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