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Relating to certain fees charged for the adjudication of pharmacy benefit claims.
No significant fiscal implication to the State is anticipated.
No fiscal implication to units of local government is anticipated.
Section 1213.005 of the Texas Insurance Code currently prohibits health maintenance organizations (HMOs) and insurance companies that provide health benefit plans from charging a fee for the submission and adjudication of a healthcare claim. However, pharmacy benefit managers utilize loopholes in the current law to charge fees for adjudication of claims.
SB 94 would explicitly prevent a person who is an administrator for pharmacy benefits, otherwise known as a pharmacy benefit manager, from charging a pharmacist or pharmacy a fee when adjudicating a benefit claim.
The healthcare and health insurance industries are so heavily regulated that they operate in an environment that bears little to no resemblance to the free market. Because of the heavy regulation of almost every aspect of these industries, marketplace distortions and manipulations are common. Unfortunately, the normal self-correcting implements of a free market economy - from price signals to supply and demand responses to improved services through competition - range from substantially muted to nonexistent.
The only way to fix such distortions and manipulations in heavily regulated industries, short of wholesale deregulation (which would be preferable), is through further regulation. This band-aid approach of fixing regulation-induced problems with added regulation, while it may temporarily solve a problem, further propagates the cycle of marketplace confusion which leads to fewer choices, less innovation, and higher consumer prices.
While we understand the problem this measure is intended to fix, a better long term approach would be to substantially deregulate the industry and allow the natural remedies of the free market to take effect. We are neutral on SB 94.