28 TAC §§21.3002-21.3005
The Texas Department of Insurance proposes new §§21.3002-21.3005,
concerning pharmacy identification cards. The new sections implement the provisions
of Senate Bill (SB) 1237, as it amended Insurance Code Article 21.07-6, and
added Article 21.53L in Acts 1999, 76th Legislature.
The proposed new sections establish standardized information that must
be included on pharmacy identification cards of enrollees in a health benefit
plan containing prescription benefits. Prior to the enactment of legislation
under SB 1237, Texas law did not require issuers of health benefit plans or
pharmacy benefit managers (PBMs) or other administrators to issue pharmacy
identification cards or to include standardized information on enrollees'
pharmacy identification cards, which could result in delays and increased
costs in processing pharmacy benefit claims. As a result of SB 1237 and these
proposed sections, issuers of health benefit plans, administrators, or PBMs
are required to issue pharmacy identification cards and are required to standardize
the information included on the cards to help eliminate these problems.
Proposed §21.3002 sets forth definitions. Proposed §21.3003 sets
forth options that issuers of health benefit plans, PBMs, or administrators
may use when issuing standard identification cards to enrollees. This section
also lists the information that must be included on a standard identification
card for the card to comply with Texas law. The section clarifies that issuers
of health benefit plans, PBMs, or administrators are not prohibited from using
a magnetic strip or other technological component to transmit information
electronically, but still requires the standardized information to be physically
printed on the card. Proposed §21.3004 addresses issuance of identification
cards, and addresses situations in which an issuer of a health benefit plan
uses a PBM or other administrator. This proposed section also requires a PBM
or administrator that administers an issuer's health benefit plan, to enter
into an agreement with the issuer as to which party will issue the standard
identification card to enrollees. Proposed §21.3005 sets forth effective
dates for issuing standard identification cards in accordance with Section
6 of SB 1237.
Kim Stokes, Senior Associate Commissioner, Life, Health, and Licensing,
has determined that for each year of the first five years the proposed sections
will be in effect, there will be no fiscal impact to state and local governments
as a result of the enforcement or administration of the rule. There will be
no measurable effect on local employment or the local economy as a result
of the proposal.
Ms. Stokes has also determined that for each year of the first five years
the sections are in effect, the public benefits anticipated as a result of
the proposed sections will result in a more efficient and expeditious processing
of pharmacy claims because of the standardized information, reduced wait time
for enrollees who are having prescriptions filled, increased disclosure of
benefits to enrollees, and an increase in the amount of time pharmacists will
be able to spend filling prescriptions and advising patients. The persons
required to comply with the new sections will be issuers of health benefit
plans that provide coverage for pharmacy benefits, and administrators and
PBMs who administer pharmacy benefit claims and/or who issue pharmacy benefit
cards. The probable economic cost to these persons required to comply with
the new sections for each year of the first five years the proposed sections
will be in effect are the result of the legislative enactment of SB 1237,
and not the result of the adoption, enforcement, or administration of the
proposed new sections. It is the department's position that the adoption of
these proposed sections will have no adverse economic impact on issuers of
health benefit plans, and administrators or PBMs who are small and micro businesses.
The requirements of these sections are mandated by SB 1237, and considering
the statute's purposes, it is neither legal nor feasible to waive or modify
the requirement of these sections for such small and micro businesses, as
doing so would result in a disparate effect on persons utilizing standardized
pharmacy benefit cards.
To be considered, written comments on the proposal must be submitted no
later than 5:00 p.m. on August 14, 2000, to Lynda H. Nesenholtz, General Counsel
and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P.O. Box
149104, Austin, Texas, 78714-9104. An additional copy of the comment must
be simultaneously submitted to Diane Moellenberg, Chief Director, Regulatory
Development, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104,
Austin, Texas, 78714-9104. Any requests for a public hearing should be submitted
separately to the Office of the Chief Clerk.
The new sections are proposed under Insurance Code Articles 21.07-6,
21.53L, and §36.001. Article 21.07-6 provides that the commissioner may
adopt rules to implement the provisions of the article, and requires the commissioner
to adopt the standard information to be included on a standard identification
card. Article 21.53L provides that the commissioner shall adopt rules necessary
to implement the provisions of the article. Section 36.001 provides that the
Commissioner of Insurance may adopt rules for the conduct and execution of
the powers and duties of the department only as authorized by statute.
