Bill Text: TX HB3982 | 2017-2018 | 85th Legislature | Comm Sub
Bill Title: Relating to the Medicaid program, including the administration and operation of the Medicaid managed care program.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2017-05-10 - Placed on General State Calendar [HB3982 Detail]
Download: Texas-2017-HB3982-Comm_Sub.html
85R24666 KFF-F | |||
By: Raymond | H.B. No. 3982 | ||
Substitute the following for H.B. No. 3982: | |||
By: Minjarez | C.S.H.B. No. 3982 |
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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. Section 531.024172, Government Code, is amended | ||
to read as follows: | ||
Sec. 531.024172. ELECTRONIC VISIT VERIFICATION SYSTEM; | ||
REIMBURSEMENT OF CERTAIN RELATED CLAIMS. (a) Subject to | ||
Subsection (g), [ |
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shall, in accordance with federal law, implement an electronic | ||
visit verification system to electronically verify [ |
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through a telephone, global positioning, or computer-based system | ||
that personal care services or attendant care services provided to | ||
recipients under Medicaid, including personal care services or | ||
attendant care services provided under the Texas Health Care | ||
Transformation and Quality Improvement Program waiver issued under | ||
Section 1115 of the federal Social Security Act (42 U.S.C. Section | ||
1315) or any other Medicaid waiver program, are provided to | ||
recipients in accordance with a prior authorization or plan of | ||
care. The electronic visit verification system implemented under | ||
this subsection must allow for verification of only the following[ |
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(1) the type of service provided [ |
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(2) the name of the recipient to whom the service is | ||
provided [ |
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(3) the date and times [ |
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[ |
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(4) the location, including the address, at which the | ||
service was provided; | ||
(5) the name of the individual who provided the | ||
service; and | ||
(6) other information the commission determines is | ||
necessary to ensure the accurate adjudication of Medicaid claims. | ||
(b) The commission shall establish minimum requirements for | ||
third-party entities seeking to provide electronic visit | ||
verification system services to health care providers providing | ||
Medicaid services and must certify that a third-party entity | ||
complies with those minimum requirements before the entity may | ||
provide electronic visit verification system services to a health | ||
care provider. | ||
(c) The commission shall inform each Medicaid recipient who | ||
receives personal care services or attendant care services that the | ||
health care provider providing the services and the recipient are | ||
each required to comply with the electronic visit verification | ||
system. A managed care organization that contracts with the | ||
commission to provide health care services to Medicaid recipients | ||
described by this subsection shall also inform recipients enrolled | ||
in a managed care plan offered by the organization of those | ||
requirements. | ||
(d) In implementing the electronic visit verification | ||
system: | ||
(1) subject to Subsection (e), the executive | ||
commissioner shall adopt compliance standards for health care | ||
providers; and | ||
(2) the commission shall ensure that: | ||
(A) the information required to be reported by | ||
health care providers is standardized across managed care | ||
organizations that contract with the commission to provide health | ||
care services to Medicaid recipients and across commission | ||
programs; and | ||
(B) time frames for the maintenance of electronic | ||
visit verification data by health care providers align with claims | ||
payment time frames. | ||
(e) In establishing compliance standards for health care | ||
providers under this section, the executive commissioner shall | ||
consider: | ||
(1) the administrative burdens placed on health care | ||
providers required to comply with the standards; and | ||
(2) the benefits of using emerging technologies for | ||
ensuring compliance, including Internet-based, mobile | ||
telephone-based, and global positioning-based technologies. | ||
(f) A health care provider that provides personal care | ||
services or attendant care services to Medicaid recipients shall: | ||
(1) use an electronic visit verification system to | ||
document the provision of those services; | ||
(2) comply with all documentation requirements | ||
established by the commission; | ||
(3) comply with applicable federal and state laws | ||
regarding confidentiality of recipients' information; | ||
(4) ensure that the commission or the managed care | ||
organization with which a claim for reimbursement for a service is | ||
filed may review electronic visit verification system | ||
documentation related to the claim or obtain a copy of that | ||
documentation at no charge to the commission or the organization; | ||
and | ||
