Bill Text: OH HB361 | 2013-2014 | 130th General Assembly | Introduced
Bill Title: To prohibit health insurers from excluding coverage related to acquired brain injuries.
Spectrum: Partisan Bill (Republican 3-0)
Status: (Introduced - Dead) 2013-11-26 - To Health and Aging [HB361 Detail]
Download: Ohio-2013-HB361-Introduced.html
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Representatives Gonzales, Smith
Cosponsor:
Representative Landis
To amend section 1739.05 and to enact sections | 1 |
1751.68, 3901.046, and 3923.591 of the Revised | 2 |
Code to prohibit health insurers from excluding | 3 |
coverage related to acquired brain injuries. | 4 |
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That section 1739.05 be amended and sections | 5 |
1751.68, 3901.046, and 3923.591 of the Revised Code be enacted to | 6 |
read as follows: | 7 |
Sec. 1739.05. (A) A multiple employer welfare arrangement | 8 |
that is created pursuant to sections 1739.01 to 1739.22 of the | 9 |
Revised Code and that operates a group self-insurance program may | 10 |
be established only if any of the following applies: | 11 |
(1) The arrangement has and maintains a minimum enrollment of | 12 |
three hundred employees of two or more employers. | 13 |
(2) The arrangement has and maintains a minimum enrollment of | 14 |
three hundred self-employed individuals. | 15 |
(3) The arrangement has and maintains a minimum enrollment of | 16 |
three hundred employees or self-employed individuals in any | 17 |
combination of divisions (A)(1) and (2) of this section. | 18 |
(B) A multiple employer welfare arrangement that is created | 19 |
pursuant to sections 1739.01 to 1739.22 of the Revised Code and | 20 |
that operates a group self-insurance program shall comply with all | 21 |
laws applicable to self-funded programs in this state, including | 22 |
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381 | 23 |
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, | 24 |
3923.24, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.591, | 25 |
3923.63, 3923.80, 3924.031, 3924.032, and 3924.27 of the Revised | 26 |
Code. | 27 |
(C) A multiple employer welfare arrangement created pursuant | 28 |
to sections 1739.01 to 1739.22 of the Revised Code shall solicit | 29 |
enrollments only through agents or solicitors licensed pursuant to | 30 |
Chapter 3905. of the Revised Code to sell or solicit sickness and | 31 |
accident insurance. | 32 |
(D) A multiple employer welfare arrangement created pursuant | 33 |
to sections 1739.01 to 1739.22 of the Revised Code shall provide | 34 |
benefits only to individuals who are members, employees of | 35 |
members, or the dependents of members or employees, or are | 36 |
eligible for continuation of coverage under section 1751.53 or | 37 |
3923.38 of the Revised Code or under Title X of the "Consolidated | 38 |
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 39 |
U.S.C.A. 1161, as amended. | 40 |
Sec. 1751.68. (A) As used in this section: | 41 |
(1) "Covered service" means any of the following services | 42 |
that the treating physician considers medically necessary as a | 43 |
result of or related to an acquired brain injury: | 44 |
(a) Cognitive rehabilitation therapy; | 45 |
(b) Cognitive communication therapy; | 46 |
(c) Neurocognitive therapy and rehabilitation; | 47 |
(d) Neurobehavioral, neurophysiological, neuropsychological, | 48 |
and psychophysiological testing or treatment; | 49 |
(e) Neurofeedback therapy; | 50 |
(f) Remediation; | 51 |
(g) Post-acute rehabilitation care treatment; | 52 |
(h) Community reintegration services. | 53 |
(2) "Acquired brain injury" means a brain injury caused by | 54 |
events occurring after birth. | 55 |
(B) Notwithstanding section 3901.71 of the Revised Code, an | 56 |
individual or group health insuring corporation policy, contract, | 57 |
or agreement that provides basic health care services that is | 58 |
issued, delivered, or renewed in this state shall not exclude | 59 |
coverage for any covered service. | 60 |
(C)(1) To ensure that appropriate post-acute rehabilitation | 61 |
care treatment is provided, an individual or group health insuring | 62 |
corporation policy, contract, or agreement shall include coverage | 63 |
for reasonable expenses related to periodic reevaluation of the | 64 |
care of an enrollee that: | 65 |
(a) Has an acquired brain injury; | 66 |
(b) Has been unresponsive to treatment; and | 67 |
(c) Becomes responsive to treatment at a later date. | 68 |
(2) Whether the expenses described in division (C)(1) of this | 69 |
section are reasonable may include consideration of any factor | 70 |
including: | 71 |
(a) Cost; | 72 |
(b) Time that has expired since the previous evaluation; | 73 |
