BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 320
AUTHOR: Beall
AMENDED: April 3, 2013
HEARING DATE: May 1, 2013
CONSULTANT: Robinson-Taylor
SUBJECT : Health care coverage: acquired brain injury.
SUMMARY : Prohibits a health care service plan contract or a
health insurance policy from denying coverage for medically
necessary medical or rehabilitation treatment for acquired brain
injury (ABI) at specified facilities. Permits enrollees to seek
facilities outside of their service area.
Existing law:
1.Enacts, in federal law, the Patient Protection and Affordable
Care and Education Reconciliation Act of 2010 (ACA), as
amended by the federal Health Care and Education
Reconciliation Act of 2010, to among other things, makes
statutory changes affecting the regulation of, and payment
for, certain types of private health insurance. Includes the
definition of essential health benefits (EHBs) that all
qualified health plans must cover, at a minimum, with some
exceptions.
2.Establishes as California's EHBs the Kaiser Small Group Health
Maintenance Organization plan along with the following ten ACA
mandated benefits:
a. Ambulatory patient services;
b. Emergency services;
c. Hospitalization;
d. Maternity and newborn care;
e. Mental health and substance use disorder services,
including behavioral health treatment;
f. Prescription drugs;
g. Rehabilitative and habilitative services and devices;
h. Laboratory services;
i. Preventive and wellness services and chronic disease
management; and,
j. Pediatric services, including oral and vision care.
3.Establishes the Knox-Keene Health Care Service Plan Act of
1975 (Knox-Keene) to regulate and license health plans and
Continued---
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specialized health plans by California Department of Managed
Health Care (DMHC) and provides for the regulation of health
insurers by the California Department of Insurance (CDI).
4.Establishes the California Traumatic Brain Injury (TBI)
Program within the Department of Rehabilitation (DOR) and
requires DOR to designate project sites for a system of
post-acute continuum of care models for adults with TBI.
5.Establishes the State Penalty Fund (SPF) as a depository for
assessments on specified fines, penalties, and forfeitures
imposed and collected by the courts as specified. Establishes
funding for the TBI Program through the TBI Fund which is
funded by the monthly transfer of 0.66 percent of the SPF.
This bill:
1.Prohibits a health care service plan or a health insurance
policy issued, amended, renewed, or delivered on or after
January 1, 2014 from denying coverage for medically necessary
medical or rehabilitative treatment for an ABI at a facility
within the carrier's network that is properly licensed and
accredited at which appropriate services may be provided,
including any of the following facilities:
a. A hospital;
b. An acute rehabilitation hospital;
c. A long-term acute care hospital;
d. An adult residential or post-acute residential
transitional rehabilitation facility accredited by the
Commission on Accreditation of Rehabilitation Facilities;
e. A medical office; and,
f. Another analogous facility within the plan's network at
which appropriate services may be provided.
2.Prohibits a health care service plan or health insurance
policy from denying coverage, because the treating facility
within the carrier's network is not near the enrollee's home.
3.Exempts accident-only, specified disease, hospital indemnity,
Medicare supplement, dental-only, or vision-only health care
service plan contracts from the requirements in this bill.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. ABI is a catastrophic injury.
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Evidence-based literature demonstrates the critical need for
these patients to have access to medically necessary and
appropriate treatments, including rehabilitative services and
chronic disease management conducted in a continuum of
treatment settings. Appropriate rehabilitation, in the
appropriate treatment setting, leads to faster and more
significant functional gains, reduced hospital length of stay,
improved clinical outcomes, improved productivity, decreased
institutionalization, and lessens the need for and cost of
long-term support. According to the author, this bill is
needed because some carriers do not recognize the full
continuum of treatment settings. The effect of this
variability is significantly diminished quality of life for
individuals who need, but are not provided access to, these
programs and increased costs for the state resulting from
these individual's dependency on federal and state programs,
including Medicaid. The author maintains that this bill
clarifies the standard of care for individuals experiencing
ABI and clarifies that, for DMHC-regulated plans and
CDI-regulated policies, medically necessary and appropriate
coverage of rehabilitation services for ABI patients includes
treatment for such patients at recognized licensed and
certified facilities.