The following articles are affected by this proposal: Insurance Code Articles
21.07-6, 21.53L
§21.3002.Definitions; Pharmacy Identification Cards.
The following words and terms, when used in §§21.3002-21.3005
of this subchapter shall have the following meanings, unless the context clearly
indicates otherwise:
(1)
Administrator--As defined in Insurance Code Article 21.07-6, §1(1),
but does not include an administrator for a self-funded employee welfare benefit
plan covered by the federal Employee Retirement Income Security Act of 1974
(ERISA), 29 U.S.C. §1002(1)(A).
(2)
Drug--As defined in the Texas Pharmacy Act, Occupations
Code §551.003.
(3)
Drug formulary--A list of drugs for which a health benefit
plan provides coverage, approves payment, or encourages or offers incentives
for physicians or other health care providers to prescribe.
(4)
Enrollee--A person covered by a health benefit plan.
(5)
Enrollee identification card--A printed card issued to
enrollees of a health benefit plan that includes all necessary information
to allow an enrollee to access all coverage under the health benefit plan.
(6)
Health benefit plan--As described in Insurance Code Article
21.53L, including a health benefit plan providing coverage for pharmacy benefits
only. This definition includes the term, "plan," as defined in Insurance Code
Article 21.07-6, §1(6), but does not include a self-funded employee welfare
benefit plan covered by ERISA, 29 U.S.C. §1002(1)(A).
(7)
Identification code--Any unique code utilized by an issuer
of a health benefit plan, administrator, or pharmacy benefit manager that
identifies and differentiates amongst enrollees.
(8)
Issuer--Those entities identified in Insurance Code Article
21.53L, §2(a)(1)-(8).
(9)
Pharmacy benefit manager--As defined in Insurance Code
Article 21.07-6, §1(9), but does not include a pharmacy benefit manager
for a self-funded employee welfare benefit plan covered by ERISA, 29 U.S.C. §1002(1)(A).
(10)
Pharmacy benefits--Coverage in a health benefit plan for
prescription drugs that are ordinarily and customarily dispensed by a pharmacy
or pharmacist licensed under the Texas Pharmacy Act, Occupations Code §551.001
et seq.
(11)
Standard identification card--A printed card containing
the written information required by §21.3003(b) of this subchapter (relating
to Standard Identification Cards).
(12)
Subscriber--The individual who is the contract holder
and who is responsible for payment of premiums to the issuer of an individual
health benefit plan; or the individual who is the certificate holder and whose
employment or membership status, except for family dependency, is the basis
for eligibility for enrollment in a group health benefit plan.
§21.3003.Standard Identification Cards.
(a)
The issuer of a health benefit plan that provides pharmacy
benefits, or a pharmacy benefit manager or administrator issuing standard
identification cards to enrollees shall issue standard identification cards
as follows:
(1)
For a subscriber who is an enrollee, and has no enrolled
dependents, a single card shall be issued to the subscriber, with additional
cards available upon request.
(2)
For a subscriber who is an enrollee, and who has enrolled
dependents, either:
(A)
a card shall be issued to the subscriber and to each of
the enrolled dependents, with additional cards available upon request; or
(B)
two cards shall be issued to the subscriber for use by
the subscriber and all enrolled dependents, with additional cards available
upon request.
(3)
For coverage under an individual health benefit plan in
which the subscriber is not an enrollee, or for coverage under a group health
benefit plan which is continued by an enrollee pursuant to Insurance Code
Article 3.51-6, §3B, either:
(A)
a card shall be issued to each enrollee, with additional
cards available upon request; or
(B)
two cards shall be issued for use by all enrollees, with
additional cards available upon request.
