1-1 By: Madla S.B. No. 628
1-2 (In the Senate - Filed February 16, 1995; February 20, 1995,
1-3 read first time and referred to Committee on Health and Human
1-4 Services; April 11, 1995, rereferred to Committee on Economic
1-5 Development; April 28, 1995, reported adversely, with favorable
1-6 Committee Substitute by the following vote: Yeas 8, Nays 0;
1-7 April 28, 1995, sent to printer.)
1-8 COMMITTEE SUBSTITUTE FOR S.B. No. 628 By: Madla
1-9 A BILL TO BE ENTITLED
1-10 AN ACT
1-11 relating to access to pharmaceutical services through certain
1-12 managed care health plans.
1-13 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-14 SECTION 1. Section 1, Article 21.52B, Insurance Code, is
1-15 amended by adding Subdivision (6) to read as follows:
1-16 (6) "Managed care plan" means a health maintenance
1-17 organization, a preferred provider organization, or another
1-18 organization that, under a contract or other agreement entered into
1-19 with a participant in the plan:
1-20 (A) provides health care benefits, or arranges
1-21 for health care benefits to be provided, to a participant in the
1-22 plan; and
1-23 (B) requires or encourages those participants to
1-24 use health care providers designated by the plan.
1-25 SECTION 2. Section 2, Article 21.52B, Insurance Code, is
1-26 amended to read as follows:
1-27 Sec. 2. Prohibited contractual provisions. (a) A health
1-28 insurance policy or managed care plan that is delivered, issued for
1-29 delivery, or renewed or for which a contract or other agreement is
1-30 executed may not:
1-31 (1) prohibit or limit a person who is a beneficiary of
1-32 the policy or a participant in the plan from selecting a pharmacy
1-33 or pharmacist of the person's choice to be a provider under the
1-34 policy or plan to furnish pharmaceutical services offered or
1-35 provided by that policy or plan, or interfere with that person's
1-36 selection of a pharmacy or pharmacist;
1-37 (2) deny a pharmacy or pharmacist the right to
1-38 participate as a contract provider under the policy or plan if the
1-39 pharmacy or pharmacist agrees to provide pharmaceutical services
1-40 that meet all terms and requirements and to include the same
1-41 administrative, financial, and professional conditions that apply
1-42 to pharmacies and pharmacists who have been designated as providers
1-43 under the policy or plan; or
1-44 (3) require a beneficiary of a policy or a participant
1-45 in a plan to obtain or request a specific quantity or dosage supply
1-46 of pharmaceutical products.
1-47 (b) Notwithstanding Subsection (a)(3) of this section, a
1-48 health insurance<, but the> policy or managed care plan may allow
1-49 the <beneficiary's> physician of a beneficiary or participant to
1-50 prescribe drugs in a quantity or dosage supply the physician
1-51 determines appropriate and that is in compliance with state and
1-52 federal statutes.
1-53 (c) <(b)> This section does not prohibit:
1-54 (1) a provision of a policy or plan from limiting the
1-55 quantity or dosage supply of pharmaceutical products for which
1-56 coverage is provided or providing financial incentives to encourage
1-57 the beneficiary or participant and the prescribing physician to use
1-58 a program that provides pharmaceutical products in quantities that
1-59 result in cost savings to the insurance program or managed care
1-60 plan and the beneficiary or participant if the provision applies
1-61 equally to all designated providers of pharmaceutical services
1-62 under the policy or plan; <or>
1-63 (2) a pharmacy card program that provides a means of
1-64 obtaining pharmaceutical services offered by the policy or plan
1-65 through all designated providers of pharmaceutical services; or
1-66 (3) a plan from establishing reasonable application
1-67 and recertification fees for a pharmacy which provides
1-68 pharmaceutical services as a contract provider under the plan,
2-1 provided that such fees are uniformly charged to each pharmacy
2-2 under contract to the plan.
2-3 SECTION 3. Section 3, Article 21.52B, Insurance Code, is
2-4 amended to read as follows:
2-5 Sec. 3. Provision void. A provision of a health insurance
2-6 policy or managed care plan that is delivered, issued for delivery,
2-7 entered into, or renewed in this state that conflicts with Section
2-8 2 of this article is void to the extent of the conflict.
2-9 SECTION 4. Section 4, Article 21.52B, Insurance Code, is
2-10 amended to read as follows:
2-11 Sec. 4. Construction of article. This article does not
2-12 require a health insurance policy or managed care plan to provide
2-13 pharmaceutical services.
2-14 SECTION 5. Subsection (g), Section 14, Texas Health
2-15 Maintenance Organization Act (Article 20A.14, Vernon's Texas
2-16 Insurance Code), is amended to read as follows:
2-17 (g) No type of provider licensed or otherwise authorized to
2-18 practice in this state may be denied participation to provide
2-19 health care services which are delivered by the health maintenance
2-20 organization and which are within the scope of licensure or
2-21 authorization of the type of provider on the sole basis of type of
2-22 license or authorization. This section may not be construed to
2-23 (1) require a health maintenance organization to utilize a
2-24 particular type of provider in its operation; (2) require, except
2-25 as provided by Article 21.52B of this code, that a health
2-26 maintenance organization accept each provider of a category or
2-27 type; or (3) require that health maintenance organizations contract
2-28 directly with such providers. Notwithstanding any other provision
2-29 nothing herein shall be construed to limit the health maintenance
2-30 organization's authority to set the terms and conditions under
2-31 which health care services will be rendered by providers. All
2-32 providers must comply with the terms and conditions established by
2-33 the health maintenance organization for the provision of health
2-34 services and for designation as a provider.
2-35 SECTION 6. The provisions of this Act do apply to a group
2-36 model health maintenance organization that is a state certified
2-37 health maintenance organization that provides the majority of its
2-38 professional services through a single group medical practice that
2-39 is formally affiliated with the medical school component of a Texas
2-40 state supported public college or university and that received its
2-41 certification as a health maintenance organization prior to
2-42 November 1, 1981.
2-43 SECTION 7. This Act takes effect September 1, 1995, and
2-44 applies only to an insurance policy or evidence of coverage under a
2-45 managed care plan that is delivered, issued for delivery, or
2-46 renewed on or after January 1, 1996. A policy or evidence of
2-47 coverage that is delivered, issued for delivery, or renewed before
2-48 January 1, 1996, is governed by the law as it existed immediately
2-49 before the effective date of this Act, and that law is continued in
2-50 effect for that purpose.
2-51 SECTION 8. The importance of this legislation and the
2-52 crowded condition of the calendars in both houses create an
2-53 emergency and an imperative public necessity that the
2-54 constitutional rule requiring bills to be read on three several
2-55 days in each house be suspended, and this rule is hereby suspended.
2-56 * * * * *