Texas 2021 - 87th Regular

Texas House Bill HB1763 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	H.B. No. 1763
	1	+	By: Oliverson, et al. (Senate Sponsor - Hughes) H.B. No. 1763
	2	+	(In the Senate - Received from the House April 27, 2021;
	3	+	May 3, 2021, read first time and referred to Committee on Business &
	4	+	Commerce; May 10, 2021, reported favorably by the following vote:
	5	+	Yeas 7, Nays 0; May 10, 2021, sent to printer.)
	6	+	Click here to see the committee vote
2	7
3	8
	9	+	A BILL TO BE ENTITLED
4	10		AN ACT
5	11		relating to the contractual relationship between a pharmacist or
6	12		pharmacy and a health benefit plan issuer or pharmacy benefit
7	13		manager.
8	14		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	15		SECTION 1. Chapter 1369, Insurance Code, is amended by
10	16		adding Subchapter L to read as follows:
11	17		SUBCHAPTER L. CONTRACTS WITH PHARMACISTS AND PHARMACIES
12	18		Sec. 1369.551. DEFINITIONS. In this subchapter:
13	19		(1) "Pharmacy benefit manager" has the meaning
14	20		assigned by Section 4151.151.
15	21		(2) "Pharmacy benefit network" means a network of
16	22		pharmacies that have contracted with a pharmacy benefit manager to
17	23		provide pharmacist services to enrollees.
18	24		(3) "Pharmacy services administrative organization"
19	25		means an entity that contracts with a pharmacist or pharmacy to
20	26		conduct on behalf of the pharmacist or pharmacy the pharmacist's or
21	27		pharmacy's business with a third-party payor, including a pharmacy
22	28		benefit manager, in connection with pharmacy benefits and to assist
23	29		the pharmacist or pharmacy by providing administrative services,
24	30		including negotiating, executing, and administering a contract
25	31		with a third-party payor and communicating with the third-party
26	32		payor in connection with a contract or pharmacy benefits.
27	33		Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This
28	34		subchapter applies only to a health benefit plan that provides
29	35		benefits for medical or surgical expenses incurred as a result of a
30	36		health condition, accident, or sickness, including an individual,
31	37		group, blanket, or franchise insurance policy or insurance
32	38		agreement, a group hospital service contract, or an individual or
33	39		group evidence of coverage or similar coverage document that is
34	40		offered by:
35	41		(1) an insurance company;
36	42		(2) a group hospital service corporation operating
37	43		under Chapter 842;
38	44		(3) a health maintenance organization operating under
39	45		Chapter 843;
40	46		(4) an approved nonprofit health corporation that
41	47		holds a certificate of authority under Chapter 844;
42	48		(5) a multiple employer welfare arrangement that holds
43	49		a certificate of authority under Chapter 846;
44	50		(6) a stipulated premium company operating under
45	51		Chapter 884;
46	52		(7) a fraternal benefit society operating under
47	53		Chapter 885;
48	54		(8) a Lloyd's plan operating under Chapter 941; or
49	55		(9) an exchange operating under Chapter 942.
50	56		(b) Notwithstanding any other law, this subchapter applies
51	57		to:
52	58		(1) a small employer health benefit plan subject to
53	59		Chapter 1501, including coverage provided through a health group
54	60		cooperative under Subchapter B of that chapter;
55	61		(2) a standard health benefit plan issued under
56	62		Chapter 1507;
57	63		(3) health benefits provided by or through a church
58	64		benefits board under Subchapter I, Chapter 22, Business
59	65		Organizations Code;
60	66		(4) group health coverage made available by a school
61	67		district in accordance with Section 22.004, Education Code;
62	68		(5) a regional or local health care program operated
63	69		under Section 75.104, Health and Safety Code; and
64	70		(6) a self-funded health benefit plan sponsored by a
65	71		professional employer organization under Chapter 91, Labor Code.
