SECTION 353.913. Managed Care Organization Requirements Concerning Out-of-Network Outpatient Pharmacy Services

(a) Network adequacy.

(1) The Health and Human Services Commission (HHSC) is the state agency responsible for overseeing and monitoring the Medicaid managed care program. A health care managed care organization (health care MCO) participating in the Medicaid managed care program must offer a network of pharmacy providers that is sufficient to meet the needs of the health care MCO's members. HHSC will monitor health care MCO members' access to an adequate provider network through reports from the health care MCOs and complaints received from providers and members. The reporting requirements are discussed in subsection (c) of this section.

(2) A health care MCO may not refuse to reimburse an out-of-network pharmacy provider for emergency covered outpatient pharmacy services.

(b) Reasonable reimbursement methodology. If a health care MCO and an out-of-network pharmacy provider cannot agree on a reimbursement amount, then the health care MCO must reimburse the provider at the usual and customary rate that prevails in the service area, unless payment is limited by state or federal law.

(c) Reporting requirements. A health care MCO must submit a quarterly report to HHSC regarding out-of-network pharmacy utilization, as described in §353.4 of this chapter (relating to Managed Care Organization Requirements Concerning Out-of-Network Providers). For purposes of such reporting, the health care MCO will include out-of-network pharmacy utilization under the "other services" category.

(d) Utilization.

(1) Upon review of a report described in subsection (c) of this section, HHSC may determine that a health care MCO exceeded maximum out-of-network usage standards set by HHSC for out-of-network access to covered outpatient pharmacy services during the reporting period.

(2) Out-of-network usage standards. No more than 20 percent of total dollars billed to a health care MCO for covered outpatient pharmacy services may be billed by out-of-network providers.

(e) Provider complaints.

(1) HHSC will accept provider complaints regarding reimbursement for or overuse of out-of-network pharmacy providers and will conduct investigations into any such complaints.

(2) When a pharmacy provider files a complaint regarding out-of-network payment, HHSC will require the health care MCO to submit data to support its position on the adequacy of the payment to the provider. The data will include at a minimum a copy of the claim for services rendered and an explanation of the amount paid and of any amounts denied.

(3) Not later than the 60th day after HHSC receives a pharmacy provider complaint, HHSC will notify the pharmacy provider of the conclusions of HHSC's investigation regarding the complaint. The notification to the complaining pharmacy provider will include:

(A) a description of the corrective actions, if any, required of the health care MCO in order to resolve the complaint; and

(B) if applicable, a conclusion regarding the amount of reimbursement owed to an out-of-network pharmacy provider.

(4) If HHSC determines through investigation that a health care MCO did not reimburse an out-of-network pharmacy provider based on a reasonable reimbursement methodology as described in subsection (b) of this section, HHSC will initiate a corrective action plan. Refer to subsection (f) of this section for information about the contents of the corrective action plan.

(5) If, after an investigation, HHSC determines that additional reimbursement is owed to an out-of-network pharmacy provider, the health care MCO must pay the additional reimbursement owed to the out-of-network pharmacy provider within 90 days from the date the complaint was received by HHSC, or 18 days from the date the clean claim, or information required that makes the claim clean, is received by the health care MCO, whichever comes first.

(6) If the health care MCO does not pay the entire amount of the additional reimbursement by the due date described in paragraph (5) of this subsection, HHSC may require the health care MCO to pay interest on the unpaid amount. If required by HHSC, interest accrues at a rate of 18 percent simple interest per year on the unpaid amount from the due date described in paragraph (5) of this subsection until the date the entire amount of the additional reimbursement is paid.

(7) HHSC will pursue any appropriate remedy authorized in the contract between the health care MCO and HHSC if the MCO fails to comply with a corrective action plan under subsection (f) of this section.

(f) Corrective action plan.

(1) A corrective action plan is required by HHSC in the following situations:

(A) The health care MCO exceeds a maximum standard established by HHSC for out-of-network access to covered outpatient pharmacy services described in subsection (d) of this section; or

(B) The health care MCO does not reimburse an out-of-network pharmacy provider based on a reasonable reimbursement methodology as described in subsection (b) of this section.

(2) A corrective action plan imposed by HHSC will require one of the following:

(A) Reimbursements by the health care MCO to out-of-network pharmacy providers at rates that equal the allowable rates for the health care services as determined under Human Resources Code §32.028 and §32.0281 for all covered outpatient pharmacy services provided during the period:

(i) the health care MCO is not in compliance with a utilization standard established by HHSC; or

(ii) the health care MCO is not reimbursing out-of-network pharmacy providers based on a reasonable reimbursement methodology, as described in subsection (c) of this section;

(B) Initiation of an immediate freeze by HHSC on the enrollment of additional recipients in the health care MCO until HHSC determines that the provider network under the health care MCO can adequately meet the needs of its members;

(C) Education of the health care MCO's members regarding the proper use of the health care MCO's pharmacy provider network; or

(D) Any other actions HHSC determines are necessary to ensure that the health care MCO members have access to appropriate covered outpatient pharmacy services and that pharmacy providers are properly reimbursed by the health care MCO for providing such services to those recipients.

Source Note: The provisions of this §353.913 adopted to be effective March 1, 2012, 37 TexReg 1292; amended to be effective September 1, 2013, 38 TexReg 5429