Texas 2023 - 88th Regular

Texas House Bill HB826 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	88R578 RDS-F
2	2	By: Lambert H.B. No. 826
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to modification of certain prescription drug benefits and
8	8	coverage offered by certain health benefit plans.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 1369.053, Insurance Code, is amended to
11	11	read as follows:
12	12	Sec. 1369.053. EXCEPTION. This subchapter does not apply
13	13	to:
14	14	(1) a health benefit plan that provides coverage:
15	15	(A) only for a specified disease or for another
16	16	single benefit;
17	17	(B) only for accidental death or dismemberment;
18	18	(C) for wages or payments in lieu of wages for a
19	19	period during which an employee is absent from work because of
20	20	sickness or injury;
21	21	(D) as a supplement to a liability insurance
22	22	policy;
23	23	(E) for credit insurance;
24	24	(F) only for dental or vision care;
25	25	(G) only for hospital expenses; or
26	26	(H) only for indemnity for hospital confinement;
27	27	(2) a Medicare supplemental policy as defined by
28	28	Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
29	29	as amended;
30	30	(3) a workers' compensation insurance policy;
31	31	(4) medical payment insurance coverage provided under
32	32	a motor vehicle insurance policy;
33	33	(5) a long-term care insurance policy, including a
34	34	nursing home fixed indemnity policy, unless the commissioner
35	35	determines that the policy provides benefit coverage so
36	36	comprehensive that the policy is a health benefit plan as described
37	37	by Section 1369.052;
38	38	(6) the child health plan program under Chapter 62,
39	39	Health and Safety Code, or the health benefits plan for children
40	40	under Chapter 63, Health and Safety Code; [or]
41	41	(7) a Medicaid managed care program operated under
42	42	Chapter 533, Government Code, or a Medicaid program operated under
43	43	Chapter 32, Human Resources Code; or
44	44	(8) a self-funded health benefit plan as defined by
45	45	the Employee Retirement Income Security Act of 1974 (29 U.S.C.
46	46	Section 1001 et seq.).
47	47	SECTION 2. Section 1369.0541, Insurance Code, is amended by
48	48	amending Subsections (a) and (b) and adding Subsections (a-1) and
49	49	(b-1) to read as follows:
50	50	(a) Except as provided by Section 1369.055(a-1) and
51	51	Subsection (b-1) of this section, a [A] health benefit plan issuer
52	52	may modify drug coverage provided under a health benefit plan if:
53	53	(1) the modification occurs at the time of coverage
54	54	renewal;
55	55	(2) the modification is effective uniformly among all
56	56	group health benefit plan sponsors covered by identical or
57	57	substantially identical health benefit plans or all individuals
58	58	covered by identical or substantially identical individual health
59	59	benefit plans, as applicable; and
60	60	(3) not later than the 60th day before the date the
61	61	modification is effective, the issuer provides written notice of
62	62	the modification to the commissioner, each affected group health
63	63	benefit plan sponsor, each affected enrollee in an affected group
64	64	health benefit plan, and each affected individual health benefit
65	65	plan holder.
66	66	(a-1) The notice described by Subsection (a)(3) must
67	67	include a statement:
68	68	(1) indicating that the health benefit plan issuer is
69	69	modifying drug coverage provided under the health benefit plan;
70	70	(2) explaining the type of modification; and
71	71	(3) indicating that, on renewal of the health benefit
72	72	plan, the health benefit plan issuer may not modify an enrollee's
73	73	contracted benefit level for any prescription drug that was
74	74	approved or covered under the plan in the immediately preceding
75	75	plan year as provided by Section 1369.055(a-1).
76	76	(b) Modifications affecting drug coverage that require
77	77	notice under Subsection (a) include:
78	78	(1) removing a drug from a formulary;
79	79	(2) adding a requirement that an enrollee receive
80	80	prior authorization for a drug;
81	81	(3) imposing or altering a quantity limit for a drug;
82	82	(4) imposing a step-therapy restriction for a drug;
83	83	[and]
84	84	(5) moving a drug to a higher cost-sharing tier;
85	85	(6) increasing a coinsurance, copayment, deductible,
86	86	or other out-of-pocket expense that an enrollee must pay for a drug;
87	87	and
88	88	(7) reducing the maximum drug coverage amount [unless
89	89	a generic drug alternative to the drug is available].
