S.B. No. 628
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 from selecting a pharmacy or pharmacist of the person's
1-23 choice to be a provider under the policy to furnish pharmaceutical
1-24 services offered or provided by that policy or interfere with that
2-1 person's selection of a pharmacy or pharmacist;
2-2 (2) deny a pharmacy or pharmacist the right to
2-3 participate as a contract provider under the policy or plan if the
2-4 pharmacy or pharmacist agrees to provide pharmaceutical services
2-5 that meet all terms and requirements and to include the same
2-6 administrative, financial, and professional conditions that apply
2-7 to pharmacies and pharmacists who have been designated as providers
2-8 under the policy or plan; or
2-9 (3) require a beneficiary of a policy or a participant
2-10 in a plan to obtain or request a specific quantity or dosage supply
2-11 of pharmaceutical products.
2-12 (b) Notwithstanding Subsection (a)(3) of this section, a
2-13 health insurance<, but the> policy or managed care plan may allow
2-14 the <beneficiary's> physician of a beneficiary or participant to
2-15 prescribe drugs in a quantity or dosage supply the physician
2-16 determines appropriate and that is in compliance with state and
2-17 federal statutes.
2-18 (c) <(b)> This section does not prohibit:
2-19 (1) a provision of a policy or plan from limiting the
2-20 quantity or dosage supply of pharmaceutical products for which
2-21 coverage is provided or providing financial incentives to encourage
2-22 the beneficiary or participant and the prescribing physician to use
2-23 a program that provides pharmaceutical products in quantities that
2-24 result in cost savings to the insurance program or managed care
2-25 plan and the beneficiary or participant if the provision applies
2-26 equally to all designated providers of pharmaceutical services
2-27 under the policy or plan; <or>
3-1 (2) a pharmacy card program that provides a means of
3-2 obtaining pharmaceutical services offered by the policy or plan
3-3 through all designated providers of pharmaceutical services; or
3-4 (3) a plan from establishing reasonable application
3-5 and recertification fees for a pharmacy which provides
3-6 pharmaceutical services as a contract provider under the plan,
3-7 provided that such fees are uniformly charged to each pharmacy
3-8 under contract to the plan.
3-9 SECTION 3. Section 3, Article 21.52B, Insurance Code, is
3-10 amended to read as follows:
3-11 Sec. 3. Provision void. A provision of a health insurance
3-12 policy or managed care plan that is delivered, issued for delivery,
3-13 entered into, or renewed in this state that conflicts with Section
3-14 2 of this article is void to the extent of the conflict.
3-15 SECTION 4. Section 4, Article 21.52B, Insurance Code, is
3-16 amended to read as follows:
3-17 Sec. 4. Construction of article. This article does not
3-18 require a health insurance policy or managed care plan to provide
3-19 pharmaceutical services.
3-20 SECTION 5. Subsection (g), Section 14, Texas Health
3-21 Maintenance Organization Act (Article 20A.14, Vernon's Texas
3-22 Insurance Code), is amended to read as follows:
3-23 (g) No type of provider licensed or otherwise authorized to
3-24 practice in this state may be denied participation to provide
3-25 health care services which are delivered by the health maintenance
3-26 organization and which are within the scope of licensure or
3-27 authorization of the type of provider on the sole basis of type of
4-1 license or authorization. This section may not be construed to
4-2 (1) require a health maintenance organization to utilize a
4-3 particular type of provider in its operation; (2) require, except
4-4 as provided by Article 21.52B of this code, that a health
4-5 maintenance organization accept each provider of a category or
4-6 type; or (3) require that health maintenance organizations contract
4-7 directly with such providers. Notwithstanding any other provision
4-8 nothing herein shall be construed to limit the health maintenance
4-9 organization's authority to set the terms and conditions under
4-10 which health care services will be rendered by providers. All
4-11 providers must comply with the terms and conditions established by
4-12 the health maintenance organization for the provision of health
4-13 services and for designation as a provider.
4-14 SECTION 6. (a) The provisions of this Act do not apply to:
4-15 (1) a group model health maintenance organization that
4-16 is a state certified health maintenance organization that provides
4-17 the majority of its professional services through a single group
4-18 medical practice that is formally affiliated with the medical
4-19 school component of a Texas state supported public college or
4-20 university and that received its certification as a health
4-21 maintenance organization prior to November 1, 1981; or
4-22 (2) a nonprofit group practice model health
4-23 maintenance organization that provides pharmaceutical services to
4-24 its enrollees only through pharmacies located at medical offices
4-25 owned, leased, or contracted for by the health maintenance
4-26 organization and that received its certification prior to
4-27 November 1, 1985.
5-1 SECTION 7. This Act takes effect September 1, 1995, and
5-2 applies only to an insurance policy or evidence of coverage under a
5-3 managed care plan that is delivered, issued for delivery, or
5-4 renewed on or after January 1, 1996. A policy or evidence of
5-5 coverage that is delivered, issued for delivery, or renewed before
5-6 January 1, 1996, is governed by the law as it existed immediately
5-7 before the effective date of this Act, and that law is continued in
5-8 effect for that purpose.
5-9 SECTION 8. The importance of this legislation and the
5-10 crowded condition of the calendars in both houses create an
5-11 emergency and an imperative public necessity that the
5-12 constitutional rule requiring bills to be read on three several
5-13 days in each house be suspended, and this rule is hereby suspended.