Texas 2021 - 87th Regular

Texas House Bill HB942 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	87R586 SMT-F
2	2	By: Raymond H.B. No. 942
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the use of clinical decision support software and
8	8	laboratory benefits management programs in connection with the
9	9	provision of clinical laboratory services to certain managed care
10	10	plan enrollees.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Chapter 1451, Insurance Code, is amended by
13	13	adding Subchapter L to read as follows:
14	14	SUBCHAPTER L. CLINICAL LABORATORY SERVICES
15	15	Sec. 1451.551. DEFINITIONS. In this subchapter:
16	16	(1) "Clinical decision support software" means
17	17	computer software that compares patient characteristics to a
18	18	database of clinical knowledge to produce patient-specific
19	19	assessments or recommendations to assist a physician or health care
20	20	provider in making clinical decisions.
21	21	(2) "Clinical laboratory service" means the
22	22	examination of a specimen taken from a human body ordered by a
23	23	physician or health care provider for use in the diagnosis,
24	24	prevention, or treatment of a disease or the identification or
25	25	assessment of a medical or physical condition.
26	26	(3) "Enrollee" means an individual enrolled in a
27	27	managed care plan.
28	28	(4) "Esoteric molecular and genomic testing" means any
29	29	test of a patient specimen analyzing multiple biomarkers of
30	30	deoxyribonucleic acid, ribonucleic acid, or proteins using a unique
31	31	algorithm to yield a patient-specific prognosis or diagnosis.
32	32	(5) "Laboratory benefits management program" means a
33	33	managed care plan issuer protocol or program administered by the
34	34	managed care plan issuer or an entity under contract with the
35	35	managed care plan issuer that directs or limits decision making of a
36	36	physician or health care provider authorized to order clinical
37	37	laboratory services. The term includes a requirement for a
38	38	physician or health care provider to provide advance notice of an
39	39	order for clinical laboratory services.
40	40	(6) "Managed care plan" means a health benefit plan
41	41	under which health care services are provided to enrollees through
42	42	contracts with physicians or health care providers and that
43	43	requires enrollees to use participating providers or that provides
44	44	a different level of coverage for enrollees who use participating
45	45	providers. The term includes a health benefit plan issued by:
46	46	(A) a health maintenance organization;
47	47	(B) a preferred or exclusive provider benefit
48	48	plan issuer; or
49	49	(C) any other entity that issues a health benefit
50	50	plan described by this subdivision, including an insurance company.
51	51	(7) "National medical consensus guidelines" means
52	52	applicable generally accepted practice guidelines that are:
53	53	(A) supported by peer-reviewed medical
54	54	literature; and
55	55	(B) promulgated by the federal government or by a
56	56	national professional medical society, board, or association.
57	57	(8) "Participating provider" means a physician or
58	58	health care provider who has contracted with a managed care plan
59	59	issuer to provide services to enrollees.
60	60	(9) "Physician" means a person licensed to practice
61	61	medicine in this state.
62	62	Sec. 1451.552. CERTAIN REQUIREMENTS FOR CLINICAL
63	63	LABORATORY SERVICES PROHIBITED; EXCEPTION. (a) Except as provided
64	64	by Subsection (d), a managed care plan issuer may not require the
65	65	use of clinical decision support software or a laboratory benefits
66	66	management program by an enrollee's physician or health care
67	67	provider before, at the time, or after the physician or health care
68	68	provider orders a clinical laboratory service for the enrollee.
69	69	(b) A managed care plan issuer may not direct or limit the
70	70	decision making of an enrollee's physician or health care provider
71	71	relating to the referral of a patient specimen to a laboratory in
72	72	the managed care plan network or a network otherwise designated by
73	73	the managed care plan issuer.
74	74	(c) A managed care plan issuer may not limit, reduce, or
75	75	deny payment for a clinical laboratory service based on whether the
76	76	ordering physician or health care provider uses clinical decision
77	77	support software or a laboratory benefits management program.
78	78	(d) Subsection (a) does not apply to an order for a clinical
79	79	laboratory service if the specimen is not obtained in a hospital or
80	80	ambulatory surgical center and:
81	81	(1) the order is for esoteric molecular and genomic
82	82	testing; or
83	83	(2) there are national medical consensus guidelines
84	84	available for the clinical laboratory service ordered.
85	85	Sec. 1451.553. CERTAIN REQUIREMENTS FOR SECOND OPINION
86	86	PROHIBITED. A managed care plan issuer may not routinely require a
87	87	second opinion of a pathologist's finding from another pathologist
88	88	unless the second opinion is medically warranted based on the
89	89	specific clinical presentation of the enrollee or other clinical
90	90	factors relevant to the enrollee.
91	91	Sec. 1451.554. CLINICAL DECISION SUPPORT SOFTWARE AND
92	92	LABORATORY BENEFITS MANAGEMENT PROGRAM REQUIREMENTS. (a) A
93	93	managed care plan issuer may only use clinical decision support
94	94	software or a laboratory benefits management program that:
95	95	(1) is transparently based on published,
96	96	peer-reviewed medical literature;
97	97	(2) is subject to timely and routine updates based on
98	98	national medical consensus guidelines and the most current medical
99	99	knowledge; and
100	100	(3) may be immediately overridden by a physician based
101	101	on the physician's medical judgment.
102	102	(b) A managed care plan issuer may not use a laboratory
103	103	benefits management program that is administered, created, or owned
104	104	by an individual or entity with an interest in a clinical laboratory
105	105	in the managed care plan network.
106	106	Sec. 1451.555. SUPERVISION BY COMPARABLE PROFESSIONAL
107	107	REQUIRED. A managed care plan issuer may only use clinical decision
108	108	support software, a laboratory benefits management program, or a
109	109	prior authorization protocol for clinical laboratory services that
110	110	is supervised by a physician of the same or a similar specialty as
111	111	the ordering physician or health care provider.
112	112	Sec. 1451.556. APPLICABILITY OF SUBCHAPTER TO ENTITIES
113	113	CONTRACTING WITH MANAGED CARE PLAN ISSUER. This subchapter applies
114	114	to a person with whom a managed care plan issuer contracts to:
115	115	(1) manage or administer benefits for clinical
116	116	laboratory services;
117	117	(2) process or pay claims;
118	118	(3) obtain the services of physicians or other health
119	119	care providers to provide health care services to enrollees; or
120	120	(4) issue verifications or prior authorizations.
121	121	Sec. 1451.557. CONSTRUCTION OF SUBCHAPTER. This subchapter
122	122	may not be construed to regulate the implementation or
123	123	administration of clinical decision support software, a laboratory
124	124	benefits management program, or a prior authorization protocol by
125	125	an entity, including a health care entity, that is not acting on
126	126	behalf of or at the direction of a managed care plan issuer in
127	127	adopting the software, program, or protocol.
128	128	SECTION 2. Subchapter L, Chapter 1451, Insurance Code, as
129	129	added by this Act, applies only to a contract between a managed care
130	130	plan issuer and a physician or health care provider that is entered
131	131	into or renewed on or after the effective date of this Act. A
132	132	contract entered into or renewed before the effective date of this
133	133	Act is governed by the law as it existed immediately before the
134	134	effective date of this Act, and that law is continued in effect for
135	135	that purpose.
136	136	SECTION 3. This Act takes effect September 1, 2021.