82R2426 RWG-D
By: Carona S.B. No. 262
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for orally administered
anticancer medications.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter E to read as follows:
SUBCHAPTER E. COVERAGE FOR ORALLY ADMINISTERED ANTICANCER
MEDICATIONS
Sec. 1369.201. DEFINITION. In this subchapter, "enrollee"
means an individual entitled to coverage under a health benefit
plan.
Sec. 1369.202. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan, including a small
employer health benefit plan written under Chapter 1501 or coverage
provided by a health group cooperative under Subchapter B of that
chapter, that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage or similar coverage
document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) an exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under
Chapter 843;
(8) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this subchapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
Sec. 1369.203. EXCEPTION. This subchapter does not apply
to:
(1) a plan that provides coverage:
(A) only for fixed indemnity benefits for a
specified disease or diseases;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) only for dental or vision care; or
(F) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
an automobile insurance policy;
(5) a credit insurance policy;
(6) a limited benefit policy that does not provide
coverage for physical examinations or wellness exams; or
(7) a long-term care insurance policy, including a
nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described
by Section 1369.202.
Sec. 1369.204. REQUIRED COVERAGE FOR ORALLY ADMINISTERED
ANTICANCER MEDICATIONS. (a) A health benefit plan that provides
coverage for cancer treatment must provide coverage for a
prescribed, orally administered anticancer medication that is used
to kill or slow the growth of cancerous cells on a basis no less
favorable than intravenously administered or injected cancer
medications that are covered as medical benefits by the plan.
(b) This section does not prohibit a health benefit plan
from requiring prior authorization for an orally administered
anticancer medication. If an orally administered anticancer
medication is authorized, the patient's out-of-pocket costs may not
be greater than the out-of-pocket costs for an intravenously
administered anticancer medication.
(c) Before a health benefit plan issuer increases patients'
out-of-pocket costs for intravenously administered anticancer
medications under the plan, the plan issuer must file the proposed
increase with the department with evidence that shows the proposed
increase is directly related to and necessitated by an increase in
costs to the plan for intravenous medication. The commissioner may
deny the proposed increase if the plan issuer does not make the
showing required by this subsection. A proposed increase may not
violate Subsection (a) or (b). If the commissioner does not deny
the proposed increase before the 61st day after the date the
proposed increase is filed with the department, the proposed
increase is considered approved, and subject to Subsections (a) and
(b), the plan issuer may implement the proposed increase.
SECTION 2. Subchapter E, Chapter 1369, Insurance Code, as
added by this Act, applies only to a health benefit plan that is
delivered, issued for delivery, or renewed on or after January 1,
2012. A health benefit plan that is delivered, issued for delivery,
or renewed before January 1, 2012, is covered by the law in effect
at the time the plan was delivered, issued for delivery, or renewed,
and that law is continued in effect for that purpose.
SECTION 3. This Act takes effect September 1, 2011.