Benefits Related Related Legislation »

HB 806 by Gallego/Zaffirini - Relating to health benefit plan coverage for certain prosthetic devices, orthotic devices, and related services. HB 806 is applicable to the HMOs and PPOs used by the A&M System. The legislation states that the plans must provide coverage for prosthetic devices, orthotic devices, and professional services equal to coverage provided under federal laws for health insurance for the aged and disabled. Covered benefits are limited to the most appropriate model of device that adequately meets the medical needs of the enrollee as determined by the enrollee's treating physician. Subject to applicable copayments and deductibles, the repair and replacement of a prosthetic device or orthotic device is a covered benefit under this chapter unless the repair or replacement is necessitated by misuse or loss by the enrollee. Coverage may be subject to annual deductibles, copayments, and coinsurance that are consistent with annual deductibles, copayments, and coinsurance required for other coverage under the health benefit plan; and may not be subject to annual dollar limits.

HB 1138 by Shelton/Davis - Relating to information required on pharmacy benefit cards.

The bill would require certain healthcare plans (inclusive of the A&M System health benefit plan) to provide certain information; the additional information would include: the name of the entity administering the pharmacy benefits if the entity is different from the health benefit plan issuer; the group number applicable to the enrollee; an identification number for the enrollee, which may not be the enrollee's social security number; the bank identification number necessary for electronic billing; the effective date of the coverage evidenced by the card; and copayment information for generic and brand name prescription drugs. The bill would be effective September 1, 2009 and would apply to coverage issued or renewed after on or after January 1, 2010.

HB 1290 by Oliviera/Lucio - Relating to health benefit plan coverage for bariatric surgery and for certain tests for the early detection of cardiovascular disease. HB 1290 stipulates that a health benefit plan (including the A&M System health benefit plan) must provide the minimum coverage required to males older than 45 years of age and younger than 76 years of age and females older than 55 years of age and younger than 76 years of age; and those who are diabetic or have a risk of developing coronary heart disease.

The minimum requirement is coverage of up to $200 for one of the following tests every five years:

(1) computed tomography (CT) scanning measuring coronary artery calcification; or

(2) ultrasonography measuring carotid intima-media thickness and plaque.

The Section of the bill that applies to ERS employees regarding coverage for bariatric surgery is already covered under the A&M System plan.

HB 1342 by Mendenez/Harris - Relating to adoption of certain information technology. HB 1342 will require health benefits plans (including the A&M System health benefit plan) to use information technology to provide participating providers with real-time information at the point of care concerning the enrollee's copayment and coinsurance; applicable deductibles; and covered benefits and services; and the enrollee's estimated total financial responsibility for the care.

A physician, hospital, or other health care provider that receives an overpayment from an enrollee must refund the amount of the overpayment to the enrollee not later than the 30th day after the date the physician, hospital, or health care provider determines that an overpayment has been made.

HB 2000 by McCall / Van de Putte - Relating to health benefit plan coverage for certain amino acid-based elemental formulas. HB 2000 requires that a health benefit plan (including the A&M System health benefit plan)must provide coverage for amino acid-based elemental formulas, regardless of the formula delivery method, that are used for the diagnosis and treatment of: (1) immunoglobulin E and non-immunoglobulin E mediated allergies to multiple food proteins; (2) severe food protein-induced enterocolitis syndrome; (3) eosinophilic disorders, as evidenced by the results of a biopsy; and (4) impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract.

The coverage should be provided on a basis no less favorable than the basis on which prescription drugs and other medications and related services are covered by the plan.

HB 3347 by Truitt / Duncan - Relating to plan qualification provisions for and certain supplemental payments and health insurance deductions under the Teacher Retirement System of Texas. HB 3347 changes state law in the TRS plan to include "differential pay" for active duty military under the federal "Heroes Act" (Heroes Earnings Assistance and Relief Tax Act of 2008). The bill also conforms state law to federal law for members who die while performing active military duty and their survivors. The bill also allows a non-spouse beneficiary to rollover an eligible distribution to an IRA and makes additional updates needed to keep TRS rollover provisions consistent with federal rollover provisions.

