| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to prior authorization for prescription drug benefits |
|
|
related to the treatment of autoimmune diseases. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Chapter 1369, Insurance Code, is amended by |
|
|
adding Subchapter L to read as follows: |
|
|
SUBCHAPTER L. COVERAGE OF PRESCRIPTION DRUGS FOR AUTOIMMUNE |
|
|
DISEASES |
|
|
Sec. 1369.551. DEFINITION. In this subchapter, |
|
|
"prescription drug" has the meaning assigned by Section 551.003, |
|
|
Occupations Code. |
|
|
Sec. 1369.552. APPLICABILITY OF SUBCHAPTER. (a) This |
|
|
subchapter applies only to a health benefit plan that provides |
|
|
benefits for medical, surgical, or prescription drug expenses |
|
|
incurred as a result of a health condition, accident, or sickness, |
|
|
including an individual, group, blanket, or franchise insurance |
|
|
policy or insurance agreement, a group hospital service contract, |
|
|
or an individual or group evidence of coverage or similar coverage |
|
|
document that is issued by: |
|
|
(1) an insurance company; |
|
|
(2) a group hospital service corporation operating |
|
|
under Chapter 842; |
|
|
(3) a health maintenance organization operating under |
|
|
Chapter 843; |
|
|
(4) an approved nonprofit health corporation that |
|
|
holds a certificate of authority under Chapter 844; |
|
|
(5) a multiple employer welfare arrangement that holds |
|
|
a certificate of authority under Chapter 846; |
|
|
(6) a stipulated premium company operating under |
|
|
Chapter 884; |
|
|
(7) a fraternal benefit society operating under |
|
|
Chapter 885; |
|
|
(8) a Lloyd's plan operating under Chapter 941; or |
|
|
(9) an exchange operating under Chapter 942. |
|
|
(b) Notwithstanding any other law, this subchapter applies |
|
|
to: |
|
|
(1) a small employer health benefit plan subject to |
|
|
Chapter 1501, including coverage provided through a health group |
|
|
cooperative under Subchapter B of that chapter; |
|
|
(2) a standard health benefit plan issued under |
|
|
Chapter 1507; |
|
|
(3) a basic coverage plan under Chapter 1551; |
|
|
(4) a basic plan under Chapter 1575; |
|
|
(5) a primary care coverage plan under Chapter 1579; |
|
|
(6) a plan providing basic coverage under Chapter |
|
|
1601; |
|
|
(7) health benefits provided by or through a church |
|
|
benefits board under Subchapter I, Chapter 22, Business |
|
|
Organizations Code; |
|
|
(8) group health coverage made available by a school |
|
|
district in accordance with Section 22.004, Education Code; |
|
|
(9) the state Medicaid program, including the Medicaid |
|
|
managed care program operated under Chapter 533, Government Code; |
|
|
(10) the child health plan program under Chapter 62, |
|
|
Health and Safety Code; |
|
|
(11) a regional or local health care program operated |
|
|
under Section 75.104, Health and Safety Code; and |
|
|
(12) a self-funded health benefit plan sponsored by a |
|
|
professional employer organization under Chapter 91, Labor Code. |
|
|
(c) This subchapter applies to coverage under a group health |
|
|
benefit plan provided to a resident of this state regardless of |
|
|
whether the group policy, agreement, or contract is delivered, |
|
|
issued for delivery, or renewed in this state. |
|
|
Sec. 1369.553. EXCEPTIONS. (a) This subchapter does not |
|
|
apply to: |
|
|
(1) a plan that provides coverage: |
|
|
(A) for wages or payments in lieu of wages for a |
|
|
period during which an employee is absent from work because of |
|
|
sickness or injury; |
|
|
(B) as a supplement to a liability insurance |
|
|
policy; |
|
|
(C) for credit insurance; |
|
|
(D) only for dental or vision care; |
|
|
(E) only for hospital expenses; or |
|
|
(F) only for indemnity for hospital confinement; |
|
|
(2) a Medicare supplemental policy as defined by |
|
|
Section 1882(g)(1), Social Security Act (42 U.S.C. Section |
|
|
1395ss(g)(1)); |
|
|
(3) a workers' compensation insurance policy; |
|
|
(4) medical payment insurance coverage provided under |
|
|
a motor vehicle insurance policy; or |
|
|
(5) a long-term care policy, including a nursing home |
|
|
fixed indemnity policy, unless the commissioner determines that the |
|
|
policy provides benefit coverage so comprehensive that the policy |
|
|
is a health benefit plan as described by Section 1369.552. |
|
|
(b) This subchapter does not apply to an individual health |
|
|
benefit plan issued on or before March 23, 2010, that has not had |
|
|
any significant changes since that date that reduce benefits or |
|
|
increase costs to the individual. |
|
|
Sec. 1369.554. PROHIBITION ON MULTIPLE PRIOR |
|
|
AUTHORIZATIONS. A health benefit plan issuer that provides |
|
|
prescription drug benefits may not require an enrollee to receive |
|
|
more than one prior authorization annually of the prescription drug |
|
|
benefit for a prescription drug prescribed to treat an autoimmune |
|
|
disease. |
|
|
SECTION 2. The change in law made by this Act applies only |
|
|
to a health benefit plan that is delivered, issued for delivery, or |
|
|
renewed on or after January 1, 2022. |
|
|
SECTION 3. If before implementing any provision of this Act |
|
|
a state agency determines that a waiver or authorization from a |
|
|
federal agency is necessary for implementation of that provision, |
|
|
the agency affected by the provision shall request the waiver or |
|
|
authorization and may delay implementing that provision until the |
|
|
waiver or authorization is granted. |
|
|
SECTION 4. This Act takes effect September 1, 2021. |