SRC-TBR C.S.S.B. 804 77(R)BILL ANALYSIS


Senate Research CenterC.S.S.B. 804
77R10408 DLF-DBy: Madla
Business & Commerce
3/22/2001
Committee Report (Substituted)


DIGEST AND PURPOSE 

Current Texas law requires health benefit plans to provide enrollees with
continuous access to prescribed formulary drugs at the same benefit level
until the enrollee's plan renewal date, even if the drug has been removed
from the formulary.  C.S.S.B. 804 narrows the scope of current law and
requires health plans to provide enrollees with access to prescription
drugs that were prescribed for an enrollee during the plan year.  Such
prescriptions would have to be available at the contracted benefit level
until the enrollee's plan renewal date, whether or not the prescribed drug
has been removed from the health benefit plan's drug formulary. 
 
RULEMAKING AUTHORITY

This bill does not expressly grant any additional rulemaking authority to a
state officer, institution, or agency. 

SECTION BY SECTION ANALYSIS

SECTION 1.  Amends Section 3, Article 21.52J, Insurance Code, to require a
group health benefit plan that covers prescription drugs and that uses one
or more drug formularies to specify which prescription drugs the plan will
cover to provide a statement of the enrollee's right to complain in a
circumstance in which benefits for a drug are denied because the drug is
not included in the plan's drug formulary, including the enrollee's rights
under Section 4(c) of this article. 

SECTION 2.  Amends Section 4, Article 21.52J, Insurance Code, by amending
Subsection (a) and adding Subsections (c) and (d), as follows: 

(a)  Requires, except as provided by Subsection (d), a group health benefit
plan that offers prescription drug benefits to make a prescription drug
that, at the beginning of the plan year, was included on the health benefit
plan's drug formulary available to an enrollee at the contracted benefit
level for that prescription drug until the enrollee's plan renewal date,
regardless of whether the prescribed drug has been removed from the health
benefit plan's drug formulary, if the drug was at any time previously
prescribed to the enrollee and provided under the plan, regardless of
whether the drug was prescribed during the plan year or the enrollee can
demonstrate, in accordance with Subsection (c) of this section, that the
drug was at any time previously prescribed to the enrollee. 

(c)  Authorizes an enrollee who is denied benefits for a prescription drug
because the drug has been removed from the group health benefit plan's drug
formulary during a plan year and who believes the benefits are required
under Subsection (a)(2) of this section to file a complaint in accordance
with the complaint procedures of the group health benefit plan.  Requires,
that on an initial showing by the enrollee that the drug was previously
prescribed at any time to the enrollee, the group health benefit plan to
provide the benefits at the contracted benefit level from the date the
benefits were initially requested until the enrollee's plan renewal date.
Provides that an initial showing under this subsection may be made by any
means that demonstrates that a prescription drug was previously prescribed
to an enrollee, including a  copy of a prescription or a letter or other
appropriate documentation from the physician who prescribed the drug or
pharmacist who distributed the drug. 


(d)  Provides that Subsection (a) of this section does not require a group
health benefit plan to continue to provide prescription drug benefits for a
prescription drug if certain requirements are met. 

SECTION 3.  Amends Section 6, Article 21.52J, Insurance Code, as follows:

Sec. 6.  RULES.  Authorizes the commissioner to adopt rules to implement
this article, including rules governing documents or other evidence that
must be accepted under Section 4 (c) of this article by a group health
benefit plan as an initial showing that a drug was at any time previously
prescribed to an enrollee. 

SECTION 4.  Effective date:September 1, 2001.
    Makes application of this Act prospective.


SUMMARY OF COMMITTEE CHANGES

SECTION 1.  Amends the As Filed S.B. 804 by amending Section 3, rather than
Section 4, of Article 21.52J, Insurance Code, the As Filed version proposed
language that is now included in SECTION 2(Section 4(d), Aricle 21.52J,
Insurance Code) of the substitute. 

SECTION 2.  Amends the As Filed S.B. 804 by adding language regarding the
plan's year and provisions allowing an enrollee to obtain a prescription
drug that is not on the company's formulary and provisions for an enrollee
to file a complaint. 

SECTION 3.  Amends the As Filed S.B. 804 by amending Section 6, Article
2152J, Insurance Code, implementing rules governing documents.