Texas 2023 - 88th Regular

Texas Senate Bill SB1138 Compare Versions

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Version 2 (New)

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1	1	88R10498 KBB-F
2	2	By: Schwertner S.B. No. 1138
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan coverage of clinician-administered
8	8	drugs.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1369, Insurance Code, is amended by
11	11	adding Subchapter Q to read as follows:
12	12	SUBCHAPTER Q. CLINICIAN-ADMINISTERED DRUGS
13	13	Sec. 1369.761. DEFINITIONS. In this subchapter:
14	14	(1) "Administer" means to directly apply a drug to the
15	15	body of a patient by injection, inhalation, ingestion, or any other
16	16	means.
17	17	(2) "Clinician-administered drug" means an outpatient
18	18	prescription drug other than a vaccine that:
19	19	(A) cannot reasonably be:
20	20	(i) self-administered by the patient to
21	21	whom the drug is prescribed; or
22	22	(ii) administered by an individual
23	23	assisting the patient with the self-administration; and
24	24	(B) is typically administered:
25	25	(i) by a physician or other health care
26	26	provider authorized under the laws of this state to administer the
27	27	drug, including when acting under a physician's delegation and
28	28	supervision; and
29	29	(ii) in a physician's office, hospital,
30	30	hospital outpatient infusion center, or other clinical setting.
31	31	(3) "Health care provider" means an individual who is
32	32	licensed, certified, or otherwise authorized to provide health care
33	33	services in this state.
34	34	(4) "Physician" means an individual licensed to
35	35	practice medicine in this state.
36	36	Sec. 1369.762. APPLICABILITY OF SUBCHAPTER. (a) This
37	37	subchapter applies only to a health benefit plan that provides
38	38	benefits for medical or surgical expenses incurred as a result of a
39	39	health condition, accident, or sickness, including an individual,
40	40	group, blanket, or franchise insurance policy or insurance
41	41	agreement, a group hospital service contract, or an individual or
42	42	group evidence of coverage or similar coverage document that is
43	43	offered by:
44	44	(1) an insurance company;
45	45	(2) a group hospital service corporation operating
46	46	under Chapter 842;
47	47	(3) a health maintenance organization operating under
48	48	Chapter 843;
49	49	(4) an approved nonprofit health corporation that
50	50	holds a certificate of authority under Chapter 844;
51	51	(5) a multiple employer welfare arrangement that holds
52	52	a certificate of authority under Chapter 846;
53	53	(6) a stipulated premium company operating under
54	54	Chapter 884;
55	55	(7) a fraternal benefit society operating under
56	56	Chapter 885;
57	57	(8) a Lloyd's plan operating under Chapter 941; or
58	58	(9) an exchange operating under Chapter 942.
59	59	(b) Notwithstanding any other law, this subchapter applies
60	60	to:
61	61	(1) a small employer health benefit plan subject to
62	62	Chapter 1501, including coverage provided through a health group
63	63	cooperative under Subchapter B of that chapter;
64	64	(2) a standard health benefit plan issued under
65	65	Chapter 1507;
66	66	(3) health benefits provided by or through a church
67	67	benefits board under Subchapter I, Chapter 22, Business
68	68	Organizations Code;
69	69	(4) group health coverage made available by a school
70	70	district in accordance with Section 22.004, Education Code;
71	71	(5) a regional or local health care program operating
72	72	under Section 75.104, Health and Safety Code; and
73	73	(6) a self-funded health benefit plan sponsored by a
74	74	professional employer organization under Chapter 91, Labor Code.
75	75	Sec. 1369.763. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER.
76	76	This subchapter does not apply to an issuer or provider of health
77	77	benefits under or a pharmacy benefit manager administering pharmacy
78	78	benefits under:
79	79	(1) the state Medicaid program, including the Medicaid
80	80	managed care program under Chapter 533, Government Code;
81	81	(2) the child health plan program under Chapter 62,
82	82	Health and Safety Code;
83	83	(3) the TRICARE military health system; or
84	84	(4) a workers' compensation insurance policy or other
85	85	form of providing medical benefits under Title 5, Labor Code.
86	86	Sec. 1369.764. CERTAIN LIMITATIONS ON COVERAGE OF
87	87	CLINICIAN-ADMINISTERED DRUGS PROHIBITED. (a) A health benefit
88	88	plan issuer may not, for an enrollee with a chronic, complex, rare,
89	89	or life-threatening medical condition:
90	90	(1) require clinician-administered drugs to be
91	91	dispensed only by certain pharmacies or only by pharmacies
92	92	participating in the health benefit plan issuer's network;
93	93	(2) if a clinician-administered drug is otherwise
94	94	covered, limit or exclude coverage for such drugs based on the
95	95	enrollee's choice of pharmacy, or because the drug was not
96	96	dispensed by a pharmacy that participates in the health benefit
97	97	plan issuer's network;
98	98	(3) reimburse at a lesser amount
99	99	clinician-administered drugs based on the enrollee's choice of
100	100	pharmacy, or because the drug was dispensed by a pharmacy that does
101	101	not participate in the health benefit plan issuer's network; or
102	102	(4) require that an enrollee pay an additional fee,
103	103	higher copay, higher coinsurance, second copay, second
104	104	coinsurance, or any other price increase for
105	105	clinician-administered drugs based on the enrollee's choice of
106	106	pharmacy, or because the drug was not dispensed by a pharmacy that
107	107	participates in the health benefit plan issuer's network.
108	108	(b) Nothing in this section may be construed to:
109	109	(1) authorize a person to administer a drug when
110	110	otherwise prohibited under the laws of this state or federal law; or
111	111	(2) modify drug administration requirements under the
112	112	laws of this state, including any requirements related to
113	113	delegation and supervision of drug administration.
114	114	SECTION 2. Subchapter Q, Chapter 1369, Insurance Code, as
115	115	added by this Act, applies only to a health benefit plan that is
116	116	delivered, issued for delivery, or renewed on or after January 1,
117	117	2024.
118	118	SECTION 3. This Act takes effect September 1, 2023.