By Najera H.B. No. 1967
77R6281 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to a state prescription drug plan for certain older
1-3 individuals and individuals who have serious health care
1-4 conditions.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subtitle C, Title 2, Health and Safety Code, is
1-7 amended by adding Chapter 65 to read as follows:
1-8 CHAPTER 65. PRESCRIPTION DRUG PLAN
1-9 SUBCHAPTER A. GENERAL PROVISIONS
1-10 Sec. 65.001. OBJECTIVE OF STATE PRESCRIPTION DRUG PLAN. The
1-11 state prescription drug plan provides prescription drug benefits to
1-12 individuals who reside in this state and who are at least 65 years
1-13 of age or have a serious health care condition.
1-14 Sec. 65.002. DEFINITIONS. In this chapter:
1-15 (1) "Commission" means the Health and Human Services
1-16 Commission.
1-17 (2) "Commissioner" means the commissioner of health
1-18 and human services.
1-19 (3) "Prescription drug plan provider" means an
1-20 insurance company, health maintenance organization, or other entity
1-21 that provides prescription drug benefits coverage under the
1-22 prescription drug plan program.
1-23 (4) "Regional advisory committee" means a committee
1-24 appointed under Section 65.057.
2-1 Sec. 65.003. NOT AN ENTITLEMENT. This chapter does not
2-2 establish an entitlement to assistance in obtaining prescription
2-3 drug benefits.
2-4 Sec. 65.004. BIENNIAL REVIEW OF PROGRAM. (a) At the
2-5 conclusion of each fiscal biennium, the commissioner and the office
2-6 of the state auditor shall review the operation of the prescription
2-7 drug plan program established under this chapter. In reviewing the
2-8 program, the commissioner and the office of the state auditor shall
2-9 evaluate the enrollment levels for individuals receiving coverage
2-10 under the prescription drug plan at reduced premium rates.
2-11 (b) The state auditor shall assign a team of three persons
2-12 from the auditor's office to participate in the review required by
2-13 this section.
2-14 (Sections 65.005-65.050 reserved for expansion
2-15 SUBCHAPTER B. ADMINISTRATION OF PRESCRIPTION DRUG PLAN PROGRAM
2-16 Sec. 65.051. DUTIES OF COMMISSION. (a) The commission
2-17 shall develop and implement a prescription drug plan program to
2-18 obtain coverage for prescription drug benefits for eligible
2-19 individuals.
2-20 (b) The commission is the agency responsible for making
2-21 policy for the prescription drug plan program, including policy
2-22 related to eligibility for coverage under the plan and to
2-23 prescription drug benefits provided under the plan. The commission
2-24 may not delegate this duty to another agency or entity.
2-25 (c) The commission shall oversee the implementation of the
2-26 prescription drug plan program and coordinate the activities of
2-27 each agency necessary to the implementation of the program,
3-1 including the Texas Department of Health, Texas Department of Human
3-2 Services, and Texas Department of Insurance.
3-3 (d) The commission shall adopt rules as necessary to
3-4 implement this chapter. The commission shall require the
3-5 appropriate health and human services agency, including the Texas
3-6 Department of Health and the Texas Department of Human Services, to
3-7 adopt, with the approval of the commission, the rules that are
3-8 necessary to implement the prescription drug plan program. With
3-9 the consent of another agency, including the Texas Department of
3-10 Insurance, the commission may delegate to that agency the authority
3-11 to adopt, with the approval of the commission, any rules that are
3-12 necessary to implement the program.
3-13 (e) The commission shall conduct a review of each entity
3-14 that enters into a contract under Section 65.055 or Section 65.155,
3-15 to ensure that the entity is available, prepared, and able to
3-16 fulfill the entity's obligations under the contract in compliance
3-17 with the contract, this chapter, and rules adopted under this
3-18 chapter.
3-19 Sec. 65.052. DUTIES OF TEXAS DEPARTMENT OF HEALTH. (a) The
3-20 commission may direct the Texas Department of Health to:
3-21 (1) implement contracts with prescription drug plan
3-22 providers under Section 65.155;
3-23 (2) monitor the prescription drug plan providers,
3-24 through reporting requirements and other means, to ensure
3-25 performance under the contracts and quality delivery of services;
3-26 (3) monitor the quality of services delivered to
3-27 enrollees; and
4-1 (4) provide payment under the contracts to the
4-2 prescription drug plan providers.
4-3 (b) The commission, or the Texas Department of Health under
4-4 the direction of and in consultation with the commission, shall
4-5 adopt rules as necessary to implement this section.
4-6 Sec. 65.053. DUTIES OF TEXAS DEPARTMENT OF HUMAN SERVICES.
