85R13805 SMT-F
By: Raymond H.B. No. 3990
A BILL TO BE ENTITLED
AN ACT
relating to the use of clinical decision support software and
laboratory benefits management programs by physicians and health
care providers in connection with provision of clinical laboratory
services to certain managed care plan enrollees.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1451, Insurance Code, is amended by
adding Subchapter M to read as follows:
SUBCHAPTER M. CLINICAL LABORATORIES
Sec. 1451.601. DEFINITIONS. (a) In this subchapter:
(1) "Clinical decision support software" means
computer software that compares patient characteristics to a
database of clinical knowledge to produce patient-specific
assessments or recommendations to assist a physician or health care
provider in making clinical decisions.
(2) "Clinical laboratory service" means the
examination of a sample of fluid or other material taken from a
human body ordered by a physician or health care provider for use in
the diagnosis, prevention, or treatment of a disease or the
identification or assessment of a medical or physical condition.
(3) "Enrollee" means an individual enrolled in a
managed care plan.
(4) "Laboratory benefits management program" means a
managed care plan issuer protocol or program administered by the
managed care plan issuer or another entity under contract with the
managed care plan issuer that dictates, directs, or limits decision
making of a physician or health care provider who is authorized to
order clinical laboratory services.
(5) "Managed care plan" means a health plan provided
by a health maintenance organization under Chapter 843 or a
preferred provider or exclusive provider plan provided by an
insurer under Chapter 1301.
(6) "Managed care plan issuer" means a health
maintenance organization or an insurer that provides a managed care
plan.
Sec. 1451.602. CERTAIN REQUIREMENTS FOR USE OF CLINICAL
LABORATORIES AND LABORATORY SERVICES PROHIBITED. (a) A managed
care plan issuer may not by contract or otherwise require the use of
clinical decision support software or a laboratory benefits
management program by an enrollee's physician or health care
provider before, at the time, or after the physician or health care
provider orders a clinical laboratory service for the enrollee.
(b) A managed care plan issuer may not by contract or
otherwise direct or limit an enrollee's physician or health care
provider in the physician's or provider's clinical decision making
relating to the use of a clinical laboratory service or the referral
of a patient specimen to a clinical laboratory.
(c) A managed care plan issuer may not by contract or
otherwise require, steer, encourage, or otherwise direct an
enrollee's physician or health care provider to refer a patient
specimen to a particular clinical laboratory in the managed care
plan network designated by the managed care plan issuer other than
the clinical laboratory in the network selected by the physician or
health care provider.
(d) A managed care plan issuer may not by contract or
otherwise limit or deny payment of a claim for a clinical laboratory
service based on whether the ordering physician or health care
provider uses or fails to use clinical decision support software or
a laboratory benefits management program.
(e) Nothing in this section prohibits a managed care plan
issuer from requiring a prior authorization for clinical laboratory
services provided that the managed care plan issuer imposes the
requirement uniformly to all laboratories providing clinical
laboratory services in the managed care plan's provider network.
Sec. 1451.603. APPLICABILITY OF SUBCHAPTER TO ENTITIES
CONTRACTING WITH MANAGED CARE PLAN ISSUER. This subchapter applies
to a person to whom a managed care plan issuer contracts to:
(1) manage or administer laboratory benefits;
(2) process or pay claims;
(3) obtain the services of physicians or other
providers to provide health care services to enrollees; or
(4) issue verifications or preauthorizations.
SECTION 2. Subchapter M, Chapter 1451, Insurance Code, as
added by this Act, applies only to a contract between a managed care
plan and a physician or provider that is entered into or renewed on
or after the effective date of this Act. A contract entered into or
renewed before the effective date of this Act 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 3. This Act takes effect September 1, 2017.