2.ABI. SB 320 does not define ABI, however, ABI is usually
defined as an acute (rapid onset) brain injury of any cause
sustained any time after birth. According to the California
Health Benefits Review Program (CHBRP), severity of ABI ranges
from a mild concussion - requiring little to no treatment - to
coma or death. CHBRP reports that ABI may result in
short-term or long-term impairments that affect physical or
cognitive abilities (thinking, memory, and reasoning), sensory
processing (using the five senses), communication (expression
and understanding), and behavior or mental health (depression,
anxiety, personality changes, aggression, and social
inappropriateness). According to the author, consequences of
ABI often require a major life adjustment around a person's
new circumstances, and making that adjustment is a critical
factor in recovery and rehabilitation. While the outcome of a
given injury depends largely upon the nature and severity of
the injury, appropriate treatment plays a vital role in
determining the level of recovery.
3.Facility and rehabilitative treatments and services.
According to CHBRP, medical and rehabilitative treatment
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outcomes for ABI range from complete restoration of pre-injury
function to permanent, severe disability. In addition to
acute medical care treatment (emergency department and
hospitalization), post-acute rehabilitation treatments for ABI
are prescribed in accordance with the severity and location of
the brain injury among other factors.
CHBRP reports that those diagnosed with moderate to severe brain
injuries are most likely patients to be prescribed
rehabilitation that involve multidisciplinary treatment
programs. Treatments may include physical therapy,
occupational therapy, speech/language therapy,
psychology/psychiatry, and social support provided at an array
of inpatient and outpatient facilities or programs.
Additionally, according to CHBRP, neuropsychology, cognitive
behavioral therapy, and vocational rehabilitation are other
treatments that may be recommended.
4.CHBRP. CHBRP was created in response to AB 1996 (Thomson),
Chapter 795, Statutes of 2002, which requests the University
of California to assess legislation proposing a mandated
benefit or service, and prepare a written analysis with
relevant data on the public health, medical, and economic
impact of proposed health plan and health insurance benefit
mandate legislation. Among CHBRP's findings of their analysis
of SB 320 are the following:
a. Analytic Approach and Key Assumptions . CHBRP notes that
SB 320 approaches coverage by emphasizing: 1) a condition -
ABI - which itself is a broad category of injuries, and 2)
facilities, listing six categories of facilities. CHBRP
maintains that the bill does not define specific treatments
to be covered and thus the bill's broad language posed
analytical challenges.
According to CHBRP, the emphasis on facilities, rather than
treatments, presented analysis challenges because coverage
of facilities does not necessarily equate to coverage for
the treatments and services that are available at that
facility, or what an enrollee with ABI may require.
Therefore, a carrier could report 100 percent coverage for
a facility, but it would not be clear whether an enrollee
would have benefit coverage for all treatments available at
that facility or whether the coverage would be subject to
limitations. Furthermore, CHBRP asserts, there are a wide
array of treatments for ABI and assessing coverage for the
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myriad variations of treatments was not possible during the
analysis timeframe.
b. Medical Effectiveness . CHBRP assumes that DMHC-regulated
plans and CDI-regulated policies provide coverage for all
medically necessary medical treatments for ABI. CHBRP's
review of medical effectiveness focused on the impact of
utilizing packages of multidisciplinary rehabilitation
treatments and not on the effects of specific types of
treatments. Most of the people enrolled in studies of
multidisciplinary rehabilitation for ABI had a TBI. CHBRP
found evidence that among persons with mild TBI, only
persons with injuries that require hospitalization benefit
from multidisciplinary post-acute rehabilitation. Evidence
also shows, according to CHBRP, persons with moderate to
severe ABI benefit from multidisciplinary post-acute
rehabilitation treatment as compared to those who receive
little or no intervention.
c. Benefit Coverage Impact . According to CHBRP, currently
enrollees appear to have nearly full coverage at
facilities required by SB 320. Carriers reported 100
percent coverage of facilities specified, except for
coverage for adult residential or post-acute residential
transitional rehabilitation facilities, at which carriers
reported 58 percent coverage of facilities. CHBRP
emphasizes, however, that coverage of facilities does not
necessarily mean coverage for all treatments and services.
