Amended in Senate April 6, 2015

Senate Bill No. 190

Introduced by Senator Beall

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(Coauthor: Assembly Member Waldron)

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February 10, 2015

An act to add Section 1367.81 to the Health and Safety Code, and to add Section 10123.65 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 190, as amended, 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 1.  

Section 1367.81 is added to the Health and Safety
Code, to read:

1367.81.  

(a) A health care service plan contract issued,
amended, renewed, or delivered on or after January 1, 2016, shall
include coverage for post-acute residential transitional
rehabilitation services made necessary as a result of and related to
an acquired brain injury.

(1) The health care service plan contract shall not include any
acquired brain injury post-acute care treatment covered under the
plan contract in any lifetime limitation on the number of days of
covered acute care treatment. Any limitation imposed under the
plan contract on days of acquired brain injury post-acute care
treatment shall be separately stated in the plan contract.

(2) (A) The health care service plan contract shall provide the
services described in this section under the same terms and
conditions as are applicable to similar coverage provided under
the plan contract.

(B) Those terms and conditions include, but are not limited to,
all of the following:

(i) Deductibles.

(ii) Copayments.

(iii) Coinsurance.

(iv) Annual or lifetime maximum payment limits.

(b) A health care service plan that contracts with or approves
admission to a service provider under this section shall not, solely
because a facility is licensed by this state as an adult residential
facility, refuse to contract with or approve admission to that facility
to provide services that are all of the following:

(1) Required by this section.

(2) Within the scope of its license as an adult residential facility.

(3) Within the scope of the services of an adult residential
facility or post-acute residential begin insert transitional end insert rehabilitation facility
that has a specialty in brain injury rehabilitation, which may include
accreditation by the Commission on Accreditation of Rehabilitation
Facilities or other state licensed or nationally recognized or
accredited rehabilitation program for brain injury.

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(c) (1) As used in this section, “post-acute residential
transitional rehabilitation” means physician-prescribed
rehabilitation indicated for individuals specified in paragraph (4)
that utilizes an interdisciplinary, coordinated team approach in a
residential facility and provides direct medical and goal-oriented
treatment for a complex range of medical, physical, communicative,
cognitive, neurobehavioral, and psychological conditions arising
from, or associated with, an acquired brain injury.

end insert begin insert

(2) As used in this subdivision, “interdisciplinary, coordinated
team approach” means a treatment approach that includes physical
therapy, occupational therapy, speech therapy, rehabilitation
nursing, respiratory therapy, neuropsychology and psychology
services, prosthetic and orthotic services, or a combination thereof.

end insert begin insert

(3) As used in this subdivision, “goal-oriented treatment” means
treatment that has the goal of minimizing or eliminating medical
complications, reducing disability, and returning the person to
self-sufficiency or maximal possible functional independence.

end insert begin insert

(4)  Post-acute residential transitional rehabilitation may be
indicated for individuals who can be treated more effectively in a
residential setting or may not have access to appropriate or
adequate hospital rehabilitation or subacute rehabilitation in a
long-term acute care hospital or skilled nursing facility and who
have any combination of the following conditions and factors
arising from, or associated with, an acquired brain injury:

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(A) Have continuing medical complexity.

end insert begin insert

(B) Have significant functional deficits.

end insert begin insert

(C) Are deemed unsafe to be discharged to his or her personal
residence.

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(D) Require continued neurobehavioral treatment.

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(E) Have a deteriorated medical, physical, communicative,
cognitive, neurobehavioral, or psychological status.

end insert begin delete

(c)

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begin insert (d) end insert  This section begin delete shall end delete begin insert does end insert not apply to begin delete accident-only, end delete begin insert any of
the following: end insert

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(1) A specialized health care service plan that does not cover
treatment for brain injury.

end insert

begin insert (2) end insert begin insert   end insert begin insert Accident-only, end insert specified disease, hospital indemnity,
Medicare supplement, dental-only, or vision-only health care
service plan contracts.

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(3) A health care service plan issued, sold, renewed, or offered
for health care services or coverage provided in the Medi-Cal
program (Chapter 7 (commencing with Section 14000) of Part 3
of Division 9 of the Welfare and Institutions Code).