(5) at any time, allow the commission or a managed care | ||
organization with which a health care provider contracts to provide | ||
health care services to recipients enrolled in the organization's | ||
managed care plan to have direct, on-site access to the electronic | ||
visit verification system in use by the health care provider. | ||
(g) The commission may recognize a health care provider's | ||
proprietary electronic visit verification system as complying with | ||
this section and allow the health care provider to use that system | ||
for a period determined by the commission if the commission | ||
determines that the system: | ||
(1) complies with all necessary data submission, | ||
exchange, and reporting requirements established under this | ||
section; | ||
(2) meets all other standards and requirements | ||
established under this section; and | ||
(3) has been in use by the health care provider since | ||
at least June 1, 2014. | ||
(h) The commission or a managed care organization that | ||
contracts with the commission to provide health care services to | ||
Medicaid recipients may not pay a claim for reimbursement for | ||
personal care services or attendant care services provided to a | ||
recipient unless the information from the electronic visit | ||
verification system corresponds with the information contained in | ||
the claim and the services were provided consistent with a prior | ||
authorization or plan of care. A previously paid claim is subject | ||
to retrospective review and recoupment if unverified. | ||
(i) The commission shall create a stakeholder work group | ||
comprised of representatives of affected health care providers, | ||
managed care organizations, and Medicaid recipients and | ||
periodically solicit from that work group input regarding the | ||
ongoing operation of the electronic visit verification system under | ||
this section. | ||
(j) The executive commissioner may adopt rules necessary to | ||
implement this section. | ||
SECTION 2. 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 3. Section 531.120, Government Code, is amended by | ||
adding Subsection (c) to read as follows: | ||
(c) The commission shall provide the notice required by | ||
Subsection (a) to a provider that is a hospital not later than the | ||
90th day before the date the overpayment or debt that is the subject | ||
of the notice must be paid. | ||
SECTION 4. Section 533.00281, Government Code, is | ||
redesignated as Section 533.0121, Government Code, and amended to | ||
read as follows: | ||
Sec. 533.0121 [ |
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FINANCIAL AUDIT PROCESS FOR [ |
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ORGANIZATIONS CONDUCTED BY OFFICE OF CONTRACT MANAGEMENT. (a) The | ||
commission's office of contract management shall establish an | ||
annual utilization review and financial audit process for managed | ||
care organizations participating in the [ |
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managed care program. The commission shall determine the topics to | ||
be examined in a [ |
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a managed care organization participating in the STAR + PLUS | ||
Medicaid managed care program, the review [ |
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thorough investigation of the [ |
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procedures for determining whether a recipient should be enrolled | ||
in the STAR + PLUS home and community-based services and supports | ||
(HCBS) program, including the conduct of functional assessments for | ||
that purpose and records relating to those assessments. | ||
(b) The office of contract management shall use the | ||
utilization review and financial audit process established under | ||
this section to review each fiscal year: | ||
(1) each managed care organization [ |
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care program in this state for that organization's first five years | ||
of participation; [ |
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(2) each managed care organization providing health | ||
care services to a population of recipients new to receiving those | ||
services through a Medicaid [ |
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for the first three years that organization provides those services | ||
to that population; or | ||
(3) managed care organizations that, using a | ||
risk-based assessment process and evaluation of prior history, the | ||
office determines have a higher likelihood of contract or financial | ||
noncompliance [ |
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(c) In addition to the reviews required by Subsection (b), | ||
the office of contract management shall use the utilization review | ||
and financial audit process established under this section to | ||
review each managed care organization participating in the Medicaid | ||
managed care program at least once every five years. | ||
(d) In conjunction with the commission's office of contract | ||
management, the commission shall provide a report to the standing | ||
committees of the senate and house of representatives with | ||
jurisdiction over Medicaid not later than December 1 of each year. | ||
The report must: | ||
(1) summarize the results of the [ |
