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A BILL TO BE ENTITLED
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AN ACT
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relating to the creation of a standard request form for prior |
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authorization of prescription drug benefits. |
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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 F to read as follows: |
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SUBCHAPTER F. STANDARD REQUEST FORM FOR PRIOR AUTHORIZATION OF |
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PRESCRIPTION DRUG BENEFITS |
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Sec. 1369.251. DEFINITION. In this subchapter, |
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"prescription drug" has the meaning assigned by Section 551.003, |
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Occupations Code. |
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Sec. 1369.252. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or a small or large |
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employer group contract or similar coverage document that is |
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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) a reciprocal exchange operating under Chapter 942; |
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(6) a health maintenance organization operating under |
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Chapter 843; |
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(7) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(8) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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(b) This subchapter applies to group health coverage made |
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available by a school district in accordance with Section 22.004, |
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Education Code. |
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(c) Notwithstanding Section 172.014, Local Government Code, |
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or any other law, this subchapter applies to health and accident |
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coverage provided by a risk pool created under Chapter 172, Local |
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Government Code. |
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(d) 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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(e) Notwithstanding any other law, this subchapter applies |
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to medical benefits provided to an injured employee under a |
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workers' compensation insurance policy or otherwise under Title 5, |
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Labor Code. |
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(f) Notwithstanding any other law, this subchapter applies |
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to coverage under: |
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(1) the child health plan program under Chapter 62, |
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Health and Safety Code, or the health benefits plan for children |
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under Chapter 63, Health and Safety Code; and |
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(2) the medical assistance program under Chapter 32, |
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Human Resources Code. |
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Sec. 1369.253. EXCEPTION. This subchapter does not apply |
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to: |
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(1) a health benefit plan that provides coverage: |
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(A) only for a specified disease or for another |
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single benefit; |
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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) for credit insurance; |
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(F) only for dental or vision care; |
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(G) only for hospital expenses; or |
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(H) 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) medical payment insurance coverage provided under |
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a motor vehicle insurance policy; or |
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(4) 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 1369.252. |
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Sec. 1369.254. STANDARD FORM. (a) The commissioner by rule |
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shall: |
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(1) prescribe a single, standard form for requesting |
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prior authorization of prescription drug benefits; |
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(2) require a health benefit plan issuer or the agent |
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of the health benefit plan issuer that manages or administers |
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prescription drug benefits to use the form for any prior |
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authorization of prescription drug benefits required by the plan; |
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(3) require that the department and a health benefit |
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plan issuer or the agent of the health benefit plan issuer that |
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manages or administers prescription drug benefits make the form |
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available electronically; and |
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(4) allow a completed form to be submitted |
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electronically by the prescribing provider to the health benefit |
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plan issuer or the agent of the health benefit plan issuer that |
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manages or administers prescription drug benefits. |
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(b) In prescribing a form under this section, the |
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commissioner shall: |
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(1) limit the form, as printed, to not more than two |
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pages; |
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(2) develop the form with input from the advisory |
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committee on uniform prior authorization forms established under |
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Section 1369.255; and |
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(3) take into consideration: |
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(A) any form for requesting prior authorization |
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of benefits that is widely used in this state or any form currently |
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used by the department; |
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(B) request forms for prior authorization of |
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benefits established by the federal Centers for Medicare and |
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Medicaid Services; and |
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(C) national standards, or draft standards, |
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pertaining to electronic prior authorization of benefits. |
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Sec. 1369.255. ADVISORY COMMITTEE ON UNIFORM PRIOR |
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AUTHORIZATION FORMS. (a) The commissioner shall appoint a |
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committee to advise the commissioner on the technical, operational, |
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and practical aspects of developing the single, standard prior |
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authorization form required under Section 1369.254 for requesting |
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prior authorization of prescription drug benefits. |
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(b) The commissioner shall consult the committee with |
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respect to any rule relating to a subject described by Section |
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1369.254 before adopting the rule. |
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(c) The committee shall be composed of an equal number of |
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members from each of the following groups: |
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(1) physicians; |
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(2) other prescribing health care providers; |
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(3) hospitals; |
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(4) pharmacists; |
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(5) pharmacy benefit managers; and |
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(6) health benefit plans. |
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(d) A member of the advisory committee serves without |
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compensation. |
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(e) Section 39.003(a) of this code and Chapter 2110, |
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Government Code, do not apply to the advisory committee. |
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Sec. 1369.256. FAILURE TO USE OR RESPOND TO STANDARD FORM. |
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If a health benefit plan issuer or the agent of the health benefit |
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plan issuer that manages or administers prescription drug benefits |
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fails to use or accept the form prescribed under this subchapter or |
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fails to respond within two business days of receipt to a completed |
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form submitted by a prescribing provider, the prior authorization |
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is considered granted by the health benefit plan. |
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SECTION 2. Not later than January 1, 2014, the commissioner |
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of insurance by rule shall prescribe a standard form under Section |
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1369.254, Insurance Code, as added by this Act. |
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SECTION 3. The change in law made by this Act applies only |
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to a request for prior authorization of prescription drug benefits |
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made on or after March 1, 2014. A request for prior authorization |
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of prescription drug benefits made before March 1, 2014, under a |
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health benefit plan delivered, issued for delivery, or renewed |
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before that date is governed by the law in effect immediately before |
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the effective date of this Act, and that law is continued in effect |
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for that purpose. |
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SECTION 4. This Act takes effect September 1, 2013. |