(c) Expertise of the physician or practitioner performing the | 74 |
evaluation; | 75 |
(d) Changes in technology; | 76 |
(e) Advances in medicine. | 77 |
(D)(1) An individual or group health insuring corporation | 78 |
policy, contract, or agreement shall not deny coverage under this | 79 |
chapter for covered services solely because a service is provided | 80 |
at a facility other than a hospital. Covered services may be | 81 |
provided at any appropriate facility able to provide the services | 82 |
including all of the following: | 83 |
(a) A hospital licensed under Chapter 3727. of the Revised | 84 |
Code, including an acute or post-acute rehabilitation hospital; | 85 |
(b) A residential care facility licensed under Chapter 3721. | 86 |
of the Revised Code; | 87 |
(c) A freestanding inpatient rehabilitation facility licensed | 88 |
under section 3702.30 of the Revised Code. | 89 |
(2) The issuer of an individual or group health insuring | 90 |
corporation policy, contract, or agreement, including a preferred | 91 |
provider benefit plan or health maintenance organization plan, | 92 |
that contracts with or approves admission to a service provider's | 93 |
facility to provide covered services shall not refuse, solely | 94 |
because that facility is licensed as a residential care facility | 95 |
or freestanding inpatient rehabilitation center, to contract with | 96 |
or approve admission to that facility to provide covered services | 97 |
that are within the scope of the license of that facility and | 98 |
within the scope of the services provided under a rehabilitation | 99 |
program for acquired brain injury accredited by the commission on | 100 |
accreditation of rehabilitation facilities or another nationally | 101 |
recognized accreditation organization. | 102 |
(3) The issuer of an individual or group health insuring | 103 |
corporation policy, contract, or agreement that requires or | 104 |
encourages enrollees to use health care providers designated by | 105 |
the plan shall ensure that covered services within the scope of a | 106 |
residential care facility's or freestanding inpatient | 107 |
rehabilitation facility's license are made available and | 108 |
accessible to enrollees at an adequate number of residential care | 109 |
facilities or freestanding inpatient rehabilitation facilities. | 110 |
(4) The issuer of an individual or group health insuring | 111 |
corporation policy, contract, or agreement shall not treat covered | 112 |
services as custodial care solely because the services are | 113 |
provided by a residential care facility if the facility has a | 114 |
rehabilitation program for acquired brain injury accredited by the | 115 |
commission on accreditation of rehabilitation facilities or | 116 |
another nationally recognized accreditation organization. | 117 |
(5) To ensure the health and safety of enrollees, the | 118 |
superintendent may require that a residential care facility or | 119 |
freestanding inpatient rehabilitation facility that provides | 120 |
covered services through post-acute rehabilitation care treatment | 121 |
other than custodial care to an enrollee with an acquired brain | 122 |
injury has a rehabilitation program for acquired brain injury | 123 |
accredited by the commission on accreditation of rehabilitation | 124 |
facilities or another nationally recognized accreditation | 125 |
organization. | 126 |
(E) An individual or group health insuring corporation | 127 |
policy, contract, or agreement that provides basic health care | 128 |
services that is issued, delivered, or renewed in this state is | 129 |
not required to provide benefits for covered services if all of | 130 |
the following apply: | 131 |
(1) The issuer of the policy, contract, or agreement submits | 132 |
documentation certified by an independent member of the American | 133 |
academy of actuaries to the superintendent of insurance showing | 134 |
that incurred claims for covered services for a period of at least | 135 |
six months independently caused the issuer's costs for claims and | 136 |
administrative expenses for the coverage of all other physical | 137 |
diseases and disorders to increase by more than one per cent per | 138 |
year. | 139 |
(2) The issuer of the policy, contract, or agreement submits | 140 |
a signed letter from an independent member of the American academy | 141 |
of actuaries to the superintendent opining that the increase from | 142 |
incurred claims for covered services could reasonably justify an | 143 |
increase of more than one per cent in the annual premiums or rates | 144 |
charged by the issuer for the coverage of all other physical | 145 |
diseases and disorders. | 146 |
(3) The superintendent makes both of the following | 147 |
