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.