4-7 (a) Under the direction of the commission, the Texas Department of
4-8 Human Services shall:
4-9 (1) accept applications for coverage under the
4-10 prescription drug plan and implement the prescription drug plan
4-11 program eligibility screening and enrollment procedures;
4-12 (2) resolve grievances relating to eligibility
4-13 determinations; and
4-14 (3) coordinate the prescription drug plan program with
4-15 the Medicaid program, as necessary.
4-16 (b) If the commission contracts with a third party
4-17 administrator under Section 65.055, the commission may direct the
4-18 Texas Department of Human Services to:
4-19 (1) implement the contract;
4-20 (2) monitor the third party administrator, through
4-21 reporting requirements and other means, to ensure performance under
4-22 the contract and quality delivery of services; and
4-23 (3) provide payment under the contract to the third
4-24 party administrator.
4-25 (c) The commission, or the Texas Department of Human
4-26 Services under the direction of and in consultation with the
4-27 commission, shall adopt rules as necessary to implement this
5-1 section.
5-2 Sec. 65.054. DUTIES OF TEXAS DEPARTMENT OF INSURANCE. (a)
5-3 At the request of the commission, the Texas Department of Insurance
5-4 shall provide any necessary assistance with the development of the
5-5 prescription drug plan. The department shall monitor the quality
5-6 of the services provided by prescription drug plan providers and
5-7 shall coordinate with the Texas Department of Human Services to
5-8 resolve grievances relating to the prescription drug plan
5-9 providers.
5-10 (b) The commission and the Texas Department of Insurance may
5-11 adopt a memorandum of understanding that addresses the
5-12 responsibilities of each agency in developing the plan.
5-13 (c) The Texas Department of Insurance, in consultation with
5-14 the commission, shall adopt rules as necessary to implement this
5-15 section.
5-16 Sec. 65.055. CONTRACTS FOR IMPLEMENTATION OF PRESCRIPTION
5-17 DRUG PLAN. (a) It is the intent of the legislature that the
5-18 commission maximize the use of private resources in administering
5-19 the prescription drug plan program created under this chapter. In
5-20 administering the program, the commission may contract with a third
5-21 party administrator to provide enrollment and related services
5-22 under the state prescription drug plan.
5-23 (b) A third party administrator may perform tasks under the
5-24 contract that would otherwise be performed by the Texas Department
5-25 of Health or Texas Department of Human Services under this chapter.
5-26 (c) The commission shall:
5-27 (1) retain all policymaking authority over the state
6-1 prescription drug plan;
6-2 (2) procure all contracts with a third party
6-3 administrator through a competitive procurement process in
6-4 compliance with applicable state laws; and
6-5 (3) ensure that all contracts with prescription drug
6-6 plan providers under Section 65.155 are procured through a
6-7 competitive procurement process in compliance with applicable law.
6-8 (d) The commission shall ensure that each contract with a
6-9 third party administrator or prescription drug plan provider
6-10 requires compliance with Section 65.059.
6-11 Sec. 65.056. COMMUNITY OUTREACH CAMPAIGN; TOLL-FREE HOTLINE.
6-12 (a) The commission shall conduct a community outreach and
6-13 education campaign to provide information relating to the
6-14 availability of prescription drug plan coverage under this chapter.
6-15 (b) The community outreach campaign must include a toll-free
6-16 telephone number through which individuals may obtain information
6-17 about the prescription drug plan program.
6-18 (c) The commission shall contract with community-based and
6-19 interfaith organizations or coalitions of those organizations to
6-20 implement the community outreach campaign and shall promote and
6-21 encourage voluntary efforts to implement the community outreach
6-22 campaign.
6-23 (d) The commission shall direct that the Texas Department of
6-24 Health or the Texas Department of Human Services coordinate the
6-25 community outreach campaign.
6-26 Sec. 65.057. REGIONAL ADVISORY COMMITTEES. The commission
6-27 shall appoint regional advisory committees to provide
7-1 recommendations concerning the implementation and operation of the
7-2 prescription drug plan program. The regional advisory committees
7-3 must be composed of knowledgeable representatives of the Texas
7-4 Department of Human Services, the Texas Department of Health, and
7-5 local community health providers.
7-6 Sec. 65.058. FRAUD PREVENTION. (a) The commission, in
7-7 consultation with the office of the attorney general, shall adopt
7-8 and implement rules for the prevention and detection of fraud in
7-9 the prescription drug plan program.
7-10 (b) The rules must authorize the exclusion of any individual
7-11 who commits fraud from the prescription drug plan after notice to
7-12 the individual and an opportunity for hearing.
