84R7415 PMO-D
By: Seliger S.B. No. 1520
A BILL TO BE ENTITLED
AN ACT
relating to transparency of certain information related to certain
health benefit plan coverage.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter B, Chapter 1369, Insurance Code, is
amended by adding Sections 1369.0542 and 1369.0543 to read as
follows:
Sec. 1369.0542. FORMULARY INFORMATION ON INTERNET WEBSITE.
(a) A health benefit plan issuer shall display on a public Internet
website maintained by the issuer formulary information as required
by the commissioner by rule. The information must be displayed in
the template format developed under Section 1369.0543.
(b) A direct electronic link to the formulary information
must be displayed in a conspicuous manner on the home page of the
health benefit plan issuer's Internet website. The information must
be publicly accessible without necessity of providing a password, a
user name, or personally identifiable information.
Sec. 1369.0543. DEVELOPMENT OF TEMPLATE. (a) The
department shall develop a template that all health benefit plan
issuers must use to display formulary information as required by
Section 1369.0542.
(b) The commissioner shall appoint a committee to advise the
department on the development of the template, which must be
electronically searchable by drug name and include:
(1) detailed information about cost-sharing tiers,
including coinsurance amounts or range of amounts for each drug;
(2) disclosure of prior authorization, step therapy,
or other protocol requirements for each drug;
(3) identification of preferred formulary drugs;
(4) an explanation of coverage of each formulary drug;
and
(5) an indication of each formulary that applies to
each health benefit plan issued by the issuer.
(c) The advisory committee shall be composed of an equal
number of members from each of the following groups of
stakeholders:
(1) physicians;
(2) health care providers other than physicians;
(3) consumers; and
(4) health benefit plan issuers.
SECTION 2. Chapter 1451, Insurance Code, is amended by
adding Subchapter K to read as follows:
SUBCHAPTER K. HEALTH CARE PROVIDER DIRECTORIES
Sec. 1451.501. DEFINITIONS. In this subchapter:
(1) "Health care provider" means a practitioner,
institutional provider, or other person or organization that
furnishes health care services and that is licensed or otherwise
authorized to practice in this state. The term includes a
pharmacist, pharmacy, hospital, nursing home, or other medical or
health-related service facility that provides care for the sick or
injured or other care. The term does not include a physician.
(2) "Physician" means an individual licensed to
practice medicine in this state.
Sec. 1451.502. APPLICABILITY OF SUBCHAPTER. 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.
Sec. 1451.503. 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),
as amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy;
(5) 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 1451.502;
(6) 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; or
(7) a Medicaid managed care program operated under
Chapter 533, Government Code, or a Medicaid program operated under
Chapter 32, Human Resources Code.
Sec. 1451.504. PHYSICIAN AND HEALTH CARE PROVIDER
DIRECTORIES. (a) A health benefit plan issuer that offers coverage
for health care services through preferred providers, exclusive
providers, or a network of physicians or health care providers
shall develop and maintain a physician and health care provider
directory in accordance with this subchapter.
(b) The directory must include the name, street address, and
telephone number of each physician and health care provider
described by Subsection (a) and indicate whether the physician or
provider is accepting new patients.
Sec. 1451.505. PHYSICIAN AND HEALTH CARE PROVIDER DIRECTORY
ON INTERNET WEBSITE. (a) A health benefit plan issuer shall display
on a public Internet website maintained by the issuer the directory
required by Section 1451.504. A direct electronic link to the
directory must be displayed in a conspicuous manner on the home page
of the Internet website.
(b) The health benefit plan issuer shall clearly indicate in
the directory each health benefit plan issued by the issuer that may
provide coverage for services provided by each physician or health
care provider included in the directory.
(c) The directory must be:
(1) electronically searchable by physician or health
care provider name and location; and
(2) publicly accessible without necessity of
providing a password, a user name, or personally identifiable
information.
(d) The health benefit plan issuer shall conduct an ongoing
review of the directory and correct or update the information as
necessary. Except as provided by Subsection (e), corrections and
updates, if any, must be made not less than once each month.
(e) The health benefit plan issuer shall conspicuously
display in the directory required by Section 1451.504 an e-mail
address and a toll-free telephone number to which any individual
may report any inaccuracy in the directory. If the issuer receives a
report from any person that specifically identified directory
information may be inaccurate, the issuer shall investigate the
report and correct the information, as necessary, not later than
the seventh day after the date the report is received.
SECTION 3. The commissioner of insurance shall ensure that
the template developed under Section 1369.0543, Insurance Code, as
added by this Act, is available for initial use under Section
1369.0542, Insurance Code, as added by this Act, not later than
January 1, 2016.
SECTION 4. This Act applies only to a health benefit plan
that is delivered, issued for delivery, or renewed on or after
January 1, 2016. A plan delivered, issued for delivery, or renewed
before January 1, 2016, is governed by the law as it existed
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
SECTION 5. This Act takes effect September 1, 2015.