BILL REQ. #: H-1027.1
State of Washington | 63rd Legislature | 2013 Regular Session |
Read first time 02/04/13. Referred to Committee on Health Care & Wellness.
AN ACT Relating to prescription review for medicaid managed care enrollees; and reenacting and amending RCW 74.09.522.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1 RCW 74.09.522 and 2011 1st sp.s. c 15 s 29, 2011 1st sp.s.
c 9 s 2, and 2011 c 316 s 4 are each reenacted and amended to read as
follows:
(1) For the purposes of this section:
(a) "Comprehensive medication management process" means the
provision of the following services utilizing the professional practice
of pharmaceutical care by a licensed pharmacist for patients taking
five or more medications for two or more chronic medical conditions:
(i) Assessment of the patient's health status including the
personal medication experience and use patterns of all prescribed and
over-the-counter medications;
(ii) Documentation of the patient's current clinical status and
clinical goals of therapy;
(iii) Assessment of each medication for appropriateness,
effectiveness, safety, and adherence focusing on achievement of desired
clinical goals;
(iv) Identification of all drug therapy problems including
additions or deletions in medications or changes in dosage needed to
meet desired clinical goals;
(v) Development of a comprehensive medication therapy plan for the
patient in consultation with the prescribing practitioner; and
(vi) Documentation and follow up of the effects of recommended drug
therapy changes on the patient's clinical status and outcomes;
(b) "Managed health care system" means any health care
organization, including health care providers, insurers, health care
service contractors, health maintenance organizations, health insuring
organizations, or any combination thereof, that provides directly or by
contract health care services covered under this chapter and rendered
by licensed providers, on a prepaid capitated basis and that meets the
requirements of section 1903(m)(1)(A) of Title XIX of the federal
social security act or federal demonstration waivers granted under
section 1115(a) of Title XI of the federal social security act;
(((b))) (c) "Nonparticipating provider" means a person, health care
provider, practitioner, facility, or entity, acting within their scope
of practice, that does not have a written contract to participate in a
managed health care system's provider network, but provides health care
services to enrollees of programs authorized under this chapter whose
health care services are provided by the managed health care system.
(2) The authority shall enter into agreements with managed health
care systems to provide health care services to recipients of temporary
assistance for needy families under the following conditions:
(a) Agreements shall be made for at least thirty thousand
recipients statewide;
(b) Agreements in at least one county shall include enrollment of
all recipients of temporary assistance for needy families;
(c) To the extent that this provision is consistent with section
1903(m) of Title XIX of the federal social security act or federal
demonstration waivers granted under section 1115(a) of Title XI of the
federal social security act, recipients shall have a choice of systems
in which to enroll and shall have the right to terminate their
enrollment in a system: PROVIDED, That the authority may limit
recipient termination of enrollment without cause to the first month of
a period of enrollment, which period shall not exceed twelve months:
AND PROVIDED FURTHER, That the authority shall not restrict a
recipient's right to terminate enrollment in a system for good cause as
established by the authority by rule;
(d) To the extent that this provision is consistent with section
1903(m) of Title XIX of the federal social security act, participating
managed health care systems shall not enroll a disproportionate number
of medical assistance recipients within the total numbers of persons
served by the managed health care systems, except as authorized by the
authority under federal demonstration waivers granted under section
1115(a) of Title XI of the federal social security act;
(e)(i) In negotiating with managed health care systems the
authority shall adopt a uniform procedure to enter into contractual
arrangements, to be included in contracts issued or renewed on or after
January 1, 2012, including:
(A) Standards regarding the quality of services to be provided;
(B) The financial integrity of the responding system;
(C) Provider reimbursement methods that incentivize chronic care
management and comprehensive medication management services within
health homes;
(D) Provider reimbursement methods that reward health homes that,
by using chronic care management, reduce emergency department and
inpatient use; and
(E) Promoting provider participation in the program of training and
technical assistance regarding care of people with chronic conditions
described in RCW 43.70.533, including allocation of funds to support
provider participation in the training, unless the managed care system
is an integrated health delivery system that has programs in place for
chronic care management.
(ii)(A) Health home services contracted for under this subsection
may be prioritized to enrollees with complex, high cost, or multiple
chronic conditions.
(B) Contracts that include the items in (e)(i)(C) through (E) of
this subsection must not exceed the rates that would be paid in the
absence of these provisions;
(f) The authority shall seek waivers from federal requirements as
necessary to implement this chapter;
(g) The authority shall, wherever possible, enter into prepaid
capitation contracts that include inpatient care. However, if this is
not possible or feasible, the authority may enter into prepaid
capitation contracts that do not include inpatient care;
(h) The authority shall define those circumstances under which a
managed health care system is responsible for out-of-plan services and
assure that recipients shall not be charged for such services;
(i) Nothing in this section prevents the authority from entering
into similar agreements for other groups of people eligible to receive
services under this chapter; and
(j) The department must consult with the federal center for
medicare and medicaid innovation and seek funding opportunities to
support health homes.