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SEC. 2.  

Section 10123.65 is added to the Insurance Code, to
read:

10123.65.  

(a) A health insurance policy issued, amended,
renewed, or delivered on or after January 1, 2016, shall include
coverage for post-acute residential transitional rehabilitation
services made necessary as a result of and related to an acquired
brain injury.

(1) The health insurance policy shall not include any acquired
brain injury post-acute care treatment covered under the policy in
any lifetime limitation on the number of days of covered acute
care treatment. Any limitation imposed under the policy on days
of acquired brain injury post-acute care treatment shall be
separately stated in the policy.

(2) (A) The health insurance policy shall provide the services
described in this section under the same terms and conditions as
are applicable to similar coverage provided under the policy.

(B) Those terms and conditions include, but are not limited to,
all of the following:

(i) Deductibles.

(ii) Copayments.

(iii) Coinsurance.

(iv) Annual or lifetime maximum payment limits.

(b) An insurer that contracts with or approves admission to a
service provider under this section shall not, solely because a
facility is licensed by this state as an adult residential facility,
refuse to contract with or approve admission to that facility to
provide services that are all of the following:

(1) Required by this section.

(2) Within the scope of its license as an adult residential facility.

(3) Within the scope of the services of an adult residential
facility or post-acute residential begin insert transitional end insert rehabilitation facility
that has a specialty in brain injury rehabilitation, which may include
accreditation by the Commission on Accreditation of Rehabilitation
Facilities or other state licensed or nationally recognized or
accredited rehabilitation program for brain injury.

begin insert

(c) (1) As used in this section, “post-acute residential
transitional rehabilitation” means physician-prescribed
rehabilitation indicated for individuals specified in paragraph (4)
that utilizes an interdisciplinary, coordinated team approach in a
residential facility and provides direct medical and goal-oriented
treatment for a complex range of medical, physical, communicative,
cognitive, neurobehavioral, and psychological conditions arising
from, or associated with, an acquired brain injury.

end insert begin insert

(2) As used in this subdivision, “interdisciplinary, coordinated
team approach” means a treatment approach that includes physical
therapy, occupational therapy, speech therapy, rehabilitation
nursing, respiratory therapy, neuropsychology and psychology
services, prosthetic and orthotic services, or a combination thereof.

end insert begin insert

(3) As used in this subdivision, “goal-oriented treatment” means
treatment that has the goal of minimizing or eliminating medical
complications, reducing disability, and returning the person to
self-sufficiency or maximal possible functional independence.

end insert begin insert

(4)  Post-acute residential transitional rehabilitation may be
indicated for individuals who can be treated more effectively in a
residential setting or may not have access to appropriate or
adequate hospital rehabilitation or subacute rehabilitation in a
long-term acute care hospital or skilled nursing facility and who
have any combination of the following conditions and factors
arising from, or associated with, an acquired brain injury:

end insert begin insert

(A) Have continuing medical complexity.

end insert begin insert

(B) Have significant functional deficits.

end insert begin insert

(C) Are deemed unsafe to be discharged to his or her personal
residence.

end insert begin insert

(D) Require continued neurobehavioral treatment.

end insert begin insert

(E) Have a deteriorated medical, physical, communicative,
cognitive, neurobehavioral, or psychological status.

end insert begin delete

(c)

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begin insert (d) end insert  This section begin delete shall end delete begin insert does end insert not apply to begin delete accident-only, end delete begin insert any of
the following: end insert

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(1) Specialized health insurance policies that do not cover
treatment for brain injury.

end insert

begin insert (2) end insert begin insert   end insert begin insert Accident-only, end insert specified disease, hospital indemnity,
Medicare supplement, dental-only, or vision-only health insurance
policies.

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(3) A health insurance policy issued, sold, renewed, or offered
for health care services or coverage provided in the Medi-Cal
program (Chapter 7 (commencing with Section 14000) of Part 3
of Division 9 of the Welfare and Institutions Code).

end insert

SEC. 3.  

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.