House Bill 1033
By: Representatives Scott of the 76th, Davis of the 87th, Schofield of the 63rd, and Burnough
of the 77th
A BILL TO BE ENTITLED
AN ACT
To amend Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to
insurance generally, so as to provide for coverage for diagnostic testing and treatment for
Alzheimer's disease and Alzheimer's related dementias; to provide for definitions; to include
certain diagnostic imaging services under biomarker testing; to prohibit certain utilization
management practices that unreasonably delay or deny medically necessary biomarker
testing; to require health benefit policies to cover certain diagnostic testing and treatments
for Alzheimer's disease and Alzheimer's related dementias; to allow but limit cost sharing
requirements; to require access to healthcare services that are timely and proximal; to provide
for coverage of healthcare services by out-of-network providers; to provide for annual
reporting; to provide for rules and regulations; to provide for a short title; to provide for an
effective date and applicability; to provide for related matters; to repeal conflicting laws; and
for other purposes.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION 1.
This Act shall be known and may be cited as the "Georgia Access to Healthcare for
Alzheimer's Disease and Dementias Act."
SECTION 2.
Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to insurance
generally, is amended by revising Code Section 33-24-59.33, relating to required coverage
for biomarker testing, as follows:
"33-24-59.33.
(a) As used in this Code section, the term:
(1) 'Biomarker' means a characteristic that is objectively measured and evaluated as an
indicator of normal biological processes, pathogenic processes, or pharmacologic
responses to a specific therapeutic intervention. Such term includes, but is not limited to,
gene mutations, protein expression, known gene-drug interactions for medications, and
characteristics of genes. <ins>Such term also includes blood based biomarkers used in the
detection of Alzheimer's disease and Alzheimer's related dementias.
</ins> (2) 'Biomarker testing' means the analysis of a patient's tissue, blood, or other
biospecimen for the presence of a biomarker. Such term includes, but is not limited to,
single-analyte tests, multiplex panel tests, whole genome sequencing, protein expression,
whole exome, <del>and</del> whole transcriptome, <ins>diagnostic imaging, and cerebrospinal fluid
analysis.
</ins> (3) 'Consensus statements' means statements developed by an independent,
multidisciplinary panel of experts utilizing a transparent methodology and reporting
structure and with a conflict-of-interest policy. Such statements are aimed at specific
clinical circumstances and base the statements on the best available evidence for the
purpose of optimizing the outcomes of clinical care.
<ins>(4) 'Diagnostic imaging' means magnetic resonance imaging, computed tomography
(CT) scanning, positron emission tomography (PET) scanning, amyloid PET imaging,
tau PET imaging, positron emission tomography/computed tomography (PET/CT), and
other advanced imaging services.
</ins> <del>(4)(5)</del> 'Health benefit policy' means any individual or group plan, policy, or contract for
healthcare services issued, delivered, issued for delivery, or renewed in this state which
provides major medical benefits, including those contracts executed by the State of
Georgia on behalf of state employees under Article 1 of Chapter 18 of Title 45, by a
health care corporation, health maintenance organization, preferred provider organization,
accident and sickness insurer, fraternal benefit society, hospital service corporation,
medical service corporation, or other insurer or similar entity.
<del>(5)(6)</del> 'Nationally recognized clinical practice guidelines' means evidence based clinical
practice guidelines developed by independent organizations or medical professional
societies utilizing a transparent methodology and reporting structure and with a
conflict-of-interest policy. Such guidelines establish standards of care informed by a
systematic review of evidence and an assessment of the benefits and risks of alternative
care options and include recommendations intended to optimize patient care.
<ins>(7) 'Step therapy protocol' means a protocol that establishes the specific sequence in
which a healthcare treatment or service for Alzheimer's disease or Alzheimer's related
dementias is deemed medically appropriate for a particular patient and covered by an
insurer under a health benefit policy. Such term includes fail-first requirements.
</ins> (b) All health benefit policies renewed or issued on or after July 1, 2023, shall include
coverage for biomarker testing as provided in this Code section. <ins>All health benefit policies
renewed or issued on or after July 1, 2026, shall include coverage for biomarker testing for
Alzheimer's disease and Alzheimer's related dementias as provided in this Code section.
</ins>
(c) Biomarker testing shall be covered for the purposes of diagnosis, treatment, appropriate
management, or ongoing monitoring of an enrollee's disease or condition when the testing
is supported by medical and scientific evidence, including, but not limited to:
(1) A labeled indication for a test that has been approved or cleared by the United States
Food and Drug Administration (FDA);
(2) An indicated test for an FDA approved drug;
(3) A national coverage determination made by the federal Centers for Medicare and
Medicaid Services or a local coverage determination made by a medicare administrative
contractor;
(4) Nationally recognized clinical practice guidelines and consensus statements; or
(5) Warnings and precautions on FDA approved drugs.
(d) Health benefit policies shall ensure biomarker testing coverage is provided in a manner
that limits disruptions in care, including the need for multiple biopsies or biospecimen
samples. <ins>Biomarker testing coverage provided under this Code section shall not be subject
to step therapy protocols or other utilization management practices that unreasonably delay
or deny such testing.
</ins> (e) The insurer or similar entity subject to this Code section shall approve or deny a prior
authorization request and notify the enrollee and the enrollee's healthcare provider within
seven calendar days for nonurgent requests or within 72 hours for urgent requests. If the
insurer or similar entity fails to respond in accordance with such time frames, such request
shall be deemed approved.
(f) Enrollees, healthcare providers, and testing service providers shall have access to a
clear, readily accessible, and convenient process to request an exception to a coverage
policy or an adverse utilization review determination under a health benefit policy,
including, but not limited to, the rights of consumers under Article 2 of Chapter 20A of
Title 33, the 'Patient's Right to Independent Review Act.' Such process shall be made
readily accessible on the insurer's or similar entity's website."
