86R13164 KFF-F
 
  By: Kolkhorst S.B. No. 2262
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to delivery of outpatient prescription drug benefits under
  certain public benefit programs, including Medicaid and the child
  health plan program.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
  ARTICLE 1. DELIVERY OF OUTPATIENT PRESCRIPTION DRUG BENEFITS USING
  FEE-FOR-SERVICE DELIVERY MODEL UNDER CERTAIN PUBLIC BENEFIT
  PROGRAMS
         SECTION 1.01.  Subchapter B, Chapter 531, Government Code,
  is amended by adding Section 531.068 to read as follows:
         Sec. 531.068.  DELIVERY OF OUTPATIENT PRESCRIPTION DRUG
  BENEFITS UNDER CERTAIN PROGRAMS. (a)  In this section, "recipient"
  means a person receiving benefits under a program described by
  Subsection (b).
         (b)  Notwithstanding any other law, beginning January 1,
  2020, the commission shall provide outpatient prescription drug
  benefits through the vendor drug program using a transparent
  fee-for-service delivery model to persons, including persons
  enrolled in a managed care program, receiving benefits under:
               (1)  Medicaid;
               (2)  the child health plan program;
               (3)  the kidney health care program; and
               (4)  any other benefits program administered by the
  commission that provides an outpatient prescription drug benefit.
         (c)  In providing outpatient prescription drug benefits
  under this section, the commission shall:
               (1)  eliminate any obligation to pay fees included in
  the capitation rate or other amounts paid to managed care
  organizations that are associated with the provision of outpatient
  prescription drug benefits, including:
                     (A)  the guaranteed risk margin; and
                     (B)  the health insurance providers fee imposed
  under 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), and the
  associated effects of that fee on federal income taxes;
               (2)  pay claims in accordance with the deadlines
  imposed by Section 843.339, Insurance Code;
               (3)  if the commission contracts with a claims
  processor for purposes of this section, pay the processor only for
  reimbursement of any prescribed drug and a contracted
  administrative fee; and
               (4)  in accordance with the findings of the study
  conducted by the commission in response to Section 60 following the
  Article II appropriations to the commission in Chapter 605
  (S.B. 1), Acts of the 85th Legislature, Regular Session, 2017 (the
  General Appropriations Act):
                     (A)  consistently apply clinical prior
  authorization requirements statewide and use prior authorizations
  to control unnecessary utilization;
                     (B)  ensure the preferred drug list is not
  disadvantaged;
                     (C)  maintain drug utilization review; and
                     (D)  coordinate data exchange under existing data
  warehouse and enterprise data resources.
         (d)  In providing outpatient prescription drug benefits
  under this section, the commission may not:
               (1)  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 by imposing different
  copayments associated with a pharmacy or pharmacist; and
               (2)  prevent a pharmacy or pharmacist from
  participating as a provider if the pharmacy or pharmacist agrees to
  comply with the financial terms of the program and any contract
  required under the program.
         (e)  In providing outpatient prescription drug benefits
  under this section, the commission may include mail-order
  pharmacies in the commission's network of pharmacy providers,
  except the commission may not:
               (1)  require recipients to use a mail-order pharmacy;
  or
               (2)  charge a recipient who elects to use a mail-order
  pharmacy a fee for using the mail order service, including a postage
  or handling fee.
         (f)  Notwithstanding any other law, a managed care
  organization providing health care services under a benefit program
  described by Subsection (b) may not develop, implement, or
  maintain an outpatient pharmacy benefit plan for recipients
  beginning on the 180th day after the date the commission begins
  providing outpatient prescription drug benefits under this
  section.
         SECTION 1.02.  As soon as practicable after the effective
  date of this article, but not later than December 31, 2019, the
  Health and Human Services Commission shall amend each contract with
  a managed care organization entered into before the effective date
  of this article to prohibit the organization from providing
  outpatient prescription drug benefits to recipients under a public
  benefits program subject to Section 531.068, Government Code, as
  added by this Act, beginning on the 180th day after the date the
  commission begins providing outpatient prescription drug benefits
  in the manner required by that section.
  ARTICLE 2. CESSATION OF DELIVERY OF OUTPATIENT PRESCRIPTION DRUG
  BENEFITS BY MANAGED CARE ORGANIZATIONS
         SECTION 2.01.  Section 533.012(a), Government Code, is
  amended to read as follows:
         (a)  Each managed care organization contracting with the
  commission under this chapter shall submit the following, at no
  cost, to the commission and, on request, the office of the attorney
  general:
               (1)  a description of any financial or other business
  relationship between the organization and any subcontractor
  providing health care services under the contract;
               (2)  a copy of each type of contract between the
  organization and a subcontractor relating to the delivery of or
  payment for health care services;
               (3)  a description of the fraud control program used by
  any subcontractor that delivers health care services; and
               (4)  a description and breakdown of all funds paid to or
  by the managed care organization, including a health maintenance
  organization, primary care case management provider, [pharmacy
  benefit manager,] and exclusive provider organization, necessary
  for the commission to determine the actual cost of administering
  the managed care plan.
         SECTION 2.02.  Section 32.046(a), Human Resources Code, is
  amended to read as follows:
         (a)  The executive commissioner shall adopt rules governing
  sanctions and penalties that apply to a provider [who participates]
  in the vendor drug program [or is enrolled as a network pharmacy
  provider of a managed care organization contracting with the
  commission under Chapter 533, Government Code, or its subcontractor
  and] who submits an improper claim for reimbursement under the
  program.
         SECTION 2.03.  The following provisions are repealed:
               (1)  Sections 531.0697, 533.003(b), and 533.056,
  Government Code; and
               (2)  Section 32.073(c), Human Resources Code.
         SECTION 2.04.  The changes in law made by this article apply
  beginning on the 180th day after the date the Health and Human
  Services Commission begins providing outpatient prescription drug
  benefits in the manner required by Section 531.068, Government
  Code, as added by this Act. Until the changes in law made by this
  article apply, the law as it existed on the day immediately before
  the effective date of this article governs, and the former law is
  continued in effect for that purpose.
  ARTICLE 3. FEDERAL AUTHORIZATION AND EFFECTIVE DATE
         SECTION 3.01.  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 3.02.  This Act takes effect September 1, 2019.