66	72		(c) This subchapter does not apply to an issuer or provider
67	73		of health benefits under or a pharmacy benefit manager
68	74		administering pharmacy benefits under a workers' compensation
69	75		insurance policy or other form of providing medical benefits under
70	76		Title 5, Labor Code.
71	77		Sec. 1369.553. REDUCTION OF CERTAIN CLAIM PAYMENT AMOUNTS
72	78		PROHIBITED. (a) A health benefit plan issuer or pharmacy benefit
73	79		manager may not directly or indirectly reduce the amount of a claim
74	80		payment to a pharmacist or pharmacy after adjudication of the claim
75	81		through the use of an aggregated effective rate, quality assurance
76	82		program, other direct or indirect remuneration fee, or otherwise,
77	83		except in accordance with an audit performed under Subchapter F.
78	84		(b) Nothing in this section prohibits a health benefit plan
79	85		issuer or pharmacy benefit manager from increasing a claim payment
80	86		amount after adjudication of the claim.
81	87		Sec. 1369.554. REIMBURSEMENT OF AFFILIATED AND
82	88		NONAFFILIATED PHARMACISTS AND PHARMACIES. (a) In this section:
83	89		(1) "Affiliated pharmacist or pharmacy" means a
84	90		pharmacist or pharmacy that directly, or indirectly through one or
85	91		more intermediaries, controls or is controlled by, or is under
86	92		common control with, a pharmacy benefit manager.
87	93		(2) "Nonaffiliated pharmacist or pharmacy" means a
88	94		pharmacist or pharmacy that does not directly, or indirectly
89	95		through one or more intermediaries, control and is not controlled
90	96		by or under common control with a pharmacy benefit manager.
91	97		(b) A pharmacy benefit manager may not pay an affiliated
92	98		pharmacist or pharmacy a reimbursement amount that is more than the
93	99		amount the pharmacy benefit manager pays a nonaffiliated pharmacist
94	100		or pharmacy for the same pharmacist service.
95	101		Sec. 1369.555. NETWORK CONTRACT FEE SCHEDULE. A pharmacy
96	102		benefit network contract must specify or reference a separate fee
97	103		schedule. Unless otherwise available in the contract, the fee
98	104		schedule must be provided electronically in an easily accessible
99	105		and complete spreadsheet format and, on request, in writing to each
100	106		contracted pharmacist and pharmacy. The fee schedule must
101	107		describe:
102	108		(1) specific services or procedures that the
103	109		pharmacist or pharmacy may deliver and the amount of the
104	110		corresponding payment;
105	111		(2) a methodology for calculating the amount of the
106	112		payment based on a published fee schedule; or
107	113		(3) any other reasonable manner that provides an
108	114		ascertainable amount for payment for services.
109	115		Sec. 1369.556. DISCLOSURE OF PHARMACY SERVICES
110	116		ADMINISTRATIVE ORGANIZATION CONTRACT. A pharmacist or pharmacy
111	117		that is a member of a pharmacy services administrative organization
112	118		that enters into a contract with a health benefit plan issuer or
113	119		pharmacy benefit manager on the pharmacist's or pharmacy's behalf
114	120		is entitled to receive from the pharmacy services administrative
115	121		organization a copy of the contract provisions applicable to the
116	122		pharmacist or pharmacy, including each provision relating to the
117	123		pharmacist's or pharmacy's rights and obligations under the
118	124		contract.
119	125		Sec. 1369.557. DELIVERY OF DRUGS. (a) Except in a case in
120	126		which the health benefit plan issuer or pharmacy benefit manager
121	127		makes a credible allegation of fraud against the pharmacist or
122	128		pharmacy and provides reasonable notice of the allegation and the
123	129		basis of the allegation to the pharmacist or pharmacy, a health
124	130		benefit plan issuer or pharmacy benefit manager may not as a
125	131		condition of a contract with a pharmacist or pharmacy prohibit the
126	132		pharmacist or pharmacy from:
127	133		(1) mailing or delivering a drug to a patient on the
128	134		patient's request, to the extent permitted by law; or
129	135		(2) charging a shipping and handling fee to a patient
130	136		requesting a prescription be mailed or delivered if the pharmacist
131	137		or pharmacy discloses to the patient before the delivery:
132	138		(A) the fee that will be charged; and
133	139		(B) that the fee may not be reimbursable by the
134	140		health benefit plan issuer or pharmacy benefit manager.
