Texas 2019 - 86th Regular

Texas House Bill HB2817 Compare Versions

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Version 2 (New)

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1		-	By: Lucio III, et al. H.B. No. 2817
2		-	(Senate Sponsor - Hughes, et al.)
3		-	(In the Senate - Received from the House May 1, 2019;
4		-	May 3, 2019, read first time and referred to Committee on Business &
5		-	Commerce; May 21, 2019, reported adversely, with favorable
6		-	Committee Substitute by the following vote: Yeas 8, Nays 0;
7		-	May 21, 2019, sent to printer.)
8		-	Click here to see the committee vote
9		-	COMMITTEE SUBSTITUTE FOR H.B. No. 2817 By: Nichols
	1	+	By: Lucio III, Raney, Oliverson, Raymond H.B. No. 2817
10	2
11	3
12	4		A BILL TO BE ENTITLED
13	5		AN ACT
14	6		relating to the contractual relationship between a pharmacist or
15	7		pharmacy and a health benefit plan issuer or pharmacy benefit
16	8		manager.
17	9		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
18	10		SECTION 1. Chapter 1369, Insurance Code, is amended by
19	11		adding Subchapter K to read as follows:
20	12		SUBCHAPTER K. CONTRACTS WITH PHARMACISTS AND PHARMACIES
21	13		Sec. 1369.501. DEFINITIONS. In this subchapter:
22	14		(1) "Pharmacy benefit manager" has the meaning
23	15		assigned by Section 4151.151.
24		-	(2) "Pharmacy benefit network" means a network of
25		-	pharmacies that have contracted with a pharmacy benefit manager to
26		-	provide pharmacist services to enrollees.
27		-	(3) "Pharmacy services administrative organization"
	16	+	(2) "Pharmacy services administrative organization"
28	17		means an entity that contracts with a pharmacist or pharmacy to
29	18		conduct on behalf of the pharmacist or pharmacy the pharmacist's or
30	19		pharmacy's business with a third-party payor, including a pharmacy
31	20		benefit manager, in connection with pharmacy benefits and to assist
32	21		the pharmacist or pharmacy by providing administrative services,
33	22		including negotiating, executing, and administering a contract
34	23		with a third-party payor and communicating with the third-party
35	24		payor in connection with a contract or pharmacy benefits.
36	25		Sec. 1369.502. APPLICABILITY OF SUBCHAPTER. (a) This
37	26		subchapter applies only to a health benefit plan that provides
38	27		benefits for medical or surgical expenses incurred as a result of a
39	28		health condition, accident, or sickness, including an individual,
40	29		group, blanket, or franchise insurance policy or insurance
41	30		agreement, a group hospital service contract, or an individual or
42	31		group evidence of coverage or similar coverage document that is
43	32		offered by:
44	33		(1) an insurance company;
45	34		(2) a group hospital service corporation operating
46	35		under Chapter 842;
47	36		(3) a health maintenance organization operating under
48	37		Chapter 843;
49	38		(4) an approved nonprofit health corporation that
50	39		holds a certificate of authority under Chapter 844;
51	40		(5) a multiple employer welfare arrangement that holds
52	41		a certificate of authority under Chapter 846;
53	42		(6) a stipulated premium company operating under
54	43		Chapter 884;
55	44		(7) a fraternal benefit society operating under
56	45		Chapter 885;
57	46		(8) a Lloyd's plan operating under Chapter 941; or
58	47		(9) an exchange operating under Chapter 942.
59	48		(b) Notwithstanding any other law, this subchapter applies
60	49		to:
61	50		(1) a small employer health benefit plan subject to
62	51		Chapter 1501, including coverage provided through a health group
63	52		cooperative under Subchapter B of that chapter;
64	53		(2) a standard health benefit plan issued under
65	54		Chapter 1507;
66	55		(3) health benefits provided by or through a church
67	56		benefits board under Subchapter I, Chapter 22, Business
68	57		Organizations Code;
69	58		(4) group health coverage made available by a school
70	59		district in accordance with Section 22.004, Education Code;
71	60		(5) a regional or local health care program operated
72	61		under Section 75.104, Health and Safety Code; and
73	62		(6) a self-funded health benefit plan sponsored by a
74	63		professional employer organization under Chapter 91, Labor Code.
75	64		(c) This subchapter does not apply to an issuer or provider
76	65		of health benefits under or a pharmacy benefit manager
77	66		administering pharmacy benefits under a workers' compensation
78	67		insurance policy or other form of providing medical benefits under
79	68		Title 5, Labor Code.
