By Van de Putte H.B. No. 1455
74R4395 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to access to pharmaceutical services through certain
1-3 managed care health plans.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 1, Article 21.52B, Insurance Code, is
1-6 amended by adding Subdivision (6) to read as follows:
1-7 (6) "Managed care plan" means a health maintenance
1-8 organization, a preferred provider organization, or another
1-9 organization that, under a contract or other agreement entered into
1-10 with a participant in the plan:
1-11 (A) provides health care benefits, or arranges
1-12 for health care benefits to be provided, to a participant in the
1-13 plan; and
1-14 (B) requires or encourages those participants to
1-15 use health care providers designated by the plan.
1-16 SECTION 2. Section 2, Article 21.52B, Insurance Code, is
1-17 amended to read as follows:
1-18 Sec. 2. PROHIBITED CONTRACTUAL PROVISIONS. (a) A health
1-19 insurance policy or managed care plan that is delivered, issued for
1-20 delivery, or renewed or for which a contract or other agreement is
1-21 executed may not:
1-22 (1) prohibit or limit a person who is a beneficiary of
1-23 the policy or a participant in the plan from selecting a pharmacy
1-24 or pharmacist of the person's choice to be a provider under the
2-1 policy or plan to furnish pharmaceutical services offered or
2-2 provided by that policy or plan, or interfere with that person's
2-3 selection of a pharmacy or pharmacist;
2-4 (2) deny a pharmacy or pharmacist the right to
2-5 participate as a contract provider under the policy or plan if the
2-6 pharmacy or pharmacist agrees to provide pharmaceutical services
2-7 that meet all terms and requirements and to include the same
2-8 administrative, financial, and professional conditions that apply
2-9 to pharmacies and pharmacists who have been designated as providers
2-10 under the policy or plan; or
2-11 (3) require a beneficiary of a policy or a participant
2-12 in a plan to obtain or request a specific quantity or dosage supply
2-13 of pharmaceutical products.
2-14 (b) Notwithstanding Subsection (a)(3) of this section, a
2-15 health insurance <, but the> policy or managed care plan may allow
2-16 the <beneficiary's> physician of a beneficiary or participant to
2-17 prescribe drugs in a quantity or dosage supply the physician
2-18 determines appropriate and that is in compliance with state and
2-19 federal statutes.
2-20 (c) <(b)> This section does not prohibit:
2-21 (1) a provision of a policy or plan from limiting the
2-22 quantity or dosage supply of pharmaceutical products for which
2-23 coverage is provided or providing financial incentives to encourage
2-24 the beneficiary or participant and the prescribing physician to use
2-25 a program that provides pharmaceutical products in quantities that
2-26 result in cost savings to the insurance program or managed care
2-27 plan and the beneficiary or participant if the provision applies
3-1 equally to all designated providers of pharmaceutical services
3-2 under the policy or plan; or
3-3 (2) a pharmacy card program that provides a means of
3-4 obtaining pharmaceutical services offered by the policy or plan
3-5 through all designated providers of pharmaceutical services.
3-6 SECTION 3. Section 3, Article 21.52B, Insurance Code, is
3-7 amended to read as follows:
3-8 Sec. 3. PROVISION VOID. A provision of a health insurance
3-9 policy or managed care plan that is delivered, issued for delivery,
3-10 entered into, or renewed in this state that conflicts with Section
3-11 2 of this article is void to the extent of the conflict.
3-12 SECTION 4. Section 4, Article 21.52B, Insurance Code, is
3-13 amended to read as follows:
3-14 Sec. 4. CONSTRUCTION OF ARTICLE. This article does not
3-15 require a health insurance policy or managed care plan to provide
3-16 pharmaceutical services.
3-17 SECTION 5. Section 14(g), Texas Health Maintenance
3-18 Organization Act (Article 20A.14, Vernon's Texas Insurance Code),
3-19 is amended to read as follows:
3-20 (g) No type of provider licensed or otherwise authorized to
3-21 practice in this state may be denied participation to provide
3-22 health care services which are delivered by the health maintenance
3-23 organization and which are within the scope of licensure or
3-24 authorization of the type of provider on the sole basis of type of
3-25 license or authorization. This section may not be construed to (1)
3-26 require a health maintenance organization to utilize a particular
3-27 type of provider in its operation; (2) require, except as provided
4-1 by Article 21.52B of this code, that a health maintenance
4-2 organization accept each provider of a category or type; or (3)
4-3 require that health maintenance organizations contract directly
4-4 with such providers. Notwithstanding any other provision nothing
4-5 herein shall be construed to limit the health maintenance
4-6 organization's authority to set the terms and conditions under
4-7 which health care services will be rendered by providers. All
4-8 providers must comply with the terms and conditions established by
4-9 the health maintenance organization for the provision of health
4-10 services and for designation as a provider.
4-11 SECTION 6. This Act takes effect September 1, 1995, and
4-12 applies only to an insurance policy or evidence of coverage under a
4-13 managed care plan that is delivered, issued for delivery, or
4-14 renewed on or after January 1, 1996. A policy or evidence of
4-15 coverage that is delivered, issued for delivery, or renewed before
4-16 January 1, 1996, is governed by the law as it existed immediately
4-17 before the effective date of this Act, and that law is continued in
4-18 effect for that purpose.
4-19 SECTION 7. The importance of this legislation and the
4-20 crowded condition of the calendars in both houses create an
4-21 emergency and an imperative public necessity that the
4-22 constitutional rule requiring bills to be read on three several
4-23 days in each house be suspended, and this rule is hereby suspended.