Health-Care Coverage for Biomarker Testing

The bill requires all individual and group large group health benefit plans to provide coverage for biomarker testing to guide treatment decisions if the testing is supported by medical and scientific evidence. The bill defines "biomarker testing" as an analysis of a patient's tissue, blood, or other biospecimen for the presence of an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention. The required testing under the bill does not include biomarker testing for screening purposes or direct-to-consumer genetic tests.

The bill requires the commissioner of insurance to implement biomarker testing coverage for all individual and group large employer health benefit plans issued or renewed on or after January 1, 2026 2025 . To the extent biomarker testing is not in addition to the benefits provided pursuant to the benchmark plan, all individual and small group health benefit plans must provide coverage for biomarker testing. Within 120 days after the bill takes effect, the division of insurance (division) shall submit to the federal department of health and human services (HHS) its determination of whether biomarker testing is in addition to essential health benefits and would require state defrayal of costs pursuant to federal law. The division shall implement the requirement for coverage for biomarker testing for individual and small group health benefit plans once the division has received confirmation from HHS that biomarker coverage does not require defrayal or more than 365 days have passed since the division submitted its determination that defrayal was not necessary.

Biomarker testing is subject to the health benefit plan's annual deductibles, copayment, or coinsurance but is not subject to any annual or lifetime maximum benefit limit.

Subject to federal authorization and federal financial participation, beginning on and after July 1, 2025 2024 , the bill includes coverage for biomarker testing as part of the state medical assistance program to guide treatment decisions if the testing is supported by medical and scientific evidence. Coverage of biomarker testing will be implemented pursuant to the established process under the medical assistance program for determining coverage of services based on clinical utility.

The bill requires the medical assistance program to have a clear, easily accessible appeals process if biomarker testing is denied.

(Note: Italicized words indicate new material added to the original summary; dashes through words indicate deletions from the original summary.)

(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)