(b)
Each standard identification card issued shall, at all
times the card is in effect, include current information as follows:
(1)
the enrolled subscriber's or enrolled dependents' names
and identification codes, as follows:
(A)
For cards issued pursuant to subsection (a)(1) of this
section, the enrolled subscriber's name and identification code;
(B)
For cards issued pursuant to subsection (a)(2)(A) of this
section, the enrolled subscriber's name and identification code on the enrolled
subscriber's card, and on each enrolled dependent's card, the name and identification
code of the enrolled dependent to whom the card will be issued;
(C)
For cards issued pursuant to subsection (a)(2)(B) of this
section, the names and identification codes of the enrolled subscriber and
the names and identification codes of all the enrolled dependents;
(D)
For cards issued pursuant to subsection (a)(3)(A) of this
section, on each enrolled dependent's card, the name and identification code
of the enrolled dependent to whom the card will be issued;
(E)
For cards issued pursuant to subsection (a)(3)(B) of this
section, the names and identification codes of all enrolled dependents;
(2)
if applicable, the name or logo of the issuer;
(3)
if applicable, the name or logo of the administrator or
pharmacy benefit manager for the health benefit plan;
(4)
as applicable, the group number applicable to the enrollee(s)
covered by a group health benefit plan or the policy number or evidence of
coverage number applicable to the enrollee(s) covered by an individual health
benefit plan;
(5)
the effective date of coverage;
(6)
a telephone number of the appropriate person for purposes
of obtaining information relating to the pharmacy benefits provided under
the health benefit plan;
(7)
the corresponding copayment or coinsurance for generic
and brand-name drugs; provided that, if the health benefit plan uses a drug
formulary with benefit levels in addition to generic and brand-name prescription
drugs, the card shall include the corresponding copayments or coinsurance
for each benefit level of the drug formulary; and
(8)
as applicable, the International Identification Number,
also known as the Banking Identification Number, assigned to the administrator
or pharmacy benefit manager by the American National Standards Institute.
(c)
Nothing in this section prohibits the issuer of a health
benefit plan, or an administrator or pharmacy benefit manager, from issuing
a standard identification card containing a magnetic strip or other technological
component enabling the electronic transmission of information, provided that
the information required by subsection (b) of this section is printed on the
card.
§21.3004.Issuance of Standard Identification Cards.
(a)
An issuer of a health benefit plan, or an administrator
or pharmacy benefit manager, is not required to issue a standard identification
card in addition to an enrollee identification card if:
(1)
the enrollee identification card contains the information
required by §21.3003(b) of this subchapter (relating to Standard Identification
Cards); and
(2)
the enrollee identification card is issued in accordance
with §21.3003(a) of this subchapter and subsections (c) and (d) of this
section.
(b)
Pursuant to subsection (a) of this section, if a standard
identification card is required to be issued, and an administrator or pharmacy
benefit manager administers a health benefit plan of an issuer, the administrator
or pharmacy benefit manager and the issuer shall enter into an agreement as
to which entity will issue the standard identification card in accordance
with this subchapter.
(c)
When an administrator or pharmacy benefit manager for a
health benefit plan is designated or required to issue a standard identification
card, the administrator or pharmacy benefit manager shall issue the standard
identification card in accordance with this subchapter not later than the
30th calendar day after the date the administrator or pharmacy benefit manager
receives notice from the issuer, or from the health benefit plan, that the
enrollee is eligible for the pharmacy benefits.
(d)
If the issuer of a health benefit plan is required to issue
a standard identification card, the issuer of the health benefit plan shall
issue the standard identification card in accordance with this subchapter
not later than the 30th calendar day after the enrollee is eligible for pharmacy
benefits.
§21.3005.Previously Issued Identification Cards.
(a)
If an enrollee holds an enrollee identification card or
other card used by the enrollee to access pharmacy benefits, and such card
was both in effect on September 1, 1999, and includes the information required
by §21.3003(b)(4), (5), (6), and (8) of this subchapter (relating to
Standard Identification Cards), an administrator or pharmacy benefit manager
for a health benefit plan is not required to issue a new standard identification
card pursuant to this subchapter that contains all the information required
by §21.3003(b)(1)-(8) of this subchapter until coverage under the health
benefit plan is modified or until a new card is issued to enrollees, whichever
occurs first.
(b)
If an enrollee holds an enrollee identification card, or
other card used by the enrollee to access pharmacy benefits, and such card
was both in effect on September 1, 1999, and includes the information required
by §21.3003(b)(4)-(6) of this subchapter, an issuer of a health benefit
plan issuing its own identification card is not required to issue a new standard
identification card pursuant to this subchapter that contains all the information
required by §21.3003(b)(1)-(8) of this subchapter until coverage under
the health benefit plan is modified or until a new card is issued to enrollees,
whichever occurs first.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on July 3, 2000.
TRD-200004619
Lynda Nesenholtz
General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: August 13, 2000
For further information, please call: (512) 463-6327