Bill Text: TX SB1207 | 2019-2020 | 86th Legislature | Comm Sub
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to the operation and administration of Medicaid, including the Medicaid managed care program and the medically dependent children (MDCP) waiver program.
Spectrum: Slight Partisan Bill (Republican 5-2)
Status: (Passed) 2019-06-10 - Effective on 9/1/19 [SB1207 Detail]
Download: Texas-2019-SB1207-Comm_Sub.html
Bill Title: Relating to the operation and administration of Medicaid, including the Medicaid managed care program and the medically dependent children (MDCP) waiver program.
Spectrum: Slight Partisan Bill (Republican 5-2)
Status: (Passed) 2019-06-10 - Effective on 9/1/19 [SB1207 Detail]
Download: Texas-2019-SB1207-Comm_Sub.html
By: Perry | S.B. No. 1207 | |
(In the Senate - Filed February 27, 2019; March 7, 2019, | ||
read first time and referred to Committee on Health & Human | ||
Services; April 11, 2019, reported adversely, with favorable | ||
Committee Substitute by the following vote: Yeas 9, Nays 0; | ||
April 11, 2019, sent to printer.) | ||
COMMITTEE SUBSTITUTE FOR S.B. No. 1207 | By: Perry |
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relating to the coordination of private health benefits with | ||
Medicaid benefits. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter A, Chapter 533, Government Code, is | ||
amended by adding Section 533.038 to read as follows: | ||
Sec. 533.038. COORDINATION OF BENEFITS. (a) In this | ||
section: | ||
(1) "Medicaid managed care organization" means a | ||
managed care organization that contracts with the commission under | ||
this chapter to provide health care services to recipients. | ||
(2) "Medicaid wrap-around benefit" means a | ||
Medicaid-covered service, including a pharmacy or medical benefit, | ||
that is provided to a recipient with both Medicaid and primary | ||
health benefit plan coverage when the recipient has exceeded the | ||
primary health benefit plan coverage limit or when the service is | ||
not covered by the primary health benefit plan issuer. | ||
(b) The commission, in coordination with Medicaid managed | ||
care organizations, shall develop and adopt a clear policy for a | ||
Medicaid managed care organization to ensure the coordination and | ||
timely delivery of Medicaid wrap-around benefits for recipients | ||
with both primary health benefit plan coverage and Medicaid | ||
coverage. | ||
(c) To further assist with the coordination of benefits, the | ||
commission, in coordination with Medicaid managed care | ||
organizations, shall develop and maintain a list of services that | ||
are not traditionally covered by primary health benefit plan | ||
coverage that a Medicaid managed care organization may approve | ||
without having to coordinate with the primary health benefit plan | ||
issuer and that can be resolved through third-party liability | ||
resolution processes. The commission shall review and update the | ||
list quarterly. | ||
(d) A Medicaid managed care organization that in good faith | ||
and following commission policies provides coverage for a Medicaid | ||
wrap-around benefit shall include the cost of providing the benefit | ||
in the organization's financial reports. The commission shall | ||
include the reported costs in computing capitation rates for the | ||
managed care organization. | ||
(e) If the commission determines that a recipient's primary | ||
health benefit plan issuer should have been the primary payor of a | ||
claim, the Medicaid managed care organization that paid the claim | ||
shall work with the commission on the recovery process and make | ||
every attempt to reduce health care provider and recipient | ||
abrasion. | ||
(f) The executive commissioner may seek a waiver from the | ||
federal government as needed to: | ||
(1) address federal policies related to coordination | ||
of benefits and third-party liability; and | ||
(2) maximize federal financial participation for | ||
recipients with both primary health benefit plan coverage and | ||
Medicaid coverage. | ||
(g) Notwithstanding Sections 531.073 and 533.005(a)(23) or | ||
any other law, the commission shall ensure that a prescription drug | ||
that is covered under the Medicaid vendor drug program or other | ||
applicable formulary and is prescribed to a recipient with primary | ||
health benefit plan coverage is not subject to any prior | ||
authorization requirement if: | ||
(1) the primary health benefit plan issuer will pay at | ||
