Texas 2021 - 87th Regular

Texas House Bill HB1646 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		87R2075 SMT-F
2		-	By: Lambert, Price, Vo, Thompson of Harris, H.B. No. 1646
3		-	et al.
	2	+	By: Lambert H.B. No. 1646
4	3
5	4
6	5		A BILL TO BE ENTITLED
7	6		AN ACT
8	7		relating to modification of certain prescription drug benefits and
9	8		coverage offered by certain health benefit plans.
10	9		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	10		SECTION 1. Section 1369.053, Insurance Code, is amended to
12	11		read as follows:
13	12		Sec. 1369.053. EXCEPTION. This subchapter does not apply
14	13		to:
15	14		(1) a health benefit plan that provides coverage:
16	15		(A) only for a specified disease or for another
17	16		single benefit;
18	17		(B) only for accidental death or dismemberment;
19	18		(C) for wages or payments in lieu of wages for a
20	19		period during which an employee is absent from work because of
21	20		sickness or injury;
22	21		(D) as a supplement to a liability insurance
23	22		policy;
24	23		(E) for credit insurance;
25	24		(F) only for dental or vision care;
26	25		(G) only for hospital expenses; or
27	26		(H) only for indemnity for hospital confinement;
28	27		(2) a Medicare supplemental policy as defined by
29	28		Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
30	29		as amended;
31	30		(3) a workers' compensation insurance policy;
32	31		(4) medical payment insurance coverage provided under
33	32		a motor vehicle insurance policy;
34	33		(5) a long-term care insurance policy, including a
35	34		nursing home fixed indemnity policy, unless the commissioner
36	35		determines that the policy provides benefit coverage so
37	36		comprehensive that the policy is a health benefit plan as described
38	37		by Section 1369.052;
39	38		(6) the child health plan program under Chapter 62,
40	39		Health and Safety Code, or the health benefits plan for children
41	40		under Chapter 63, Health and Safety Code; [or]
42	41		(7) a Medicaid managed care program operated under
43	42		Chapter 533, Government Code, or a Medicaid program operated under
44	43		Chapter 32, Human Resources Code; or
45	44		(8) a self-funded health benefit plan as defined by
46	45		the Employee Retirement Income Security Act of 1974 (29 U.S.C.
47	46		Section 1001 et seq.).
48	47		SECTION 2. Section 1369.0541, Insurance Code, is amended by
49	48		amending Subsections (a) and (b) and adding Subsections (a-1) and
50	49		(b-1) to read as follows:
51	50		(a) Except as provided by Section 1369.055(a-1) and
52	51		Subsection (b-1) of this section, a [A] health benefit plan issuer
53	52		may modify drug coverage provided under a health benefit plan if:
54	53		(1) the modification occurs at the time of coverage
55	54		renewal;
56	55		(2) the modification is effective uniformly among all
57	56		group health benefit plan sponsors covered by identical or
58	57		substantially identical health benefit plans or all individuals
59	58		covered by identical or substantially identical individual health
60	59		benefit plans, as applicable; and
61	60		(3) not later than the 60th day before the date the
62	61		modification is effective, the issuer provides written notice of
63	62		the modification to the commissioner, each affected group health
64	63		benefit plan sponsor, each affected enrollee in an affected group
65	64		health benefit plan, and each affected individual health benefit
66	65		plan holder.
67	66		(a-1) The notice described by Subsection (a)(3) must
68	67		include a statement:
69	68		(1) indicating that the health benefit plan issuer is
70	69		modifying drug coverage provided under the health benefit plan;
71	70		(2) explaining the type of modification; and
72	71		(3) indicating that, on renewal of the health benefit
73	72		plan, the health benefit plan issuer may not modify an enrollee's
74	73		contracted benefit level for any prescription drug that was
75	74		approved or covered under the plan in the immediately preceding
76	75		plan year as provided by Section 1369.055(a-1).
77	76		(b) Modifications affecting drug coverage that require
78	77		notice under Subsection (a) include:
79	78		(1) removing a drug from a formulary;
80	79		(2) adding a requirement that an enrollee receive
81	80		prior authorization for a drug;
82	81		(3) imposing or altering a quantity limit for a drug;
83	82		(4) imposing a step-therapy restriction for a drug;
84	83		[and]
85	84		(5) moving a drug to a higher cost-sharing tier;
86	85		(6) increasing a coinsurance, copayment, deductible,
87	86		or other out-of-pocket expense that an enrollee must pay for a drug;
88	87		and
89	88		(7) reducing the maximum drug coverage amount [unless
90	89		a generic drug alternative to the drug is available].
