Bill Text: TX SB2082 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to the Medicaid program, including the administration and operation of the Medicaid managed care program.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2019-03-21 - Referred to Health & Human Services [SB2082 Detail]
Download: Texas-2019-SB2082-Introduced.html
86R14210 KFF-F | ||
By: Hinojosa | S.B. No. 2082 |
|
||
|
||
relating to the Medicaid program, including the administration and | ||
operation of the Medicaid managed care program. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter C, Chapter 531, Government Code, is | ||
amended by adding Section 531.1133 to read as follows: | ||
Sec. 531.1133. PROVIDER NOT LIABLE FOR MANAGED CARE | ||
ORGANIZATION OVERPAYMENT OR DEBT. (a) If the commission's office | ||
of inspector general makes a determination to recoup an overpayment | ||
or debt from a managed care organization that contracts with the | ||
commission to provide health care services to Medicaid recipients, | ||
a provider that contracts with the managed care organization may | ||
not be held liable for the good faith provision of services under | ||
the provider's contract with the managed care organization that | ||
were provided with prior authorization. | ||
(b) This section does not: | ||
(1) limit the office of inspector general's authority | ||
to recoup an overpayment or debt from a provider that is owed by the | ||
provider as a result of the provider's failure to comply with | ||
applicable law or a contract provision, notwithstanding any prior | ||
authorization for a service provided; or | ||
(2) apply to an action brought under Chapter 36, Human | ||
Resources Code. | ||
SECTION 2. Section 533.005, Government Code, is amended by | ||
amending Subsection (a) and adding Subsection (e) to read as | ||
follows: | ||
(a) A contract between a managed care organization and the | ||
commission for the organization to provide health care services to | ||
recipients must contain: | ||
(1) procedures to ensure accountability to the state | ||
for the provision of health care services, including procedures for | ||
financial reporting, quality assurance, utilization review, and | ||
assurance of contract and subcontract compliance; | ||
(2) capitation rates that ensure access to and the | ||
cost-effective provision of quality health care; | ||
(3) a requirement that the managed care organization | ||
provide ready access to a person who assists recipients in | ||
resolving issues relating to enrollment, plan administration, | ||
education and training, access to services, and grievance | ||
procedures; | ||
(4) a requirement that the managed care organization | ||
provide ready access to a person who assists providers in resolving | ||
issues relating to payment, plan administration, education and | ||
training, and grievance procedures; | ||
(5) a requirement that the managed care organization | ||
provide information and referral about the availability of | ||
educational, social, and other community services that could | ||
benefit a recipient; | ||
(6) procedures for recipient outreach and education; | ||
(7) subject to Subdivision (7-b), a requirement that | ||
the managed care organization make payment to a physician or | ||
provider for health care services rendered to a recipient under a | ||
managed care plan offered by the managed care organization on any | ||
claim for payment that is received with documentation reasonably | ||
necessary for the managed care organization to process the claim: | ||
(A) not later than[ |
||
[ |
||
is received if the claim relates to services provided by a nursing | ||
facility, intermediate care facility, or group home; and | ||
(B) on average, not later than [ |
||
[ |
||
including a claim that relates to the provision of long-term | ||
services and supports, is not subject to Paragraph (A) | ||
[ |
||
[ |
||
|
||
|
||
[ |
||
|
||
|
||
(7-a) a requirement that the managed care organization | ||
demonstrate to the commission that the organization pays claims to | ||
which [ |
||
average not later than the 15th [ |
||
is received by the organization; | ||
(7-b) a requirement that the managed care organization | ||
demonstrate to the commission that, within each provider category | ||
and service delivery area designated by the commission, the | ||
organization pays at least 98 percent of claims within the times | ||
prescribed by Subdivision (7); | ||
(7-c) a requirement that the managed care organization | ||
establish an electronic process for use by providers in submitting | ||
claims documentation that complies with Section 533.0055(b)(6) and | ||
allows providers to submit additional documentation on a claim when | ||
the organization determines the claim was not submitted with | ||
documentation reasonably necessary to process the claim; | ||
(8) a requirement that the commission, on the date of a | ||
recipient's enrollment in a managed care plan issued by the managed | ||
care organization, inform the organization of the recipient's | ||
Medicaid certification date; | ||
(9) a requirement that the managed care organization | ||
comply with Section 533.006 as a condition of contract retention | ||
and renewal; | ||
(10) a requirement that the managed care organization | ||
provide the information required by Section 533.012 and otherwise | ||
comply and cooperate with the commission's office of inspector | ||
general and the office of the attorney general; | ||
(11) a requirement that the managed care | ||
organization's utilization [ |
||
groups of out-of-network providers may not exceed limits determined | ||
by the commission, including limits [ |
||
(A) total inpatient admissions, total outpatient | ||
services, and emergency room admissions [ |
||
|
||
(B) acute care services not described by | ||
Paragraph (A); and | ||
(C) long-term services and supports; | ||
(12) if the commission finds that a managed care | ||
organization has violated Subdivision (11), a requirement that the | ||
managed care organization reimburse an out-of-network provider for | ||
health care services at a rate that is equal to the allowable rate | ||
for those services, as determined under Sections 32.028 and | ||
