By: Madla, West S.B. No. 628
A BILL TO BE ENTITLED
AN ACT
1-1 relating to access to pharmaceutical services through certain
1-2 managed care health plans.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Section 1, Article 21.52B, Insurance Code, is
1-5 amended by adding Subdivision (6) to read as follows:
1-6 (6) "Managed care plan" means a health maintenance
1-7 organization, a preferred provider organization, or another
1-8 organization that, under a contract or other agreement entered into
1-9 with a participant in the plan:
1-10 (A) provides health care benefits, or arranges
1-11 for health care benefits to be provided, to a participant in the
1-12 plan; and
1-13 (B) requires or encourages those participants to
1-14 use health care providers designated by the plan.
1-15 SECTION 2. Section 2, Article 21.52B, Insurance Code, is
1-16 amended to read as follows:
1-17 Sec. 2. Prohibited contractual provisions. (a) A health
1-18 insurance policy or managed care plan that is delivered, issued for
1-19 delivery, or renewed or for which a contract or other agreement is
1-20 executed may not:
1-21 (1) prohibit or limit a person who is a beneficiary of
1-22 the policy or a participant in the plan from selecting a pharmacy
1-23 or pharmacist of the person's choice to be a provider under the
1-24 policy or plan to furnish pharmaceutical services offered or
2-1 provided by that policy or plan, or interfere with that person's
2-2 selection of a pharmacy or pharmacist;
2-3 (2) deny a pharmacy or pharmacist the right to
2-4 participate as a contract provider under the policy or plan if the
2-5 pharmacy or pharmacist agrees to provide pharmaceutical services
2-6 that meet all terms and requirements and to include the same
2-7 administrative, financial, and professional conditions that apply
2-8 to pharmacies and pharmacists who have been designated as providers
2-9 under the policy or plan; or
2-10 (3) require a beneficiary of a policy or a participant
2-11 in a plan to obtain or request a specific quantity or dosage supply
2-12 of pharmaceutical products.
2-13 (b) Notwithstanding Subsection (a)(3) of this section, a
2-14 health insurance<, but the> policy or managed care plan may allow
2-15 the <beneficiary's> physician of a beneficiary or participant to
2-16 prescribe drugs in a quantity or dosage supply the physician
2-17 determines appropriate and that is in compliance with state and
2-18 federal statutes.
2-19 (c) <(b)> This section does not prohibit:
2-20 (1) a provision of a policy or plan from limiting the
2-21 quantity or dosage supply of pharmaceutical products for which
2-22 coverage is provided or providing financial incentives to encourage
2-23 the beneficiary or participant and the prescribing physician to use
2-24 a program that provides pharmaceutical products in quantities that
2-25 result in cost savings to the insurance program or managed care
2-26 plan and the beneficiary or participant if the provision applies
2-27 equally to all designated providers of pharmaceutical services
3-1 under the policy or plan; <or>
3-2 (2) a pharmacy card program that provides a means of
3-3 obtaining pharmaceutical services offered by the policy or plan
3-4 through all designated providers of pharmaceutical services; or
3-5 (3) a plan from establishing reasonable application
3-6 and recertification fees for a pharmacy which provides
3-7 pharmaceutical services as a contract provider under the plan,
3-8 provided that such fees are uniformly charged to each pharmacy
3-9 under contract to the plan.
3-10 SECTION 3. Section 3, Article 21.52B, Insurance Code, is
3-11 amended to read as follows:
3-12 Sec. 3. Provision void. A provision of a health insurance
3-13 policy or managed care plan that is delivered, issued for delivery,
3-14 entered into, or renewed in this state that conflicts with Section
3-15 2 of this article is void to the extent of the conflict.
3-16 SECTION 4. Section 4, Article 21.52B, Insurance Code, is
3-17 amended to read as follows:
3-18 Sec. 4. Construction of article. This article does not
3-19 require a health insurance policy or managed care plan to provide
3-20 pharmaceutical services.
3-21 SECTION 5. Subsection (g), Section 14, Texas Health
3-22 Maintenance Organization Act (Article 20A.14, Vernon's Texas
3-23 Insurance Code), is amended to read as follows:
3-24 (g) No type of provider licensed or otherwise authorized to
3-25 practice in this state may be denied participation to provide
3-26 health care services which are delivered by the health maintenance
3-27 organization and which are within the scope of licensure or
4-1 authorization of the type of provider on the sole basis of type of
4-2 license or authorization. This section may not be construed to
4-3 (1) require a health maintenance organization to utilize a
4-4 particular type of provider in its operation; (2) require, except
4-5 as provided by Article 21.52B of this code, that a health
4-6 maintenance organization accept each provider of a category or
4-7 type; or (3) require that health maintenance organizations contract
4-8 directly with such providers. Notwithstanding any other provision
4-9 nothing herein shall be construed to limit the health maintenance
4-10 organization's authority to set the terms and conditions under
4-11 which health care services will be rendered by providers. All
4-12 providers must comply with the terms and conditions established by
4-13 the health maintenance organization for the provision of health
4-14 services and for designation as a provider.
4-15 SECTION 6. The provisions of this Act do not apply to a
4-16 group model health maintenance organization that is a state
4-17 certified health maintenance organization that provides the
4-18 majority of its professional services through a single group
4-19 medical practice that is formally affiliated with the medical
4-20 school component of a Texas state supported public college or
4-21 university and that received its certification as a health
4-22 maintenance organization prior to November 1, 1981.
4-23 SECTION 7. This Act takes effect September 1, 1995, and
4-24 applies only to an insurance policy or evidence of coverage under a
4-25 managed care plan that is delivered, issued for delivery, or
4-26 renewed on or after January 1, 1996. A policy or evidence of
4-27 coverage that is delivered, issued for delivery, or renewed before
5-1 January 1, 1996, is governed by the law as it existed immediately
5-2 before the effective date of this Act, and that law is continued in
5-3 effect for that purpose.
5-4 SECTION 8. The importance of this legislation and the
5-5 crowded condition of the calendars in both houses create an
5-6 emergency and an imperative public necessity that the
5-7 constitutional rule requiring bills to be read on three several
5-8 days in each house be suspended, and this rule is hereby suspended.