HB1033: HB1033 Georgia Access to Healthcare for Alzheimer's Disease and Dementias Act; enact

26 LC 52 0887 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 to1 insurance generally, so as to provide for coverage for diagnost ic testing and treatment for2 Alzheimer's disease and Alzheimer's related dementias; to provide for definitions; to include3 certain diagnostic imaging services under biomarker testing; to prohibit certain utilization4 management practices that unreasonably delay or deny medically necessary biomarker5 testing; to require health benefit policies to cover certain diagnostic testing and treatments6 for Alzheimer's disease and Alzheimer's related dementias; to a llow but limit cost sharing7 requirements; to require access to healthcare services that are timely and proximal; to provide8 for coverage of healthcare services by out-of-network providers ; to provide for annual9 reporting; to provide for rules and regulations; to provide for a short title; to provide for an10 effective date and applicability; to provide for related matters; to repeal conflicting laws; and11 for other purposes.12 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:13 H. B. 1033 - 1 - 26 LC 52 0887 SECTION 1.14 This Act shall be known and may be cited as the "Georgia Access to Healthcare for15 Alzheimer's Disease and Dementias Act."16 SECTION 2. 17 Chapter 24 of Title 33 of the Official Code of Georgia Annotate d, relating to insurance18 generally, is amended by revising Code Section 33-24-59.33, relating to required coverage19 for biomarker testing, as follows:20 "33-24-59.33.21 (a) As used in this Code section, the term:22 (1) 'Biomarker' means a characteristic that is objectively measured and evaluated as an23 indicator of normal biological processes, pathogenic processes, or pharmacologic24 responses to a specific therapeutic intervention. Such term includes, but is not limited to,25 gene mutations, protein expression, known gene-drug interactions for medications, and26 characteristics of genes. Such term also includes blood based biomarkers used in the27 detection of Alzheimer's disease and Alzheimer's related dementias.28 (2) 'Biomarker testing' means the analysis of a patient's tiss ue, blood, or other29 biospecimen for the presence of a biomarker. Such term includes, but is not limited to,30 single-analyte tests, multiplex panel tests, whole genome sequencing, protein expression,31 whole exome, and whole transcriptome, diagnostic imaging, and cerebrospinal flu id32 analysis.33 (3) 'Consensus statements' means statements developed by an in dependent,34 multidisciplinary panel of experts utilizing a transparent meth odology and reporting35 structure and with a conflict-of-interest policy. Such stateme nts are aimed at specific36 clinical circumstances and base the statements on the best avai lable evidence for the37 purpose of optimizing the outcomes of clinical care.38 H. B. 1033 - 2 - 26 LC 52 0887 (4) 'Diagnostic imaging' means magnetic resonance imaging, com puted tomography39 (CT) scanning, positron emission tomography (PET) scanning, amy loid PET imaging,40 tau PET imaging, positron emission tomography/computed tomography (PET/CT), and41 other advanced imaging services.42 (4)(5) 'Health benefit policy' means any individual or group plan, policy, or contract for43 healthcare services issued, delivered, issued for delivery, or renewed in this state which44 provides major medical benefits, including those contracts exec uted by the State of45 Georgia on behalf of state employees under Article 1 of Chapter 18 of Title 45, by a46 health care corporation, health maintenance organization, preferred provider organization,47 accident and sickness insurer, fraternal benefit society, hospi tal service corporation,48 medical service corporation, or other insurer or similar entity.49 (5)(6) 'Nationally recognized clinical practice guidelines' means evidence based clinical50 practice guidelines developed by independent organizations or m edical professional51 societies utilizing a transparent methodology and reporting str ucture and with a52 conflict-of-interest policy. Such guidelines establish standar ds of care informed by a53 systematic review of evidence and an assessment of the benefits and risks of alternative54 care options and include recommendations intended to optimize patient care.55 (7) 'Step therapy protocol' means a protocol that establishes the specific sequence in56 which a healthcare treatment or service for Alzheimer's disease or Alzheimer's related57 dementias is deemed medically appropriate for a particular pati ent and covered by an58 insurer under a health benefit policy. Such term includes fail-first requirements.59 (b) All health benefit policies renewed or