85R7017 PMO-F
By: Muñoz, Jr. H.B. No. 1881
A BILL TO BE ENTITLED
AN ACT
relating to pharmacy benefit networks and pharmacy benefit
managers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1458.001, Insurance Code, is amended by
amending Subdivisions (2), (7), and (8) and adding Subdivision
(3-a) to read as follows:
(2) "Contracting entity" means a person who:
(A) enters into a direct contract with a provider
for the delivery of health care services or drugs to covered
individuals; and
(B) in the ordinary course of business
establishes a provider network or networks for access by another
party.
(3-a) "Drug" has the meaning assigned by Section
551.003, Occupations Code.
(7)(A) "Provider" means:
(i) an advanced practice nurse;
(ii) an optometrist;
(iii) a therapeutic optometrist;
(iv) a physician;
(v) a physician assistant;
(vi) a professional association composed
solely of physicians, optometrists, or therapeutic optometrists;
(vii) a single legal entity authorized to
practice medicine owned by two or more physicians;
(viii) a nonprofit health corporation
certified by the Texas Medical Board under Chapter 162, Occupations
Code;
(ix) a partnership composed solely of
physicians, optometrists, or therapeutic optometrists;
(x) a physician-hospital organization that
acts exclusively as an administrator for a provider to facilitate
the provider's participation in health care contracts; [or]
(xi) an institution that is licensed under
Chapter 241, Health and Safety Code; or
(xii) a pharmacist or pharmacy.
(B) "Provider" does not include a
physician-hospital organization that leases or rents the
physician-hospital organization's network to another party.
(8) "Provider network contract" means a contract
between a contracting entity and a provider for the delivery of, and
payment for, health care services or drugs to a covered individual.
SECTION 2. Section 1458.002(a), Insurance Code, is amended
to read as follows:
(a) In this chapter, "health benefit plan" means:
(1) a hospital and medical expense incurred policy;
(2) a nonprofit health care service plan contract;
(3) a health maintenance organization subscriber
contract; or
(4) any other health care plan or arrangement that
pays for or furnishes medical or health care services or drugs.
SECTION 3. Sections 1458.101(c), (d), and (e), Insurance
Code, are amended to read as follows:
(c) A contracting entity may not provide a person access to
health care services, drugs, or contractual discounts under a
provider network contract unless the provider network contract
specifically states that the contracting entity may contract with a
person to provide access to the contracting entity's rights and
responsibilities under the provider network contract.
(d) The provider network contract must require that on the
request of the provider, the contracting entity will provide
information necessary to determine whether a particular person has
been authorized to access the provider's health care services,
drugs, and contractual discounts.
(e) To be enforceable against a provider, a provider network
contract, including the lines of business described by Subsections
(a) and (f), must also specify or reference a separate fee schedule
for each such line of business. The separate fee schedule may
describe specific services or procedures or drugs that the provider
will deliver along with a corresponding payment, may describe a
methodology for calculating payment based on a published fee
schedule, or may describe payment in any other reasonable manner
that specifies a definite payment for services or drugs. The fee
information may be provided by any reasonable method, including
electronically.
SECTION 4. Section 1458.102(a), Insurance Code, is amended
to read as follows:
(a) A contracting entity may not provide a person access to
health care services, drugs, or contractual discounts under a
provider network contract unless the provider network contract
specifically states that the person must comply with all applicable
terms, limitations, and conditions of the provider network
contract.
SECTION 5. Section 4151.001, Insurance Code, is amended by
adding Subdivisions (3-a) and (5-a) to read as follows:
(3-a) "Pharmacy benefit management" means the
administration or management of prescription drug benefits,
including:
(A) retail pharmacy network management;
(B) pharmacy discount card management;
(C) claims payment to a retail pharmacy for
prescription medications dispensed to plan participants;
(D) clinical formulary development and
management services, including utilization management and quality
assurance programs;
(E) rebate contracting and administration;
(F) auditing contracted pharmacies;
(G) establishing pharmacy reimbursement pricing
and methodologies; and
(H) determining single and multiple source
medications.
(5-a) "Retail pharmacy" means a pharmacy licensed
under Chapter 560, Occupations Code, that dispenses medications to
the public, including an independent pharmacy, a chain pharmacy, a
supermarket pharmacy, or a mass merchandiser pharmacy. The term
does not include a pharmacy that dispenses prescription medications
primarily through the mail, a nursing home pharmacy, a long-term
care facility pharmacy, a hospital pharmacy, a clinic pharmacy, a
charitable or nonprofit pharmacy, a government pharmacy, or a
pharmacy benefit manager that is serving in its capacity as a
pharmacy benefit manager.
SECTION 6. Section 4151.151, Insurance Code, is amended to
read as follows:
Sec. 4151.151. DEFINITION. In this subchapter, "pharmacy
benefit manager" means a person, other than a pharmacy or
pharmacist, who acts as an administrator that provides pharmacy
benefit management in connection with pharmacy benefits.
SECTION 7. Chapter 1458, Insurance Code, as amended by this
Act, applies only to a provider network contract entered into or
renewed on or after January 1, 2018. A provider network contract
entered into or renewed before January 1, 2018, 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 8. This Act takes effect September 1, 2017.