determinations from the documentation and opinion submitted under | 148 |
divisions (E)(1) and (2) of this section: | 149 |
(a) Incurred claims for covered services for a period of at | 150 |
least six months independently caused the issuer's costs for | 151 |
claims and administrative expenses for the coverage of all other | 152 |
physical diseases and disorders to increase by more than one per | 153 |
cent per year. | 154 |
(b) The increase in costs reasonably justifies an increase of | 155 |
more than one per cent in the annual premiums or rates charged by | 156 |
the issuer for the coverage of all other physical diseases and | 157 |
disorders. | 158 |
(F) This section does not prohibit such coverage from being | 159 |
subject to the deductibles, copayments, and coinsurance prescribed | 160 |
under a health insuring corporation policy, contract, or | 161 |
agreement. | 162 |
Sec. 3901.046. The superintendent shall adopt rules | 163 |
requiring health insuring corporations, sickness and accident | 164 |
insurers, multiple employer welfare arrangements, and public | 165 |
employee benefit plans to provide adequate training to personnel | 166 |
responsible for preauthorization of coverage or utilization | 167 |
reviews to prevent wrongful denial of the coverage required under | 168 |
sections 1751.68 and 3923.591 of the Revised Code and to avoid | 169 |
confusion of medical benefits with mental health benefits as they | 170 |
pertain to these sections. Before adopting rules prescribing the | 171 |
basic requirements for the training described in this section, the | 172 |
superintendent shall consult with the brain injury advisory | 173 |
committee created in section 3304.241 of the Revised Code about | 174 |
those requirements. | 175 |
Sec. 3923.591. (A) As used in this section, "covered | 176 |
service" and "acquired brain injury" have the same meanings as in | 177 |
section 1751.68 of the Revised Code. | 178 |
(B) Notwithstanding section 3901.71 of the Revised Code, a | 179 |
policy of individual or group sickness and accident insurance that | 180 |
is issued, delivered, or renewed in this state, and each public | 181 |
employee benefit plan that is established or modified in this | 182 |
state, shall not exclude coverage for any covered service. | 183 |
(C)(1) To ensure that appropriate post-acute rehabilitation | 184 |
care treatment is provided, a policy of individual or group | 185 |
sickness and accident insurance or a public employee benefit plan | 186 |
shall include coverage for reasonable expenses related to periodic | 187 |
reevaluation of the care of an insured that: | 188 |
(a) Has an acquired brain injury; | 189 |
(b) Has been unresponsive to treatment; and | 190 |
(c) Becomes responsive to treatment at a later date. | 191 |
(2) Whether the expenses described in division (C)(1) of this | 192 |
section are reasonable may include consideration of any factor | 193 |
including: | 194 |
(a) Cost; | 195 |
(b) Time that has expired since the previous evaluation; | 196 |
(c) Expertise of the physician or practitioner performing the | 197 |
evaluation; | 198 |
(d) Changes in technology; | 199 |
(e) Advances in medicine. | 200 |
(D)(1) A policy of individual or group sickness and accident | 201 |
insurance or a public employee benefit plan shall not deny | 202 |
coverage under this chapter for covered services solely because a | 203 |
service is provided at a facility other than a hospital. Covered | 204 |
services may be provided at any appropriate facility able to | 205 |
provide the services including all of the following: | 206 |
(a) A hospital licensed under Chapter 3727. of the Revised | 207 |
Code, including an acute or post-acute rehabilitation hospital; | 208 |
(b) A residential care facility licensed under Chapter 3721. | 209 |
of the Revised Code; | 210 |
(c) A freestanding inpatient rehabilitation facility licensed | 211 |
under section 3702.30 of the Revised Code. | 212 |
(2) The issuer of a policy of individual or group sickness | 213 |
and accident insurance or a public employee benefit plan, | 214 |
including a preferred provider benefit plan, that contracts with | 215 |
or approves admission to a service provider's facility to provide | 216 |
covered services shall not refuse, solely because that facility is | 217 |
licensed as a residential care facility or freestanding inpatient | 218 |
rehabilitation center, to contract with or approve admission to | 219 |
that facility to provide covered services that are within the | 220 |
scope of the license of that facility and within the scope of the | 221 |
services provided under a rehabilitation program for acquired | 222 |
brain injury accredited by the commission on accreditation of | 223 |
