Ohio-2013-HB361-Introduced

As Introduced

130th General Assembly

Regular Session

2013-2014

H. B. No. 361

Representatives Gonzales, Smith

Cosponsor: Representative Landis

A BILL

To amend section 1739.05 and to enact sections

1751.68, 3901.046, and 3923.591 of the Revised

Code to prohibit health insurers from excluding

coverage related to acquired brain injuries.

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:

(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;

(b) Cognitive communication therapy;

(d) Neurobehavioral, neurophysiological, neuropsychological,	48
and psychophysiological testing or treatment;	49

(e) Neurofeedback therapy;

(f) Remediation;

(g) Post-acute rehabilitation care treatment;

(h) Community reintegration services.

(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;

(b) Has been unresponsive to treatment; and

(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;

(b) Time that has expired since the previous evaluation;

(c) Expertise of the physician or practitioner performing the	74
evaluation;	75

(d) Changes in technology;

(e) Advances in medicine.

(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