(3) The authority shall ensure that publicly supported community
health centers and providers in rural areas, who show serious intent
and apparent capability to participate as managed health care systems
are seriously considered as contractors. The authority shall
coordinate its managed care activities with activities under chapter
70.47 RCW.
(4) The authority shall work jointly with the state of Oregon and
other states in this geographical region in order to develop
recommendations to be presented to the appropriate federal agencies and
the United States congress for improving health care of the poor, while
controlling related costs.
(5) The legislature finds that competition in the managed health
care marketplace is enhanced, in the long term, by the existence of a
large number of managed health care system options for medicaid
clients. In a managed care delivery system, whose goal is to focus on
prevention, primary care, and improved enrollee health status,
continuity in care relationships is of substantial importance, and
disruption to clients and health care providers should be minimized.
To help ensure these goals are met, the following principles shall
guide the authority in its healthy options managed health care
purchasing efforts:
(a) All managed health care systems should have an opportunity to
contract with the authority to the extent that minimum contracting
requirements defined by the authority are met, at payment rates that
enable the authority to operate as far below appropriated spending
levels as possible, consistent with the principles established in this
section.
(b) Managed health care systems should compete for the award of
contracts and assignment of medicaid beneficiaries who do not
voluntarily select a contracting system, based upon:
(i) Demonstrated commitment to or experience in serving low-income
populations;
(ii) Quality of services provided to enrollees;
(iii) Accessibility, including appropriate utilization, of services
offered to enrollees;
(iv) Demonstrated capability to perform contracted services,
including ability to supply an adequate provider network;
(v) Payment rates; and
(vi) The ability to meet other specifically defined contract
requirements established by the authority, including consideration of
past and current performance and participation in other state or
federal health programs as a contractor.
(c) Consideration should be given to using multiple year
contracting periods.
(d) Quality, accessibility, and demonstrated commitment to serving
low-income populations shall be given significant weight in the
contracting, evaluation, and assignment process.
(e) All contractors that are regulated health carriers must meet
state minimum net worth requirements as defined in applicable state
laws. The authority shall adopt rules establishing the minimum net
worth requirements for contractors that are not regulated health
carriers. This subsection does not limit the authority of the
Washington state health care authority to take action under a contract
upon finding that a contractor's financial status seriously jeopardizes
the contractor's ability to meet its contract obligations.
(f) Procedures for resolution of disputes between the authority and
contract bidders or the authority and contracting carriers related to
the award of, or failure to award, a managed care contract must be
clearly set out in the procurement document.
(6) The authority may apply the principles set forth in subsection
(5) of this section to its managed health care purchasing efforts on
behalf of clients receiving supplemental security income benefits to
the extent appropriate.
(7) A managed health care system shall pay a nonparticipating
provider that provides a service covered under this chapter to the
system's enrollee no more than the lowest amount paid for that service
under the managed health care system's contracts with similar providers
in the state.
(8) For services covered under this chapter to medical assistance
or medical care services enrollees and provided on or after August 24,
2011, nonparticipating providers must accept as payment in full the
amount paid by the managed health care system under subsection (7) of
this section in addition to any deductible, coinsurance, or copayment
that is due from the enrollee for the service provided. An enrollee is
not liable to any nonparticipating provider for covered services,
except for amounts due for any deductible, coinsurance, or copayment
under the terms and conditions set forth in the managed health care
system contract to provide services under this section.
(9) Pursuant to federal managed care access standards, 42 C.F.R.
Sec. 438, managed health care systems must maintain a network of
appropriate providers that is supported by written agreements
sufficient to provide adequate access to all services covered under the
contract with the department, including hospital-based physician
services. The department will monitor and periodically report on the
proportion of services provided by contracted providers and
nonparticipating providers, by county, for each managed health care
system to ensure that managed health care systems are meeting network
adequacy requirements. No later than January 1st of each year, the
department will review and report its findings to the appropriate
policy and fiscal committees of the legislature for the preceding state
fiscal year.
(10) Subsections (7) through (9) of this section expire July 1,
2016.
(11) By January 1, 2014, contracts with managed care plans must
include a requirement that any patient with five or more medications
for two or more chronic medical conditions be placed in a comprehensive
medication management process with the primary care provider or
Washington state licensed pharmacist to verify that all the
prescriptions are medically appropriate and to review for drug
interactions and opportunities to improve clinical outcomes and reduce
emergency care.