By: Kolkhorst, et al. S.B. No. 827
A BILL TO BE ENTITLED
AN ACT
relating to pricing of and health benefit plan cost-sharing
requirements for prescription insulin.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1358, Insurance Code, is amended by
adding Subchapter C to read as follows:
SUBCHAPTER C. COST-SHARING LIMIT
Sec. 1358.101. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that provides
benefits for medical or surgical expenses incurred as a result of a
health condition, accident, or sickness, including an individual,
group, blanket, or franchise insurance policy or insurance
agreement, a group hospital service contract, or a small or large
employer group contract or similar coverage document that is
offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) This subchapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this subchapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
(d) Notwithstanding any other law, this subchapter applies
to coverage under:
(1) the child health plan program under Chapter 62,
Health and Safety Code, or the health benefits plan for children
under Chapter 63, Health and Safety Code; and
(2) the medical assistance program under Chapter 32,
Human Resources Code.
Sec. 1358.102. EXCEPTION. This subchapter does not apply
to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another
single benefit;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3) medical payment insurance coverage provided under
a motor vehicle insurance policy;
(4) a long-term care insurance policy, including a
nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described
by Section 1358.101;
(5) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code; or
(6) a workers' compensation insurance policy.
Sec. 1358.103. LIMIT ON COST-SHARING REQUIREMENT. (a) In
this section, "insulin" means a prescription drug that contains
insulin and is used to treat diabetes. The term does not include an
insulin drug that is administered to a patient intravenously.
(b) A health benefit plan may not impose a cost-sharing
provision for insulin if the total amount the enrollee is required
to pay exceeds $50 for a 30-day supply, regardless of the amount or
type of insulin needed to fill the enrollee's prescription.
SECTION 2. (a) In this section, "commission" means the
Health and Human Services Commission.
(b) The commission shall conduct a study evaluating pricing
of prescription insulin drugs to ensure adequate consumer
protections in pricing of prescription insulin drugs and consider
whether additional consumer protections are necessary.
(c) The commission shall request from health benefit plan
issuers and prescription drug manufacturers information concerning
the organization, business practices, pricing information, data,
reports, or other information the commission determines is
necessary to conduct the study. The commission shall also consider
any publicly available information related to prescription insulin
pricing.
(d) A health benefit plan issuer or prescription drug
manufacturer who receives a request from the commission under
Subsection (c) of this section shall furnish the commission with
the information as soon as practicable after the date the issuer or
manufacturer receives the request.
(e) The commission may not require a health benefit plan
issuer or prescription drug manufacturer to disclose trade secrets
in information provided to the commission under Subsection (d) of
this section.
(f) Not later than September 1, 2022, the commission shall
prepare and submit to the governor, the lieutenant governor, and
the speaker of the house of representatives a written report
containing the results of the study. The report must include:
(1) a summary of insulin pricing practices and
variables that contribute to pricing of health benefit plans;
(2) policy recommendations to control and prevent
overpricing of prescription insulin; and
(3) any other information the commission determines is
necessary.
(g) The commission shall publish the report described by
Subsection (f) of this section on its Internet website.
(h) This section expires September 1, 2023.
SECTION 3. The changes in law made by this Act apply only to
a health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2022. A health benefit plan
delivered, issued for delivery, or renewed before January 1, 2022,
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 4. This Act takes effect September 1, 2021.