627.4236 Coverage for bone marrow transplant procedures. - Florida Statutes

627.4236 Coverage for bone marrow transplant procedures.

   (1) As used in this section, the term “bone marrow transplant” means human blood precursor cells administered to a patient to restore normal hematological and immunological functions following ablative or nonablative therapy with curative or life-prolonging intent. Human blood precursor cells may be obtained from the patient in an autologous transplant or from a medically acceptable related or unrelated donor, and may be derived from bone marrow, circulating blood, or a combination of bone marrow and circulating blood. If chemotherapy is an integral part of the treatment involving bone marrow transplantation, the term “bone marrow transplant” includes both the transplantation and the chemotherapy.

   (2) An insurer or a health maintenance organization may not exclude coverage for bone marrow transplant procedures recommended by the referring physician and the treating physician under a policy exclusion for experimental, clinical investigative, educational, or similar procedures contained in any individual or group health insurance policy or health maintenance organization contract issued, amended, delivered, or renewed in this state that covers treatment for cancer, if the particular use of the bone marrow transplant procedure is determined to be accepted within the appropriate oncological specialty and not experimental pursuant to subsection (3). Covered bone marrow transplant procedures must include costs associated with the donor-patient to the same extent and limitations as costs associated with the insured, except the reasonable costs of searching for the donor may be limited to immediate family members and the National Bone Marrow Donor Program.

   (3)(a) The Agency for Health Care Administration shall adopt rules specifying the bone marrow transplant procedures that are accepted within the appropriate oncological specialty and are not experimental for purposes of this section. The rules must be based upon recommendations of an advisory panel appointed by the secretary of the agency, composed of:

   1. One adult oncologist, selected from a list of three names recommended by the Florida Medical Association;

   2. One pediatric oncologist, selected from a list of three names recommended by the Florida Pediatric Society;

   3. One representative of the J. Hillis Miller Health Center at the University of Florida;

   4. One representative of the H. Lee Moffitt Cancer Center and Research Institute, Inc.;

   5. One consumer representative, selected from a list of three names recommended by the Chief Financial Officer;

   6. One representative of the Health Insurance Association of America;

   7. Two representatives of health insurers, one of whom represents the insurer with the largest Florida health insurance premium volume and one of whom represents the insurer with the second largest Florida health insurance premium volume; and

   8. One representative of the insurer with the largest Florida small group health insurance premium volume.

   (b) The director shall also appoint a member of the advisory panel to serve as chairperson.

   (c) The agency shall provide, within existing resources, staff support to enable the panel to carry out its responsibilities under this section.

   (d) In making recommendations and adopting rules under this section, the advisory panel and the director shall:

   1. Take into account findings, studies, or research of the federal Agency for Health Care Policy, National Cancer Institute, National Academy of Sciences, Health Care Financing Administration, and Congressional Office of Technology Assessment, and any other relevant information.

   2. Consider whether the federal Food and Drug Administration or National Cancer Institute is conducting or sponsoring assessment procedures to determine the safety and efficacy of the procedure or substantially similar procedures, or of any part of such procedures.

   3. Consider practices of providers with respect to requesting or requiring patients to sign a written acknowledgment that a bone marrow transplant procedure is experimental.

   (e) The advisory panel shall conduct, at least biennially, a review of scientific evidence to ensure that its recommendations are based on current research findings and that insurance policies offer coverage for the latest medically acceptable bone marrow transplant procedures.

   (4) Any rule adopted under this section applies only to claims filed under policies issued or renewed after the effective date of the rule.

History. s. 42, ch. 92-318; s. 84, ch. 93-129; s. 5, ch. 95-188; s. 79, ch. 97-237; s. 2, ch. 99-299; s. 21, ch. 2000-305; s. 1122, ch. 2003-261; s. 1, ch. 2008-119.