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.