SECTION 3.
Said chapter is further amended by adding a new Code section to read as follows:
<ins>"33-24-59.37.
(a) As used in this Code section, the term:
(1) 'Alzheimer's disease' means a progressive, degenerative disease or condition that
attacks the brain and results in impaired memory, thinking, and behavior.
(2) 'Alzheimer's related dementia' means any disease from a class of degenerative brain
disorders that cause impairment or changes in memory, thinking, or behavior that are
progressive and irreversible. Such diseases include, but are not limited to, Alzheimer's
disease, Lewy body dementia, frontotemporal dementia, and vascular dementia.
(3) 'Cost sharing requirement' means a deductible, coinsurance, copayment, or
out-of-pocket expense and any maximum limitation on the application of such deductible,
coinsurance, copayment, or out-of-pocket expense.
(4) 'Health benefit policy' means any individual or group plan, policy, or contract for
healthcare services issued, delivered, issued for delivery, or renewed in this state which
provides major medical benefits, including the state health benefit plan, by a health
insurer. Such term shall not include any self-insured health benefit plan subject to the
exclusive jurisdiction of the federal Employee Retirement Income Security Act of 1974,
29 U.S.C. Section 1001, et seq.
(5) 'Health insurer' means an entity subject to the insurance laws and regulations of this
state, or subject to the jurisdiction of the Commissioner, that contracts, offers to contract,
or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of
the costs of healthcare services, including those of an accident and sickness insurance
company, a health maintenance organization, a healthcare plan, a managed care plan, or
any other entity providing a health benefit policy.
(6) 'Medically necessary' means such healthcare services that a prudent physician or
other healthcare provider would provide to a patient for the purpose of screening,
</ins>
<ins>preventing, diagnosing, managing, or treating Alzheimer's disease or Alzheimer's related
dementias and their symptoms, including minimizing the progression of such disease or
related dementias, in a manner that is:
(A) In accordance with the generally accepted standards of medical or other healthcare
practice;
(B) Clinically appropriate in terms of type, frequency, extent, site, and duration; and
(C) Not primarily for the economic benefit of the insurer or for the convenience of the
patient, treating physician, or other healthcare provider.
(7) 'State health benefit plan' means the health insurance plan or plans established
pursuant to Part 6 of Article 17 of Chapter 2 of Title 20, Code Section 31-2-2, and
Article 1 of Chapter 18 of Title 45 for state and public employees, members and
employees of the Board of Regents, public school teachers and employees, and their
dependents, and retirees.
(8) 'Step therapy protocol' means a protocol that establishes the specific sequence in
which a healthcare treatment or service for Alzheimer's disease or Alzheimer's related
dementias is deemed medically appropriate for a particular patient and covered by an
insurer under a health benefit policy. Such term includes fail-first requirements.
(b) All health benefit policies issued or renewed on or after July 1, 2026, and all health
benefit policies under the state health benefit plan issued or renewed on or after
January 1, 2027, shall include coverage for:
(1) Medically necessary treatments for Alzheimer's disease and Alzheimer's related
dementias that are approved by the federal Food and Drug Administration for the
treatment of such diseases; and
(2) Diagnostic testing for Alzheimer's disease and Alzheimer's related dementias and
administrative costs for such testing.
(c) Coverage provided under this Code section shall not be subject to step therapy
protocols or other utilization management practices that unreasonably delay or deny access
</ins>
<ins>to covered healthcare treatments or services for Alzheimer's disease or Alzheimer's related
dementias.
(d) The coverage provided under this Code section shall be subject to the same cost
sharing requirements established for all covered benefits within such health benefit policy;
provided, however, that at least one diagnostic testing per covered individual per year shall
be covered without any cost sharing requirement. The cost sharing requirements for the
coverage provided under this Code section shall not exceed the maximum annual
out-of-pocket limit applicable to essential health benefits under federal law.
(e) Health insurers shall ensure a covered person has access to healthcare services for the
diagnosis and treatment of Alzheimer's disease or Alzheimer's related dementias, including,
but not limited to, biomarker testing, diagnostic imaging, and infusion services provided
by an in-network healthcare provider within a reasonable time and within reasonable
geographic proximity to such covered person. If such healthcare service by an in-network
healthcare provider within a reasonable time and within reasonable proximity to the
covered person is not available, then the health insurer shall cover such healthcare service
provided by an out-of-network healthcare provider at in-network rates and shall reimburse
reasonable travel costs incurred by the covered person.
(f) No later than July 1, 2027, and annually thereafter, the Commissioner shall submit a
report to the chairpersons of the House Committee on Insurance and the Senate Insurance
and Labor Committee regarding the implementation of the coverage required under this
Code section. All health insurers issuing or renewing health benefit policies subject to the
provisions of this Code section shall provide the department with all data requested by the
department for inclusion in such report. The report shall include, but not be limited to:
(1) The number of claims for diagnostic testing and healthcare treatments for
Alzheimer's disease and Alzheimer's related dementias submitted, approved, and denied;
(2) The average amount of cost sharing requirement per such claim;
(3) The average time for processing of prior authorization requests for such claims; and
</ins>
<ins>(4) Aggregate demographic and geographic utilization data.
(g) The Commissioner shall promulgate rules and regulations necessary to implement the
provisions of this Code section."
</ins> SECTION 4.
This Act shall become effective on July 1, 2026, and shall apply to all health benefit plans,
policies, and contracts issued, delivered, issued for delivery, or renewed in this state on or
after such date.
SECTION 5.
All laws and parts of laws in conflict with this Act are repealed.