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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for certain biomarker |
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testing. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle E, Title 8, Insurance Code, is amended |
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by adding Chapter 1372 to read as follows: |
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CHAPTER 1372. COVERAGE FOR BIOMARKER TESTING |
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Sec. 1372.001. DEFINITIONS. In this chapter: |
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(1) "Biomarker" means a characteristic that is |
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objectively measured and evaluated as an indicator of normal |
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biological processes, pathogenic processes, or pharmacologic |
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responses to a specific therapeutic intervention. The term |
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includes: |
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(A) gene mutations; and |
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(B) protein expression. |
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(2) "Biomarker testing" means the analysis of a |
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patient's tissue, blood, or other biospecimen for the presence of a |
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biomarker. The term includes: |
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(A) single-analyte tests; |
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(B) multiplex panel tests; and |
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(C) whole genome sequencing. |
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(3) "Consensus statements" means statements that: |
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(A) address specific clinical circumstances |
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based on the best available evidence for the purpose of optimizing |
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clinical care outcomes; and |
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(B) are developed by an independent, |
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multidisciplinary panel of experts that uses a transparent |
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methodology and reporting structure and is subject to a conflict of |
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interest policy. |
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(4) "Nationally recognized clinical practice |
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guidelines" means evidence-based clinical practice guidelines |
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that: |
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(A) establish a standard of care informed by a |
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systematic review of evidence and an assessment of the benefits and |
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costs of alternative care options; |
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(B) include recommendations intended to optimize |
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patient care; and |
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(C) are developed by an independent organization |
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or medical professional society that uses a transparent methodology |
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and reporting structure and is subject to a conflict of interest |
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policy. |
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Sec. 1372.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or an individual or group evidence |
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of coverage or similar coverage document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this chapter applies to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) a basic coverage plan under Chapter 1551; |
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(4) a basic plan under Chapter 1575; |
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(5) a primary care coverage plan under Chapter 1579; |
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(6) a plan providing basic coverage under Chapter |
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1601; |
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(7) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(8) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(9) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(10) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; |
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(11) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code; |
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(12) county employee group health benefits provided |
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under Chapter 157, Local Government Code; and |
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(13) health and accident coverage provided by a risk |
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pool created under Chapter 172, Local Government Code. |
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Sec. 1372.003. COVERAGE REQUIRED. (a) Subject to |
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Subsection (b), a health benefit plan must provide coverage for |
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biomarker testing for the purpose of diagnosis, treatment, |
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appropriate management, or ongoing monitoring of an enrollee's |
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disease or condition to guide treatment when the test is supported |
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by medical and scientific evidence, including: |
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(1) a labeled indication for a test approved or |
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cleared by the United States Food and Drug Administration; |
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(2) an indicated test for a drug approved by the United |
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States Food and Drug Administration; |
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(3) a national coverage determination made by the |
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Centers for Medicare and Medicaid Services or a local coverage |
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determination made by a Medicare administrative contractor; |
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(4) nationally recognized clinical practice |
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guidelines; or |
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(5) consensus statements. |
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(b) A health benefit plan issuer must provide coverage under |
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Subsection (a) only when use of biomarker testing provides clinical |
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utility because use of the test for the condition: |
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(1) is evidence-based; |
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(2) is scientifically valid; |
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(3) is outcome focused; and |
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(4) predominately addresses the acute issue for which |
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the test is being ordered, except that a test may include some |
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information that cannot be immediately used in the formulation of a |
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clinical decision. |
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(c) A health benefit plan must provide coverage under |
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Subsection (a) in a manner that limits disruptions in care, |
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including limiting the number of biopsies and biospecimen samples. |
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SECTION 2. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 3. The change in law made by this Act applies only |
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to a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2024. |
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SECTION 4. This Act takes effect September 1, 2023. |