Relating to health benefit plan coverage for chimeric antigen receptor T-cell therapy.

Contracts

• Provider Agreements: Review all hospital and cancer center contracts immediately. Exclusivity clauses or "carve-outs" that restrict CAR T therapy to specific facilities are unenforceable as of the 2026 plan year if the facility is otherwise in-network.
• Fee Schedules: If your current master agreements with general hospitals exclude CAR T codes (anticipating they would go to a Center of Excellence), you must negotiate fee schedules for these services immediately to avoid defaulting to higher out-of-network or chargemaster rates.
• Reinsurance/Stop-Loss: Notify your stop-loss carriers immediately. The removal of steering mechanisms increases the probability of high-dollar claims at higher-cost facilities.

Hiring/Training

• Utilization Review (UR) Teams: Update clinical guidelines and decision trees. Staff must be trained that they cannot deny pre-authorization based on facility network status if the facility is in-network for other services.
• Credentialing: Staff must verify facility certifications against FDA lists specifically for the CAR T product requested (e.g., Yescarta vs. Kymriah).

Reporting & Record-Keeping

• FDA Verification: Implement a workflow to document that the treating facility held a valid FDA certification for the specific product *at the time of service*. This will be your primary defense in a bad-faith claim or audit.
• Medical Necessity: Ensure clinical denials are strictly based on patient medical status, not provider location. Documentation must be robust to survive TDI scrutiny.

Fees & Costs

• Premium Adjustments: Based on the Fiscal Note regarding TRS (projected $3.4M+ annual increase), carriers and PEOs must factor increased utilization and unit costs into 2026 premium renewals.
• Medicaid Exclusion: Do not apply these cost assumptions or operational changes to Medicaid or CHIP lines of business; they are statutorily exempt.