Bill Text: TX SB760 | 2015-2016 | 84th Legislature | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to access and assignment requirements for, support and information regarding, and investigations of certain providers of health care and long-term services.
Spectrum: Bipartisan Bill
Status: (Passed) 2015-06-20 - Effective on 9/1/15 [SB760 Detail]
Download: Texas-2015-SB760-Comm_Sub.html
Bill Title: Relating to access and assignment requirements for, support and information regarding, and investigations of certain providers of health care and long-term services.
Spectrum: Bipartisan Bill
Status: (Passed) 2015-06-20 - Effective on 9/1/15 [SB760 Detail]
Download: Texas-2015-SB760-Comm_Sub.html
By: Schwertner | S.B. No. 760 | |
(In the Senate - Filed February 25, 2015; March 2, 2015, | ||
read first time and referred to Committee on Health and Human | ||
Services; March 30, 2015, reported adversely, with favorable | ||
Committee Substitute by the following vote: Yeas 9, Nays 0; | ||
March 30, 2015, sent to printer.) | ||
COMMITTEE SUBSTITUTE FOR S.B. No. 760 | By: Schwertner |
|
||
|
||
relating to provider access and assignment requirements for a | ||
Medicaid managed care organization. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 533.005(a), Government Code, is amended | ||
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 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) 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 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: | ||
(i) the 10th day after the date the claim is | ||
received if the claim relates to services provided by a nursing | ||
facility, intermediate care facility, or group home; | ||
(ii) the 30th day after the date the claim | ||
is received if the claim relates to the provision of long-term | ||
services and supports not subject to Subparagraph (i); and | ||
(iii) the 45th day after the date the claim | ||
is received if the claim is not subject to Subparagraph (i) or (ii); | ||
or | ||
(B) within a period, not to exceed 60 days, | ||
specified by a written agreement between the physician or provider | ||
and the managed care organization; | ||
(7-a) a requirement that the managed care organization | ||
demonstrate to the commission that the organization pays claims | ||
described by Subdivision (7)(A)(ii) on average not later than the | ||
21st day after the date the claim is received by the organization; | ||
(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 usages of out-of-network providers or groups of | ||
out-of-network providers may not exceed limits for those usages | ||
relating to total inpatient admissions, total outpatient services, | ||
and emergency room admissions determined by the commission; | ||
(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 appeals related to claims payment, including | ||
a process that will require: | ||
(A) a tracking mechanism to document the status | ||
and final disposition of each provider's claims payment appeal; | ||
(B) the contracting with physicians who are not | ||
network providers and who are of the same or related specialty as | ||
the appealing physician to resolve claims disputes related to | ||
denial on the basis of medical necessity that remain unresolved | ||
subsequent to a provider appeal; | ||
(C) the determination of the physician resolving | ||
the dispute to be binding on the managed care organization and | ||
provider; and | ||
(D) the managed care organization to allow a | ||
provider with a claim that has not been paid before the time | ||
prescribed by Subdivision (7)(A)(ii) to initiate an appeal of that | ||
claim; | ||
(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 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 [ |
||
|
||
[ |
||
[ |
||
[ |
||
[ |
||
[ |
||
[ |
||
[ |
||
[ |
||
|
||
|
||
(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) 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) [ |
||
respect to access to primary care, specialty care, long-term | ||
services and supports, nursing services, and therapy services | ||
[ |
||
length of time between: | ||
(i) the date a provider requests prior | ||
authorization [ |
||
date the organization approves or denies the request [ |
||
and | ||
(ii) the date the organization approves a | ||
request for prior authorization [ |
||
and the date the care or service is initiated; | ||
(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 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 the Medicaid program; | ||
(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; [ |
||
(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. | ||
SECTION 2. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Sections 533.0061, 533.0062, 533.0063, and | ||
533.0064 to read as follows: | ||
Sec. 533.0061. PROVIDER ACCESS STANDARDS; REPORT. (a) The | ||
