Texas 2017 - 85th Regular

Texas Senate Bill SB1564 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	85R7017 PMO-F
2	2	By: Kolkhorst S.B. No. 1564
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to pharmacy benefit networks and pharmacy benefit
8	8	managers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 1458.001, Insurance Code, is amended by
11	11	amending Subdivisions (2), (7), and (8) and adding Subdivision
12	12	(3-a) to read as follows:
13	13	(2) "Contracting entity" means a person who:
14	14	(A) enters into a direct contract with a provider
15	15	for the delivery of health care services or drugs to covered
16	16	individuals; and
17	17	(B) in the ordinary course of business
18	18	establishes a provider network or networks for access by another
19	19	party.
20	20	(3-a) "Drug" has the meaning assigned by Section
21	21	551.003, Occupations Code.
22	22	(7)(A) "Provider" means:
23	23	(i) an advanced practice nurse;
24	24	(ii) an optometrist;
25	25	(iii) a therapeutic optometrist;
26	26	(iv) a physician;
27	27	(v) a physician assistant;
28	28	(vi) a professional association composed
29	29	solely of physicians, optometrists, or therapeutic optometrists;
30	30	(vii) a single legal entity authorized to
31	31	practice medicine owned by two or more physicians;
32	32	(viii) a nonprofit health corporation
33	33	certified by the Texas Medical Board under Chapter 162, Occupations
34	34	Code;
35	35	(ix) a partnership composed solely of
36	36	physicians, optometrists, or therapeutic optometrists;
37	37	(x) a physician-hospital organization that
38	38	acts exclusively as an administrator for a provider to facilitate
39	39	the provider's participation in health care contracts; [or]
40	40	(xi) an institution that is licensed under
41	41	Chapter 241, Health and Safety Code; or
42	42	(xii) a pharmacist or pharmacy.
43	43	(B) "Provider" does not include a
44	44	physician-hospital organization that leases or rents the
45	45	physician-hospital organization's network to another party.
46	46	(8) "Provider network contract" means a contract
47	47	between a contracting entity and a provider for the delivery of, and
48	48	payment for, health care services or drugs to a covered individual.
49	49	SECTION 2. Section 1458.002(a), Insurance Code, is amended
50	50	to read as follows:
51	51	(a) In this chapter, "health benefit plan" means:
52	52	(1) a hospital and medical expense incurred policy;
53	53	(2) a nonprofit health care service plan contract;
54	54	(3) a health maintenance organization subscriber
55	55	contract; or
56	56	(4) any other health care plan or arrangement that
57	57	pays for or furnishes medical or health care services or drugs.
58	58	SECTION 3. Sections 1458.101(c), (d), and (e), Insurance
59	59	Code, are amended to read as follows:
60	60	(c) A contracting entity may not provide a person access to
61	61	health care services, drugs, or contractual discounts under a
62	62	provider network contract unless the provider network contract
63	63	specifically states that the contracting entity may contract with a
64	64	person to provide access to the contracting entity's rights and
65	65	responsibilities under the provider network contract.
66	66	(d) The provider network contract must require that on the
67	67	request of the provider, the contracting entity will provide
68	68	information necessary to determine whether a particular person has
69	69	been authorized to access the provider's health care services,
70	70	drugs, and contractual discounts.
71	71	(e) To be enforceable against a provider, a provider network
72	72	contract, including the lines of business described by Subsections
73	73	(a) and (f), must also specify or reference a separate fee schedule
74	74	for each such line of business. The separate fee schedule may
75	75	describe specific services or procedures or drugs that the provider
76	76	will deliver along with a corresponding payment, may describe a
77	77	methodology for calculating payment based on a published fee
78	78	schedule, or may describe payment in any other reasonable manner
79	79	that specifies a definite payment for services or drugs. The fee
80	80	information may be provided by any reasonable method, including
81	81	electronically.
82	82	SECTION 4. Section 1458.102(a), Insurance Code, is amended
83	83	to read as follows:
84	84	(a) A contracting entity may not provide a person access to
85	85	health care services, drugs, or contractual discounts under a
86	86	provider network contract unless the provider network contract
87	87	specifically states that the person must comply with all applicable
88	88	terms, limitations, and conditions of the provider network
89	89	contract.
90	90	SECTION 5. Section 4151.001, Insurance Code, is amended by
91	91	adding Subdivisions (3-a) and (5-a) to read as follows:
92	92	(3-a) "Pharmacy benefit management" means the
93	93	administration or management of prescription drug benefits,
94	94	including:
95	95	(A) retail pharmacy network management;
96	96	(B) pharmacy discount card management;
97	97	(C) claims payment to a retail pharmacy for
98	98	prescription medications dispensed to plan participants;
99	99	(D) clinical formulary development and
100	100	management services, including utilization management and quality
101	101	assurance programs;
102	102	(E) rebate contracting and administration;
103	103	(F) auditing contracted pharmacies;
104	104	(G) establishing pharmacy reimbursement pricing
105	105	and methodologies; and
106	106	(H) determining single and multiple source
107	107	medications.
108	108	(5-a) "Retail pharmacy" means a pharmacy licensed
109	109	under Chapter 560, Occupations Code, that dispenses medications to
110	110	the public, including an independent pharmacy, a chain pharmacy, a
111	111	supermarket pharmacy, or a mass merchandiser pharmacy. The term
112	112	does not include a pharmacy that dispenses prescription medications
113	113	primarily through the mail, a nursing home pharmacy, a long-term
114	114	care facility pharmacy, a hospital pharmacy, a clinic pharmacy, a
115	115	charitable or nonprofit pharmacy, a government pharmacy, or a
116	116	pharmacy benefit manager that is serving in its capacity as a
117	117	pharmacy benefit manager.
118	118	SECTION 6. Section 4151.151, Insurance Code, is amended to
119	119	read as follows:
120	120	Sec. 4151.151. DEFINITION. In this subchapter, "pharmacy
121	121	benefit manager" means a person, other than a pharmacy or
122	122	pharmacist, who acts as an administrator that provides pharmacy
123	123	benefit management in connection with pharmacy benefits.
124	124	SECTION 7. Chapter 1458, Insurance Code, as amended by this
125	125	Act, applies only to a provider network contract entered into or
126	126	renewed on or after January 1, 2018. A provider network contract
127	127	entered into or renewed before January 1, 2018, is governed by the
128	128	law as it existed immediately before the effective date of this Act,
129	129	and that law is continued in effect for that purpose.
130	130	SECTION 8. This Act takes effect September 1, 2017.