By: Huffman S.B. No. 644
(Zerwas)
A BILL TO BE ENTITLED
AN ACT
relating to the creation of a standard request form for prior
authorization of prescription drug benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1369, Insurance Code, is amended by
adding Subchapter F to read as follows:
SUBCHAPTER F. STANDARD REQUEST FORM FOR PRIOR AUTHORIZATION OF
PRESCRIPTION DRUG BENEFITS
Sec. 1369.251. DEFINITION. In this subchapter,
"prescription drug" has the meaning assigned by Section 551.003,
Occupations Code.
Sec. 1369.252. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan 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 a small or large
employer group contract 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) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) This subchapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding Section 172.014, Local Government Code,
or any other law, this subchapter applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
(d) 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.
(e) Notwithstanding any other law, this subchapter applies
to coverage under:
(1) the child health plan program under Chapter 62,
Health and Safety Code, or the health benefits plan for children
under Chapter 63, Health and Safety Code; and
(2) the medical assistance program under Chapter 32,
Human Resources Code.
Sec. 1369.253. EXCEPTION. This subchapter does not apply
to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another
single benefit;
(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) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) 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) medical payment insurance coverage provided under
a motor vehicle insurance policy;
(4) 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 1369.252; or
(5) a workers' compensation insurance policy.
Sec. 1369.254. STANDARD FORM. (a) The commissioner by
rule shall:
(1) prescribe a single, standard form for requesting
prior authorization of prescription drug benefits;
(2) require a health benefit plan issuer or the agent
of the health benefit plan issuer that manages or administers
prescription drug benefits to use the form for any prior
authorization of prescription drug benefits required by the plan;
(3) require that the department and a health benefit
plan issuer or the agent of the health benefit plan issuer that
manages or administers prescription drug benefits make the form
available electronically on the website of:
(A) the department;
(B) the health benefit plan issuer; and
(C) the agent of the health benefit plan issuer;
and
(4) establish penalties for failure to accept the form
and acknowledge receipt of the form as required by commissioner
rule.
(b) Not later than the second anniversary of the date
national standards for electronic prior authorization of benefits
are adopted, a health benefit plan issuer or the agent of the health
benefit plan issuer that manages or administers prescription drug
benefits shall exchange prior authorization requests
electronically with a prescribing provider who has e-prescribing
capability and who initiates a request electronically.
(c) In prescribing a form under this section, the
commissioner shall:
(1) develop the form with input from the advisory
committee on uniform prior authorization forms established under
Section 1369.255; and
(2) take into consideration:
(A) any form for requesting prior authorization
of benefits that is widely used in this state or any form currently
used by the department;
(B) request forms for prior authorization of
benefits established by the federal Centers for Medicare and
Medicaid Services; and
(C) national standards, or draft standards,
pertaining to electronic prior authorization of benefits.
Sec. 1369.255. ADVISORY COMMITTEE ON UNIFORM PRIOR
AUTHORIZATION FORMS. (a) The commissioner shall appoint a
committee to advise the commissioner on the technical, operational,
and practical aspects of developing the single, standard prior
authorization form required under Section 1369.254 for requesting
prior authorization of prescription drug benefits.
(b) The advisory committee shall determine the following:
(1) a single standard form for requesting prior
authorization of prescription drug benefits;
(2) the length of the standard prior authorization
form;
(3) the length of time allowed for acknowledgement of
receipt of the form by the health benefit plan issuer or the agent
of the health benefit plan issuer that manages or administers
prescription drug benefits;
(4) the acceptable methods to acknowledge receipt; and
(5) the penalty imposed on the health benefit plan
issuer or the agent of the health benefit plan issuer that manages
or administers prescription drug benefits for failure to
acknowledge receipt of the form.
(c) The commissioner shall consult the advisory committee
with respect to any rule relating to a subject described by Section
1369.254 or this section before adopting the rule and may consult
the committee as needed with respect to a subsequent amendment of an
adopted rule.
(d) Not later than the second anniversary of the final
approval of the standard prior authorization form, and every two
years subsequently, the commissioner shall convene the advisory
committee to review the standard prior authorization form and
determine if changes are needed.
(e) The advisory committee shall be composed of the
executive commissioner of the Health and Human Services Commission
or the executive commissioner's designee and an equal number of
members from each of the following groups:
(1) physicians;
(2) other prescribing health care providers;
(3) hospitals;
(4) pharmacists;
(5) specialty pharmacies;
(6) pharmacy benefit managers;
(7) health benefit plan issuers for the Texas Health
Insurance Pool established under Chapter 1506;
(8) health benefit plan issuers; and
(9) health benefit plan networks of providers.
(f) A member of the advisory committee serves without
compensation.
(g) Section 39.003(a) of this code and Chapter 2110,
Government Code, do not apply to the advisory committee.
Sec. 1369.256. FAILURE TO USE OR ACKNOWLEDGE STANDARD FORM.
If a health benefit plan issuer or the agent of the health benefit
plan issuer that manages or administers prescription drug benefits
fails to use or accept the form prescribed under this subchapter or
fails to acknowledge the receipt of a completed form submitted by a
prescribing provider, as required by commissioner rule, the health
benefit plan issuer or the agent of the health benefit plan issuer
is subject to the penalties established by the commissioner.
SECTION 2. Not later than January 1, 2015, the commissioner
of insurance by rule shall prescribe a standard form under Section
1369.254, Insurance Code, as added by this Act.
SECTION 3. The change in law made by this Act applies only
to a request for prior authorization of prescription drug benefits
made on or after September 1, 2015. A request for prior
authorization of prescription drug benefits made before September
1, 2015, under a health benefit plan delivered, issued for
delivery, or renewed before that date is governed by the law in
effect immediately before the effective date of this Act, and that
law is continued in effect for that purpose.
SECTION 4. This Act takes effect September 1, 2013.