88R13793 RDS-F
By: Thompson of Harris H.B. No. 5211
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for certain medically
necessary therapeutic nutritional formulas.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The heading to Chapter 1377, Insurance Code, is
amended to read as follows:
CHAPTER 1377. COVERAGE FOR CERTAIN NUTRITIONAL [AMINO ACID-BASED
ELEMENTAL] FORMULAS
SECTION 2. The heading to Subchapter B, Chapter 1377,
Insurance Code, is amended to read as follows:
SUBCHAPTER B. REQUIRED COVERAGE [FOR CERTAIN AMINO ACID-BASED
ELEMENTAL FORMULAS]
SECTION 3. Section 1377.051, Insurance Code, is amended to
read as follows:
Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN NUTRITIONAL
[AMINO ACID-BASED ELEMENTAL] FORMULAS. (a) A health benefit plan
must provide coverage as provided by this chapter for amino
acid-based elemental formulas, regardless of the formula delivery
method, that are used for the diagnosis and treatment of:
(1) immunoglobulin E and non-immunoglobulin E
mediated allergies to multiple food proteins;
(2) severe food protein-induced enterocolitis
syndrome;
(3) eosinophilic disorders, as evidenced by the
results of a biopsy; and
(4) impaired absorption of nutrients caused by
disorders affecting the absorptive surface, functional length, and
motility of the gastrointestinal tract.
(b) In addition to the coverage required under Subsection
(a) and subject to Subsection (d), a health benefit plan must
provide coverage for a therapeutic nutritional formula if the
treating physician has issued a written order stating that the
formula is medically necessary, including for the treatment of an
enrollee at risk for growth or developmental delays.
(c) Subject to Subsection (d) [(c)], the coverage required
under Subsection (a) is required if the treating physician has
issued a written order stating that the amino acid-based elemental
formula is medically necessary for the treatment of an enrollee who
is diagnosed with a disease or disorder listed in Subsection (a).
The coverage must include coverage of any medically necessary
services associated with the administration of the formula.
(d) [(c)] A health benefit plan must provide the coverage
described by Subsections [Subsection] (a) and (b) on a basis no less
favorable than the basis on which prescription drugs and other
medications and related services are covered by the plan, and to the
same extent that the plan provides coverage for drugs that are
available only on the orders of a physician.
SECTION 4. Section 1377.052(a), Insurance Code, is amended
to read as follows:
(a) A utilization review agent acting on behalf of a health
benefit plan issuer may review a treating physician's determination
of the medical necessity of the use of:
(1) an amino acid-based elemental formula for the
treatment of an enrollee who is diagnosed with a disease or disorder
listed in Section 1377.051(a); or
(2) a nutritional formula under Section 1377.051(b).
SECTION 5. 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, 2024. A health benefit plan that is
delivered, issued for delivery, or renewed before January 1, 2024,
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 6. This Act takes effect September 1, 2023.