commission shall establish minimum provider access standards for | ||
the provider network of a managed care organization that contracts | ||
with the commission to provide health care services to recipients. | ||
The access standards must ensure that a managed care organization | ||
provides recipients sufficient access to: | ||
(1) preventive care; | ||
(2) primary care; | ||
(3) specialty care; | ||
(4) after-hours urgent care; | ||
(5) chronic care; | ||
(6) long-term services and supports; | ||
(7) nursing services; | ||
(8) therapy services, including services provided in a | ||
clinical setting or in a home or community-based setting; and | ||
(9) any other services identified by the commission. | ||
(b) To the extent it is feasible, the provider access | ||
standards established under this section must: | ||
(1) distinguish between access to providers in urban | ||
and rural settings; and | ||
(2) consider the number and geographic distribution of | ||
Medicaid-enrolled providers in a particular service delivery area. | ||
(c) The commission shall biennially submit to the | ||
legislature and make available to the public a report containing | ||
information and statistics about recipient access to providers | ||
through the provider networks of the managed care organizations and | ||
managed care organization compliance with contractual obligations | ||
related to provider access standards established under this | ||
section. The report must contain: | ||
(1) a compilation and analysis of information | ||
submitted to the commission under Section 533.005(a)(20)(D); | ||
(2) for both primary care providers and specialty | ||
providers, information on provider-to-recipient ratios in an | ||
organization's provider network, as well as benchmark ratios to | ||
indicate whether deficiencies exist in a given network; and | ||
(3) a description of, and analysis of the results | ||
from, the commission's monitoring process established under | ||
Section 533.007(l). | ||
Sec. 533.0062. PENALTIES AND OTHER REMEDIES FOR FAILURE TO | ||
COMPLY WITH PROVIDER ACCESS STANDARDS. If a managed care | ||
organization that has contracted with the commission to provide | ||
health care services to recipients fails to comply with one or more | ||
provider access standards established under Section 533.0061 and | ||
the commission determines the organization has not made substantial | ||
efforts to mitigate or remedy the noncompliance, the commission: | ||
(1) may: | ||
(A) elect to not retain or renew the commission's | ||
contract with the organization; or | ||
(B) require the organization to pay liquidated | ||
damages in accordance with Section 533.005(a)(20)(C); and | ||
(2) shall suspend default enrollment to the | ||
organization in a given service delivery area for at least one | ||
calendar quarter if the organization's noncompliance occurs in the | ||
service delivery area for two consecutive calendar quarters. | ||
Sec. 533.0063. PROVIDER NETWORK DIRECTORIES. (a) The | ||
commission shall ensure that a managed care organization that | ||
contracts with the commission to provide health care services to | ||
recipients: | ||
(1) posts on the organization's Internet website: | ||
(A) the organization's provider network | ||
directory; and | ||
(B) a direct telephone number and e-mail address | ||
through which a recipient enrolled in the organization's managed | ||
care plan or the recipient's provider may contact the organization | ||
to receive assistance with: | ||
(i) identifying in-network providers and | ||
services available to the recipient; and | ||
(ii) scheduling an appointment for the | ||
recipient with an available in-network provider or to access | ||
available in-network services; and | ||
(2) updates the online directory required under | ||
Subdivision (1)(A) at least monthly. | ||
(b) Except as provided by Subsection (c), a managed care | ||
organization is required to send a paper form of the organization's | ||
provider network directory for the program only to a recipient who | ||
requests to receive the directory in paper form. | ||
(c) A managed care organization participating in the STAR + | ||
PLUS Medicaid managed care program or STAR Kids Medicaid managed | ||
care program established under Section 533.00253 shall, for a | ||
recipient in that program, issue a provider network directory for | ||
the program in paper form unless the recipient opts out of receiving | ||
the directory in paper form. | ||
Sec. 533.0064. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN | ||
PROVIDERS. (a) In this section, "applicant provider" means a | ||
physician or other health care provider applying for expedited | ||
credentialing under this section. | ||
(b) Notwithstanding any other law and subject to Subsection | ||
