84R11353 PMO-D
 
  By: Smithee H.B. No. 1624
 
  Substitute the following for H.B. No. 1624:
 
  By:  Sheets C.S.H.B. No. 1624
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to transparency of certain information related to certain
  health benefit plan coverage.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter B, Chapter 1369, Insurance Code, is
  amended by adding Sections 1369.0542, 1369.0543, and 1369.0544 to
  read as follows:
         Sec. 1369.0542.  FORMULARY INFORMATION ON INTERNET WEBSITE.
  (a) A health benefit plan issuer shall display on a public Internet
  website maintained by the issuer formulary information as required
  by the commissioner by rule. The information must be displayed in
  the template format developed under Section 1369.0543.
         (b)  A direct electronic link to the formulary information
  must be displayed in a conspicuous manner in the electronic summary
  of benefits and coverage of each health benefit plan issued by the
  health benefit plan issuer on the health benefit plan issuer's
  Internet website. The information must be publicly accessible to
  enrollees, prospective enrollees, and others without necessity of
  providing a password, a user name, or personally identifiable
  information.
         Sec. 1369.0543.  DEVELOPMENT OF TEMPLATE. (a) The
  department shall develop a template that all health benefit plan
  issuers must use to display formulary information as required by
  Section 1369.0542.
         (b)  The commissioner shall appoint a committee to advise the
  department on the development of the template, which must be
  electronically searchable by drug name and include:
               (1)  for each prescription drug included in the
  formulary that is subject to coinsurance and dispensed at an
  in-network pharmacy:
                     (A)  each enrollee's cost-sharing amount; or
                     (B)  a cost-sharing range, denoted as follows:
                           (i)  under $100 - $;
                           (ii)  $100-$250 - $$;
                           (iii)  $251-$500 - $$$;
                           (iv)  $501-$1,000 - $$$$; or
                           (v)  over $1,000 - $$$$$;
               (2)  a disclosure of prior authorization, step therapy,
  or other protocol requirements for each drug;
               (3)  if the health benefit plan uses a tier-based
  formulary, the specific tier for each drug listed in the formulary
  and the specific copayments for each tier as set out in the evidence
  of coverage;
               (4)  for prescription drugs covered under the health
  benefit plan and typically administered by a provider, any cost
  sharing for each drug;
               (5)  a description of how prescription drugs will
  specifically be included in or excluded from the deductible,
  including a description of out-of-pocket costs for a prescription
  drug that may not apply to the deductible;
               (6)  identification of preferred formulary drugs;
               (7)  an explanation of coverage of each formulary drug;
  and
               (8)  an indication of each formulary that applies to
  each health benefit plan issued by the issuer.
         (c)  The advisory committee shall be composed of an equal
  number of members from each of the following groups of
  stakeholders:
               (1)  physicians;
               (2)  health care providers other than physicians;
               (3)  consumers; and
               (4)  health benefit plan issuers.
         Sec. 1369.0544.  FORMULARY INFORMATION PROVIDED BY TOLL-FREE
  TELEPHONE NUMBER.  In addition to providing the information
  described by Section 1369.0543(b)(4), a health benefit plan issuer
  may make the information available to enrollees, prospective
  enrollees, and others through a toll-free telephone number that
  operates at least during normal business hours.
         SECTION 2.  Chapter 1451, Insurance Code, is amended by
  adding Subchapter K to read as follows:
  SUBCHAPTER K. HEALTH CARE PROVIDER DIRECTORIES
         Sec. 1451.501.  DEFINITIONS. In this subchapter:
               (1)  "Health care provider" means a practitioner,
  institutional provider, or other person or organization that
  furnishes health care services and that is licensed or otherwise
  authorized to practice in this state. The term includes a
  pharmacist, pharmacy, hospital, nursing home, or other medical or
  health-related service facility that provides care for the sick or
  injured or other care. The term does not include a physician.
               (2)  "Physician" means an individual licensed to
  practice medicine in this state.
         Sec. 1451.502.  APPLICABILITY OF SUBCHAPTER.  This
  subchapter applies only to a health benefit plan that provides
  benefits for medical or surgical expenses incurred as a result of a
  health condition, accident, or sickness, including an individual,
  group, blanket, or franchise insurance policy or insurance
  agreement, a group hospital service contract, or a small or large
  employer group contract or similar coverage document that is
  offered by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a fraternal benefit society operating under
