SB 190, 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 require health care service plan contracts and health insurance policies issued, amended, renewed, or delivered on or after January 1, 2016, to include coverage for post-acute residential transitional rehabilitation services made necessary as a result of and related to an acquired brain injury. The bill would prohibit the plan contract or policy from including any acquired brain injury post-acute care treatment covered under the plan contract or policy in any lifetime limitation on the number of days of covered acute care treatment, and would require the plan contract or policy to provide the post-acute residential transitional rehabilitation services under the same terms and conditions, including, but not limited to, deductibles and copayments, as are applicable to similar coverage provided under the plan contract or policy. The bill would also prohibit a health care service plan or health insurer that contracts with or approves admission to a service provider pursuant to these requirements from refusing to contract with or approve admission to that facility to provide services that meet specified criteria solely because a facility is licensed by this state as an adult residential facility. 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, 2016, shall
5include coverage for post-acute residential transitional
6rehabilitation services made necessary as a result of and related to
7an acquired brain injury.
8(1) The health care service plan contract shall not include any
9acquired brain injury post-acute care treatment covered under the
10plan contract in any lifetime limitation on the number of days of
11covered acute care treatment. Any limitation imposed under the
12plan contract on days of acquired brain injury post-acute care
13treatment shall be separately stated in the plan contract.
14(2) (A) The health
care service plan contract shall provide the
15services described in this section under the same terms and
16conditions as are applicable to similar coverage provided under
17the plan contract.
18(B) Those terms and conditions include, but are not limited to,
19all of the following:
20(i) Deductibles.
21(ii) Copayments.
22(iii) Coinsurance.
23(iv) Annual or lifetime maximum payment limits.
P3 1(b) A health care service plan that contracts with or approves
2admission to a service provider under this section shall not, solely
3because a facility is licensed by this state as an adult residential
4facility, refuse to contract with or approve admission to
that facility
5to provide services that are all of the following:
6(1) Required by this section.
7(2) Within the scope of its license as an adult residential facility.
8(3) Within the scope of the services of an adult residential
9facility or post-acute residential rehabilitation facility that has a
10specialty in brain injury rehabilitation, which may include
11accreditation by the Commission on Accreditation of Rehabilitation
12Facilities or other state licensed or nationally recognized or
13accredited rehabilitation program for brain injury.
14(c) This section shall not apply to accident-only, specified
15disease, hospital indemnity, Medicare supplement, dental-only, or
16vision-only health care service plan contracts.
Section 10123.65 is added to the Insurance Code, to
18read:
(a) A health insurance policy issued, amended,
20renewed, or delivered on or after January 1, 2016, shall include
21coverage for post-acute residential transitional rehabilitation
22services made necessary as a result of and related to an acquired
23brain injury.
24(1) The health insurance policy shall not include any acquired
25brain injury post-acute care treatment covered under the policy in
26any lifetime limitation on the number of days of covered acute
27care treatment. Any limitation imposed under the policy on days
28of acquired brain injury post-acute care treatment shall be
29separately stated in the policy.
30(2) (A) The health insurance policy shall provide the
services
31described in this section under the same terms and conditions as
32are applicable to similar coverage provided under the policy.
33(B) Those terms and conditions include, but are not limited to,
34all of the following:
35(i) Deductibles.
36(ii) Copayments.
37(iii) Coinsurance.
38(iv) Annual or lifetime maximum payment limits.
39(b) An insurer that contracts with or approves admission to a
40service provider under this section shall not, solely because a
P4 1facility is licensed by this state as an adult residential facility,
2refuse to contract with or approve admission to that facility to
3provide services that are all of the
following:
4(1) Required by this section.
5(2) Within the scope of its license as an adult residential facility.
6(3) Within the scope of the services of an adult residential
7facility or post-acute residential rehabilitation facility that has a
8specialty in brain injury rehabilitation, which may include
9accreditation by the Commission on Accreditation of Rehabilitation
10Facilities or other state licensed or nationally recognized or
11accredited rehabilitation program for brain injury.
12(c) This section shall not apply to accident-only, specified
13disease, hospital indemnity, Medicare supplement, dental-only, or
14vision-only health insurance policies.
No reimbursement is required by this act pursuant to
16Section 6 of Article XIII B of the California Constitution because
17the only costs that may be incurred by a local agency or school
18district will be incurred because this act creates a new crime or
19infraction, eliminates a crime or infraction, or changes the penalty
20for a crime or infraction, within the meaning of Section 17556 of
21the Government Code, or changes the definition of a crime within
22the meaning of Section 6 of Article XIII B of the California
23Constitution.
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