80	69		Sec. 1369.503. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS
81	70		PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit
82	71		manager may not directly or indirectly reduce the amount of a claim
83	72		payment to a pharmacist or pharmacy after adjudication of the claim
84	73		through the use of an aggregated effective rate, a quality
85	74		assurance program, other direct or indirect remuneration fee, or
86		-	otherwise, except:
87		-	(1) in accordance with an audit performed under
88		-	Subchapter F; or
89		-	(2) by mutual agreement of the parties under a
90		-	pharmacy benefit network contract under which the health benefit
91		-	plan issuer or pharmacy benefit manager does not require as a
92		-	condition of the pharmacy benefit network contract or of
93		-	participation in the pharmacy benefit network that a pharmacist or
94		-	pharmacy agree to allow the health benefit plan issuer or pharmacy
95		-	benefit manager to reduce the amount of a claim payment to the
96		-	pharmacist or pharmacy after adjudication of the claim.
	75	+	otherwise, except in accordance with an audit performed under
	76	+	Subchapter F.
97	77		(b) Nothing in this section prohibits a health benefit plan
98	78		issuer or pharmacy benefit manager from increasing a claim payment
99	79		amount after adjudication of the claim.
100	80		Sec. 1369.504. REIMBURSEMENT OF AFFILIATED AND
101	81		NONAFFILIATED PHARMACISTS AND PHARMACIES. (a) In this section:
102	82		(1) "Affiliated pharmacist or pharmacy" means a
103	83		pharmacist or pharmacy that directly, or indirectly through one or
104	84		more intermediaries, controls or is controlled by, or is under
105	85		common control with, a pharmacy benefit manager.
106	86		(2) "Nonaffiliated pharmacist or pharmacy" means a
107	87		pharmacist or pharmacy that does not directly, or indirectly
108	88		through one or more intermediaries, control and is not controlled
109	89		by or under common control with a pharmacy benefit manager.
110	90		(b) A pharmacy benefit manager may not pay an affiliated
111	91		pharmacist or pharmacy a reimbursement amount that is more than the
112	92		amount the pharmacy benefit manager pays a nonaffiliated pharmacist
113	93		or pharmacy for the same pharmacist service.
114		-	Sec. 1369.505. NETWORK CONTRACT FEE SCHEDULE. A pharmacy
115		-	benefit network contract must specify or reference a separate fee
116		-	schedule. Unless otherwise available in the contract, the fee
117		-	schedule must be provided electronically in an easily accessible
118		-	and complete spreadsheet format and, on request, in writing to each
119		-	contracted pharmacist and pharmacy. The fee schedule must
120		-	describe:
	94	+	Sec. 1369.505. NETWORK CONTRACT FEE SCHEDULE. (a) In this
	95	+	section, "pharmacy benefit network" means a network of pharmacies
	96	+	that have contracted with a pharmacy benefit manager to provide
	97	+	pharmacist services to enrollees.
	98	+	(b) A pharmacy benefit network contract must specify or
	99	+	reference a separate fee schedule. The fee schedule must be
	100	+	provided electronically in an easily accessible and complete
	101	+	spreadsheet format and, on request, in writing to each contracted
	102	+	pharmacist and pharmacy. The fee schedule must describe:
121	103		(1) specific services or procedures that the
122	104		pharmacist or pharmacy may deliver and the amount of the
123	105		corresponding payment;
124	106		(2) a methodology for calculating the amount of the
125	107		payment based on a published fee schedule; or
126	108		(3) any other reasonable manner that provides an
127	109		ascertainable amount for payment for services.
128	110		Sec. 1369.506. DISCLOSURE OF PHARMACY SERVICES
129	111		ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy
130	112		that is a member of a pharmacy services administrative organization
131	113		that enters into a contract with a health benefit plan issuer or
132	114		pharmacy benefit manager on the pharmacist's or pharmacy's behalf
133	115		is entitled to receive from the pharmacy services administrative
134	116		organization a copy of the contract provisions applicable to the
135	117		pharmacist or pharmacy, including each provision relating to the
136	118		pharmacist's or pharmacy's rights and obligations under the
137	119		contract.
138		-	Sec. 1369.507. DELIVERY OF DRUGS. (a) Except in a case in
139		-	which the health benefit plan issuer or pharmacy benefit manager
140		-	makes a credible allegation of fraud against the pharmacist or
141		-	pharmacy and provides reasonable notice of the allegation and the
142		-	basis of the allegation to the pharmacist or pharmacy, a health
143		-	benefit plan issuer or pharmacy benefit manager may not as a
144		-	condition of a contract with a pharmacist or pharmacy prohibit the
145		-	pharmacist or pharmacy from:
	120	+	Sec. 1369.507. DELIVERY OF DRUGS. (a) A health benefit
	121	+	plan issuer or pharmacy benefit manager may not as a condition of a
	122	+	contract with a pharmacist or pharmacy prohibit the pharmacist or
	123	+	pharmacy from:
146	124		(1) mailing or delivering a drug to a patient on the
147	125		patient's request, to the extent permitted by law; or
148	126		(2) charging a shipping and handling fee to a patient
149	127		requesting a prescription be mailed or delivered if the pharmacist
150	128		or pharmacy discloses to the patient before the delivery:
151	129		(A) the fee that will be charged; and
152	130		(B) that the fee may not be reimbursable by the
153	131		health benefit plan issuer or pharmacy benefit manager.
