By: Perry, Hinojosa, Lucio S.B. No. 1207
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the coordination of private health benefits with
  Medicaid benefits.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter A, Chapter 533, Government Code, is
  amended by adding Section 533.038 to read as follows:
         Sec. 533.038.  COORDINATION OF BENEFITS. (a)  In this
  section:
               (1)  "Medicaid managed care organization" means a
  managed care organization that contracts with the commission under
  this chapter to provide health care services to recipients.
               (2)  "Medicaid wrap-around benefit" means a
  Medicaid-covered service, including a pharmacy or medical benefit,
  that is provided to a recipient with both Medicaid and primary
  health benefit plan coverage when the recipient has exceeded the
  primary health benefit plan coverage limit or when the service is
  not covered by the primary health benefit plan issuer.
         (b)  The commission, in coordination with Medicaid managed
  care organizations, shall develop and adopt a clear policy for a
  Medicaid managed care organization to ensure the coordination and
  timely delivery of Medicaid wrap-around benefits for recipients
  with both primary health benefit plan coverage and Medicaid
  coverage.
         (c)  To further assist with the coordination of benefits, the
  commission, in coordination with Medicaid managed care
  organizations, shall develop and maintain a list of services that
  are not traditionally covered by primary health benefit plan
  coverage that a Medicaid managed care organization may approve
  without having to coordinate with the primary health benefit plan
  issuer and that can be resolved through third-party liability
  resolution processes.  The commission shall review and update the
  list quarterly.
         (d)  A Medicaid managed care organization that in good faith
  and following commission policies provides coverage for a Medicaid
  wrap-around benefit shall include the cost of providing the benefit
  in the organization's financial reports.  The commission shall
  include the reported costs in computing capitation rates for the
  managed care organization.
         (e)  If the commission determines that a recipient's primary
  health benefit plan issuer should have been the primary payor of a
  claim, the Medicaid managed care organization that paid the claim
  shall work with the commission on the recovery process and make
  every attempt to reduce health care provider and recipient
  abrasion.
         (f)  The executive commissioner may seek a waiver from the
  federal government as needed to:
               (1)  address federal policies related to coordination
  of benefits and third-party liability; and
               (2)  maximize federal financial participation for
  recipients with both primary health benefit plan coverage and
  Medicaid coverage.
         (g)  Notwithstanding Sections 531.073 and 533.005(a)(23) or
  any other law, the commission shall ensure that a prescription drug
  that is covered under the Medicaid vendor drug program or other
  applicable formulary and is prescribed to a recipient with primary
  health benefit plan coverage is not subject to any prior
  authorization requirement if:
               (1)  the primary health benefit plan issuer will pay at
  least $0.01 on the prescription drug claim; or
               (2)  the prescription drug is covered by the primary
  health benefit plan issuer but the primary health benefit plan
  issuer will pay nothing on the claim because the recipient has not
  met the deductible.
         (h)  Except as provided by Subsection (g)(2), a prescription
  drug prescribed to a recipient with primary health benefit plan
  coverage is subject to any applicable Medicaid clinical or
  nonpreferred prior authorization requirement if the primary health
  benefit plan issuer will pay nothing on the prescription drug
  claim.
         (i)  The commission may include in the Medicaid managed care
  eligibility files an indication of whether a recipient has primary
  health benefit plan coverage or is enrolled in a group health
  benefit plan for which the commission provides premium assistance
  under the health insurance premium payment program.  For recipients
  with that coverage or for whom that premium assistance is provided,
  the files may include the following up-to-date, accurate
  information related to primary health benefit plan coverage to the
  extent the information is available to the commission:
               (1)  the health benefit plan issuer's name and address
  and the recipient's policy number;
               (2)  the primary health benefit plan coverage start and
  end dates; and
               (3)  the primary health benefit plan coverage benefits,
  limits, copayment, and coinsurance information.
         (j)  The commission shall maintain processes and policies to
  allow a health care provider who is primarily providing services to
  a recipient through primary health benefit plan coverage to receive
  Medicaid reimbursement for services ordered, referred, prescribed,
  or delivered, regardless of whether the provider is enrolled as a
  Medicaid provider.  The commission shall allow a provider who is not
  enrolled as a Medicaid provider to order, refer, prescribe, or
  deliver services to a recipient based on the provider's national
  provider identifier number and may not require an additional state
  provider identifier number to receive reimbursement for the
  services.  The commission may seek a waiver of Medicaid provider
  enrollment requirements for providers of recipients with primary
  health benefit plan coverage to implement this subsection.
         (k)  The commission shall develop and implement a clear and
  easy process to allow a recipient with complex medical needs who has
  established a relationship with a specialty provider in an area
  outside of the recipient's Medicaid managed care organization's
  service delivery area to continue receiving care from that
  provider.  If a provider outside of the organization's service
  delivery area enters into a single-case agreement with the Medicaid
  managed care organization to continue providing that care, the
  single-case agreement is not considered an out-of-network
  agreement.
         (l)  The commission shall develop and implement processes
  to:
               (1)  reimburse a recipient with primary health benefit
  plan coverage who pays a copayment or coinsurance amount out of
  pocket because the primary health benefit plan issuer refuses to
  enroll in Medicaid, enter into a single-case agreement, or bill the
  recipient's Medicaid managed care organization; and
               (2)  capture encounter data for the Medicaid
  wrap-around benefits provided by the Medicaid managed care
  organization under this subsection.
         SECTION 2.  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 3.  The Health and Human Services Commission is
  required to implement a provision of this Act only if the
  legislature appropriates money specifically for that purpose.  If
  the legislature does not appropriate money specifically for that
  purpose, the commission may, but is not required to, implement a
  provision of this Act using other appropriations available for that
  purpose.
         SECTION 4.  This Act takes effect September 1, 2019.