organization with which the provider contracts of any |
|
applicable criteria and guidelines the office will use in the |
|
course of the audit. |
|
(b) The commission's office of inspector general shall |
|
ensure that each person conducting a utilization review audit under |
|
this section has experience and training regarding the operations |
|
of managed care organizations. |
|
(c) The commission's office of inspector general may not, as |
|
the result of a utilization review audit, recoup an overpayment or |
|
debt from a provider that contracts with a managed care |
|
organization based on a determination that a provided service was |
|
not medically necessary unless the office: |
|
(1) uses the same criteria and guidelines that were |
|
used by the managed care organization in its determination of |
|
medical necessity for the service; and |
|
(2) verifies with the managed care organization and |
|
the provider that the provider: |
|
(A) at the time the service was delivered, had |
|
reasonable notice of the criteria and guidelines used by the |
|
managed care organization to determine medical necessity; and |
|
(B) did not follow the criteria and guidelines |
|
used by the managed care organization to determine medical |
|
necessity that were in effect at the time the service was delivered. |
|
(d) If the commission's office of inspector general |
|
conducts a utilization review audit that results in a determination |
|
to recoup money from a managed care organization that contracts |
|
with the commission to provide health care services to recipients, |
|
the provider protections from liability under Section 531.1133 |
|
apply. |
|
SECTION 14. Subchapter A, Chapter 533, Government Code, is |
|
amended by adding Section 533.01316 to read as follows: |
|
Sec. 533.01316. MANAGED CARE ORGANIZATION POLICIES FOR |
|
CERTAIN HOSPITAL STAYS. The commission shall ensure that managed |
|
care organizations that contract with the commission to provide |
|
health care services to recipients have policies regarding |
|
treatment and services related to a recipient's inpatient hospital |
|
stay, including a behavioral health hospital stay, that is less |
|
than 48 hours. For purposes of this section, the commission shall |
|
ensure that the organization: |
|
(1) specifies criteria that: |
|
(A) warrant reimbursement of services related to |
|
the stay as either inpatient hospital services or outpatient |
|
hospital services, including criteria for determining what |
|
services constitute outpatient observation services; |
|
(B) account for medical necessity based on |
|
recognized inpatient criteria, the severity of any psychological |
|
disorder, and the judgment of the treating physician or other |
|
provider; and |
|
(C) do not permit classification of services as |
|
either inpatient or outpatient hospital services for purposes of |
|
reimbursement based solely on the duration of the stay; |
|
(2) provides an opportunity for direct discussions |
|
regarding the medical necessity of a recipient's inpatient hospital |
|
admission; and |
|
(3) reviews documentation in a recipient's medical |
|
record that supports the medical necessity of the inpatient |
|
hospital stay at the time of admission for reimbursement of |
|
services related to the stay. |
|
SECTION 15. Subchapter B, Chapter 534, Government Code, is |
|
amended by adding Section 534.0511 to read as follows: |
|
Sec. 534.0511. ENSURING PROVISION OF MEDICALLY NECESSARY |
|
SERVICES. (a) This section applies only to an individual with an |
|
intellectual or developmental disability who is receiving services |
|
under a Medicaid waiver program or ICF-IID program and who requires |
|
medically necessary acute care services or long-term services and |
|
supports that are not available to the individual through the |
|
delivery model implemented under this chapter. |
|
(b) Notwithstanding any other law, the Medicaid waiver |
|
program or ICF-IID program that serves an individual to which this |
|
section applies shall pay the cost of the service and may submit to |
|
the commission a claim for reimbursement for the cost of that |
|
service. |
|
(c) If the commission determines that a claim paid by the |
|
commission under Subsection (b) should have been covered and paid |
|
by a managed care organization that contracts with the commission, |
|
the commission may recoup the entire cost of that claim from the |
|
organization. |
|
SECTION 16. (a) In this section, "commission" and |
|
"Medicaid" have the meanings assigned by Section 531.001, |
|
Government Code. |
|
(b) As soon as practicable after the effective date of this |
|
Act, the commission shall develop and implement a pilot program in |
|
up to three urban service delivery areas that is designed to |
|
increase the incidence of ambulance service providers directing |
|
recipients of Medicaid managed care program services who are |
|
experiencing a behavioral health emergency to more appropriate |
|
health care providers for treatment of behavioral health illnesses. |
|
(c) Not later than December 1, 2018, the commission shall |
|
develop a report analyzing any cost savings and other benefits |