Benefit coverage may include limitations on number of
visits or inpatient days or number of treatments.
According to CHBRP, some enrollees with ABI may reach
these limits depending on the extent of their
rehabilitation needs. As a result of this bill, CHBRP
finds that coverage for treatments at adult residential or
post-acute residential transitional rehabilitation
facilities would increase from 58 percent to 100 percent,
but it is unknown which treatments or services would be
included in the coverage, the intensity of those
treatments, their duration, or whether regulators will
deem these treatments to be medically necessary.
d. Utilization Impacts . CHBRP estimates that currently
approximately 129,700 enrollees with health insurance
subject to this bill have been diagnosed with and treated
for ABI. Of these enrollees, approximately 4,500 were
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admitted to one of the six facilities that would be
subject to this bill during the past year; 2,900 patients
were seen at medical offices, 1,400 at general acute care
hospitals, and the rest at other facilities. These 4,500
patients used approximately 68,200 different treatments.
According to CHBRP, the impact of SB 320 on utilization is
unknown because it is not clear whether benefit coverage
for treatments administered in these facilities would
change post-mandate. CHBRP also reports that unmet demand
is unclear stating that a data source or research
literature that addressed unmet demand for ABI-related
treatments could not be found. Therefore, CHBRP could not
estimate potential change in utilization due to this
mandate.
e. Cost Impacts. Because of the uncertainty of the impact
of this bill on benefit coverage and utilization, CHBRP
deemed the impact and cost of this mandate as unknown.
f. Public Health Impacts . CHBRP was unable to estimate a
change in coverage or utilization of rehabilitation
treatments at specified facilities because: 1) the bill's
focus on facilities precludes capturing pre-mandate
coverage or utilization of treatments; and, 2) CHBRP was
unable to estimate the unmet demand for these treatments.
Therefore, CHBRP concludes that the overall public health
impact of SB 320 is unknown.
5.EHBs. Effective 2014, the ACA requires non-grandfathered
small-group and individual market health insurance, including
those qualified health plans that will be sold in Covered
California, to cover 10 specified categories of EHBs. The
federal Department of Health and Human Services (HHS) has
allowed each state to define its own EHBs for 2014 and 2015 by
selecting one of a set of specified benchmark plan options.
California has selected the Kaiser Foundation Health Plan
Small Group Health Maintenance Organization 30 Plan (Kaiser
HMO 30 plan) as its benchmark plan. According to CHBRP, the
ACA allows a state to "require that a qualified health plan
offered in an exchange to offer benefits in addition to the
EHBs." If the state does so, the state must make payments to
defray the cost of those additionally mandated benefits.
According to CHBRP, it is unknown whether SB 320 exceeds or
falls within EHBs, because of ambiguity in the bill language.
The ACA's EHBs explicitly include "rehabilitative and
habilitative services and devices." In addition, both
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proposed rules and final rules on EHBs have specified that
mandates relating to provider types (such as facilities) do
not fall under the ACA's interpretation of state-required
benefits. However, rehabilitation treatments and services
offered at facilities mentioned in SB 320 may differ from the
specific treatments outlined in California's EHB package, as
defined by the Kaiser HMO 30 plan. Additionally, the medical
necessity of such treatments may also be in dispute, and
contested through the state's existing independent medical
review process at each state health insurance regulatory
agency.
According to CHBRP, state regulators would first need to
determine each type of ABI rehabilitation services provided at
a listed facility - which range from a hospital to an
"analogous facility" - is medically necessary. Then
regulators need to determine if those treatments differ from
California's EHB package. To the extent that those treatments
exceed EHBs as defined in the Kaiser HMO 30 plan, the state
would be required to defray the additional cost for Qualified
Health Plans purchased in Covered California.
