Texas 2023 - 88th Regular

Texas House Bill HB5211 Compare Versions

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Version 2 (New)

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1	1	88R13793 RDS-F
2	2	By: Thompson of Harris H.B. No. 5211
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan coverage for certain medically
8	8	necessary therapeutic nutritional formulas.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. The heading to Chapter 1377, Insurance Code, is
11	11	amended to read as follows:
12	12	CHAPTER 1377. COVERAGE FOR CERTAIN NUTRITIONAL [AMINO ACID-BASED
13	13	ELEMENTAL] FORMULAS
14	14	SECTION 2. The heading to Subchapter B, Chapter 1377,
15	15	Insurance Code, is amended to read as follows:
16	16	SUBCHAPTER B. REQUIRED COVERAGE [FOR CERTAIN AMINO ACID-BASED
17	17	ELEMENTAL FORMULAS]
18	18	SECTION 3. Section 1377.051, Insurance Code, is amended to
19	19	read as follows:
20	20	Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN NUTRITIONAL
21	21	[AMINO ACID-BASED ELEMENTAL] FORMULAS. (a) A health benefit plan
22	22	must provide coverage as provided by this chapter for amino
23	23	acid-based elemental formulas, regardless of the formula delivery
24	24	method, that are used for the diagnosis and treatment of:
25	25	(1) immunoglobulin E and non-immunoglobulin E
26	26	mediated allergies to multiple food proteins;
27	27	(2) severe food protein-induced enterocolitis
28	28	syndrome;
29	29	(3) eosinophilic disorders, as evidenced by the
30	30	results of a biopsy; and
31	31	(4) impaired absorption of nutrients caused by
32	32	disorders affecting the absorptive surface, functional length, and
33	33	motility of the gastrointestinal tract.
34	34	(b) In addition to the coverage required under Subsection
35	35	(a) and subject to Subsection (d), a health benefit plan must
36	36	provide coverage for a therapeutic nutritional formula if the
37	37	treating physician has issued a written order stating that the
38	38	formula is medically necessary, including for the treatment of an
39	39	enrollee at risk for growth or developmental delays.
40	40	(c) Subject to Subsection (d) [(c)], the coverage required
41	41	under Subsection (a) is required if the treating physician has
42	42	issued a written order stating that the amino acid-based elemental
43	43	formula is medically necessary for the treatment of an enrollee who
44	44	is diagnosed with a disease or disorder listed in Subsection (a).
45	45	The coverage must include coverage of any medically necessary
46	46	services associated with the administration of the formula.
47	47	(d) [(c)] A health benefit plan must provide the coverage
48	48	described by Subsections [Subsection] (a) and (b) on a basis no less
49	49	favorable than the basis on which prescription drugs and other
50	50	medications and related services are covered by the plan, and to the
51	51	same extent that the plan provides coverage for drugs that are
52	52	available only on the orders of a physician.
53	53	SECTION 4. Section 1377.052(a), Insurance Code, is amended
54	54	to read as follows:
55	55	(a) A utilization review agent acting on behalf of a health
56	56	benefit plan issuer may review a treating physician's determination
57	57	of the medical necessity of the use of:
58	58	(1) an amino acid-based elemental formula for the
59	59	treatment of an enrollee who is diagnosed with a disease or disorder
60	60	listed in Section 1377.051(a); or
61	61	(2) a nutritional formula under Section 1377.051(b).
62	62	SECTION 5. The changes in law made by this Act apply only to
63	63	a health benefit plan that is delivered, issued for delivery, or
64	64	renewed on or after January 1, 2024. A health benefit plan that is
65	65	delivered, issued for delivery, or renewed before January 1, 2024,
66	66	is governed by the law as it existed immediately before the
67	67	effective date of this Act, and that law is continued in effect for
68	68	that purpose.
69	69	SECTION 6. This Act takes effect September 1, 2023.