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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 of prescription drugs for |
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serious mental illnesses and opioid and substance use disorders. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1369, Insurance Code, is amended by |
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adding Subchapter E-2 to read as follows: |
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SUBCHAPTER E-2. PRESCRIPTION DRUG COVERAGE FOR SERIOUS MENTAL |
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ILLNESSES |
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Sec. 1369.221. DEFINITION. In this subchapter, "serious |
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mental illness" has the meaning assigned by Section 1355.001. |
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Sec. 1369.222. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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issued by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this subchapter applies |
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to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(4) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; and |
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(5) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code. |
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(c) This subchapter applies to coverage under a group health |
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benefit plan provided to a resident of this state regardless of |
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whether the group policy, agreement, or contract is delivered, |
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issued for delivery, or renewed in this state. |
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Sec. 1369.223. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. |
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This subchapter does not apply to an issuer or provider of health |
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benefits under or a pharmacy benefit manager administering pharmacy |
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benefits under: |
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(1) the state Medicaid program, including the Medicaid |
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managed care program under Chapter 533, Government Code; or |
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(2) the child health plan program under Chapter 62, |
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Health and Safety Code. |
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Sec. 1369.224. PROHIBITED CONDUCT. (a) A health benefit |
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plan that provides coverage for a serious mental illness may not |
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require, before the health benefit plan provides coverage of a |
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prescription drug approved by the United States Food and Drug |
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Administration, that the enrollee: |
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(1) fail to successfully respond to a different drug; |
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or |
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(2) prove a history of failure of a different drug. |
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(b) This section applies only to a drug the use of which is: |
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(1) prescribed by a physician or other health care |
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provider for the serious mental illness; |
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(2) determined by the prescribing physician or health |
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care provider in consultation with the enrollee as the most |
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appropriate course of treatment for the serious mental illness; and |
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(3) approved by the United States Food and Drug |
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Administration. |
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(c) This section applies only to a drug prescribed to an |
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enrollee who is 18 years of age or older. |
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(d) This section does not affect a pharmacist's authority to |
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substitute a generic equivalent or one or more interchangeable |
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biological products under Section 562.008, Occupations Code, for a |
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prescription drug prescribed for a serious mental illness. |
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SECTION 2. Chapter 1369, Insurance Code, is amended by |
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adding Subchapter E-3 to read as follows: |
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SUBCHAPTER E-3. COVERAGE OF MEDICATION-ASSISTED TREATMENT FOR |
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OPIOID OR SUBSTANCE USE DISORDER |
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Sec. 1369.231. DEFINITION. In this subchapter, |
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"medication-assisted opioid or substance use disorder treatment" |
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means the use of methadone, buprenorphine, oral |
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buprenorphine/naloxone, or naltrexone to treat opioid or substance |
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use disorder. |
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Sec. 1369.232. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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|
benefits for medical or surgical 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; |
|
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(8) a Lloyd's plan operating under Chapter 941; or |
|
|
(9) an exchange operating under Chapter 942. |
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|
(b) Notwithstanding any other law, this subchapter applies |
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|
to: |
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(1) a small employer health benefit plan subject to |
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|
Chapter 1501, including coverage provided through a health group |
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|
cooperative under Subchapter B of that chapter; |
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|
(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) nonprofit agricultural organization health |
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benefits offered by a nonprofit agricultural organization under |
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Chapter 1682; |
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(4) alternative health benefit coverage offered by a |
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subsidiary of the Texas Mutual Insurance Company under Subchapter |
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M, Chapter 2054; |
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(5) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(6) a regional or local health care program operated |
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|
under Section 75.104, Health and Safety Code; or |
|
|
(7) 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. 1369.233. EXCEPTIONS TO APPLICABILITY OF SUBCHAPTER. |
|
|
This subchapter does not apply to an issuer or provider of health |
|
|
benefits under or a pharmacy benefit manager administering pharmacy |
|
|
benefits under: |
|
|
(1) the state Medicaid program, including the Medicaid |
|
|
managed care program under Chapter 533, Government Code; or |
|
|
(2) the child health plan program under Chapter 62, |
|
|
Health and Safety Code. |
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|
Sec. 1369.234. LIMITATIONS ON PRIOR AUTHORIZATION. A |
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health benefit plan that provides coverage for medication-assisted |
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opioid or substance use disorder treatment may not require an |
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enrollee to obtain prior authorization for the treatment, except as |
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needed to minimize the opportunity for fraud, waste, and abuse. |
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SECTION 3. Section 32.03115(e), Human Resources Code, is |
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repealed. |
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SECTION 4. This Act applies only to a health benefit plan |
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delivered, issued for delivery, or renewed on or after January 1, |
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2024. A health benefit plan delivered, issued for delivery, or |
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renewed before January 1, 2024, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 5. This Act takes effect September 1, 2023. |