TPA Shares Concerns About Medicaid Proposed Rule Concerning Access to Network Pharmacies

Changes Could Result in More Stores Closing

The Texas Pharmacy Association is taking action and raising concerns about a proposed rule relating to access to network pharmacies under the Texas Medicaid program. Today, the Association submitted informal comments in a letter to Texas Health and Human Services Executive Commissioner Cecile Erwin Young expressing substantial concern about the rule’s potential impact.

“The proposal, as drafted, could inadvertently restrict [patient] access and lead to higher long-term costs of care,” TPA wrote. “We strongly recommend a comprehensive discussion before the rule advances.”

The draft rule reduces the expectations placed on managed care organizations (MCOs) at a time when HHSC’s own reports reflect worsening network compliance and rising total cost of care. TPA asserted that MCOs should be increasing their efforts to enroll Texas pharmacies to improve their members’ access to health care in every county, and maintain fidelity to their contractual expectations.

Potential Impact on Pharmacies

“We are concerned that the proposed changes will result in more stores closing or, at minimum, fewer pharmacies serving Medicaid customers,” TPA wrote, noting that Medicaid patients “may face substantial delays in obtaining medications and basic health care support, running counter to both state and national conversations about strengthening rural care infrastructure.”

TPA also explained that pharmacy benefit managers’ inadequate reimbursement has resulted in fewer pharmacies and is the root cause of health plans' inability to comply with the state’s network adequacy standards. “Loosening the network adequacy standards fails to address the root cause of the problem and, instead, rewards the entities responsible for the problem,” the letter says.

TPA’s requests include:

• For HHSC to meet with TPA and other Texas pharmacy organizations to communicate the intent of the project and share the data supporting the proposed changes
• Clear and publicly available oversight documentation
• Regular reporting on MCO corrective action plans
• Assurance that the proposed rule changes do not inadvertently reward poor performance or disadvantage Texans, via results of data analytics and geomapping
• Consideration for pharmacy representation on the HHSC Managed Care Advisory Committee.

Legislative Support

Additionally, TPA is securing meetings with state legislators and other elected officials to share these concerns, especially since the proposed rule appears to thwart the legislative intent of SB 760, passed by the 84th Legislature (2015), meant to strengthen network adequacy requirements and ensure enforcement.