7-13 Sec. 65.059. CONFIDENTIALITY OF INFORMATION. Information
7-14 relating to an applicant for or participant in the prescription
7-15 drug plan program is confidential and may not be disclosed to any
7-16 person except as necessary for the administration of the
7-17 prescription drug plan. The information is not subject to
7-18 disclosure under Chapter 552, Government Code.
7-19 (Sections 65.060-65.100 reserved for expansion
7-20 SUBCHAPTER C. ELIGIBILITY FOR COVERAGE UNDER PRESCRIPTION DRUG PLAN
7-21 Sec. 65.101. ELIGIBILITY. (a) An individual is eligible for
7-22 coverage under the prescription drug plan if the individual is a
7-23 legal resident of this state and:
7-24 (1) is not less than 65 years of age;
7-25 (2) has a chronic health care condition that is likely
7-26 to last at least one year and result in limitations of function and
7-27 activities;
8-1 (3) has a disease or condition for which the
8-2 likelihood of death is probable unless the course of the disease or
8-3 condition is interrupted; or
8-4 (4) has a mental or physical disability.
8-5 (b) The commission by rule shall establish eligibility
8-6 standards for individuals described by Subsection (a)(2), (3), or
8-7 (4).
8-8 Sec. 65.102. ELIGIBILITY FOR REDUCED PREMIUMS. (a) The
8-9 commission by rule shall establish eligibility standards for
8-10 individuals to receive coverage under the prescription drug plan
8-11 for a reduced premium in accordance with Section 65.153. In
8-12 adopting rules under this section, the commission shall consult
8-13 with the regional advisory committees.
8-14 (b) The standards must consider the family income of the
8-15 individual, but may not consider the value of:
8-16 (1) a homestead in which the individual resides; and
8-17 (2) one motor vehicle owned by the family.
8-18 (c) The standards must be developed to provide the broadest
8-19 possible availability of reduced premium coverage under the
8-20 prescription drug plan program, considering available appropriated
8-21 funds.
8-22 Sec. 65.103. APPLICATION FORM AND PROCEDURES. (a) The
8-23 commission, with the assistance of the regional advisory
8-24 committees, shall adopt an application form and application
8-25 procedures for requesting prescription drug plan coverage under
8-26 this chapter.
8-27 (b) To the extent possible, the application form shall be
9-1 made available in languages other than English.
9-2 (c) The commission shall permit application to be made by
9-3 mail, by telephone, and through the Internet.
9-4 Sec. 65.104. ELIGIBILITY SCREENING AND ENROLLMENT. (a) The
9-5 commission, with the assistance of the regional advisory
9-6 committees, shall develop eligibility screening and enrollment
9-7 procedures for the prescription drug plan program.
9-8 (b) A determination of whether an individual is eligible for
9-9 reduced premium coverage under the prescription drug plan and the
9-10 enrollment of an eligible individual with a prescription drug plan
9-11 provider must be completed, and information on the individual's
9-12 available choice of prescription drug plan providers must be
9-13 provided, in a timely manner, as determined by the commission. The
9-14 commission must require that the determination be made and the
9-15 information be provided not later than the 30th day after the date
9-16 the individual submits a complete application.
9-17 (c) The commission may establish enrollment periods for the
9-18 prescription drug plan program, except that an individual described
9-19 by Section 65.101(a)(2), (3), or (4) is eligible for enrollment in
9-20 the plan without regard to any enrollment period requirement.
9-21 (Sections 65.105-65.150 reserved for expansion
9-22 SUBCHAPTER D. PRESCRIPTION DRUG PLAN
9-23 Sec. 65.151. PRESCRIPTION DRUG PLAN COVERAGE. (a) The
9-24 commission, in consultation with the commissioner of insurance, by
9-25 rule shall establish the benefits provided under the prescription
9-26 drug plan.
9-27 (b) Benefits provided under the prescription drug plan shall
10-1 be coordinated with other benefits for which an enrollee is
10-2 eligible, including benefits provided under Medicare and the
10-3 Medicaid program, so that the prescription drug plan benefits
10-4 supplement, but do not duplicate, the other benefits.
10-5 (c) The prescription drug plan may use a prescription drug
10-6 formulary.
10-7 Sec. 65.152. APPLICATION OF INSURANCE LAW. The prescription
10-8 drug plan is not subject to:
10-9 (1) a law that requires:
10-10 (A) coverage or the offer of coverage of a
10-11 health care service or benefit;
10-12 (B) coverage or the offer of coverage for the
10-13 provision of services by a particular pharmacy or pharmacist; or
10-14 (C) the use of a particular policy or contract
10-15 form or of particular language in a policy or contract form; or
10-16 (2) Article 21.52J, Insurance Code.