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conducted under this section during the preceding fiscal year; | ||
(2) provide analysis of errors committed by each | ||
reviewed managed care organization; and | ||
(3) extrapolate those findings and make | ||
recommendations for improving the efficiency of the Medicaid | ||
managed care program. | ||
(e) If a [ |
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results in a determination to recoup money from a managed care | ||
organization, the provider protections from liability under | ||
Section 531.1133 apply [ |
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SECTION 5. Section 533.005, Government Code, is amended by | ||
amending Subsection (a) and adding Subsection (d) 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[ |
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[ |
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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 [ |
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including a claim that relates to the provision of long-term | ||
services and supports, is not subject to Paragraph (A) | ||
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(7-a) a requirement that the managed care organization | ||
demonstrate to the commission that the organization pays claims to | ||
which [ |
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average not later than the 15th [ |
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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 [ |
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groups of out-of-network providers may not exceed limits determined | ||
by the commission, including limits [ |
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(A) total inpatient admissions, total outpatient | ||
services, and emergency room admissions [ |
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(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 [ |
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(A) allow providers to electronically track and | ||
determine [ |
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disposition of the [ |
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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 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; [ |
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(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 [ |
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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, as added by Chapter | ||
1272 (S.B. 760), Acts of the 84th Legislature, Regular Session, | ||
2015; | ||
(B) as a condition of contract retention and | ||
renewal: | ||
(i) continue to comply with the provider | ||
access standards established under Section 533.0061, as added by | ||
Chapter 1272 (S.B. 760), Acts of the 84th Legislature, Regular | ||
Session, 2015; 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, as added by Chapter 1272 (S.B. 760), Acts of the | ||
84th Legislature, Regular Session, 2015; | ||
(C) pay liquidated damages for each failure, as | ||
determined by the commission, to comply with the provider access | ||
standards established under Section 533.0061, as added by Chapter | ||
1272 (S.B. 760), Acts of the 84th Legislature, Regular Session, | ||
2015, in amounts that are reasonably related to the noncompliance; | ||
and | ||
(D) annually [ |
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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), as added by | ||
Chapter 1272 (S.B. 760), Acts of the 84th Legislature, Regular | ||
Session, 2015, 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[ |
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[ |
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authorization for the care or service and the date the organization | ||
approves or denies the request; [ |
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(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, as | ||
added by Chapter 1272 (S.B. 760), Acts of the 84th Legislature, | ||
Regular Session, 2015: | ||
(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 [ |
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(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 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; and | ||
(25) a requirement that the managed care organization | ||
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assignments and changes. | ||
(d) 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 6. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.00541 to read as follows: | ||
Sec. 533.00541. PRIOR AUTHORIZATION REQUIREMENTS FOR | ||
CERTAIN POST-ACUTE CARE SERVICES. 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: | ||
(1) approve or pend a request from a provider of acute | ||
care inpatient services for prior authorization for the following | ||
services or equipment not later than 72 hours after receiving the | ||
request to allow for a safe and timely discharge of a patient from | ||
an inpatient facility: | ||
(A) home health services; | ||
(B) long-term services and supports, including | ||
care provided through a nursing facility; | ||
(C) private-duty nursing; | ||
(D) therapy services; and | ||