The bill allows for the withholding of health insurance premiums for eligible retired public safety officers participating in the University of Texas System and Texas A&M University System retiree health programs from their Teacher Retirement System (TRS) retirement annuities. Retirees would need to meet the requirements of Section 845 of the Pension Protection Act of 2006 or a similar law to exclude from annual gross income up to $3,000 of distributions from an eligible retirement plan used for qualified health insurance premiums.

The bill also allows the TRS board of Trustees to make a one-time payment to qualified retired public school employees in an amount equivalent to the annuitant's monthly benefit, not to exceed $500. The one-time payment is payable only if General Revenue funds are appropriated and may not be paid from pension trust funds.

HB 4402 by Martinez Fischer / Van de Putte - Relating to a study regarding insurance coverage of prescription drugs provided under a health benefit plan. HB 4402 requires that the Texas Department of Insurance will conduct a study to evaluate the ways in which pharmacy benefit managers use prescription drug information to manage therapeutic drug interchange programs and other drug substitution recommendations made by pharmacy benefit managers. It is likely that the Department will require information from the A&M System throughout the year to perform this study.

SB 39 by Zaffirini / Zerwas - Relating to health benefit plan coverage for routine patient care costs for enrollees participating in certain clinical trials. SB 39 requires that a health benefit plan issuer (including the A&M System benefit plan) shall provide benefits for routine patient care costs to an enrollee in connection with a phase I, phase II, phase III, or phase IV clinical trial if the clinical trial is conducted in relation to the prevention, detection, or treatment of a life-threatening disease or condition. Routine patient care costs means the costs of any medically necessary health care service for which benefits are provided under a health benefit plan, without regard to whether the enrollee is participating in a clinical trial. Routine patient care costs do not include an investigational new drug or device that is not approved for any indication by the United States Food and Drug Administration, or the cost of a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis or a health care service that is specifically excluded from coverage under a health benefit plan.

A health benefit plan issuer is not required to provide benefits under this section for services that are a part of a clinical trial and that are customarily paid for by the research institution conducting the clinical trial. The benefits required under this chapter may be subject to a deductible, coinsurance, or copayment requirement comparable to other those for other services under the health benefit plan.

SB 704 by Nelson/Kolkhorst - Relating to the regulation of pharmacy benefit managers and mail order pharmacies. SB 704 requires that a state agency (including the A&M System) on request of another state agency shall disclose information relating to the amounts charged by a pharmacy benefit manager for pharmacy benefit manager services and other requested pricing information related to a contract for pharmacy benefit manager services. This does not require a state agency to disclose information the agency is specifically prohibited from disclosing under a contract with a pharmacy benefit manager executed before September 1, 2009. The information received by a state agency under this subchapter may not be disclosed to a person outside of the state agency or its agents.

In awarding a contract to provide pharmacy benefit manager services under this chapter, the contract must state that: 1) the system is entitled to audit the pharmacy benefit manager to verify costs and discounts associated with drug claims, pharmacy benefit manager compliance with contract requirements, and services provided by subcontractors; (2) the audit must be conducted by an independent auditor in accordance with established auditing standards; and (3) to conduct the audit, the system and the independent auditor are entitled access to information related to the services and the costs associated with the services performed under the contract, including access to the pharmacy benefit manager's facilities, records, contracts, medical records, and agreements with subcontractors.

The contract must define the information that the pharmacy benefit manager is required to provide to the system concerning the audit of the retail, independent, and mail order pharmacies performing services under the contract and describe how the results of these audits must be reported to the system, including how often the results must be reported.

SB 1143 by Carona/McCall - Relating to requirements regarding employer liability for certain group health benefit plan premiums and to a health benefits study to be conducted by the Texas Department of Insurance. SB 1143 is a follow-up to last session's SB 51 that holds the employer liable for an enrollee's premiums from the time the enrollee is no longer part of the group eligible for coverage under the contract until the end of the month in which the contract holder notifies the health maintenance organization that the enrollee is no longer part of the group eligible for coverage by the contract; and the enrollee remains covered by the contract until the end of that period. SB 1143 expands these rules & regulations to PPOs; however, interpretation on its applicability upon self-insured groups is underway.