NOTE: As provided in LFC policy, this report is intended for use by the standing finance committees of the legislature.  The Legislative Finance Committee does not assume responsibility for the accuracy of the information in this report when used in any other situation.

Only the most recent FIR version, excluding attachments, is available on the Intranet. Previously issued FIRs and attachments may be obtained from the LFC office in Suite 101 of the State Capitol Building North.

(Parenthesis ( ) Indicate Expenditure Decreases)

SOURCES OF INFORMATION

LFC files

Public Regulation Commission

No Response

Health Policy Commission

Attorney General's Office

Retiree Health Care Authority

General Services Department

SUMMARY

     Synopsis of SCORC Amendment

The SCORC amendment enlarges the scope of the clinical trial that must be covered to include early detection and the prevention of reoccurrence. The amendment also adds a section stating that if a patient is denied coverage they may appeal to the Superintendent of Insurance and that appeal must be handled within thirty days. The amendment also clarifies that the health insurer does not have to pay for tests that are related to the research of the clinical trial. The rest of the amendment is technical changes.

SUBSTANTIVE ISSUE

The portion of the amendment that covers the appeal rights should track with the managed health care regulations promulgated by the Superintendent. Many of the patients who are entering clinical trials cannot wait thirty days. The managed health care regulations call for expedited reviews of 72 hours, or more rapidly if necessary.

Synopsis of SPAC Amendment

• A health care plan will not be required to cover Phase I (the most experiemental) and related expenses.
• A health care plan will be required to cover clinical trials for reoccurring cancer.
• The patient does not have to undergo or prove that standard cancer treatment is not effective, must merely show that no equally or more effective standard cancer treatment exists.
• The clinical trial does not need to be conducted in New Mexico.
• The clinical trial does not have to conducted as part of a larger study.
• The provider of the treatment must agree to provide written notification to the health plan when a patient enters or leaves a clinical trial.
• Does not cover individual policies intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident only, hospital indemnity or other limited benefit policies.
• The Act is repealed on July 1, 2004.
• Other technical and style changes.

There is a technical problem on page 6: strike lines 1, 2 and 3. It was replaced on the previous page in the amendment.

The amended bill does not cover specific disease policies. Does this include a cancer policy?

     Synopsis of Original Bill

SB 240 requires that health care plans cover the routine patient care costs incurred while a patient is participating in phase I, II, III or IV of a cancer clinical trial.

     Significant Issues.

Persons currently participating in clinical trials have medical benefits excluded because they are considered experimental and therefore they are not covered. SB 240 requires that an insurance health plan cover "routine benefits." These routine costs are a medical service or treatment that is a benefit under a health plan that would be covered if the patient were receiving standard cancer treatment.

FISCAL IMPLICATIONS

SB 240 might cause a small increase in health premiums paid by the State on behalf of the state employees, the retirees and public school employees since this would extend coverage in the health plans.

POSSIBLE QUESTIONS

Why does SB 240 only cover clinical trials for cancer? Aren't there clinical trials for other diseases?

DW/ar/njw