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► HB 1293 Overview/Talking Points
Three bills of major importance to Texas independent pharmacies were heard in the House and Senate this week, headed by a critical measure to significantly raise pharmacy reimbursement in the Texas Medicaid program.
American Pharmacies General Counsel Miguel Rodriguez (right, speaking to Senate Health & Human Services Committee) testified Wednesday in the House Human Services Committee in favor of HB 1293 by Rep. Toni Rose.
The bill would require health plans and their PBMs in Texas Medicaid Managed Care to reimburse network pharmacies for product cost using the NADAC standard (National Average Drug Acquisition Cost),the product cost standard for Medicaid Fee for Service (FFS). Medicaid FFS also pays a formula-based dispensing fee that averages $10.12. Managed care PBMs routinely pay Medicaid dispensing fees that range from $0 to less than $1. The bill would require MCOs to reimburse pharmacies using the same dispensing fee as used in Medicaid FFS.
Rodriguez told the House panel that reimbursing pharmacies inadequately in the Texas Medicaid program can harm both access to pharmacy care and patient outcomes, triggering more expensive medical interventions.
"I think this comes under the category of penny-wise and pound-foolish," he said. "If you skimp on funding an accessible network, that's going to have a more expensive consequence for the program."
"If we take the CMS reimbursement standard as a fair one, then what's really happening is that pharmacy providers are significantly subsidizing MCOs' cost of providing medications."
After hearing testimony on the bill, the committee left the legislation pending. American Pharmacies is working hard to get this critical legislation out of committee and to the full House for a vote.
Senate Testimony
On Wednesday, Rodriguez testified before the Senate Health & Human Services Committee in support of SB 1137 by longtime pharmacy ally Charles Schwertner. The bill would strengthen the Texas Department of Insurance's (TDI) ability to apply previous PBM reforms –― such as TPBC's anti-steering and PBM reform bills from the 2021 session –― to insurers based outside Texas. TDI has stated that it lacks authority to enforce the provision of those bills on behalf of patients whose plans are based outside the state.
Rodriguez told the panel that TDI's perceived limitation in uniformly enforcing provisions of the two bills means that not all patients and pharmacy providers in Texas are protected by the legislation as the Legislature intended.
Later in the hearing, he testified in favor of SB 1619 by Sen. Charles Perry of Lubbock. That bill would require the state to exclude the value of any cash discount –― including those offered through third-party discount cards –― from the usual and customary (U&C) charge used to determine reimbursement for a Medicaid-covered drug.
Rodriguez said that Medicaid pharmacies do not set the value of discount cards sponsored by third parties, but accept them in order to reduce patients' out-of-pocket expense. Doing so, however, lowers the U&C charge submitted to TX Medicaid for reimbursement under current standards.
Both SB 1137 and SB 1619 were left pending by the committee. APRx will continue to work hard for their movement out of the committee and through the Senate.
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