Texas § IN.1372.003 - COVERAGE REQUIRED

§ IN.1372.003. COVERAGE REQUIRED

COVERAGE REQUIRED. (a) Subject to Subsection (b), a health benefit plan must provide coverage for biomarker testing for the purpose of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition to guide treatment when the test is supported by the following kinds of medical and scientific evidence: (1) a labeled indication for a test approved or cleared by the United States Food and Drug Administration; (2) an indicated test for a drug approved by the United States Food and Drug Administration; (3) a national coverage determination made by the Centers for Medicare and Medicaid Services or a local coverage determination made by a Medicare administrative contractor; (4) nationally recognized clinical practice guidelines; or (5) consensus statements. (b) A health benefit plan issuer must provide coverage under Subsection (a) only when use of biomarker testing provides clinical utility because use of the test for the condition: (1) is evidence-based; (2) is scientifically valid based on the medical and scientific evidence described by Subsection (a); (3) informs a patient's outcome and a provider's clinical decision; and (4) predominately addresses the acute or chronic issue for which the test is being ordered, except that a test may include some information that cannot be immediately used in the formulation of a clinical decision. (c) A health benefit plan must provide coverage under Subsection (a) in a manner that limits disruptions in care, including limiting the number of biopsies and biospecimen samples. Added by Acts 2023, 88th Leg., R.S., Ch. 279 (S.B. 989 ), Sec. 1, eff. September 1, 2023.