issued on or after July 1, 2023, shall include60 coverage for biomarker testing as provided in this Code section. All health benefit policies61 renewed or issued on or after July 1, 2026, shall include coverage for biomarker testing for62 Alzheimer's disease and Alzheimer's related dementias as provided in this Code section.63 H. B. 1033 - 3 - 26 LC 52 0887 (c) Biomarker testing shall be covered for the purposes of diagnosis, treatment, appropriate64 management, or ongoing monitoring of an enrollee's disease or condition when the testing65 is supported by medical and scientific evidence, including, but not limited to:66 (1) A labeled indication for a test that has been approved or cleared by the United States67 Food and Drug Administration (FDA);68 (2) An indicated test for an FDA approved drug;69 (3) A national coverage determination made by the federal Cent ers for Medicare and70 Medicaid Services or a local coverage determination made by a medicare administrative71 contractor;72 (4) Nationally recognized clinical practice guidelines and consensus statements; or73 (5) Warnings and precautions on FDA approved drugs.74 (d) Health benefit policies shall ensure biomarker testing coverage is provided in a manner75 that limits disruptions in care, including the need for multipl e biopsies or biospecimen76 samples. Biomarker testing coverage provided under this Code section shall not be subject77 to step therapy protocols or other utilization management practices that unreasonably delay78 or deny such testing.79 (e) The insurer or similar entity subject to this Code section shall approve or deny a prior80 authorization request and notify the enrollee and the enrollee's healthcare provider within81 seven calendar days for nonurgent requests or within 72 hours for urgent requests. If the82 insurer or similar entity fails to respond in accordance with such time frames, such request83 shall be deemed approved.84 (f) Enrollees, healthcare providers, and testing service provi ders shall have access to a85 clear, readily accessible, and convenient process to request an exception to a coverage86 policy or an adverse utilization review determination under a h ealth benefit policy,87 including, but not limited to, the rights of consumers under Ar ticle 2 of Chapter 20A of88 Title 33, the 'Patient's Right to Independent Review Act.' Suc h process shall be made89 readily accessible on the insurer's or similar entity's website."90 H. B. 1033 - 4 - 26 LC 52 0887 SECTION 3.91 Said chapter is further amended by adding a new Code section to read as follows:92 "33-24-59.37.93 (a) As used in this Code section, the term:94 (1) 'Alzheimer's disease' means a progressive, degenerative di sease or condition that95 attacks the brain and results in impaired memory, thinking, and behavior.96 (2) 'Alzheimer's related dementia' means any disease from a class of degenerative brain97 disorders that cause impairment or changes in memory, thinking, or behavior that are98 progressive and irreversible. Such diseases include, but are not limited to, Alzheimer's99 disease, Lewy body dementia, frontotemporal dementia, and vascular dementia.100 (3) 'Cost sharing requirement' means a deductible, coinsurance , copayment, or101 out-of-pocket expense and any maximum limitation on the application of such deductible,102 coinsurance, copayment, or out-of-pocket expense.103 (4) 'Health benefit policy' means any individual or group plan , policy, or contract for104 healthcare services issued, delivered, issued for delivery, or renewed in this state which105 provides major medical benefits, including the state health ben efit plan, by a health106 insurer. Such term shall not include any self-insured health b enefit plan subject to the107 exclusive jurisdiction of the federal Employee Retirement Income Security Act of 1974,108 29 U.S.C. Section 1001, et seq.109 (5) 'Health insurer' means an entity subject to the insurance laws and regulations of this110 state, or subject to the jurisdiction of the Commissioner, that contracts, offers to contract,111 or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of112 the costs of healthcare services, including those of an acciden t and sickness insurance113 company, a health maintenance organization, a healthcare plan, a managed care plan, or114 any other entity providing a health benefit policy.115 (6) 'Medically necessary' means such healthcare services that a prudent physician or116 other healthcare provider would provide to a patient for the pu rpose of screening,117 H. B. 1033 - 5 - 26 LC 52 0887 preventing, diagnosing, managing, or treating Alzheimer's disease or Alzheimer's related118 dementias and their symptoms, including minimizing the progression of such disease or119 related