91	90		(b-1) Modifications affecting drug coverage that are more
92	91		favorable to enrollees may be made at any time and do not require
93	92		notice under Subsection (a), including:
94	93		(1) the addition of a drug to a formulary;
95	94		(2) the reduction of a coinsurance, copayment,
96	95		deductible, or other out-of-pocket expense that an enrollee must
97	96		pay for a drug; and
98	97		(3) the removal of a utilization review requirement.
99	98		SECTION 3. Section 1369.055, Insurance Code, is amended by
100	99		adding Subsections (a-1), (a-2), and (c) to read as follows:
101	100		(a-1) On renewal of a health benefit plan, the plan issuer
102	101		may not modify an enrollee's contracted benefit level for any
103	102		prescription drug that was approved or covered under the plan in the
104	103		immediately preceding plan year and prescribed during that year for
105	104		a medical condition or mental illness of the enrollee if:
106	105		(1) the enrollee was covered by the health benefit
107	106		plan on the date immediately preceding the renewal date;
108	107		(2) a physician or other prescribing provider
109	108		prescribes the drug for the medical condition or mental illness;
110	109		and
111	110		(3) the physician or other prescribing provider in
112	111		consultation with the enrollee determines that the drug is the most
113	112		appropriate course of treatment.
114	113		(a-2) Modifications prohibited under Subsection (a-1)
115	114		include:
116	115		(1) removing a drug from a formulary;
117	116		(2) adding a requirement that an enrollee receive
118	117		prior authorization for a drug;
119	118		(3) imposing or altering a quantity limit for a drug;
120	119		(4) imposing a step-therapy restriction for a drug;
121	120		(5) moving a drug to a higher cost-sharing tier;
122	121		(6) increasing a coinsurance, copayment, deductible,
123	122		or other out-of-pocket expense that an enrollee must pay for a drug;
124	123		and
125	124		(7) reducing the maximum drug coverage amount.
126	125		(c) Subsections (a-1) and (a-2) do not:
127	126		(1) prohibit a health benefit plan issuer from
128	127		requiring, by contract, written policy or procedure, or other
129	128		agreement or course of conduct, a pharmacist to provide a
130	129		substitution for a prescription drug in accordance with Subchapter
131	130		A, Chapter 562, Occupations Code, under which the pharmacist may
132	131		substitute an interchangeable biologic product or therapeutically
133	132		equivalent generic product as determined by the United States Food
134	133		and Drug Administration;
135	134		(2) prohibit a physician or other prescribing provider
136	135		from prescribing another medication;
137	136		(3) prohibit the health benefit plan issuer from
138	137		adding a new drug to a formulary;
139	138		(4) require a health benefit plan to provide coverage
140	139		to an enrollee under circumstances not described by Subsection
141	140		(a-1); or
142	141		(5) prohibit a health benefit plan issuer from
143	142		removing a drug from its formulary or denying an enrollee coverage
144	143		for the drug if:
145	144		(A) the United States Food and Drug
146	145		Administration has issued a statement about the drug that calls
147	146		into question the clinical safety of the drug;
148	147		(B) the drug manufacturer has notified the United
149	148		States Food and Drug Administration of a manufacturing
150	149		discontinuance or potential discontinuance of the drug as required
151	150		by Section 506C, Federal Food, Drug, and Cosmetic Act (21 U.S.C.
152	151		Section 356c); or
153	152		(C) the drug manufacturer has removed the drug
154	153		from the market.
155	154		SECTION 4. The changes in law made by this Act apply only to
156	155		a health benefit plan that is delivered, issued for delivery, or
157	156		renewed on or after January 1, 2022. A health benefit plan
158	157		delivered, issued for delivery, or renewed before January 1, 2022,
159	158		is governed by the law as it existed immediately before the
160	159		effective date of this Act, and that law is continued in effect for
161	160		that purpose.
162	161		SECTION 5. This Act takes effect September 1, 2021.