By the Division of Insurance


BULLETIN 2016-13
 

To:             Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations

From:         Daniel R. Judson, Commissioner of Insurance

Date:         November 8, 2016

Re:             Lyme Disease Medical Benefit Requirements

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The Division of Insurance (“Division”) issues this Bulletin to provide information to Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations (hereinafter referred to as “Carriers”) offering insured health coverage in the Commonwealth of Massachusetts.  On July 31, 2016, Chapter 183 of the Acts of 2016, “An Act Relative to Long-Term Antibiotic Therapy for the Treatment of Lyme Disease” (“Chapter 183”) was enacted, retroactively effective as of July 1, 2016.

Chapter 183 requires Carriers to “provide coverage for long-term antibiotic therapy for a patient with Lyme disease when determined to be medically necessary and ordered by a licensed physician after making a thorough evaluation of the patient’s symptoms, diagnostic test results or response to treatment. An experimental drug shall be covered as a long-term antibiotic therapy if it is approved for an indication by the United States Food and Drug Administration; provided, however, that a drug, including an experimental drug, shall be covered for an off-label use in the treatment of Lyme disease if the drug has been approved by the United States Food and Drug Administration.”

The Division expects that Carriers will have taken all necessary steps to ensure that the benefits required under Chapter 183 are available to all covered persons as of the effective date of Chapter 183.  The Division also expects Carriers to make all necessary amendments to their insured coverage documents to indicate coverage as required under Chapter 183.  Carriers should submit revised contracts, policies, certificates and evidences of coverage, or relevant riders, endorsements, or amendments that would be attached to existing documents regarding benefit changes as soon as possible.  Form filings should be filed with the Division via SERFF, with the appropriate form filing fees.  See Division Bulletins 2008-08 and 2008-19 for form filing and fee information.

If you have any questions about this Bulletin, please contact Kevin Beagan, Deputy Commissioner, Health Care Access Bureau, at 617-521-7323 or kevin.beagan@state.ma.us.