§ 33-24-59.1 - Coverage for treatment of dependent children with cancer - Georgia Statutes

O.C.G.A. 33-24-59.1 (2010)
33-24-59.1. Coverage for treatment of dependent children with cancer

(a) As used in this Code section, the term:

(1) "Accident and sickness insurance benefit plan, policy, or contract" means:

(A) An individual accident and sickness insurance policy or contract, as defined in Chapter 29 of this title;

(B) A group or blanket accident and sickness insurance policy or contract, as defined in Chapter 30 of this title;

(C) An individual or group contract of the type issued by a nonprofit hospital service corporation established under Chapter 19 of this title;

(D) An individual or group contract of the type issued by a health care plan established under Chapter 20 of this title;

(E) An individual or group contract of the type issued by a nonprofit medical service corporation established under Chapter 18 of this title;

(F) An individual or group contract of the type issued by a health maintenance organization established under Chapter 21 of this title;

(G) An individual or group contract of the type issued by a fraternal benefit society; or

(H) Any similar individual or group accident and sickness benefit plan, policy, or contract.

(2) "Approved clinical trial program for treatment of children's cancer" means a Phase II and III prescription drug clinical trial program in this state, as approved by the federal Food and Drug Administration or the National Cancer Institute for the treatment of cancer that generally first manifests itself in children under the age of 19 and that:
(A)(i) Tests new therapies, regimens, or combinations thereof against standard therapies or regimens for the treatment of cancer in children;

(ii) Introduces a new therapy or regimen to treat recurrent cancer in children; or

(iii) Seeks to discover new therapies or regimens for the treatment of cancer in children which are more cost effective than standard therapies or regimens; and

(B) Has been certified by and utilizes the standards for acceptable protocols established by the:

(i) Pediatric Oncology Group;

(ii) Children's Cancer Group; or

(iii) Commissioner as he or she may otherwise define such term by rule and regulation after due notice, any required hearing, and compliance with any other requirements of applicable law, but only providing for such definition in a manner at least as restrictive as that established in this Code section.

(3) "Routine patient care costs" means those medically necessary costs of blood tests, X-rays, bone scans, magnetic resonance images, patient visits, hospital stays, or other similar costs generally incurred by the insured party in connection with the provision of goods, services, or benefits to dependent children under an approved clinical trial program for treatment of children's cancer which otherwise would be covered under the major medical accident and sickness insurance benefit plan, policy, or contract if such medically necessary costs were not incurred in connection with an approved clinical trial program for treatment of children's cancer. Routine patient care costs specifically shall not include the costs of any clinical trial therapies, regimens, or combinations thereof, any drugs or pharmaceuticals, any costs associated with the provision of any goods, services, or benefits to dependent children which generally are furnished without charge in connection with such an approved clinical trial program for treatment of children's cancer, any additional costs associated with the provision of any goods, services, or benefits which previously have been provided to the dependent child, paid for, or reimbursed, or any other similar costs. It is specifically the intent of this Code section not to relieve the sponsor of a clinical trial program of financial responsibility for accepted costs of such program.

(4) "State health plan" means any health insurance plan established for employees of the state under Article 1 of Chapter 18 of Title 45 or Chapter 4 of Title 49 to provide health care services to state employees and indigents.

(b) On and after July 1, 1998, any state health plan or any accident and sickness insurance benefit plan, policy, or contract, by whatever name called, that provides major medical coverage for dependent children and which is issued, delivered, issued for delivery, or renewed in this state on or after July 1, 1998, shall provide coverage for routine patient care costs incurred in connection with the provision of goods, services, and benefits to such dependent children in connection with approved clinical trial programs for the treatment of children's cancer with respect to those dependent children who:

(1) Are covered dependents under a state health plan or under the major medical coverage of an accident and sickness insurance plan, policy, or contract;

(2) Have been diagnosed with cancer prior to their nineteenth birthday;

(3) Are enrolled in an approved clinical trial program for treatment of children's cancer; and

(4) Are not otherwise eligible for benefits, payments, or reimbursements from any other third party payors or other similar sources.

(c) For purposes of this Code section, any exclusions, reductions, or limitations as to coverages or any cost-sharing arrangements provided for in a state health plan or in an accident and sickness insurance benefit plan, policy, or contract which provides major medical coverage for dependent children and which applies to any benefits, payments, or reimbursements for routine patient care provided to dependent children in connection with generally recognized therapies or regimens for the treatment of children's cancer shall also apply to such benefits, payments, or reimbursements for any dependent child who is enrolled in an approved clinical trial program for treatment of children's cancer.

(d) Except as provided in subsections (b) and (c) of this Code section, nothing in this Code section shall be construed to:

(1) Prohibit a state health plan or an insurer, nonprofit corporation, health care plan, health maintenance organization, fraternal benefit society, or other person from issuing or continuing to issue an accident and sickness insurance benefit plan, policy, or contract which has benefits that are greater than the minimum benefits required by this Code section or from issuing or continuing to issue any accident and sickness insurance plan, policy, or contract which provides benefits which are generally more favorable to the insured than those required by this Code section; or

(2) Change the contractual relations between any insurer, nonprofit corporation, health care plan, health maintenance organization, fraternal benefit society, or other similar person and their insureds or covered dependents by whatever name called.