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The Health and Human Services Commission Council met at 10:00am on August 28, 2015 to discuss the following rule changes:
 
Rudy Villarreal, Director of Health Plan Management: Managed Care Organization Requirements Concerning Out-of-Network Providers

  • This is a clarification amendment
  • Since nursing facility services were carved into Medicaid managed care, this clarifies rule language to mirror managed care contract requirements related to reimbursement of nursing facility services
  • This rule also clarifies and adds new language related to emergency transports and non-emergency services for nursing facilities
  • Approved

 
Andy Vasquez, Medicaid/CHIP Deputy Director: Medicaid Drug Utilization Review Board

  • Per SB 200, P&T committee functions are transferred to DUR Committee
  • HHSC Executive Commissioner will determine the composition of the new DUR board which must include at least 17 physicians and pharmacists who provide services across the entire Medicaid recipient population
  • Approved

 
Andy Vasquez, Medicaid/CHIP Deputy Director: Medicaid Drug Utilization Review Board; Drug Clinical Prior Authorization

  • Related to the previous proposed rule change
  • This would align HHSC definitions of prospective and retrospective utilization review with similar definitions used by other payers
  • Approved

 
Andy Vasquez, Medicaid/CHIP Deputy Director: Vendor Drug Program Medicaid Audit Appeals

  • Per SB 207, this gives a pharmacy the right to request an informal hearing before the HHSC Appeals Division to contest an audit done by HHSC’s Office of Inspector General
  • Previously, appeals went through the OIG, but the legislature wants a separation
  • Approved

 
Andy Vasquez, Medicaid/CHIP Deputy Director: Reimbursement for Certain Drugs in Disasters; Medicaid Fee-For-Service Drug Reimbursement

  • Per SB 460, pharmacists are allowed to dispense a 30-day supply of a prescription drug in a Governor-declared disaster without original prescription if failure to refill might result in an interruption of a therapeutic regimen or create patient suffering
  • Fee-For-Service Drug Reimbursement changes are meant to achieve cost savings through initiatives such as increasing efficiencies in VDP, per SB 1
  • This will adopt the NADAC methodology
  • Approved

 
Andy Vasquez, Medicaid/CHIP Deputy Director: Medicaid Fee-For-Service Drug Reimbursement

  • CMS proposes to replace estimated acquisition cost with actual acquisition cost as the basis for state Medicaid pharmacy ingredient reimbursement.
  • These numbers were gathered by studies done by Myers & Stauffer
  • Approved