SB 320, as introduced, Beall. Health care coverage: acquired brain injury.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for specified benefits.
This bill would prohibit a health care service plan contract or a health insurance policy issued, amended, renewed, or delivered on or after January 1, 2014, from denying coverage for medically necessary medical or rehabilitation treatment for an acquired brain injury at a facility that is properly licensed and accredited at which appropriate services may be provided, including specified facilities such as a hospital or a long-term acute care hospital, except as provided. The bill would additionally prohibit the contract or policy from denying coverage because the treating facility is not near the enrollee’s or insured’s home. Because a willful violation of the bill’s provisions by a health care service plan would be a crime, it would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.
The people of the State of California do enact as follows:
Section 1367.81 is added to the Health and Safety
2Code, to read:
(a) A health care service plan contract issued,
4amended, renewed, or delivered on or after January 1, 2014, shall
5not deny coverage for medically necessary medical or rehabilitation
6treatment for an acquired brain injury at a facility that is properly
7licensed and accredited at which appropriate services may be
8provided, including any of the following facilities:
9(1) A hospital.
10(2) An acute rehabilitation hospital.
11(3) A long-term acute care hospital.
12(4) An adult residential or postacute residential transitional
13rehabilitation facility accredited by
the Commission on
14Accreditation of Rehabilitation Facilities as a specialty brain injury
15rehabilitation program, such as an interdisciplinary outpatient
16medical rehabilitation program, a brain injury program, or a
17residential rehabilitation program.
18(5) A medical office.
19(6) Another analogous facility at which appropriate services
20may be provided.
21(b) A health care service plan shall not deny coverage pursuant
22to subdivision (a) because the treating facility is not near the
23enrollee’s home.
24(c) This section shall not apply to accident-only, specified
25disease, hospital indemnity, Medicare supplement, dental-only, or
26vision-only health care service plan contracts.
Section 10123.65 is added to the Insurance Code, to
28read:
(a) A health insurance policy issued, amended,
30renewed, or delivered on or after January 1, 2014, shall not deny
P3 1coverage for medically necessary medical or rehabilitation
2treatment for an acquired brain injury at a facility that is properly
3licensed and accredited at which appropriate services may be
4provided, including any of the following facilities:
5(1) A hospital.
6(2) An acute rehabilitation hospital.
7(3) A long-term acute care hospital.
8(4) An adult residential or postacute residential transitional
9rehabilitation facility accredited by the Commission on
10Accreditation of Rehabilitation Facilities as a specialty brain injury
11rehabilitation program, such as an interdisciplinary outpatient
12medical
rehabilitation program, a brain injury program, or a
13residential rehabilitation program.
14(5) A medical office.
15(6) Another analogous facility at which appropriate services
16may be provided.
17(b) A health insurance policy shall not deny coverage, pursuant
18to subdivision (a) because the treating facility is not near the
19insured’s home.
20(c) This section shall not apply to accident-only, specified
21disease, hospital indemnity, Medicare supplement, dental-only, or
22vision-only health insurance policies.
No reimbursement is required by this act pursuant to
24Section 6 of Article XIII B of the California Constitution because
25the only costs that may be incurred by a local agency or school
26district will be incurred because this act creates a new crime or
27infraction, eliminates a crime or infraction, or changes the penalty
28for a crime or infraction, within the meaning of Section 17556 of
29the Government Code, or changes the definition of a crime within
30the meaning of Section 6 of Article XIII B of the California
31Constitution.
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