(E) durable medical equipment; | ||
(2) ensure that a provider described by Subdivision | ||
(1) has an opportunity to engage in direct discussions with the | ||
organization regarding the appropriate level of post-acute care | ||
while a request for prior authorization is pending; | ||
(3) contact, notify, and negotiate with a provider | ||
described by Subdivision (1) before approving a prior authorization | ||
request for personal care services or attendant care services with | ||
an expiration date different from the expiration date requested by | ||
the provider; | ||
(4) submit to a provider of personal care services or | ||
attendant care services any change to a recipient's service plan | ||
relating to personal care services or attendant care services not | ||
later than the fifth day before the date the plan is to be effective | ||
for purposes of giving the provider time to initiate the change and | ||
the recipient an opportunity to agree to the change, unless the | ||
organization is changing the plan in order to meet an emerging need | ||
for personal care services or attendant care services; | ||
(5) include on subsequent prior authorization | ||
requests approved with a retroactive effective date an expiration | ||
date that takes into account the date the service change described | ||
by Subdivision (4) was implemented by the provider; and | ||
(6) provide complete electronic access to prior | ||
authorizations through the organization's process required under | ||
Section 533.005(a)(7-c). | ||
SECTION 7. Section 533.0055(b), Government Code, is amended | ||
to read as follows: | ||
(b) The provider protection plan required under this | ||
section must provide for: | ||
(1) prompt payment and proper reimbursement of | ||
providers by managed care organizations; | ||
(2) prompt and accurate adjudication of claims | ||
through: | ||
(A) provider education on the proper submission | ||
of clean claims and on appeals; | ||
(B) acceptance of uniform forms, including HCFA | ||
Forms 1500 and UB-92 and subsequent versions of those forms, | ||
through an electronic portal; and | ||
(C) the establishment of standards for claims | ||
payments in accordance with a provider's contract; | ||
(3) adequate and clearly defined provider network | ||
standards that are specific to provider type, including physicians, | ||
general acute care facilities, and other provider types defined in | ||
the commission's network adequacy standards [ |
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greatest extent possible; | ||
(4) a prompt credentialing process for providers; | ||
(5) uniform efficiency standards and requirements for | ||
managed care organizations for the submission and electronic | ||
tracking of prior authorization [ |
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services provided under Medicaid; | ||
(6) establishment of an electronic process, including | ||
the use of an Internet portal, through which providers in any | ||
managed care organization's provider network may: | ||
(A) submit electronic claims, prior | ||
authorization request forms and attachments [ |
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appeals and reconsiderations, clinical data, and other | ||
documentation that the managed care organization requests for prior | ||
authorization and claims processing, including an electronic | ||
process that allows for the resubmission of a claim without a | ||
requirement that the resubmitted claim be submitted in paper form | ||
in order to avoid treatment of the resubmitted claim as a duplicate | ||
claim; and | ||
(B) obtain electronic remittance advice | ||
documents, explanation of benefits statements, service plans under | ||
the STAR Kids Medicaid managed care program, and other standardized | ||
reports; | ||
(7) the measurement of the rates of retention by | ||
managed care organizations of significant traditional providers; | ||
(8) the creation of a work group to review and make | ||
recommendations to the commission concerning any requirement under | ||
this subsection for which immediate implementation is not feasible | ||
at the time the plan is otherwise implemented, including the | ||
required process for submission and acceptance of attachments for | ||
claims processing and prior authorization requests through an | ||
electronic process under Subdivision (6) and, for any requirement | ||
that is not implemented immediately, recommendations regarding the | ||
expected: | ||
(A) fiscal impact of implementing the | ||
requirement; and | ||
(B) timeline for implementation of the | ||
requirement; and | ||
(9) any other provision that the commission determines | ||
will ensure efficiency or reduce administrative burdens on | ||
providers participating in a Medicaid managed care model or | ||
arrangement. | ||
SECTION 8. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.0058 to read as follows: | ||
Sec. 533.0058. RESTRICTIONS ON CERTAIN REIMBURSEMENT RATE | ||
REDUCTIONS. (a) In this section, "across-the-board provider | ||
reimbursement rate reduction" means a provider reimbursement rate | ||
reduction proposed by a managed care organization that the | ||
commission determines is likely to affect more than 50 percent of a | ||
particular type of provider participating in the organization's | ||