6.Prior legislation. SB 253 (Alquist) of 2011 was substantially
similar to this bill. SB 253 died in the Senate Health
Committee.
7.Support. The Brain Injury Association (BIA) writes in support
that brain injury is not an event or an outcome and that for
many Americans who are injured each year, brain injury is the
start of a chronic condition that can cause or accelerate
multiple disease processes. BIA maintains that rehabilitation
is the single most effective treatment to mitigate disease
progress while maximizing health and functional outcome and
increasing independence and community participation. BIA
argues in support that published research affirms the clinical
efficacy and cost efficiency of rehabilitation of sufficient
timing, scope, intensity and duration across a treatment
continuum that includes hospital, non-hospital facility-based,
and community programs involving multidisciplinary
professionals. The Traumatic Brain Injury Services of
California (TBISC) writes in support that current access to
TBI treatment is inconsistent, leaving many patients with
unnecessary levels of disease and disability. Failure to
access appropriate treatment, according to TBISC, promotes
disability, medical indigence, financial impoverishment,
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joblessness, homelessness, institutionalization and disease
progression and undue financial burden to the public sector.
8.Opposition. The California Association of Health Plans (CAHP)
writes in opposition that this bill does not specify whether
the treatments required by this bill are covered medical
services as specified under the terms of the individual's
health coverage. Without limiting this bill to "covered"
services, CAHP maintains it is concerned that this bill could
require payment for services and treatments that fall outside
the scope of the plan contract, thus inadvertently creating a
new mandate, perhaps for non-medical benefits. CAHP also
argues in opposition that this bill might also be construed to
mandate that certain facilities be included in the plan
network. While there are high levels of coverage for adult
residential or post-acute residential transitional
rehabilitation facilities listed in this bill, CAHP maintains,
some health plans may not include these facilities in their
network because the needs of enrollees can be met within
existing plan network of providers. CAHP additionally argues
that even if this type of facility is included in a plan's
network, the benefits available to enrollees may not include
the full range of services these facilities provide,
particularly if they are not medical in nature. CAHP asserts
the bill should be amended to clarify that a health plan
retains the right to exclude types of facilities, or certain
service categories, under the terms of the coverage contract.
The California Chamber of Commerce (Cal Chamber) writes in
opposition that this bill is unnecessary. Cal Chamber
maintains that existing law already requires health plans to
provide coverage for all medically necessary treatment for all
conditions, including ABIs. Cal Chamber argues that this bill
could impose a mandate that has the potential to drive up
health care costs thus premiums at a time when policymakers
and consumers are seeking to control costs and provide for
affordable coverage. Cal Chamber asserts that this mandate
could also mean that the State General Fund would be required
to defray the cost of any benefit that exceeds California's
EHB package.
SUPPORT AND OPPOSITION :
Support: Brain Injury Association of California (sponsor)
American Congress of Rehabilitation Medicine
Association of California Caregiver Resource Centers
Attention Control Systems, Inc.
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Brain Injury Association of America
Brain Injury Center of Ventura County
Brain Injury Connection
California Athletic Trainers Association
Centre for Neuro Skills
Commission on Accreditation of Rehabilitation
Facilities
County of Santa Clara
Debra Curren Marketing
Exceptional Educational Services
Jodi House Brain Injury Support Center
Kern County Fire Fighters, Local 1301
Life After Brain Injury
Miracle 4 Jade Foundation
National Association of State Head Injury
Administrators
Occupational Therapy Association of California
San Diego Community College District Continuing
Education
San Jose State University
San Diego Brain Injury Foundation
Scripps Encinitas Rehabilitation Services
Sports Legacy Institute
Traumatic Brain Injury Services of California
Hundreds of Individuals
Oppose: America's Health Insurance Plans
Association of California Life and Health Insurance
Companies
California Chamber of Commerce
California Association of Health Plans
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