10-17 Sec. 65.153. PREMIUM; REDUCED PREMIUM. (a) Subject to
10-18 Subsection (b), the commission shall require an enrollee in the
10-19 prescription drug plan to pay:
10-20 (1) a copayment or similar charge for prescription
10-21 drugs provided under the plan; and
10-22 (2) the plan premium.
10-23 (b) The commission shall provide prescription drug plan
10-24 coverage at reduced premium rates to individuals who satisfy the
10-25 eligibility requirements established under Section 65.102. Reduced
10-26 premium rates adopted under this section shall ensure that
10-27 individuals with higher levels of income are required to pay
11-1 progressively higher percentages of the cost of the plan.
11-2 (c) The commission shall specify the manner in which the
11-3 premium is paid. The commission may require that the premium be
11-4 paid to the Texas Department of Health, the Texas Department of
11-5 Human Services, or the prescription drug plan provider.
11-6 (d) For purposes of establishing the amounts of copayments
11-7 or similar charges and plan premiums, the commissioner may
11-8 establish classes of enrollees and may charge different amounts to
11-9 enrollees in different classes. Not later than August 31 of each
11-10 even-numbered year, the commissioner shall obtain an actuarial
11-11 review of the costs of providing benefits under the plan to
11-12 enrollees. If the commissioner determines that the actuarial
11-13 review demonstrates that any group of individuals described by
11-14 Section 65.101(a)(1), (2), (3), or (4) is unfairly subsidizing the
11-15 cost of plan benefits for another group of individuals, the
11-16 commissioner shall establish separate classes of enrollees.
11-17 Sec. 65.154. WAITING PERIODS; PREEXISTING CONDITION
11-18 PROVISIONS; CROWD OUT. (a) Except as provided by Subsection (d),
11-19 the prescription drug plan may include a waiting period of not more
11-20 than 180 days.
11-21 (b) Except as provided by Subsection (d), the prescription
11-22 drug plan may include a preexisting condition provision that
11-23 limits, but does not exclude, benefits for prescription drugs for a
11-24 disease or condition for not more than 60 days after the effective
11-25 date of coverage under the plan. The preexisting condition
11-26 provision may not otherwise be more restrictive than the
11-27 preexisting condition provision authorized for a small employer
12-1 health benefit plan under Article 26.49, Insurance Code.
12-2 (c) The prescription drug plan may include copayments and
12-3 other provisions intended to discourage employers and other persons
12-4 from electing to discontinue providing or offering, under employee
12-5 or other group health benefit plans, prescription drug benefits for
12-6 individuals who are at least 65 years of age.
12-7 (d) A waiting period established under Subsection (a) or a
12-8 preexisting condition provision established under Subsection (b)
12-9 may not apply to an individual who is eligible to enroll in the
12-10 prescription drug plan under Section 65.101(a)(2), (3), or (4).
12-11 Sec. 65.155. PRESCRIPTION DRUG PLAN PROVIDERS. (a) The
12-12 commission, or the Texas Department of Health at the direction of
12-13 and in consultation with the commission, shall select the
12-14 prescription drug plan providers under the program through a
12-15 competitive procurement process. A prescription drug plan provider
12-16 must hold a certificate of authority issued by the Texas Department
12-17 of Insurance that authorizes the prescription drug plan provider to
12-18 provide the type of prescription drug plan offered and must
12-19 satisfy, except as provided by this chapter, any applicable
12-20 requirement of the Insurance Code or another insurance law of this
12-21 state.
12-22 (b) In selecting a prescription drug plan provider for a
12-23 metropolitan area, the commission shall consult with the
12-24 appropriate regional advisory committee. The commission shall
12-25 provide for a choice of at least two prescription drug plan
12-26 providers in each metropolitan area. The commissioner may
12-27 authorize an exception to the requirement imposed by this
13-1 subsection if there is only one acceptable applicant to become a
13-2 prescription drug plan provider in the metropolitan area.
13-3 SECTION 2. The heading of Subtitle C, Title 2, Health and
13-4 Safety Code, is amended to read as follows:
13-5 SUBTITLE C. INDIGENT HEALTH CARE AND PUBLIC HEALTH CARE PLANS
13-6 SECTION 3. Not later than September 1, 2002, the Health and
13-7 Human Services Commission shall develop and implement the
13-8 prescription drug plan program required by Chapter 65, Health and
13-9 Safety Code, as added by this Act.
13-10 SECTION 4. This Act takes effect immediately if it receives
13-11 a vote of two-thirds of all the members elected to each house, as
13-12 provided by Section 39, Article III, Texas Constitution. If this
13-13 Act does not receive the vote necessary for immediate effect, this
13-14 Act takes effect September 1, 2001.