|
realized as a result of the pilot program and deliver a copy of the |
|
report to the governor, lieutenant governor, speaker of the house |
|
of representatives, and chairs of the standing legislative |
|
committees having primary jurisdiction over Medicaid. |
|
(d) This section expires January 1, 2019. |
|
SECTION 17. (a) In this section, "commission" and |
|
"Medicaid" have the meanings assigned by Section 531.001, |
|
Government Code. |
|
(b) Not later than November 30, 2017, the commission shall, |
|
consistent with the purpose of Sections 533.0025(b) and (d), |
|
Government Code, conduct a study to determine the |
|
cost-effectiveness and feasibility of providing prescription drug |
|
benefits to recipients of acute care services under Medicaid by |
|
pharmacies with a Class A pharmacy license, as described by Section |
|
560.051, Occupations Code, through a single statewide prescription |
|
drug administrator that adheres to a pharmacy services |
|
reimbursement methodology that uses: |
|
(1) the most accurate and transparent ingredient drug |
|
pricing model; |
|
(2) the National Average Drug Acquisition Cost |
|
published by the Centers for Medicare and Medicaid Services as the |
|
drug acquisition cost; and |
|
(3) the most recent dispensing fee study contracted |
|
for by the commission to set an accurate and transparent |
|
professional dispensing fee as defined by 1 T.A.C. Section |
|
355.8551. |
|
(c) In conducting a study under this section, the commission |
|
shall: |
|
(1) for purposes of determining cost-effectiveness, |
|
assume and calculate reductions to the anticipated capitation rate |
|
paid to Medicaid managed care organizations, including reductions |
|
resulting from: |
|
(A) the elimination or reduction of the per |
|
member per month administrative expense fee and the consolidation |
|
of the contracts relating to the prescription drug benefits; |
|
(B) the elimination of the guaranteed risk |
|
margin; and |
|
(C) any difference between pharmacy premiums |
|
paid by the commission to managed care organizations and |
|
prescription expenses reported by the managed care organizations |
|
for the preceding four fiscal years; |
|
(2) determine and consider cost savings that would be |
|
achieved through maintaining a single pharmacy claims database to |
|
enhance patient quality outcomes through implementation of: |
|
(A) a medication therapy management program; |
|
(B) a prescription monitoring program; |
|
(C) an adverse drug interaction avoidance |
|
program; or |
|
(D) other similar results-oriented programs |
|
based on pay-for-performance outcome models; |
|
(3) determine and consider cost savings associated |
|
with enhancing system audit capabilities and reducing contractor |
|
and subcontractor noncompliance, including enhanced auditing |
|
capabilities and reducing noncompliance in relation to: |
|
(A) the payment of rebates; |
|
(B) drug utilization; |
|
(C) the use of prior authorization; and |
|
(D) claims adjudication; |
|
(4) determine and consider cost savings associated |
|
with improving patient access to prescribed medications; |
|
(5) determine and consider cost savings related to |
|
further streamlining both the fee-for-service and managed care |
|
prescription drug benefits under one contract; |
|
(6) assume that the administrator described by |
|
Subsection (b) of this section is, if advantageous to the state, |
|
subject to Chapter 222, Insurance Code; and |
|
(7) consider and determine whether the administrator |
|
could be excluded from Section 9010 of the federal Patient |
|
Protection and Affordable Care Act (Pub. L. No. 111-148), as |
|
amended by the Health Care and Education Reconciliation Act of 2010 |
|
(Pub. L. No. 111-152). |
|
(d) This section does not apply to and the commission may |
|
not consider in conducting the study required by this section the |
|
provision of prescription drug benefits by long-term care facility |
|
pharmacies and specialty pharmacies. |
|
(e) The commission shall combine the study required by this |
|
section with any other similar study required to be conducted by the |
|
commission. |
|
(f) Not later than November 30, 2017, the commission shall |
|
report its findings under this section to the legislature. |
|
(g) This section expires December 31, 2017. |
|
SECTION 18. Section 533.005(a-3), Government Code, is |
|
repealed. |
|
SECTION 19. As soon as practicable after the effective date |
|
of this Act, the Health and Human Services Commission shall |
|
implement an electronic visit verification system in accordance |
|
with Section 531.024172, Government Code, as amended by this Act. |
|
SECTION 20. Section 533.005, Government Code, as amended by |
|
this Act, applies to a contract entered into or renewed on or after |
|
the effective date of this Act. A contract entered into or renewed |
|
before that date is governed by the law in effect on the date the |
|
contract was entered into or renewed, and that law is continued in |
|
effect for that purpose. |
|
SECTION 21. 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 22. This Act takes effect September 1, 2017. |