Legislators have spirited debate over biomarker testing coverage

The National Council of Insurance Legislators moved closer to adopting a model law Friday after a robust debate on a biomarker testing coverage regulation.

Members are expected to vote in July on the model law, which would then go to the state legislatures for consideration.

Biomarker testing is becoming increasingly important to cancer care because it helps providers tailor cancer treatment when actionable biomarkers are present. While guidelines exist, insurance coverage of biomarker testing varies widely, as Milliman noted in a report last year.

Biomarker testing legislation laws are on the books in nine states and legislation is being debated in 12 other states, noted Assemblywoman Pam Hunter, D-N.Y. In addition, Texas and Oklahoma passed bills covering biomarker testing and could become law within days.

NCOIL legislators and industry groups held a final discussion on the issue over the noon hour Friday. The model law would only require coverage of biomarker testing post-diagnosis, Hunter stressed several times.

"After someone has been diagnosed with cancer, then if biomarker testing should be required, can be required, based on the type of cancer that has been diagnosed, this should be an option," she said.

Previous debates over requiring coverage of things like colonoscopy testing and other cancer screening revealed concerns about adding costs that turned out not to be true, Hunter noted.

"Everyone is doing it across the country and it has been saving lives and saving money," she added.

Free market concerns

State Sen. George Lang, R-Ohio, is a survivor of stage-four colon cancer and is deaf, relying on two cochlear bone-attached hearing aids to hear. Still, Lang once refused to support a measure forcing private insurers to provide hearing aids for children. He is also not supporting the biomarker model.

"I am strongly opposed to this bill and what this bill does," Lang said. "This essentially comes down to government interfering with the private sector, with private markets. We should not be telling health plans what they should and should not do."

He was countered by state Rep. Dafna Michaelson Jenet, D-Colo., a two-time cancer survivor, recently helped steer a bipartisan biomarker bill out of committee in her state.

"I will tell you that being able to find the right treatment as opposed to trying this and trying that and seeing what's going to stick is very much an efficiency and an efficiency model that I would like to see adopt in adopted in our insurance plans," she said.

The Colorado bill requires all individual and group health benefit plans to provide coverage for biomarker testing if the testing is supported by medical and scientific evidence. It requires the commissioner of insurance to implement biomarker testing coverage for all individual and group health benefit plans issued or renewed on or after Jan. 1, 2025.

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.

'Not playing games'

Washington state Rep. My-Linh Thai argued passionately in favor of biomarker use.

"We're not playing games with people lives," said Thai, a trained pharmacist. "We're actually treating people using data and information that is now available for us and in the past was not available for providers, nor for patients. Why are we not using what's available to provide the best health care possible outcome for our patients?"

Hilary Gee Goeckner is director, state and local campaigns at American Cancer Society Cancer Action Network. Health plans vary on how they cover biomarker testing and many patients who can benefit are missing out on the testing needed to make sure they have the right treatment plan, she said,

A study revealed that more than 70% of policies reviewed are "more restrictive than those really gold standard guidelines that every oncologist consults for determining when to order biomarker testing," Goeckner said.

But bill proponents do not go too far in the other direction either, she added.

"This isn't any test under the sun that calls itself the biomarker test it has to be covered," she said. "There are clear circumstances under which testing should be covered and also sources of evidence that must be met in order for a test to call it qualify."

Health plans are opposed to mandating biomarker coverage.

Miranda Motter is senior vice president of state affairs and policy at America's Health Insurance Plans. Biomarker legislation is not needed and would likely add costs into the treatment equation, she said, asking legislators to vote No in July.

"We really do believe that with some of the more expansive definitions included in the model that could lead to more expensive and unnecessary costs and additional costs for those employers and employees," Motter said.

InsuranceNewsNet Senior Editor John Hilton covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.

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InsuranceNewsNet Senior Editor John Hilton has covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.