Bill Text: CA SB190 | 2015-2016 | Regular Session | Amended
Bill Title: Health care coverage: acquired brain injury.
Spectrum: Bipartisan Bill
Status: (Failed) 2016-02-01 - Returned to Secretary of Senate pursuant to Joint Rule 56. [SB190 Detail]
Download: California-2015-SB190-Amended.html
BILL NUMBER: SB 190 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 6, 2015
INTRODUCED BY Senator Beall
( Coauthor: Assembly Member
Waldron )
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 transitional
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.
(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.
(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.
(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.
(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:
(A) Have continuing medical complexity.
(B) Have significant functional deficits.
(C) Are deemed unsafe to be discharged to his or her personal
residence.
(D) Require continued neurobehavioral treatment.
(E) Have a deteriorated medical, physical, communicative,
cognitive, neurobehavioral, or psychological status.
(c)
(d) This section shall does
not apply to accident-only, any of the
following:
(1) A specialized health care service plan that does not cover
treatment for brain injury.
(2) Accident-only, specified
disease, hospital indemnity, Medicare supplement, dental-only, or
vision-only health care service plan contracts.
(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).
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 transitional
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.
(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.
(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.
(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.
(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:
(A) Have continuing medical complexity.
(B) Have significant functional deficits.
(C) Are deemed unsafe to be discharged to his or her personal
residence.
(D) Require continued neurobehavioral treatment.
(E) Have a deteriorated medical, physical, communicative,
cognitive, neurobehavioral, or psychological status.
(c)
(d) This section shall does
not apply to accident-only, any of the
following:
(1) Specialized health insurance policies that do not cover
treatment for brain injury.
(2) Accident-only, specified
disease, hospital indemnity, Medicare supplement, dental-only, or
vision-only health insurance policies.
(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).
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.
