Southwest Pharmacy Solutions, Inc. v. Texas Health & Human Services Commission

408 S.W.3d 549, 2013 WL 3724038, 2013 Tex. App. LEXIS 8600
CourtCourt of Appeals of Texas
DecidedJuly 12, 2013
DocketNo. 03-12-00293-CV
StatusPublished
Cited by24 cases

This text of 408 S.W.3d 549 (Southwest Pharmacy Solutions, Inc. v. Texas Health & Human Services Commission) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Southwest Pharmacy Solutions, Inc. v. Texas Health & Human Services Commission, 408 S.W.3d 549, 2013 WL 3724038, 2013 Tex. App. LEXIS 8600 (Tex. Ct. App. 2013).

Opinion

OPINION

MELISSA GOODWIN, Justice.

Southwest Pharmacy Solutions, Inc. d/b/a American Pharmacies appeals the trial court’s judgment granting the plea to the jurisdiction of the Texas Health and Human Services Commission (HHSC) and Thomas Suehs, Executive Commissioner of HHSC (jointly HHSC) and denying its requests for declaratory and injunctive relief. American Pharmacies challenged HHSC’s rulemaking obligations and certain rules promulgated by HHSC related to pharmacy benefits under Texas’s Medicaid managed care (MMC) program. For the reasons that follow, we affirm the trial court’s judgment.

STATUTORY AND REGULATORY FRAMEWORK

Medicaid is a cooperative federal-state program that provides health care to needy individuals. See generally 42 U.S.C. §§ 1396-1396w (Grants to States for Medical Assistance Programs).1 While federal law establishes Medicaid’s basic parameters, each state decides the nature and scope of its Medicaid program and submits a State plan describing its program to the federal Center for Medicare and Medicaid Services, which must approve the plan and any amendments. See 42 U.S.C. § 1396a(a), (b); 42 C.F.R. § 430.10. The federal government agrees to pay a specified percentage of a state’s expenditures for covered services provided by the state under an approved State plan. See 42 U.S.C. §§ 1396b(a), 1396c, 1396d(b). Outpatient pharmacy services are among the covered services. See id. § 1396r-8. In Texas, HHSC is the agency designated to administer federal medical assistance programs, including Medicaid. See Tex. Hum. Res.Code § 32.021(a); Tex. Gov’t Code § 531.021(a).

Traditionally, health care providers enrolled in the Medicaid program were reimbursed by HHSC on a fee-for-service basis at rates set by HHSC, with pharmacies being reimbursed under the Vendor Drug Program.2 See Act of May 26, 1979, 66th [553]*553Leg., R.S., ch. 842, §§ 32.028, .029, 1979 Tex. Gen. Laws 2833, 2351 (current versions at Tex. Hum. Res.Code §§ 32.028, .029); see also Tex. Gov’t Code § 531.021(b)(2); 1 Tex. Admin. Code §§ 354.1801-1928 (Tex. Health and Hum. Servs. Comm’n,3 Pharmacy Services), 355.201 (Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission), 355.8541-.8551 (Pharmacy Services: Reimbursement). HHSC is charged with adopting rules for determining reimbursement rates for medical assistance payments. Act of May 26, 1979, 66th Leg., R.S., ch. 842, § 32.028(a) (current version at Tex. Hum. Res.Code § 32.028(a)); Tex. Gov’t Code § 531.021(b)(2).

