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A BILL TO BE ENTITLED
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AN ACT
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relating to the use of clinical decision support software and |
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laboratory benefits management programs by physicians and health |
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care providers in connection with provision of clinical laboratory |
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services to certain managed care plan enrollees. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1451, Insurance Code, is amended by |
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adding Subchapter L to read as follows: |
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SUBCHAPTER L. CLINICAL LABORATORIES |
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Sec. 1451.551. DEFINITIONS. In this subchapter: |
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(1) "Clinical decision support software" means |
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computer software that compares patient characteristics to a |
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database of clinical knowledge to produce patient-specific |
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assessments or recommendations to assist a physician or health care |
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provider in making clinical decisions. |
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(2) "Clinical laboratory service" means the |
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examination of a specimen taken from a human body ordered by a |
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physician or health care provider for use in the diagnosis, |
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prevention, or treatment of a disease or the identification or |
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assessment of a medical or physical condition. |
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(3) "Enrollee" means an individual enrolled in a |
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managed care plan. |
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(4) "Laboratory benefits management program" means a |
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managed care plan issuer protocol or program administered by the |
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managed care plan issuer or another entity under contract with the |
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managed care plan issuer that dictates, directs, or limits decision |
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making of a physician or health care provider who is authorized to |
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order clinical laboratory services. |
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(5) "Managed care plan" means a health plan provided |
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by a health maintenance organization under Chapter 843 or a |
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preferred provider or exclusive provider plan provided by an |
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insurer under Chapter 1301. |
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(6) "Managed care plan issuer" means a health |
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maintenance organization or an insurer that provides a managed care |
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plan. |
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Sec. 1451.552. CERTAIN REQUIREMENTS FOR USE OF CLINICAL |
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LABORATORIES AND LABORATORY SERVICES PROHIBITED. (a) A managed |
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care plan issuer may not by contract or otherwise require the use of |
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clinical decision support software or a laboratory benefits |
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management program by an enrollee's physician or health care |
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provider before, at the time, or after the physician or health care |
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provider orders a clinical laboratory service for the enrollee. |
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(b) A managed care plan issuer may not by contract or |
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otherwise direct or limit an enrollee's physician or health care |
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provider in the physician's or provider's clinical decision making |
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relating to the use of a clinical laboratory service or the referral |
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of a patient specimen to a clinical laboratory. |
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(c) A managed care plan issuer may not by contract or |
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otherwise require, steer, encourage, or otherwise direct an |
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enrollee's physician or health care provider to refer a patient |
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specimen to a particular clinical laboratory in the managed care |
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plan's provider network designated by the managed care plan issuer |
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other than the clinical laboratory in the network selected by the |
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physician or health care provider. |
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(d) A managed care plan issuer may not by contract or |
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otherwise limit or deny payment of a claim for a clinical laboratory |
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service based on whether the ordering physician or health care |
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provider uses or fails to use clinical decision support software or |
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a laboratory benefits management program. |
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(e) Nothing in this section prohibits a managed care plan |
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issuer from requiring a prior authorization for clinical laboratory |
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services provided that the managed care plan issuer imposes the |
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requirement uniformly to all laboratories providing clinical |
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laboratory services in the managed care plan's provider network. |
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Sec. 1451.553. APPLICABILITY OF SUBCHAPTER TO ENTITIES |
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CONTRACTING WITH MANAGED CARE PLAN ISSUER. This subchapter applies |
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to a person with whom a managed care plan issuer contracts to: |
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(1) manage or administer laboratory benefits; |
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(2) process or pay claims; |
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(3) obtain the services of physicians or other |
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providers to provide health care services to enrollees; or |
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(4) issue verifications or preauthorizations. |
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SECTION 2. Subchapter L, Chapter 1451, Insurance Code, as |
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added by this Act, applies only to a contract between a managed care |
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plan issuer and a physician or provider that is entered into or |
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renewed on or after the effective date of this Act. A contract |
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entered into or renewed before the effective date of this Act is |
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governed by the law as it existed immediately before the effective |
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date of this Act, and that law is continued in effect for that |
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purpose. |
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SECTION 3. This Act takes effect September 1, 2019. |