90	90	(b-1) Modifications affecting drug coverage that are more
91	91	favorable to enrollees may be made at any time and do not require
92	92	notice under Subsection (a), including:
93	93	(1) the addition of a drug to a formulary;
94	94	(2) the reduction of a coinsurance, copayment,
95	95	deductible, or other out-of-pocket expense that an enrollee must
96	96	pay for a drug; and
97	97	(3) the removal of a utilization review requirement.
98	98	SECTION 3. Section 1369.055, Insurance Code, is amended by
99	99	adding Subsections (a-1), (a-2), and (c) to read as follows:
100	100	(a-1) On renewal of a health benefit plan, the plan issuer
101	101	may not modify an enrollee's contracted benefit level for any
102	102	prescription drug that was approved or covered under the plan in the
103	103	immediately preceding plan year and prescribed during that year for
104	104	a medical condition or mental illness of the enrollee if:
105	105	(1) the enrollee was covered by the health benefit
106	106	plan on the date immediately preceding the renewal date;
107	107	(2) a physician or other prescribing provider
108	108	prescribes the drug for the medical condition or mental illness;
109	109	and
110	110	(3) the physician or other prescribing provider in
111	111	consultation with the enrollee determines that the drug is the most
112	112	appropriate course of treatment.
113	113	(a-2) Modifications prohibited under Subsection (a-1)
114	114	include:
115	115	(1) removing a drug from a formulary;
116	116	(2) adding a requirement that an enrollee receive
117	117	prior authorization for a drug;
118	118	(3) imposing or altering a quantity limit for a drug;
119	119	(4) imposing a step-therapy restriction for a drug;
120	120	(5) moving a drug to a higher cost-sharing tier;
121	121	(6) increasing a coinsurance, copayment, deductible,
122	122	or other out-of-pocket expense that an enrollee must pay for a drug;
123	123	and
124	124	(7) reducing the maximum drug coverage amount.
125	125	(c) Subsections (a-1) and (a-2) do not:
126	126	(1) prohibit a health benefit plan issuer from
127	127	requiring, by contract, written policy or procedure, or other
128	128	agreement or course of conduct, a pharmacist to provide a
129	129	substitution for a prescription drug in accordance with Subchapter
130	130	A, Chapter 562, Occupations Code, under which the pharmacist may
131	131	substitute an interchangeable biologic product or therapeutically
132	132	equivalent generic product as determined by the United States Food
133	133	and Drug Administration;
134	134	(2) prohibit a physician or other prescribing provider
135	135	from prescribing another medication;
136	136	(3) prohibit the health benefit plan issuer from
137	137	adding a new drug to a formulary;
138	138	(4) require a health benefit plan to provide coverage
139	139	to an enrollee under circumstances not described by Subsection
140	140	(a-1); or
141	141	(5) prohibit a health benefit plan issuer from
142	142	removing a drug from its formulary or denying an enrollee coverage
143	143	for the drug if:
144	144	(A) the United States Food and Drug
145	145	Administration has issued a statement about the drug that calls
146	146	into question the clinical safety of the drug;
147	147	(B) the drug manufacturer has notified the United
148	148	States Food and Drug Administration of a manufacturing
149	149	discontinuance or potential discontinuance of the drug as required
150	150	by Section 506C, Federal Food, Drug, and Cosmetic Act (21 U.S.C.
151	151	Section 356c); or
152	152	(C) the drug manufacturer has removed the drug
153	153	from the market.
154	154	SECTION 4. The changes in law made by this Act apply only to
155	155	a health benefit plan that is delivered, issued for delivery, or
156	156	renewed on or after January 1, 2024. A health benefit plan
157	157	delivered, issued for delivery, or renewed before January 1, 2024,
158	158	is governed by the law as it existed immediately before the
159	159	effective date of this Act, and that law is continued in effect for
160	160	that purpose.
161	161	SECTION 5. This Act takes effect September 1, 2023.