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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for certain medically |
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necessary therapeutic nutritional formulas. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. The heading to Chapter 1377, Insurance Code, is |
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amended to read as follows: |
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CHAPTER 1377. COVERAGE FOR CERTAIN NUTRITIONAL [AMINO ACID-BASED |
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ELEMENTAL] FORMULAS |
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SECTION 2. The heading to Subchapter B, Chapter 1377, |
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Insurance Code, is amended to read as follows: |
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SUBCHAPTER B. REQUIRED COVERAGE [FOR CERTAIN AMINO ACID-BASED |
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ELEMENTAL FORMULAS] |
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SECTION 3. Section 1377.051, Insurance Code, is amended to |
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read as follows: |
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Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN NUTRITIONAL |
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[AMINO ACID-BASED ELEMENTAL] FORMULAS. (a) A health benefit plan |
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must provide coverage as provided by this chapter for amino |
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acid-based elemental formulas, regardless of the formula delivery |
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method, that are used for the diagnosis and treatment of: |
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(1) immunoglobulin E and non-immunoglobulin E |
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mediated allergies to multiple food proteins; |
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(2) severe food protein-induced enterocolitis |
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syndrome; |
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(3) eosinophilic disorders, as evidenced by the |
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results of a biopsy; and |
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(4) impaired absorption of nutrients caused by |
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disorders affecting the absorptive surface, functional length, and |
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motility of the gastrointestinal tract. |
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(b) In addition to the coverage required under Subsection |
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(a) and subject to Subsection (d), a health benefit plan must |
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provide coverage for a therapeutic nutritional formula if the |
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treating physician has issued a written order stating that the |
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formula is medically necessary, including for the treatment of an |
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enrollee at risk for growth or developmental delays. |
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(c) Subject to Subsection (d) [(c)], the coverage required |
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under Subsection (a) is required if the treating physician has |
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issued a written order stating that the amino acid-based elemental |
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formula is medically necessary for the treatment of an enrollee who |
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is diagnosed with a disease or disorder listed in Subsection (a). |
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The coverage must include coverage of any medically necessary |
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services associated with the administration of the formula. |
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(d) [(c)] A health benefit plan must provide the coverage |
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described by Subsections [Subsection] (a) and (b) on a basis no less |
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favorable than the basis on which prescription drugs and other |
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medications and related services are covered by the plan, and to the |
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same extent that the plan provides coverage for drugs that are |
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available only on the orders of a physician. |
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SECTION 4. Section 1377.052(a), Insurance Code, is amended |
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to read as follows: |
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(a) A utilization review agent acting on behalf of a health |
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benefit plan issuer may review a treating physician's determination |
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of the medical necessity of the use of: |
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(1) an amino acid-based elemental formula for the |
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treatment of an enrollee who is diagnosed with a disease or disorder |
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listed in Section 1377.051(a); or |
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(2) a nutritional formula under Section 1377.051(b). |
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SECTION 5. The changes in law made by this Act apply only to |
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a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2024. A health benefit plan that is |
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delivered, issued for delivery, or renewed before January 1, 2024, |
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is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 6. This Act takes effect September 1, 2023. |