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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for orally administered |
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anticancer medications. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1369, Insurance Code, is amended by |
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adding Subchapter E to read as follows: |
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SUBCHAPTER E. COVERAGE FOR ORALLY ADMINISTERED ANTICANCER |
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MEDICATIONS |
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Sec. 1369.201. DEFINITION. In this subchapter, "enrollee" |
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means an individual entitled to coverage under a health benefit |
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plan. |
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Sec. 1369.202. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan, including a small |
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employer health benefit plan written under Chapter 1501 or coverage |
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provided by a health group cooperative under Subchapter B of that |
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chapter, that provides benefits for medical or surgical expenses |
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incurred as a result of a health condition, accident, or sickness, |
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including an individual, group, blanket, or franchise insurance |
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policy or insurance agreement, a group hospital service contract, |
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or an individual or group evidence of coverage or similar coverage |
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document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) an exchange operating under Chapter 942; |
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(6) a Lloyd's plan operating under Chapter 941; |
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(7) a health maintenance organization operating under |
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Chapter 843; |
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(8) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(9) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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(b) Notwithstanding any provision in Chapter 1551, 1575, |
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1579, or 1601 or any other law, this subchapter applies to: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; |
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(3) a primary care coverage plan under Chapter 1579; |
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and |
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(4) basic coverage under Chapter 1601. |
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Sec. 1369.203. EXCEPTION. This subchapter does not apply |
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to: |
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(1) a plan that provides coverage: |
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(A) only for fixed indemnity benefits for a |
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specified disease or diseases; |
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(B) only for accidental death or dismemberment; |
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(C) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(D) as a supplement to a liability insurance |
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policy; |
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(E) only for dental or vision care; or |
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(F) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
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(3) a workers' compensation insurance policy; |
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(4) medical payment insurance coverage provided under |
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an automobile insurance policy; |
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(5) a credit insurance policy; |
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(6) a limited benefit policy that does not provide |
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coverage for physical examinations or wellness exams; or |
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(7) a long-term care insurance policy, including a |
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nursing home fixed indemnity policy, unless the commissioner |
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determines that the policy provides benefit coverage so |
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comprehensive that the policy is a health benefit plan as described |
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by Section 1369.202. |
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Sec. 1369.204. REQUIRED COVERAGE FOR ORALLY ADMINISTERED |
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ANTICANCER MEDICATIONS. (a) A health benefit plan that provides |
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coverage for cancer treatment must provide coverage for a |
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prescribed, orally administered anticancer medication that is used |
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to kill or slow the growth of cancerous cells on a basis no less |
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favorable than intravenously administered or injected cancer |
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medications that are covered as medical benefits by the plan. |
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(b) This section does not prohibit a health benefit plan |
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from requiring prior authorization for an orally administered |
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anticancer medication. If an orally administered anticancer |
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medication is authorized, the patient's out-of-pocket costs may not |
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be greater than the out-of-pocket costs for an intravenously |
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administered anticancer medication. |
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(c) Before a health benefit plan issuer increases patients' |
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out-of-pocket costs for intravenously administered anticancer |
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medications under the plan, the plan issuer must file the proposed |
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increase with the department with evidence that shows the proposed |
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increase is directly related to and necessitated by an increase in |
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costs to the plan for intravenous medication. The commissioner may |
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deny the proposed increase if the plan issuer does not make the |
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showing required by this subsection. A proposed increase may not |
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violate Subsection (a) or (b). If the commissioner does not deny |
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the proposed increase before the 61st day after the date the |
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proposed increase is filed with the department, the proposed |
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increase is considered approved, and subject to Subsections (a) and |
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(b), the plan issuer may implement the proposed increase. |
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SECTION 2. Subchapter E, Chapter 1369, Insurance Code, as |
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added by this Act, applies only to a health benefit plan that is |
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delivered, issued for delivery, or renewed on or after January 1, |
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2012. A health benefit plan that is delivered, issued for delivery, |
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or renewed before January 1, 2012, is covered by the law in effect |
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at the time the plan was delivered, issued for delivery, or renewed, |
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and that law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2011. |