rehabilitation facilities or another nationally recognized | 224 |
accreditation organization. | 225 |
(3) The issuer of a policy of individual or group sickness | 226 |
and accident insurance or a public employee benefit plan that | 227 |
requires or encourages insureds to use health care providers | 228 |
designated by the policy or plan shall ensure that covered | 229 |
services within the scope of a residential care facility's or | 230 |
freestanding inpatient rehabilitation facility's license are made | 231 |
available and accessible to insureds at an adequate number of | 232 |
residential care facilities or freestanding inpatient | 233 |
rehabilitation facilities. | 234 |
(4) The issuer of a policy of individual or group sickness | 235 |
and accident insurance or a public employee benefit plan shall not | 236 |
treat covered services as custodial care solely because the | 237 |
services are provided by a residential care facility if the | 238 |
facility has a rehabilitation program for acquired brain injury | 239 |
accredited by the commission on accreditation of rehabilitation | 240 |
facilities or another nationally recognized accreditation | 241 |
organization. | 242 |
(5) To ensure the health and safety of insureds, the | 243 |
superintendent may require that a residential care facility or | 244 |
freestanding inpatient rehabilitation facility that provides | 245 |
covered services through post-acute rehabilitation care treatment | 246 |
other than custodial care to an insured with an acquired brain | 247 |
injury has a rehabilitation program for acquired brain injury | 248 |
accredited by the commission on accreditation of rehabilitation | 249 |
facilities or another nationally recognized accreditation | 250 |
organization. | 251 |
(E) A policy or individual or group sickness and accident | 252 |
insurance or a public employee benefit plan that provides basic | 253 |
health care services that is issued, delivered, renewed, | 254 |
established, or modified in this state is not required to provide | 255 |
benefits for covered services if all of the following apply: | 256 |
(1) The issuer of the policy or plan submits documentation | 257 |
certified by an independent member of the American academy of | 258 |
actuaries to the superintendent of insurance showing that incurred | 259 |
claims for covered services for a period of at least six months | 260 |
independently caused the issuer's costs for claims and | 261 |
administrative expenses for the coverage of all other physical | 262 |
diseases and disorders to increase by more than one per cent per | 263 |
year. | 264 |
(2) The issuer of the policy or plan submits a signed letter | 265 |
from an independent member of the American academy of actuaries to | 266 |
the superintendent opining that the increase from incurred claims | 267 |
for covered services could reasonably justify an increase of more | 268 |
than one per cent in the annual premiums or rates charged by the | 269 |
issuer for the coverage of all other physical diseases and | 270 |
disorders. | 271 |
(3) The superintendent makes both of the following | 272 |
determinations from the documentation and opinion submitted under | 273 |
to divisions (E)(1) and (2) of this section: | 274 |
(a) Incurred claims for covered services for a period of at | 275 |
least six months independently caused the issuer's costs for | 276 |
claims and administrative expenses for the coverage of all other | 277 |
physical diseases and disorders to increase by more than one per | 278 |
cent per year. | 279 |
(b) The increase in costs reasonably justifies an increase of | 280 |
more than one per cent in the annual premiums or rates charged by | 281 |
the issuer for the coverage of all other physical diseases and | 282 |
disorders. | 283 |
(F) This section does not prohibit such coverage from being | 284 |
subject to the deductibles, copayments, and coinsurance prescribed | 285 |
under a policy of sickness and accident insurance or a public | 286 |
employee benefit plan. | 287 |
Section 2. That existing section 1739.05 of the Revised Code | 288 |
is hereby repealed. | 289 |
Section 3. Sections 1739.05 and 1751.68 of the Revised Code, | 290 |
as amended or enacted by this act, apply only to policies, | 291 |
contracts, and agreements that are delivered, issued for delivery, | 292 |
or renewed in this state on or after the effective date of this | 293 |
act. Section 3923.591 of the Revised Code, as enacted by this act, | 294 |
applies only to policies of sickness and accident insurance | 295 |
delivered, issued for delivery, or renewed in this state and | 296 |
public employee benefit plans that are established or modified in | 297 |
this state on or after the effective date of this act. | 298 |