135	141		(b) A pharmacist or pharmacy may not charge a health benefit
136	142		plan issuer or pharmacy benefit manager for the delivery of a
137	143		prescription drug as described by this section unless the charge is
138	144		specifically agreed to by the health benefit plan issuer or
139	145		pharmacy benefit manager.
140	146		Sec. 1369.558. PROFESSIONAL STANDARDS AND SCOPE OF PRACTICE
141	147		REQUIREMENTS. A health benefit plan issuer or pharmacy benefit
142	148		manager may not as a condition of a contract with a pharmacist or
143	149		pharmacy:
144	150		(1) require pharmacist or pharmacy accreditation
145	151		standards or recertification requirements inconsistent with, more
146	152		stringent than, or in addition to federal and state requirements;
147	153		or
148	154		(2) prohibit a licensed pharmacist or pharmacy from
149	155		dispensing any drug that may be dispensed under the pharmacist's or
150	156		pharmacy's license unless:
151	157		(A) applicable state or federal law prohibits the
152	158		pharmacist or pharmacy from dispensing the drug; or
153	159		(B) the manufacturer of the drug requires that a
154	160		pharmacist or pharmacy possess one or more accreditations or
155	161		certifications to dispense the drug and the pharmacist or pharmacy
156	162		does not meet the requirement.
157	163		Sec. 1369.559. RETALIATION PROHIBITED. (a) A pharmacy
158	164		benefit manager may not retaliate against a pharmacist or pharmacy
159	165		based on the pharmacist's or pharmacy's exercise of any right or
160	166		remedy under this chapter. Retaliation prohibited by this section
161	167		includes:
162	168		(1) terminating or refusing to renew a contract with
163	169		the pharmacist or pharmacy;
164	170		(2) subjecting the pharmacist or pharmacy to increased
165	171		audits; or
166	172		(3) failing to promptly pay the pharmacist or pharmacy
167	173		any money owed by the pharmacy benefit manager to the pharmacist or
168	174		pharmacy.
169	175		(b) For purposes of this section, a pharmacy benefit manager
170	176		is not considered to have retaliated against a pharmacist or
171	177		pharmacy if the pharmacy benefit manager:
172	178		(1) takes an action in response to a credible
173	179		allegation of fraud against the pharmacist or pharmacy; and
174	180		(2) provides reasonable notice to the pharmacist or
175	181		pharmacy of the allegation of fraud and the basis of the allegation
176	182		before taking the action.
177	183		Sec. 1369.560. WAIVER PROHIBITED. The provisions of this
178	184		subchapter may not be waived, voided, or nullified by contract.
179	185		SECTION 2. The change in law made by this Act applies only
180	186		to a contract entered into or renewed on or after the effective date
181	187		of this Act. A contract entered into or renewed before the
182	188		effective date of this Act is governed by the law as it existed
183	189		immediately before the effective date of this Act, and that law is
184	190		continued in effect for that purpose.
185	191		SECTION 3. This Act takes effect September 1, 2021.
186		-	______________________________ ______________________________
187		-	President of the Senate Speaker of the House
188		-	I certify that H.B. No. 1763 was passed by the House on April
189		-	27, 2021, by the following vote: Yeas 147, Nays 0, 1 present, not
190		-	voting.
191		-	______________________________
192		-	Chief Clerk of the House
193		-	I certify that H.B. No. 1763 was passed by the Senate on May
194		-	13, 2021, by the following vote: Yeas 30, Nays 0.
195		-	______________________________
196		-	Secretary of the Senate
197		-	APPROVED: _____________________
198		-	Date
199		-	_____________________
200		-	Governor
	192	+	* * * * *