Since 1997, HHSC has had statutory authority to implement an MMC program for providing Medicaid services in Texas. See Act of May 28, 1997, 75th Leg., R.S., ch. 1262, § 2, 1997 Tex. Gen. Laws 4780, 4781 (current version at Tex. Gov’t Code §§ 533.001-.063) (Implementation of Medicaid Managed Care Program); Tex. Gov’t Code § 533.002 (“The commission shall implement the Medicaid managed care program as part of the health care delivery system ....”). Under MMC, HHSC contracts with managed care organizations (MCOs) to provide Medicaid health services under a managed care plan. See Tex. Gov’t Code §§ 533.001-.002; see also 42 U.S.C. § 1396b (authorizing federal reimbursement to state for costs of contracting with eligible MCOs). The MMC program in Texas operates as a Medicaid “demonstration project” authorized by certain waivers from the required provisions of the State plan granted by the federal government and monitored by the U.S. Department of Health and Human Services. See 42 U.S.C. § 1315; Tex. Hum. Res.Code § 32.041 (authorizing planning and evaluations of MMC demonstration project for implementation in 1996-97 biennium).

HHSC’s contracts with MCOs must include “capitation rates that ensure the cost-effective provision of quality health care.” Tex. Gov’t Code § 533.005(a)(2). “Capitation is a method of financing that distinguishes managed care service plans from traditional fee-for-serviee plans.” Hawkins v. El Paso First Health Plans, Inc., 214 S.W.3d 709, 712 (Tex.App.-Austin 2007, pet. denied). Under a “capitated” payment system, healthcare payers like Medicaid purchase services at a per person/per month rate from providers like the MCOs in return for payment pursuant to a capitated rate schedule. Id. The capitation rates are fixed sums that are calculated monthly for each enrolled member regardless of the amount of covered services used by the member and thus provide budget certainty to the state. Id.4 Capi-[554]*554tated payment arrangements are termed “full risk” because the MCO bears the risk that the capitated payment received for an insured member may be insufficient to cover that member’s medical needs for any given month. See 42 C.F.R. 438.2 (risk contract means contract under which contractor assumes risk for cost of covered services and incurs loss if cost exceeds payments); Vista Health Plan, Inc. v. Texas Health & Human Servs. Comm’n, No. 03-03-00216-CV, 2004 WL 1114551, at *1-2, 2004 Tex.App. LEXIS 4529, at *6 n. 4 (Tex.App.-Austin May 20, 2004, pet. denied) (mem. op.) (citing David M. Studdert, Direct Contracts, Data Sharing and Employee Risk Selection: New Stakes for Patient Pnvacy in Tomorrow’s Health Insurance Markets, 25 Am. J.L. & Med. 233, 236 (1999)); see also 42 U.S.C. § 1395mm(b)(2)(D) (to be eligible for federal reimbursement, MCO must assume full financial risk on prospective basis for provision of health care services).

Prior to March 1, 2012, outpatient pharmacy benefits were excluded from MMC, and Medicaid recipients obtained them outpatient drugs through pharmacies enrolled in the Vendor Drug Program. See 1 Tex. Admin. Code § 354.1873 (Freedom of Choice). In 2011, the legislature expanded the MMC program to include outpatient pharmacy benefits. See Act of June 27, 2011, 82d Leg., 1st C.S., ch. 7, § 1.02(d), 2011 Tex. Gen. Laws 5390, 5393 (SB 7) (codified at Tex. Gov’t Code § 533.005(a)(23)) (contract between HHSC and MCO must include outpatient pharmacy benefit plan).

Free access — add to your briefcase to read the full text and ask questions with AI

Related

LMV-AL Ventures, LLC v. Texas Department of Aging & Disability Services
520 S.W.3d 113 (Court of Appeals of Texas, 2017)
Untitled Texas Attorney General Opinion
Texas Attorney General Reports, 2014
City of Fritch v. Kirk Coker
Court of Appeals of Texas, 2014
McAllen Hospitals, L.P. v. Suehs
426 S.W.3d 304 (Court of Appeals of Texas, 2014)

Cite This Page — Counsel Stack

Bluebook (online)
408 S.W.3d 549, 2013 WL 3724038, 2013 Tex. App. LEXIS 8600, Counsel Stack Legal Research, https://law.counselstack.com/opinion/southwest-pharmacy-solutions-inc-v-texas-health-human-services-texapp-2013.