TX
Texas House Bill HB317

Texas 2019 - 86th Regular

Texas House Bill HB317 Compare Versions

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22 By: Raymond H.B. No. 317
3- Substitute the following for H.B. No. 317:
4- By: Lucio III C.S.H.B. No. 317
53
64
75 A BILL TO BE ENTITLED
86 AN ACT
97 relating to the use of clinical decision support software and
10- laboratory benefits management programs in connection with the
11- provision of clinical laboratory services to certain managed care
12- plan enrollees.
8+ laboratory benefits management programs by physicians and health
9+ care providers in connection with provision of clinical laboratory
10+ services to certain managed care plan enrollees.
1311 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1412 SECTION 1. Chapter 1451, Insurance Code, is amended by
1513 adding Subchapter L to read as follows:
16- SUBCHAPTER L. CLINICAL LABORATORY SERVICES
14+ SUBCHAPTER L. CLINICAL LABORATORIES
1715 Sec. 1451.551. DEFINITIONS. In this subchapter:
1816 (1) "Clinical decision support software" means
1917 computer software that compares patient characteristics to a
2018 database of clinical knowledge to produce patient-specific
2119 assessments or recommendations to assist a physician or health care
2220 provider in making clinical decisions.
2321 (2) "Clinical laboratory service" means the
2422 examination of a specimen taken from a human body ordered by a
2523 physician or health care provider for use in the diagnosis,
2624 prevention, or treatment of a disease or the identification or
2725 assessment of a medical or physical condition.
2826 (3) "Enrollee" means an individual enrolled in a
2927 managed care plan.
30- (4) "Esoteric molecular and genomic testing" means any
31- test of a patient specimen analyzing multiple biomarkers of
32- deoxyribonucleic acid, ribonucleic acid, or proteins using a unique
33- algorithm to yield a patient-specific prognosis or diagnosis.
34- (5) "Laboratory benefits management program" means a
28+ (4) "Laboratory benefits management program" means a
3529 managed care plan issuer protocol or program administered by the
3630 managed care plan issuer or another entity under contract with the
37- managed care plan issuer that directs or limits decision making of a
38- physician or health care provider authorized to order clinical
39- laboratory services. The term includes a requirement for a
40- physician or health care provider to provide advance notice of an
41- order for clinical laboratory services.
42- (6) "Managed care plan" means a health benefit plan
43- under which health care services are provided to enrollees through
44- contracts with physicians or health care providers and that
45- requires enrollees to use participating providers or that provides
46- a different level of coverage for enrollees who use participating
47- providers. The term includes a health benefit plan issued by:
48- (A) a health maintenance organization;
49- (B) a preferred or exclusive provider benefit
50- plan issuer; or
51- (C) any other entity that issues a health benefit
52- plan described by this subdivision, including an insurance company.
53- (7) "National medical consensus guidelines" means
54- applicable generally accepted practice guidelines that are:
55- (A) supported by peer-reviewed medical
56- literature; and
57- (B) promulgated by the federal government or by a
58- national professional medical society, board, or association.
59- (8) "Participating provider" means a physician or
60- health care provider who has contracted with a managed care plan
61- issuer to provide services to enrollees.
62- (9) "Physician" means a person licensed to practice
63- medicine in this state.
64- Sec. 1451.552. CERTAIN REQUIREMENTS FOR CLINICAL
65- LABORATORY SERVICES PROHIBITED; EXCEPTION. (a) Except as provided
66- by Subsection (d), a managed care plan issuer may not require the
67- use of clinical decision support software or a laboratory benefits
31+ managed care plan issuer that dictates, directs, or limits decision
32+ making of a physician or health care provider who is authorized to
33+ order clinical laboratory services.
34+ (5) "Managed care plan" means a health plan provided
35+ by a health maintenance organization under Chapter 843 or a
36+ preferred provider or exclusive provider plan provided by an
37+ insurer under Chapter 1301.
38+ (6) "Managed care plan issuer" means a health
39+ maintenance organization or an insurer that provides a managed care
40+ plan.
41+ Sec. 1451.552. CERTAIN REQUIREMENTS FOR USE OF CLINICAL
42+ LABORATORIES AND LABORATORY SERVICES PROHIBITED. (a) A managed
43+ care plan issuer may not by contract or otherwise require the use of
44+ clinical decision support software or a laboratory benefits
6845 management program by an enrollee's physician or health care
6946 provider before, at the time, or after the physician or health care
7047 provider orders a clinical laboratory service for the enrollee.
71- (b) A managed care plan issuer may not direct or limit the
72- decision making of an enrollee's physician or health care provider
73- relating to the referral of a patient specimen to a laboratory in
74- the managed care plan network or a network otherwise designated by
75- the managed care plan issuer.
76- (c) A managed care plan issuer may not limit, reduce, or
77- deny payment for a clinical laboratory service based on whether the
78- ordering physician or health care provider uses clinical decision
79- support software or a laboratory benefits management program.
