Section 27-8-14.3-10 - Coverage for biomarker testing(a) A health plan shall provide coverage for biomarker testing for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of an enrollee's disease or condition when biomarker testing is supported by medical and scientific evidence, including:(1) labeled indications for a test approved or cleared by the United States Food and Drug Administration;(2) indicated tests for a drug approved by the United States Food and Drug Administration;(3) a warning or precaution on the label of a drug approved by the United States Food and Drug Administration;(4) a national coverage determination of the Centers for Medicare and Medicaid Services (CMS);(5) a local coverage determination of a Medicare administrative contractor; or(6) nationally recognized clinical practice guidelines or consensus statements.(b) The coverage required by this section must be provided in a manner that limits disruptions in care, including the need for multiple biopsies or biospecimen samples.(c) Nothing in this section shall be construed to require coverage of biomarker testing for screening purposes.(d) If a prior authorization requirement applies to biomarker testing under a health plan, the health plan or a third party acting on behalf of the health plan must: (1) approve or deny a request for prior authorization for biomarker testing; and(2) notify the covered individual and any person requesting prior authorization of the biomarker testing on behalf of the covered individual; in not more than five (5) business days after the request in the case of a nonurgent request or in not more than forty-eight (48) hours after the request in the case of an urgent request.
(e) A health plan shall ensure that a covered individual and the practitioner who prescribes biomarker testing for the covered individual have access to a clear, readily accessible, and convenient process for requesting an exception to:(1) a coverage policy; or(2) a prior authorization determination; of the health plan that is adverse to the coverage of biomarker testing for the covered individual. The process required by this subsection shall be made readily accessible on the health plan's website.
Added by P.L. 37-2024,SEC. 2, eff. 7/1/2024.