Amends TCA Title 8; Title 56 and Title 71.

This bill requires the state group insurance program to cover a physician prescribed hypofractionated proton therapy protocol to deliver a biological effective dose by paying the same aggregate amount as would be paid for the delivery of the same biological effective dose with IMRT for the same indication, if the following conditions are satisfied:<br /> <br /> (1) Coverage is provided to an eligible patient who is being treated as part of a clinical trial or registry; and<br /> (2) The radiation oncologist prescribing the hypofractionated proton therapy protocol is board certified or board eligible in the specialty of radiation oncology.<br /> <br /> If coverage of hypofractionated proton therapy protocol is required pursuant to this bill, then:<br /> <br /> (1) The aggregate amount must be equal to the average cost actually paid by the state group insurance program for an entire course of IMRT treatment required to deliver the prescribed biological effective dose for the particular indication. Aggregate amounts will be established for the various disease indications such as breast, prostate, lung, head and neck, and gastrointestinal by reference to amounts paid for a course of IMRT treatment for each of those indications under the state group insurance program;<br /> (2) The amount that the state group insurance program must reimburse for hypofractionated proton therapy will be paid in a single payment equal to the aggregate amount as determined pursuant to this bill; and<br /> (3) Coverage will be subject to annual deductible and co-insurance established for radiation therapy and other similar benefits within the policy or contract of insurance. The annual deductible and co-insurance for any radiation therapy delivery method permitted by this section must be no greater than the annual deductible and co-insurance established for all other similar benefits within a policy or contract of insurance. <br /> <br /> Also, this bill provides that the amount:<br /> <br /> (1) Reimbursed for hypofractionated proton therapy treatment must not exceed the average amount paid by the state group insurance program for a course of IMRT treatment to deliver the prescribed biological effective dose for the same disease site; and<br /> (2) Chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy must not exceed the amount that would otherwise be chargeable to or payable by the eligible patient for a course of IMRT that is covered by the state group insurance program for the delivery of the same biological effective dose.<br /> <br /> This bill will take effect January 1, 2020.<br /> <br /> ON APRIL 4, 2019, THE SENATE ADOPTED AMENDMENT #2 AND PASSED SENATE BILL 195, AS AMENDED.<br /> <br /> AMENDMENT #2 revises various provisions of this bill, as follows:<br /> <br /> (1) Changes references from "hypofractionated proton therapy protocol" to "hypofractionated radiation therapy protocol";<br /> (2) Revises the coverage requirement, as described in the first paragraph of the bill summary, to refer to coverage being the same as it would be for the same biological effective dose "with a standard radiation therapy treatment protocol delivered with IMRT" instead of "with IMRT". This amendment makes similar reference substitutions in this bill;<br /> (3) Adds the following to the conditions that must be met for coverage: the eligible patient is diagnosed with a cancer type or indication that can be treated with hypofractionated proton therapy protocol and the hypofractionated proton therapy protocol is administered in a facility in this state;<br /> (4) Revises the requirement to establish aggregate amounts for the various disease (as described above in the bill summary in the first item (1)) to instead require that aggregate amounts be established by reference to the amount paid for a course of IMRT treatment under a standard IMRT radiation therapy protocol for the indication under the state group insurance program; <br /> (5) Removes the requirement described above in the bill summary in the first item (2) regarding the amount the state group insurance program must reimburse; and<br /> (6) Revises the reimbursement requirements described above in the bill summary in the second items (1) and (2) to instead require that the aggregate amount:<br /> (A) Reimbursed for the hypofractionated proton therapy protocol must not exceed the average aggregate amount paid by the state group insurance program for a course of IMRT treatment under a standard IMRT radiation therapy protocol to deliver the prescribed biological effective dose for the same indication;<br /> (B) Chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy by an in-network provider must not exceed the aggregate amount that would otherwise be chargeable to or payable by the eligible patient for a course of IMRT treatment under a standard IMRT radiation therapy protocol that is covered by the state group insurance program for the delivery of the same biological effective dose by an in-network provider; and<br /> (C) Chargeable to or payable by an eligible patient for a covered course of hypofractionated proton therapy by an out-of-network provider must not exceed the aggregate amount that would otherwise be chargeable to or payable by the eligible patient for a course of treatment under a standard IMRT radiation therapy protocol that is covered by the state group insurance program for the delivery of the same biological dose by an out-of-network provider. However, the patient is not responsible for amounts above the allowable maximum charge. <br /> <br /> This amendment repeals this bill effective January 1, 2023.<br /> <br />