provider network during the 12-month period following | ||
implementation of the proposed reduction, regardless of whether: | ||
(1) the organization limits the proposed reduction to | ||
specific service areas or provider types; or | ||
(2) the affected providers are likely to experience | ||
differing percentages of rate reductions or amounts of lost revenue | ||
as a result of the proposed reduction. | ||
(b) Except as provided by Subsection (e), a managed care | ||
organization that contracts with the commission to provide health | ||
care services to recipients may not implement a significant, as | ||
determined by the commission, across-the-board provider | ||
reimbursement rate reduction unless the organization: | ||
(1) at least 90 days before the proposed rate | ||
reduction is to take effect: | ||
(A) provides the commission and affected | ||
providers with written notice of the proposed rate reduction; and | ||
(B) makes a good faith effort to negotiate the | ||
reduction with the affected providers; and | ||
(2) receives prior approval from the commission, | ||
subject to Subsection (c). | ||
(c) An across-the-board provider reimbursement rate | ||
reduction is considered to have received the commission's prior | ||
approval for purposes of Subsection (b)(2) unless the commission | ||
issues a written statement of disapproval not later than the 45th | ||
day after the date the commission receives notice of the proposed | ||
rate reduction from the managed care organization under Subsection | ||
(b)(1)(A). | ||
(d) If a managed care organization proposes an | ||
across-the-board provider reimbursement rate reduction in | ||
accordance with this section and subsequently rejects alternative | ||
rate reductions suggested by an affected provider, the organization | ||
must provide the provider with written notice of that rejection, | ||
including an explanation of the grounds for the rejection, before | ||
implementing any rate reduction. | ||
(e) This section does not apply to rate reductions that are | ||
implemented because of reductions to the Medicaid fee schedule or | ||
cost containment initiatives that are specifically directed by the | ||
legislature and implemented by the commission. | ||
SECTION 9. 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 10. Section 533.0071, Government Code, is amended | ||
to read as follows: | ||
Sec. 533.0071. ADMINISTRATION OF CONTRACTS. The | ||
commission shall make every effort to improve the administration of | ||
contracts with managed care organizations. To improve the | ||
administration of these contracts, the commission shall: | ||
(1) ensure that the commission has appropriate | ||
expertise and qualified staff to effectively manage contracts with | ||
managed care organizations under the Medicaid managed care program; | ||
(2) evaluate options for Medicaid payment recovery | ||
from managed care organizations if the enrollee dies or is | ||
incarcerated or if an enrollee is enrolled in more than one state | ||
program or is covered by another liable third party insurer; | ||
(3) maximize Medicaid payment recovery options by | ||
contracting with private vendors to assist in the recovery of | ||
capitation payments, payments from other liable third parties, and | ||
other payments made to managed care organizations with respect to | ||
enrollees who leave the managed care program; | ||
(4) decrease the administrative burdens of managed | ||
care for the state, the managed care organizations, and the | ||
providers under managed care networks to the extent that those | ||
changes are compatible with state law and existing Medicaid managed | ||
care contracts, including decreasing those burdens by: | ||
(A) where possible, decreasing the duplication | ||
of administrative reporting and process requirements for the | ||
managed care organizations and providers, such as requirements for | ||
the submission of encounter data, quality reports, historically | ||
underutilized business reports, and claims payment summary | ||
reports; | ||
(B) allowing managed care organizations to | ||
provide updated address and other contact information directly to | ||
the commission for correction in the state eligibility system; | ||
(C) promoting consistency and uniformity among | ||
managed care organization policies, including policies relating to | ||
the prior authorization processes [ |
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lengths of hospital stays, filing deadlines, levels of care, and | ||
case management services; and | ||
(D) [ |
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Section 533.0055(b)(6) through which providers in any managed care | ||
organization's provider network may submit acute care services and | ||
long-term services and supports claims; and | ||
(5) reserve the right to amend the managed care | ||
organization's process for resolving provider appeals of denials | ||
based on medical necessity to include an independent review process | ||
established by the commission for final determination of these | ||
disputes. | ||
SECTION 11. Section 533.0076, Government Code, is amended | ||
by amending Subsection (c) and adding Subsection (d) to read as | ||
follows: | ||
(c) The commission shall allow a recipient who is enrolled | ||
