2001-16 HLA Testing

As noted in Division of Insurance Bulletin No. 2001-04, St. 2000, c. 355 (Chapter 355) mandates coverage for the cost of human leukocyte antigen testing or histocompatibility locus antigen testing (HLA testing) necessary to establish bone marrow transplant donor suitability. Such coverage is required to cover the costs of testing for A, B, or DR antigens, or any combination thereof, consistent with the guidelines, criteria, and rules or regulations established by the Department of Public Health (DPH).

Pursuant to chapter 355, DPH convened an advisory group of medical experts to assist in decisions relative to the guidelines. The guidelines established by DPH in collaboration with the Division of Insurance (DOI) are attached to this bulletin.

In addition to the guidelines, carriers should note the following:

• The mandate directs carriers to provide coverage for HLA testing. The mandate does not extend to any costs associated with recruitment of potential donors. Carriers are required to provide coverage only for the cost of the testing itself.
• Coverage for HLA testing should be consistent with the terms of the carrier's contract or evidence of coverage, with the exceptions noted in this bulletin.
• The mandate became effective on March 28, 2001 for all policies identified in Bulletin No. 2001-04. Claims for services on or after that date must be covered according to contract benefits.
• Carriers should note that if the terms of coverage require that insureds use contracted providers, i.e., providers within a specified network, then carriers are not required to provide coverage for out-of-network services or services by non-contracted providers. Carriers should further note, however, that if there are currently no providers within a carrier's network that can provide the mandated service, then carriers must provide coverage for any provider at the in-network level until such time as the carrier establishes an adequate number of network providers.
• If a carrier requires that services be ordered or referred by a primary care physician, coverage for HLA testing must be provided even in the absence of any such order or referral.

Carriers are encouraged to work with the HLA donor centers and registries in their respective service areas to facilitate the process of claims submission and reimbursement. In addition, carriers are encouraged to educate their insureds about bone marrow or stem cell transplantation and the process for HLA testing and registration.

If you have any questions about insurance coverage under chapter 355, please call the Health Unit at DOI at 617-521-7349. If you have questions about the attached guidelines, please call the Office of Patient Protection at DPH at 1-800-436-7757.