dementias, in a manner that is:120 (A) In accordance with the generally accepted standards of medical or other healthcare121 practice;122 (B) Clinically appropriate in terms of type, frequency, extent, site, and duration; and123 (C) Not primarily for the economic benefit of the insurer or for the convenience of the124 patient, treating physician, or other healthcare provider.125 (7) 'State health benefit plan' means the health insurance pla n or plans established126 pursuant to Part 6 of Article 17 of Chapter 2 of Title 20, Code Section 31-2-2, and127 Article 1 of Chapter 18 of Title 45 for state and public employ ees, members and128 employees of the Board of Regents, public school teachers and e mployees, and their129 dependents, and retirees.130 (8) 'Step therapy protocol' means a protocol that establishes the specific sequence in131 which a healthcare treatment or service for Alzheimer's disease or Alzheimer's related132 dementias is deemed medically appropriate for a particular pati ent and covered by an133 insurer under a health benefit policy. Such term includes fail-first requirements.134 (b) All health benefit policies issued or renewed on or after July 1, 2026, and all health135 benefit policies under the state health benefit plan issued or renewed on or after136 January 1, 2027, shall include coverage for:137 (1) Medically necessary treatments for Alzheimer's disease and Alzheimer's related138 dementias that are approved by the federal Food and Drug Admini stration for the139 treatment of such diseases; and140 (2) Diagnostic testing for Alzheimer's disease and Alzheimer's related dementias and141 administrative costs for such testing.142 (c) Coverage provided under this Code section shall not be sub ject to step therapy143 protocols or other utilization management practices that unreasonably delay or deny access144 H. B. 1033 - 6 - 26 LC 52 0887 to covered healthcare treatments or services for Alzheimer's disease or Alzheimer's related145 dementias.146 (d) The coverage provided under this Code section shall be sub ject to the same cost147 sharing requirements established for all covered benefits within such health benefit policy;148 provided, however, that at least one diagnostic testing per covered individual per year shall149 be covered without any cost sharing requirement. The cost shar ing requirements for the150 coverage provided under this Code section shall not exceed the maximum annual151 out-of-pocket limit applicable to essential health benefits under federal law.152 (e) Health insurers shall ensure a covered person has access to healthcare services for the153 diagnosis and treatment of Alzheimer's disease or Alzheimer's related dementias, including,154 but not limited to, biomarker testing, diagnostic imaging, and infusion services provided155 by an in-network healthcare provider within a reasonable time a nd within reasonable156 geographic proximity to such covered person. If such healthcare service by an in-network157 healthcare provider within a reasonable time and within reasona ble proximity to the158 covered person is not available, then the health insurer shall cover such healthcare service159 provided by an out-of-network healthcare provider at in-network rates and shall reimburse160 reasonable travel costs incurred by the covered person.161 (f) No later than July 1, 2027, and annually thereafter, the Commissioner shall submit a162 report to the chairpersons of the House Committee on Insurance and the Senate Insurance163 and Labor Committee regarding the implementation of the coverag e required under this164 Code section. All health insurers issuing or renewing health benefit policies subject to the165 provisions of this Code section shall provide the department with all data requested by the166 department for inclusion in such report. The report shall include, but not be limited to:167 (1) The number of claims for diagnostic testing and healthcare treatments for168 Alzheimer's disease and Alzheimer's related dementias submitted, approved, and denied;169 (2) The average amount of cost sharing requirement per such claim;170 (3) The average time for processing of prior authorization requests for such claims; and171 H. B. 1033 - 7 - 26 LC 52 0887 (4) Aggregate demographic and geographic utilization data.172 (g) The Commissioner shall promulgate rules and regulations necessary to implement the173 provisions of this Code section."174 SECTION 4.175 This Act shall become effective on July 1, 2026, and shall apply to all health benefit plans,176 policies, and contracts issued, delivered, issued for delivery, or renewed in this state on or177 after such date.178 SECTION 5.179 All laws and parts of laws in conflict with this Act are repealed.180 H. B. 1033 - 8 -