Before the end of the year, be sure to find out what your Medicaid reimbursement terms will be!

Texas Health and Human Services Commission (HHSC) is transitioning Texas Medicaid's prescription drug benefits from the current fee-for-service model to a managed care model. HHSC hopes to fully implement managed care by March 1. Managed pharmacy care is being rushed into place without adequate planning, with no track record for success, no economic impact study of the far-reaching effects on patients and providers, and with no meaningful public comment period. The current fee-for-service model will be replaced by two layers of for-profit middlemen -- managed care organizations and pharmacy benefit managers (PBMs) -- both of whom have a vested financial incentive to maximize profits by offering low, take-it-or-leave-it reimbursements that will drive pharmacies out of business and reduce Medicaid patients' access to providers of their choice. 

Do you know what the terms of your reimbursement will be under this new managed care model? Many of our members report that they do not. Your third-party representative and/or Pharmacy Services Administrative Organization (PSAO) has access to the Medicaid reimbursement information and can tell you what the managed care PBMs in your area will reimburse you for Medicaid claims starting March 1. We strongly encourage you to immediately contact your third-party representative and/or PSAO so that you know all the important facts governing your future as a Medicaid provider. You may be shocked to learn the terms of reimbursement.

APRx intends to pursue Medicaid managed-care reform and improvements at the Texas Legislature as well via legal actions on your behalf. APRx filed a lawsuit against HHSC over its failure to comply with state procedural requirements for meaningful public notice and public comment concerning its waiver request to CMS to allow Medicaid managed care. In a Nov. 3 court hearing, Judge Stephen Yelenosky dismissed the case on jurisdictional grounds before hearing the merits of the lawsuit. APRx filed an appeal with the Third Court of Appeals in Austin and seeks to overturn this ruling.The next step in the process is to file our "brief on the merits" which outlines our arguments why under the law, the trial court was incorrect. The Court of Appeals' decision is still likely more than six months away. In the meantime, the legal team is analyzing alternate arguments that may be presented separately from the appeal.