154	132		(b) A pharmacist or pharmacy may not charge a health benefit
155	133		plan issuer or pharmacy benefit manager for the delivery of a
156	134		prescription drug as described by this section unless the charge is
157	135		specifically agreed to by the health benefit plan issuer or
158	136		pharmacy benefit manager.
159		-	(c) Notwithstanding Subsection (a), a health benefit plan
160		-	issuer or pharmacy benefit manager may as a condition of contract
161		-	prohibit a pharmacist or pharmacy from mailing the drugs for more
162		-	than 25 percent of the claims the pharmacist or pharmacy submits to
163		-	the health benefit plan issuer or pharmacy benefit manager during a
164		-	calendar year.
165	137		Sec. 1369.508. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE
166		-	REQUIREMENTS. ~~(a)~~ A health benefit plan issuer or pharmacy benefit
	138	+	REQUIREMENTS. A health benefit plan issuer or pharmacy benefit
167	139		manager may not as a condition of a contract with a pharmacist or
168	140		pharmacy:
169		-	(1) ~~except as provided by Subsection (b), require~~
170		-	~~pharmacist or pharmacy accreditation~~ standards or recertification
171		-	~~requirements inconsistent with, more~~ stringent than, or in addition
172		-	~~to federal and state requirements;~~ or
	141	+	(1) require pharmacist or pharmacy accreditation
	142	+	standards or recertification requirements inconsistent with, more
	143	+	stringent than, or in addition to federal and state requirements;
	144	+	or
173	145		(2) prohibit a licensed pharmacist or pharmacy from
174	146		dispensing any drug that may be dispensed under the pharmacist's or
175	147		pharmacy's license unless:
176	148		(A) applicable state or federal law prohibits the
177	149		pharmacist or pharmacy from dispensing the drug; or
178	150		(B) the manufacturer of the drug requires that a
179	151		pharmacist or pharmacy possess one or more accreditations or
180	152		certifications to dispense the drug and the pharmacist or pharmacy
181	153		does not meet the requirement.
182		-	(b) A health benefit plan issuer or pharmacy benefit manager
183		-	may require as a condition of a contract with a specialty pharmacy
184		-	that the specialty pharmacy obtain accreditation from not more than
185		-	two of the following independent accreditation organizations:
186		-	(1) URAC, formerly the Utilization Review
187		-	Accreditation Commission;
188		-	(2) The Joint Commission;
189		-	(3) Accreditation Commission for Health Care (ACHC);
190		-	(4) Center for Pharmacy Practice Accreditation
191		-	(CPPA); or
192		-	(5) National Committee for Quality Assurance (NCQA).
193		-	Sec. 1369.509. RETALIATION PROHIBITED. (a) A pharmacy
194		-	benefit manager may not retaliate against a pharmacist or pharmacy
195		-	based on the pharmacist's or pharmacy's exercise of any right or
196		-	remedy under this chapter. Retaliation prohibited by this section
197		-	includes:
	154	+	Sec. 1369.509. RETALIATION PROHIBITED. A pharmacy benefit
	155	+	manager may not retaliate against a pharmacist or pharmacy based on
	156	+	the pharmacist's or pharmacy's exercise of any right or remedy under
	157	+	this chapter. Retaliation prohibited by this section includes:
198	158		(1) terminating or refusing to renew a contract with
199	159		the pharmacist or pharmacy;
200	160		(2) subjecting the pharmacist or pharmacy to increased
201	161		audits; or
202	162		(3) failing to promptly pay the pharmacist or pharmacy
203	163		any money owed by the pharmacy benefit manager to the pharmacist or
204	164		pharmacy.
205		-	(b) For purposes of this section, a pharmacy benefit manager
206		-	is not considered to have retaliated against a pharmacist or
207		-	pharmacy if the pharmacy benefit manager:
208		-	(1) takes an action in response to a credible
209		-	allegation of fraud against the pharmacist or pharmacy; and
210		-	(2) provides reasonable notice to the pharmacist or
211		-	pharmacy of the allegation of fraud and the basis of the allegation
212		-	before taking the action.
213	165		Sec. 1369.510. WAIVER PROHIBITED. The provisions of this
214	166		subchapter may not be waived, voided, or nullified by contract.
215	167		SECTION 2. The change in law made by this Act applies only
216	168		to a contract entered into or renewed on or after the effective date
217	169		of this Act. A contract entered into or renewed before the
218	170		effective date of this Act is governed by the law as it existed
219	171		immediately before the effective date of this Act, and that law is
220	172		continued in effect for that purpose.
221	173		SECTION 3. This Act takes effect September 1, 2019.
222		-	* * * * *