88R13793 RDS-F
 
  By: Thompson of Harris H.B. No. 5211
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health benefit plan coverage for certain medically
  necessary therapeutic nutritional formulas.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  The heading to Chapter 1377, Insurance Code, is
  amended to read as follows:
  CHAPTER 1377. COVERAGE FOR CERTAIN NUTRITIONAL [AMINO ACID-BASED
  ELEMENTAL] FORMULAS
         SECTION 2.  The heading to Subchapter B, Chapter 1377,
  Insurance Code, is amended to read as follows:
  SUBCHAPTER B. REQUIRED COVERAGE [FOR CERTAIN AMINO ACID-BASED
  ELEMENTAL FORMULAS]
         SECTION 3.  Section 1377.051, Insurance Code, is amended to
  read as follows:
         Sec. 1377.051.  REQUIRED COVERAGE FOR CERTAIN NUTRITIONAL
  [AMINO ACID-BASED ELEMENTAL] FORMULAS. (a) A health benefit plan
  must provide coverage as provided by this chapter 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.
         (b)  In addition to the coverage required under Subsection
  (a) and subject to Subsection (d), a health benefit plan must
  provide coverage for a therapeutic nutritional formula if the
  treating physician has issued a written order stating that the
  formula is medically necessary, including for the treatment of an
  enrollee at risk for growth or developmental delays.
         (c)  Subject to Subsection (d) [(c)], the coverage required
  under Subsection (a) is required if the treating physician has
  issued a written order stating that the amino acid-based elemental
  formula is medically necessary for the treatment of an enrollee who
  is diagnosed with a disease or disorder listed in Subsection (a).
  The coverage must include coverage of any medically necessary
  services associated with the administration of the formula.
         (d) [(c)]  A health benefit plan must provide the coverage
  described by Subsections [Subsection] (a) and (b) on a basis no less
  favorable than the basis on which prescription drugs and other
  medications and related services are covered by the plan, and to the
  same extent that the plan provides coverage for drugs that are
  available only on the orders of a physician.
         SECTION 4.  Section 1377.052(a), Insurance Code, is amended
  to read as follows:
         (a)  A utilization review agent acting on behalf of a health
  benefit plan issuer may review a treating physician's determination
  of the medical necessity of the use of:
               (1)  an amino acid-based elemental formula for the
  treatment of an enrollee who is diagnosed with a disease or disorder
  listed in Section 1377.051(a); or
               (2)  a nutritional formula under Section 1377.051(b).
         SECTION 5.  The changes in law made by this Act apply only to
  a health benefit plan that is delivered, issued for delivery, or
  renewed on or after January 1, 2024. A health benefit plan that is
  delivered, issued for delivery, or renewed before January 1, 2024,
  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 6.  This Act takes effect September 1, 2023.