32.0281, Human Resources Code; | ||
(13) a requirement that, notwithstanding any other | ||
law, including Sections 843.312 and 1301.052, Insurance Code, the | ||
organization: | ||
(A) use advanced practice registered nurses and | ||
physician assistants in addition to physicians as primary care | ||
providers to increase the availability of primary care providers in | ||
the organization's provider network; and | ||
(B) treat advanced practice registered nurses | ||
and physician assistants in the same manner as primary care | ||
physicians with regard to: | ||
(i) selection and assignment as primary | ||
care providers; | ||
(ii) inclusion as primary care providers in | ||
the organization's provider network; and | ||
(iii) inclusion as primary care providers | ||
in any provider network directory maintained by the organization; | ||
(14) a requirement that the managed care organization | ||
reimburse a federally qualified health center or rural health | ||
clinic for health care services provided to a recipient outside of | ||
regular business hours, including on a weekend day or holiday, at a | ||
rate that is equal to the allowable rate for those services as | ||
determined under Section 32.028, Human Resources Code, if the | ||
recipient does not have a referral from the recipient's primary | ||
care physician; | ||
(15) a requirement that the managed care organization | ||
develop, implement, and maintain a system for tracking and | ||
resolving all provider complaints and appeals related to claims | ||
payment and prior authorization and service denials, including a | ||
system [ |
||
(A) allow providers to electronically track and | ||
determine [ |
||
disposition of the [ |
||
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 a 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; [ |
||
[ |
||
|
||
|
||
|
||
(15-a) a requirement that the managed care | ||
organization make available on the organization's Internet website | ||
summary information that is accessible to the public regarding the | ||
number of provider appeals and the disposition of those appeals, | ||
organized by provider and service types; | ||
(16) a requirement that a medical director who is | ||
authorized to make medical necessity determinations is available to | ||
the region where the managed care organization provides health care | ||
services; | ||
(17) a requirement that the managed care organization | ||
ensure that a medical director and patient care coordinators and | ||
provider and recipient support services personnel are located in | ||
the South Texas service region, if the managed care organization | ||
provides Medicaid services to recipients [ |
||
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; | ||
(B) as a condition of contract retention and | ||
renewal: | ||
(i) continue to comply with the provider | ||
access standards established under Section 533.0061; 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; | ||
(C) pay liquidated damages for each failure, as | ||
determined by the commission, to comply with the provider access | ||
standards established under Section 533.0061 in amounts that are | ||
reasonably related to the noncompliance; and | ||
(D) annually [ |
||
|
||
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) 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[ |
||
[ |
||
authorization for the care or service and the date the organization | ||
approves or denies the request; [ |
||
(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: | ||
(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 [ |
||
|
||
(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 this [ |
||
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[ |
||
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 | ||
[ |
||
|
||
[ |
||
|
||
|
||
[ |
||
|
||
|
||
[ |
||
|
||
assignments and changes. | ||
(e) 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 3. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.00541 to read as follows: | ||
Sec. 533.00541. PRIOR AUTHORIZATION REQUIREMENT FOR | ||
CERTAIN POST-ACUTE CARE SERVICES BEFORE DISCHARGE. | ||
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, not later than 72 hours after receiving a request from a | ||
provider of acute care inpatient services for prior authorization | ||
for services or equipment to allow for discharge of a patient from | ||
an inpatient facility, approve or pend the request. | ||
SECTION 4. 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 5. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.0091 to read as follows: | ||
Sec. 533.0091. CARE COORDINATION SERVICES. (a) In this | ||
section: | ||
(1) "Care coordination" means assisting recipients to | ||
develop a plan of care, including an individual service plan, that | ||
meets the recipient's needs and coordinating the provision of | ||
Medicaid benefits in a manner that is consistent with the plan of | ||
care. The term is synonymous with "case management," "service | ||
coordination," and "service management." | ||
(2) "Care coordinator" means a person, including a | ||
case manager, engaged by a managed care organization that contracts | ||
with the commission under this chapter to provide care coordination | ||
services. | ||
(b) A managed care organization that contracts with the | ||
commission to provide health care services to recipients shall: | ||
(1) ensure that care coordinators for 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; | ||
and | ||
(2) provide comprehensive care coordination services | ||
to adult recipients with multiple chronic conditions, including | ||
trauma-related injuries, cardiac events, and cancer. | ||
(c) For purposes of this chapter, the commission and a | ||
managed care organization shall classify care coordination | ||
services as medical services instead of as an administrative | ||
service or expense. | ||
SECTION 6. 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 7. Sections 531.02176 and 533.005(a-3), Government | ||
Code, are repealed. | ||
SECTION 8. 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 9. 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 10. This Act takes effect September 1, 2019. |