| 1 | 1 | | 89R4363 SCF-D |
|---|
| 2 | 2 | | By: Martinez H.B. No. 3542 |
|---|
| 3 | 3 | | |
|---|
| 4 | 4 | | |
|---|
| 5 | 5 | | |
|---|
| 6 | 6 | | |
|---|
| 7 | 7 | | A BILL TO BE ENTITLED |
|---|
| 8 | 8 | | AN ACT |
|---|
| 9 | 9 | | relating to the effect of a pharmacy benefit manager change on |
|---|
| 10 | 10 | | prescription drug coverage. |
|---|
| 11 | 11 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|---|
| 12 | 12 | | SECTION 1. Chapter 1369, Insurance Code, is amended by |
|---|
| 13 | 13 | | adding Subchapter A-1 to read as follows: |
|---|
| 14 | 14 | | SUBCHAPTER A-1. CONTINUOUS COVERAGE REQUIREMENTS |
|---|
| 15 | 15 | | Sec. 1369.021. DEFINITION. In this subchapter, |
|---|
| 16 | 16 | | "prescription drug" has the meaning assigned by Section 551.003, |
|---|
| 17 | 17 | | Occupations Code. |
|---|
| 18 | 18 | | Sec. 1369.022. APPLICABILITY OF SUBCHAPTER. (a) This |
|---|
| 19 | 19 | | subchapter applies only to a health benefit plan that provides |
|---|
| 20 | 20 | | benefits for medical or surgical expenses incurred as a result of a |
|---|
| 21 | 21 | | health condition, accident, or sickness, including an individual, |
|---|
| 22 | 22 | | group, blanket, or franchise insurance policy or insurance |
|---|
| 23 | 23 | | agreement, a group hospital service contract, or an individual or |
|---|
| 24 | 24 | | group evidence of coverage or similar coverage document that is |
|---|
| 25 | 25 | | offered by: |
|---|
| 26 | 26 | | (1) an insurance company; |
|---|
| 27 | 27 | | (2) a group hospital service corporation operating |
|---|
| 28 | 28 | | under Chapter 842; |
|---|
| 29 | 29 | | (3) a health maintenance organization operating under |
|---|
| 30 | 30 | | Chapter 843; |
|---|
| 31 | 31 | | (4) an approved nonprofit health corporation |
|---|
| 32 | 32 | | that holds a certificate of authority under Chapter 844; |
|---|
| 33 | 33 | | (5) a multiple employer welfare arrangement that holds |
|---|
| 34 | 34 | | a certificate of authority under Chapter 846; |
|---|
| 35 | 35 | | (6) a stipulated premium company operating under |
|---|
| 36 | 36 | | Chapter 884; |
|---|
| 37 | 37 | | (7) a fraternal benefit society operating under |
|---|
| 38 | 38 | | Chapter 885; |
|---|
| 39 | 39 | | (8) a Lloyd's plan operating under Chapter 941; or |
|---|
| 40 | 40 | | (9) an exchange operating under Chapter 942. |
|---|
| 41 | 41 | | (b) Notwithstanding any other law, this subchapter applies |
|---|
| 42 | 42 | | to: |
|---|
| 43 | 43 | | (1) a small employer health benefit plan subject to |
|---|
| 44 | 44 | | Chapter 1501, including coverage provided through a health group |
|---|
| 45 | 45 | | cooperative under Subchapter B of that chapter; |
|---|
| 46 | 46 | | (2) a standard health benefit plan issued under |
|---|
| 47 | 47 | | Chapter 1507; |
|---|
| 48 | 48 | | (3) a basic coverage plan under Chapter 1551; |
|---|
| 49 | 49 | | (4) a basic plan under Chapter 1575; |
|---|
| 50 | 50 | | (5) a primary care coverage plan under Chapter 1579; |
|---|
| 51 | 51 | | (6) a plan providing basic coverage under Chapter |
|---|
| 52 | 52 | | 1601; |
|---|
| 53 | 53 | | (7) nonprofit agricultural organization health |
|---|
| 54 | 54 | | benefits offered by a nonprofit agricultural organization under |
|---|
| 55 | 55 | | Chapter 1682; |
|---|
| 56 | 56 | | (8) alternative health benefit coverage offered by a |
|---|
| 57 | 57 | | subsidiary of the Texas Mutual Insurance Company under Subchapter |
|---|
| 58 | 58 | | M, Chapter 2054; |
|---|
| 59 | 59 | | (9) health benefits provided by or through a church |
|---|
| 60 | 60 | | benefits board under Subchapter I, Chapter 22, Business |
|---|
| 61 | 61 | | Organizations Code; |
|---|
| 62 | 62 | | (10) group health coverage made available by a school |
|---|
| 63 | 63 | | district in accordance with Section 22.004, Education Code; |
|---|
| 64 | 64 | | (11) the state Medicaid program, including the |
|---|
| 65 | 65 | | Medicaid managed care program operated under Chapter 540, |
|---|
| 66 | 66 | | Government Code; |
|---|
| 67 | 67 | | (12) the child health plan program under Chapter 62, |
|---|
| 68 | 68 | | Health and Safety Code; |
|---|
| 69 | 69 | | (13) a regional or local health care program operated |
|---|
| 70 | 70 | | under Section 75.104, Health and Safety Code; |
|---|
| 71 | 71 | | (14) a self-funded health benefit plan sponsored by a |
|---|
| 72 | 72 | | professional employer organization under Chapter 91, Labor Code; |
|---|
| 73 | 73 | | (15) county employee group health benefits provided |
|---|
| 74 | 74 | | under Chapter 157, Local Government Code; and |
|---|
| 75 | 75 | | (16) health and accident coverage provided by a risk |
|---|
| 76 | 76 | | pool created under Chapter 172, Local Government Code. |
|---|
| 77 | 77 | | Sec. 1369.023. EFFECT OF PHARMACY BENEFIT MANAGER CHANGE ON |
|---|
| 78 | 78 | | PRESCRIPTION DRUG COVERAGE. A health benefit plan may not deny or |
|---|
| 79 | 79 | | limit an enrollee's coverage of a prescription drug solely because |
|---|
| 80 | 80 | | of a change in the plan's pharmacy benefit manager. |
|---|
| 81 | 81 | | SECTION 2. If before implementing any provision of this Act |
|---|
| 82 | 82 | | a state agency determines that a waiver or authorization from a |
|---|
| 83 | 83 | | federal agency is necessary for implementation of that provision, |
|---|
| 84 | 84 | | the agency affected by the provision shall request the waiver or |
|---|
| 85 | 85 | | authorization and may delay implementing that provision until the |
|---|
| 86 | 86 | | waiver or authorization is granted. |
|---|
| 87 | 87 | | SECTION 3. The changes in law made by this Act apply only to |
|---|
| 88 | 88 | | a health benefit plan delivered, issued for delivery, or renewed on |
|---|
| 89 | 89 | | or after January 1, 2026. |
|---|
| 90 | 90 | | SECTION 4. This Act takes effect September 1, 2025. |
|---|