  Chapter 885;
               (4)  a stipulated premium company operating under
  Chapter 884;
               (5)  a reciprocal exchange operating under Chapter 942;
               (6)  a health maintenance organization operating under
  Chapter 843;
               (7)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846; or
               (8)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844.
         Sec. 1451.503.  EXCEPTION. This subchapter does not apply
  to:
               (1)  a health benefit plan that provides coverage:
                     (A)  only for a specified disease or for another
  single benefit;
                     (B)  only for accidental death or dismemberment;
                     (C)  for wages or payments in lieu of wages for a
  period during which an employee is absent from work because of
  sickness or injury;
                     (D)  as a supplement to a liability insurance
  policy;
                     (E)  for credit insurance;
                     (F)  only for dental or vision care;
                     (G)  only for hospital expenses; or
                     (H)  only for indemnity for hospital confinement;
               (2)  a Medicare supplemental policy as defined by
  Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
  as amended;
               (3)  a workers' compensation insurance policy;
               (4)  medical payment insurance coverage provided under
  a motor vehicle insurance policy;
               (5)  a long-term care insurance policy, including a
  nursing home fixed indemnity policy, unless the commissioner
  determines that the policy provides benefit coverage so
  comprehensive that the policy is a health benefit plan as described
  by Section 1451.502;
               (6)  the child health plan program under Chapter 62,
  Health and Safety Code, or the health benefits plan for children
  under Chapter 63, Health and Safety Code; or
               (7)  a Medicaid managed care program operated under
  Chapter 533, Government Code, or a Medicaid program operated under
  Chapter 32, Human Resources Code.
         Sec. 1451.504.  PHYSICIAN AND HEALTH CARE PROVIDER
  DIRECTORIES. (a) A health benefit plan issuer that offers coverage
  for health care services through preferred providers, exclusive
  providers, or a network of physicians or health care providers
  shall develop and maintain a physician and health care provider
  directory in accordance with this subchapter.
         (b)  The directory must include the name, street address, and
  telephone number of each physician and health care provider
  described by Subsection (a) and indicate whether the physician or
  provider is accepting new patients.
         Sec. 1451.505.  PHYSICIAN AND HEALTH CARE PROVIDER DIRECTORY
  ON INTERNET WEBSITE. (a) A health benefit plan issuer shall display
  on a public Internet website maintained by the issuer the directory
  required by Section 1451.504. A direct electronic link to the
  directory must be displayed in a conspicuous manner in the
  electronic summary of benefits and coverage of each health benefit
  plan issued by the health benefit plan issuer on the Internet
  website.
         (b)  The health benefit plan issuer shall clearly indicate in
  the directory each health benefit plan issued by the issuer that may
  provide coverage for services provided by each physician or health
  care provider included in the directory.
         (c)  The directory must be:
               (1)  electronically searchable by physician or health
  care provider name and location; and
               (2)  publicly accessible without necessity of
  providing a password, a user name, or personally identifiable
  information.
         (d)  The health benefit plan issuer shall conduct an ongoing
  review of the directory and correct or update the information as
  necessary. Except as provided by Subsection (e), corrections and
  updates, if any, must be made not less than once each month.
         (e)  The health benefit plan issuer shall conspicuously
  display in the directory required by Section 1451.504 an e-mail
  address and a toll-free telephone number to which any individual
  may report any inaccuracy in the directory. If the issuer receives a
  report from any person that specifically identified directory
  information may be inaccurate, the issuer shall investigate the
  report and correct the information, as necessary, not later than
  the seventh day after the date the report is received.
         SECTION 3.  The commissioner of insurance shall ensure that
  the template developed under Section 1369.0543, Insurance Code, as
  added by this Act, is available for initial use under Section
  1369.0542, Insurance Code, as added by this Act, not later than
  January 1, 2016.
         SECTION 4.  This Act applies only to a health benefit plan
  that is delivered, issued for delivery, or renewed on or after
  January 1, 2016. A plan delivered, issued for delivery, or renewed
  before January 1, 2016, is governed by the law as it existed
  immediately before the effective date of this Act, and that law is
  continued in effect for that purpose.
         SECTION 5.  This Act takes effect September 1, 2015.