(c), a managed care organization that contracts with the commission | ||
to provide health services to recipients shall, in accordance with | ||
this section, establish and implement an expedited credentialing | ||
process that would allow applicant providers to provide services to | ||
recipients on a provisional basis. | ||
(c) The commission shall identify the types of providers for | ||
which an expedited credentialing process must be established and | ||
implemented under this section. | ||
(d) To qualify for expedited credentialing under this | ||
section and payment under Subsection (e), an applicant provider | ||
must: | ||
(1) be a member of an established health care provider | ||
group that has a current contract in force with a managed care | ||
organization described by Subsection (b); | ||
(2) be a Medicaid-enrolled provider; | ||
(3) agree to comply with the terms of the contract | ||
described by Subdivision (1); and | ||
(4) submit all documentation and other information | ||
required by the managed care organization as necessary to enable | ||
the organization to begin the credentialing process required by the | ||
organization to include a provider in the organization's provider | ||
network. | ||
(e) On submission by the applicant provider of the | ||
information required by the managed care organization under | ||
Subsection (d), and for Medicaid reimbursement purposes only, the | ||
organization shall treat the provider as if the provider were in the | ||
organization's provider network when the provider provides | ||
services to recipients, subject to Subsections (f) and (g). | ||
(f) Except as provided by Subsection (g), if, on completion | ||
of the credentialing process, a managed care organization | ||
determines that the applicant provider does not meet the | ||
organization's credentialing requirements, the organization may | ||
recover from the provider the difference between payments for | ||
in-network benefits and out-of-network benefits. | ||
(g) If a managed care organization determines on completion | ||
of the credentialing process that the applicant provider does not | ||
meet the organization's credentialing requirements and that the | ||
provider made fraudulent claims in the provider's application for | ||
credentialing, the organization may recover from the provider the | ||
entire amount of any payment paid to the provider. | ||
SECTION 3. Section 533.007, Government Code, is amended by | ||
adding Subsection (l) to read as follows: | ||
(l) The commission shall establish and implement a process | ||
for the direct monitoring of a managed care organization's provider | ||
network and providers in the network. The process: | ||
(1) must be used to ensure compliance with contractual | ||
obligations related to: | ||
(A) the number of providers accepting new | ||
patients under the Medicaid managed care program; and | ||
(B) the length of time a recipient must wait | ||
between scheduling an appointment with a provider and receiving | ||
treatment from the provider; | ||
(2) may use reasonable methods to ensure compliance | ||
with contractual obligations, including telephone calls made at | ||
random times without notice to assess the availability of providers | ||
and services to new and existing recipients; and | ||
(3) may be implemented directly by the commission or | ||
through a contractor. | ||
SECTION 4. (a) The Health and Human Services Commission, | ||
in a contract between the commission and a managed care | ||
organization under Chapter 533, Government Code, that is entered | ||
into or renewed on or after the effective date of this Act, shall | ||
require that the managed care organization comply with: | ||
(1) Section 533.005(a), Government Code, as amended by | ||
this Act; | ||
(2) the standards established under Section | ||
533.0061(a), Government Code, as added by this Act; and | ||
(3) Section 533.0063, Government Code, as added by | ||
this Act. | ||
(b) The Health and Human Services Commission shall seek to | ||
amend contracts entered into with managed care organizations under | ||
Chapter 533, Government Code, before the effective date of this Act | ||
to require that those managed care organizations comply with the | ||
provisions specified in Subsection (a) of this section. To the | ||
extent of a conflict between those provisions and a provision of a | ||
contract with a managed care organization entered into before the | ||
effective date of this Act, the contract provision prevails. | ||
SECTION 5. The Health and Human Services Commission shall | ||
submit to the legislature the initial report required under Section | ||
533.0061(c), Government Code, as added by this Act, not later than | ||
December 1, 2016. | ||
SECTION 6. 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 7. This Act takes effect September 1, 2015. | ||
* * * * * |