in a managed care plan under this chapter to disenroll from that | ||
plan and enroll in another managed care plan[ |
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law, including because: | ||
(1) the recipient moves out of the managed care | ||
organization's service area; | ||
(2) the plan does not, on the basis of moral or | ||
religious objections, cover the service the recipient seeks; | ||
(3) the recipient needs related services to be | ||
performed at the same time, not all related services are available | ||
within the organization's provider network, and the recipient's | ||
primary care provider or another provider determines that receiving | ||
the services separately would subject the recipient to unnecessary | ||
risk; | ||
(4) for recipients of long-term services or supports, | ||
the recipient would have to change the recipient's residential, | ||
institutional, or employment supports provider based on that | ||
provider's change in status from an in-network to an out-of-network | ||
provider with the managed care organization and, as a result, would | ||
experience a disruption in the recipient's residence or employment; | ||
or | ||
(5) of another reason permitted under federal law, | ||
including poor quality of care, lack of access to services covered | ||
under the contract, or lack of access to providers experienced in | ||
dealing with the recipient's care needs[ |
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(d) The commission shall implement a process by which the | ||
commission verifies that a recipient is permitted to disenroll from | ||
one managed care plan offered by a managed care organization and | ||
enroll in another managed care plan, including a plan offered by | ||
another managed care organization, before the disenrollment | ||
occurs. | ||
SECTION 12. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.0091 to read as follows: | ||
Sec. 533.0091. CARE COORDINATION SERVICES. A managed care | ||
organization that contracts with the commission to provide health | ||
care services to recipients shall ensure that persons providing | ||
care coordination services through 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. | ||
SECTION 13. 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 14. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.01316 to read as follows: | ||
Sec. 533.01316. MANAGED CARE ORGANIZATION POLICIES FOR | ||
CERTAIN HOSPITAL STAYS. The commission shall ensure that managed | ||
care organizations that contract with the commission to provide | ||
health care services to recipients have policies regarding | ||
treatment and services related to a recipient's inpatient hospital | ||
stay, including a behavioral health hospital stay, that is less | ||
than 48 hours. For purposes of this section, the commission shall | ||
ensure that the organization: | ||
(1) specifies criteria that: | ||
(A) warrant reimbursement of services related to | ||
the stay as either inpatient hospital services or outpatient | ||
hospital services, including criteria for determining what | ||
services constitute outpatient observation services; | ||
(B) account for medical necessity based on | ||
recognized inpatient criteria, the severity of any psychological | ||
disorder, and the judgment of the treating physician or other | ||
provider; and | ||
(C) do not permit classification of services as | ||
either inpatient or outpatient hospital services for purposes of | ||
reimbursement based solely on the duration of the stay; | ||
(2) provides an opportunity for direct discussions | ||
regarding the medical necessity of a recipient's inpatient hospital | ||
admission; and | ||
(3) reviews documentation in a recipient's medical | ||
record that supports the medical necessity of the inpatient | ||
hospital stay at the time of admission for reimbursement of | ||
services related to the stay. | ||
SECTION 15. Subchapter B, Chapter 534, Government Code, is | ||
amended by adding Section 534.0511 to read as follows: | ||
Sec. 534.0511. ENSURING PROVISION OF MEDICALLY NECESSARY | ||
SERVICES. (a) This section applies only to an individual with an | ||
intellectual or developmental disability who is receiving services | ||
under a Medicaid waiver program or ICF-IID program and who requires | ||
medically necessary acute care services or long-term services and | ||
supports that are not available to the individual through the | ||
delivery model implemented under this chapter. | ||
(b) Notwithstanding any other law, the Medicaid waiver | ||
program or ICF-IID program that serves an individual to which this | ||
section applies shall pay the cost of the service and may submit to | ||
the commission a claim for reimbursement for the cost of that | ||
service. | ||
(c) If the commission determines that a claim paid by the | ||
commission under Subsection (b) should have been covered and paid | ||
by a managed care organization that contracts with the commission, | ||
the commission may recoup the entire cost of that claim from the | ||
organization. | ||
SECTION 16. (a) In this section, "commission" and | ||
"Medicaid" have the meanings assigned by Section 531.001, | ||
Government Code. | ||
(b) As soon as practicable after the effective date of this | ||
