Subscribe to receive our Floor Reports covering all the action on the Texas House and Senate floor!
Relating to certain benefits provided through the Medicaid managed care program, including pharmacy benefits.
The fiscal implications of the bill cannot be determined at this time but a cost would be anticipated.
The agency 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 agency may, but is not required to, implement a provision of this Act using
other appropriations available for that purpose.
The Medically Dependent Children Program (MCDP) offers community-based services for children with disabilities who require a nursing facility level of care. These children may access Medicaid services on a medical-needs-based criteria through MCDP, allowing the child to remain at home with family while still accessing life-sustaining, medically necessary services. MCDP exists within the STAR Kids Medicaid managed care program that provides Medicaid benefits to children and adults ages 20 years and younger who have disabilities.
Currently, some drugs require prior authorization. SB 1096 would require a contract between a manage care organization (MCO) and the Health and Human Services Commission (HHSC) for the MCO to provide health care services to recipients to contain a requirement that the MCO develop, implement, and maintain an outpatient pharmacy benefit plan for its enrolled recipients.
The contract must also include prior authorization procedures and requirements. Under the contract, the MCO would be prohibited from requiring a prior authorization, other than a clinical prior authorization or a prior authorization imposed by HHSC to minimize the opportunity for waste, fraud, or abuse, for or imposing any other barriers to a drug that is prescribed to a child for a particular disease or treatment and that is on the vendor drug program formulary. The contract would provide for continued access to a drug prescribed to a child enrolled in the STAR Kids managed care program. No child in the STAR Kids managed care program would be required to use a prescription drug or sequence of prescription drugs other than the drug that the physician recommends before the MCO provides coverage. Noncompliance with these provisions would result in a payment of liquidated damages to HHSC for each failure to comply.
Texas Action remains neutral on SB 1096 because it does not affect our liberty principles.