Texas Senate Bill SB1287

Texas 2025 - 89th Regular

• Filed: 2/14/25

Caption

Relating to the effect of certain reductions in a health benefit plan enrollee's out-of-pocket expenses for prescription drugs that are essential health benefits on the enrollee's cost-sharing requirements.

Impact

The proposed changes in SB1287 will have significant implications on how health benefit plans manage and process out-of-pocket expenses for essential medications. By mandating that reductions in costs are applied to the enrollee's total financial responsibilities, the bill seeks to enhance transparency and potentially alleviate some financial burdens on individuals requiring essential health drugs. The provisions come in response to ongoing discussions about the rising costs of medications and the intricate structure of health benefit plans.

Summary

SB1287 is an act that addresses the impact of reductions in out-of-pocket expenses for prescription drugs deemed essential health benefits within health benefit plans. The bill aims to ensure that any reductions in these expenses are accurately reflected in the enrollee's overall cost-sharing obligations, such as deductibles and copayments. This alignment is particularly important for medications without generic alternatives or those accessed through specific processes like prior authorization or step therapy under the health benefit plan.

Contention

Despite the intent to provide clarity and support to enrollees, there may be contention surrounding the implementation of the bill. Stakeholders in the insurance industry might express concerns over the potential administrative burdens and financial impacts of recalibrating cost-sharing responsibilities for essential health benefits. Additionally, discussions may arise over how the qualification of certain drugs as essential health benefits could be subject to interpretation, potentially leading to disputes among patients, insurers, and healthcare providers.

Texas Constitutional Statutes Affected

Insurance Code

• Chapter 1369. Benefits Related To Prescription Drugs And Devices And Related Services
  • Section: 0542