Act, the commission shall develop and implement a pilot program in | ||
up to three urban service delivery areas that is designed to | ||
increase the incidence of ambulance service providers directing | ||
recipients of Medicaid managed care program services who are | ||
experiencing a behavioral health emergency to more appropriate | ||
health care providers for treatment of behavioral health illnesses. | ||
(c) Not later than December 1, 2018, the commission shall | ||
develop a report analyzing any cost savings and other benefits | ||
realized as a result of the pilot program and deliver a copy of the | ||
report to the governor, lieutenant governor, speaker of the house | ||
of representatives, and chairs of the standing legislative | ||
committees having primary jurisdiction over Medicaid. | ||
(d) This section expires January 1, 2019. | ||
SECTION 17. (a) In this section, "commission" and | ||
"Medicaid" have the meanings assigned by Section 531.001, | ||
Government Code. | ||
(b) Not later than November 30, 2017, the commission shall, | ||
consistent with the purpose of Sections 533.0025(b) and (d), | ||
Government Code, conduct a study to determine the | ||
cost-effectiveness and feasibility of providing prescription drug | ||
benefits to recipients of acute care services under Medicaid by | ||
pharmacies with a Class A pharmacy license, as described by Section | ||
560.051, Occupations Code, through a single statewide prescription | ||
drug administrator that adheres to a pharmacy services | ||
reimbursement methodology that uses: | ||
(1) the most accurate and transparent ingredient drug | ||
pricing model; | ||
(2) the National Average Drug Acquisition Cost | ||
published by the Centers for Medicare and Medicaid Services as the | ||
drug acquisition cost; and | ||
(3) the most recent dispensing fee study contracted | ||
for by the commission to set an accurate and transparent | ||
professional dispensing fee as defined by 1 T.A.C. Section | ||
355.8551. | ||
(c) In conducting a study under this section, the commission | ||
shall: | ||
(1) for purposes of determining cost-effectiveness, | ||
assume and calculate reductions to the anticipated capitation rate | ||
paid to Medicaid managed care organizations, including reductions | ||
resulting from: | ||
(A) the elimination or reduction of the per | ||
member per month administrative expense fee and the consolidation | ||
of the contracts relating to the prescription drug benefits; | ||
(B) the elimination of the guaranteed risk | ||
margin; and | ||
(C) any difference between pharmacy premiums | ||
paid by the commission to managed care organizations and | ||
prescription expenses reported by the managed care organizations | ||
for the preceding four fiscal years; | ||
(2) determine and consider cost savings that would be | ||
achieved through maintaining a single pharmacy claims database to | ||
enhance patient quality outcomes through implementation of: | ||
(A) a medication therapy management program; | ||
(B) a prescription monitoring program; | ||
(C) an adverse drug interaction avoidance | ||
program; or | ||
(D) other similar results-oriented programs | ||
based on pay-for-performance outcome models; | ||
(3) determine and consider cost savings associated | ||
with enhancing system audit capabilities and reducing contractor | ||
and subcontractor noncompliance, including enhanced auditing | ||
capabilities and reducing noncompliance in relation to: | ||
(A) the payment of rebates; | ||
(B) drug utilization; | ||
(C) the use of prior authorization; and | ||
(D) claims adjudication; | ||
(4) determine and consider cost savings associated | ||
with improving patient access to prescribed medications; | ||
(5) determine and consider cost savings related to | ||
further streamlining both the fee-for-service and managed care | ||
prescription drug benefits under one contract; | ||
(6) assume that the administrator described by | ||
Subsection (b) of this section is, if advantageous to the state, | ||
subject to Chapter 222, Insurance Code; and | ||
(7) consider and determine whether the administrator | ||
could be excluded from 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). | ||
(d) This section does not apply to and the commission may | ||
not consider in conducting the study required by this section the | ||
provision of prescription drug benefits by long-term care facility | ||
pharmacies and specialty pharmacies. | ||
(e) The commission shall combine the study required by this | ||
section with any other similar study required to be conducted by the | ||
commission. | ||
(f) Not later than November 30, 2017, the commission shall | ||
report its findings under this section to the legislature. | ||
(g) This section expires December 31, 2017. | ||
SECTION 18. Section 533.005(a-3), Government Code, is | ||
repealed. | ||
SECTION 19. As soon as practicable after the effective date | ||
of this Act, the Health and Human Services Commission shall | ||
implement an electronic visit verification system in accordance | ||
with Section 531.024172, Government Code, as amended by this Act. | ||
SECTION 20. 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 21. 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 22. This Act takes effect September 1, 2017. |