80- (d) Subsection (a) does not apply to an order for a clinical
81- laboratory service if the specimen is not obtained in a hospital or
82- ambulatory surgical center and:
83- (1) the order is for esoteric molecular and genomic
84- testing; or
85- (2) there are national medical consensus guidelines
86- available for the clinical laboratory service ordered.
87- Sec. 1451.553. CERTAIN REQUIREMENTS FOR SECOND OPINION
88- PROHIBITED. A managed care plan issuer may not routinely require a
89- second opinion of a pathologist's finding from another pathologist
90- unless the second opinion is medically warranted based on the
91- specific clinical presentation of the enrollee or other clinical
92- factors relevant to the enrollee.
93- Sec. 1451.554. CLINICAL DECISION SUPPORT SOFTWARE AND
94- LABORATORY BENEFITS MANAGEMENT PROGRAM REQUIREMENTS. (a) A
95- managed care plan issuer may only use clinical decision support
96- software or a laboratory benefits management program that:
97- (1) is transparently based on published,
98- peer-reviewed medical literature;
99- (2) is subject to timely and routine updates based on
100- national medical consensus guidelines and the most current medical
101- knowledge; and
102- (3) may be immediately overridden by a physician based
103- on the physician's medical judgment.
104- (b) A managed care plan issuer may not use a laboratory
105- benefits management program that is administered, created, or owned
106- by an individual or entity with an interest in a clinical laboratory
107- in the managed care plan network.
108- Sec. 1451.555. SUPERVISION BY COMPARABLE PROFESSIONAL
109- REQUIRED. A managed care plan issuer may only use clinical decision
110- support software, a laboratory benefits management program, or a
111- prior authorization protocol for clinical laboratory services that
112- is supervised by a physician of the same or a similar specialty as
113- the ordering physician or health care provider.
114- Sec. 1451.556. APPLICABILITY OF SUBCHAPTER TO ENTITIES
48+ (b) A managed care plan issuer may not by contract or
49+ otherwise direct or limit an enrollee's physician or health care
50+ provider in the physician's or provider's clinical decision making
51+ relating to the use of a clinical laboratory service or the referral
52+ of a patient specimen to a clinical laboratory.
53+ (c) A managed care plan issuer may not by contract or
54+ otherwise require, steer, encourage, or otherwise direct an
55+ enrollee's physician or health care provider to refer a patient
56+ specimen to a particular clinical laboratory in the managed care
57+ plan's provider network designated by the managed care plan issuer
58+ other than the clinical laboratory in the network selected by the
59+ physician or health care provider.
60+ (d) A managed care plan issuer may not by contract or
61+ otherwise limit or deny payment of a claim for a clinical laboratory
62+ service based on whether the ordering physician or health care
63+ provider uses or fails to use clinical decision support software or
64+ a laboratory benefits management program.
65+ (e) Nothing in this section prohibits a managed care plan
66+ issuer from requiring a prior authorization for clinical laboratory
67+ services provided that the managed care plan issuer imposes the
68+ requirement uniformly to all laboratories providing clinical
69+ laboratory services in the managed care plan's provider network.
70+ Sec. 1451.553. APPLICABILITY OF SUBCHAPTER TO ENTITIES
11571 CONTRACTING WITH MANAGED CARE PLAN ISSUER. This subchapter applies
11672 to a person with whom a managed care plan issuer contracts to:
117- (1) manage or administer benefits for clinical
118- laboratory services;
73+ (1) manage or administer laboratory benefits;
11974 (2) process or pay claims;
120- (3) obtain the services of physicians or other health
121- care providers to provide health care services to enrollees; or
122- (4) issue verifications or prior authorizations.
123- Sec. 1451.557. CONSTRUCTION OF SUBCHAPTER. This subchapter
124- may not be construed to regulate the implementation or
125- administration of clinical decision support software, a laboratory
126- benefits management program, or a prior authorization protocol by
127- an entity, including a health care entity, that is not acting on
128- behalf of or at the direction of a managed care plan issuer in
129- adopting the software, program, or protocol.
75+ (3) obtain the services of physicians or other
76+ providers to provide health care services to enrollees; or
77+ (4) issue verifications or preauthorizations.
13078 SECTION 2. Subchapter L, Chapter 1451, Insurance Code, as
13179 added by this Act, applies only to a contract between a managed care
132- plan issuer and a physician or health care provider that is entered
133- into or renewed on or after the effective date of this Act. A
134- contract entered into or renewed before the effective date of this
135- Act is governed by the law as it existed immediately before the
136- effective date of this Act, and that law is continued in effect for
137- that purpose.
80+ plan issuer and a physician or provider that is entered into or
81+ renewed on or after the effective date of this Act. A contract
82+ entered into or renewed before the effective date of this Act is
83+ governed by the law as it existed immediately before the effective
84+ date of this Act, and that law is continued in effect for that
85+ purpose.
13886 SECTION 3. This Act takes effect September 1, 2019.