least $0.01 on the prescription drug claim; or | ||
(2) the prescription drug is covered by the primary | ||
health benefit plan issuer but the primary health benefit plan | ||
issuer will pay nothing on the claim because the recipient has not | ||
met the deductible. | ||
(h) Except as provided by Subsection (g)(2), a prescription | ||
drug prescribed to a recipient with primary health benefit plan | ||
coverage is subject to any applicable Medicaid clinical or | ||
nonpreferred prior authorization requirement if the primary health | ||
benefit plan issuer will pay nothing on the prescription drug | ||
claim. | ||
(i) The commission may include in the Medicaid managed care | ||
eligibility files an indication of whether a recipient has primary | ||
health benefit plan coverage or is enrolled in a group health | ||
benefit plan for which the commission provides premium assistance | ||
under the health insurance premium payment program. For recipients | ||
with that coverage or for whom that premium assistance is provided, | ||
the files may include the following up-to-date, accurate | ||
information related to primary health benefit plan coverage to the | ||
extent the information is available to the commission: | ||
(1) the health benefit plan issuer's name and address | ||
and the recipient's policy number; | ||
(2) the primary health benefit plan coverage start and | ||
end dates; and | ||
(3) the primary health benefit plan coverage benefits, | ||
limits, copayment, and coinsurance information. | ||
(j) The commission shall maintain processes and policies to | ||
allow a health care provider who is primarily providing services to | ||
a recipient through primary health benefit plan coverage to receive | ||
Medicaid reimbursement for services ordered, referred, prescribed, | ||
or delivered, regardless of whether the provider is enrolled as a | ||
Medicaid provider. The commission shall allow a provider who is not | ||
enrolled as a Medicaid provider to order, refer, prescribe, or | ||
deliver services to a recipient based on the provider's national | ||
provider identifier number and may not require an additional state | ||
provider identifier number to receive reimbursement for the | ||
services. The commission may seek a waiver of Medicaid provider | ||
enrollment requirements for providers of recipients with primary | ||
health benefit plan coverage to implement this subsection. | ||
(k) The commission shall develop and implement a clear and | ||
easy process to allow a recipient with complex medical needs who has | ||
established a relationship with a specialty provider in an area | ||
outside of the recipient's Medicaid managed care organization's | ||
service delivery area to continue receiving care from that | ||
provider. If a provider outside of the organization's service | ||
delivery area enters into a single-case agreement with the Medicaid | ||
managed care organization to continue providing that care, the | ||
single-case agreement is not considered an out-of-network | ||
agreement. | ||
(l) The commission shall develop and implement processes | ||
to: | ||
(1) reimburse a recipient with primary health benefit | ||
plan coverage who pays a copayment or coinsurance amount out of | ||
pocket because the primary health benefit plan issuer refuses to | ||
enroll in Medicaid, enter into a single-case agreement, or bill the | ||
recipient's Medicaid managed care organization; and | ||
(2) capture encounter data for the Medicaid | ||
wrap-around benefits provided by the Medicaid managed care | ||
organization under this subsection. | ||
SECTION 2. If before implementing any provision of this Act | ||
a state agency determines that a waiver or authorization from a | ||
federal agency is necessary for implementation of that provision, | ||
the agency affected by the provision shall request the waiver or | ||
authorization and may delay implementing that provision until the | ||
waiver or authorization is granted. | ||
SECTION 3. The Health and Human Services Commission is | ||
required to implement a provision of this Act only if the | ||
legislature appropriates money specifically for that purpose. If | ||
the legislature does not appropriate money specifically for that | ||
purpose, the commission may, but is not required to, implement a | ||
provision of this Act using other appropriations available for that | ||
purpose. | ||
SECTION 4. This Act takes effect September 1, 2019. | ||
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