OLR Bill Analysis

sHB 5032

AN ACT REQUIRING HEALTH INSURANCE COVERAGE FOR BONE MARROW TESTING.

SUMMARY:

This bill requires health insurance policies to cover medically necessary testing to determine compatibility for bone marrow transplants, known as human leukocyte antigen testing and also referred to as histocompatibility locus antigen testing, for A, B, and DR antigens. Under the bill, a policy (1) may limit coverage to one covered test in a person's lifetime and (2) cannot impose a coinsurance, copayment, deductible, or other out-of-pocket expense for the testing that exceeds 20% of the cost for testing per year, unless it is a high-deductible policy designed to be compatible with federally qualified health savings accounts.

The bill requires a policy to (1) require bone marrow testing at a facility certified under the federal Clinical Laboratory Improvement Act and accredited by the American Society for Histocompatibility and Immunogenetics or its successor and (2) limit coverage to people who sign up for the National Marrow Donor Program when being tested.

The bill applies to individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including coverage under an HMO plan.

Under federal law (ERISA), state insurance benefit mandates do not apply to self-insured benefit plans.

EFFECTIVE DATE: January 1, 2012

BACKGROUND

Legislative History

On March 16, the House referred the bill (File 40) to the Appropriations Committee, which approved a substitute that limits the coverage requirement to only “medically necessary” human leukocyte antigen testing.

Medically Necessary

The law defines “medically necessary” as health care services that a physician, exercising prudent clinical judgment, would provide to a patient to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms, and that are:

1. in accordance with generally accepted standards of medical practice;

2. clinically appropriate, in terms of type, frequency, extent, site, and duration and considered effective for the patient's illness, injury, or disease;

3. not primarily for the convenience of the patient, physician, or other health care provider; and

4. not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

Clinical Laboratory Improvement Act

The federal Centers for Medicare and Medicaid Services regulate all laboratory testing (except research) performed on people in the United States under the Clinical Laboratory Improvement Act.

American Society for Histocompatibility and Immunogenetics

This society is a nonprofit association of clinical and research professionals, including immunologists, geneticists, transplant physicians and surgeons, and pathologists. It is a member of the United Network for Organ Sharing and works with numerous scientific and medical organizations, including the National Marrow Donor Program. It develops and maintains accreditation standards for laboratories.

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable

Yea

12

Nay

6

(02/17/2011)

Appropriations Committee

Joint Favorable Substitute

Yea

39

Nay

6

(04/25/2011)