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HCASB295 4902 5708 HOUSE COMMITTEE AMENDMENTS Regular Session ENROLLEDAmendments SENATEproposed BILLbyHouse NO.Committee on Insurance to Reengrossed Senate Bill No.
295by BYSenator SENATORWheat WHEATAMENDMENT ANDNO. REPRESENTATIVE KNOX AN ACT To enact R.S.
22:1042.1,1 relativeOn topage coverage5, ofafter medicallyline necessarytreatment17, forinsert personsthe withfollowing: acquired brain injuries;
to"I. require health insurance coverage of medically necessary treatment for persons with acquired brain injuries;
to provide relative to limitations and cost-sharing;
to providefordefinitions;
to provideforexceptions;to provide for implementation;
to provide for applicability;
and to provide for related matters.
Be it enacted by the Legislature of Louisiana:
Section 1.
R.S.
22:1042.1 is hereby enacted to read as follows:
§1042.1.
Coverage for medically necessary treatment for persons with an acquired brain injury A.
Every health coverage plan delivered or issued for delivery in this state shall provide, to the extent permitted by federal law, coverage for medically necessary treatment related to or as a result of an acquired brain injury.
B.(1) The coverage provided pursuant to this Section shall not include anylifetimelimitationorunreasonableannuallimitationofthenumberofdays or sessions of treatment services.
(2) Any limitations on rehabilitation services in an inpatient rehabilitation facility shall be separate from and shall not be included in any limitations of post-acute rehabilitation.
(3)Anylimitationsshallbeseparatelystatedbythehealthcoverageplan issuer.
C.
The coverage provided pursuant to this Section shall not be subject toanygreaterdeductible,coinsurance,copayments,orout-of-pocketlimitsthan any other similar benefit provided by the health coverage plan.
D.
A health coverage plan shall not deny coverage for medically Page 1 of 5 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
295 ENROLLED necessary treatment based solely on the location or setting in which the treatment is provided, if the treatment is provided in a setting that is clinically appropriate for the level of care necessary and in compliance with applicable state licensure, certification, registration, or accreditation requirements.
Clinically appropriate settings may include but are not limited to inpatient hospitalorrehabilitationfacilitysettings,outpatientanddaytreatmentsettings, post-acute residential treatment settings, and home- and community-based settings.
E.
For any medically necessary treatment covered pursuant to this Section,anyadversedeterminationissuedinconnectionwithapreauthorization or utilization review shall be made by a clinical peer reviewer.
F.
The commissioner shall promulgate rules and regulations, in accordancewiththeAdministrativeProcedureAct,toestablishaprocessforan expeditedappealofanyadversedeterminationbyahealthcoverageplanissuer for medically necessary treatment covered pursuant to this Section.
G.
MedicallynecessarytreatmentcoveredpursuanttothisSectionshall be provided by individual practitioners and treatment facilities qualified to provide acute care and post-acute care rehabilitation services to a person with an acquired brain injury through possession of the appropriate licenses, accreditation, training, and experience deemed customary and routine in the trade practice.
H.
For the purposes of this Section, the following definitions apply:
(1) "Acquired brain injury" or "ABI" means any injury to the brain which is not a progressive neurologic disorder, hereditary, congenital, or degenerative in nature, and which occurs after birth and may be caused by infectious diseases, metabolic disorders, endocrine disorders, diminished oxygen,braintumors,toxins,adiseasethataffectsthebloodsupplytothebrain, stroke, or a traumatic brain injury.
(2) "Adverse determination" means a determination by a clinical peer reviewer, upon review based on the clinical information provided, that an Page 2 of 5 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
295 ENROLLED admission, extension of stay, or any other covered ABI service is not medically necessary.
(3) "Clinical peer reviewer" means a healthcare professional who has experiencein the delivery of treatmentsand servicesforpersons with acquired brain injuries and possesses a current and valid license, certificate, or registrationtoprovidethesetreatmentsandservicesor,wherenoprovisionfor a license, certificate or registration exists, is credentialed by the national accrediting body appropriate to the profession.
(4) "Cognitive communication therapy" means treatment for problems with communication which have an underlying cause in one or more cognitive deficits rather than a primary language or speech deficit.
(5) "Cognitive rehabilitation therapy" means a process of relearning cognitive skills essential for daily living through the coordinated specialized, integrated therapeutic treatments which are provided in dynamic settings designed for efficient and effective relearning following damage to brain cells or brain chemistry due to brain injury.
(6) "Community reintegration services" means incremental, guided, real-world therapeutic training to develop skills essential for an individual to participate in life including functional daily activities;
to safely live independently;
and to participate in the community while avoiding rehospitalization and long-term support needs.
(7) "Functional rehabilitation therapy" means a structured approach which emphasizes learning by doing, and focuses relearning a specific task in aprescribedformat,withmaximumopportunity forrepeatedcorrectpractice.
Functional rehabilitation therapy includes compensatory strategies developed forthoseskillswhicharepersistentlyimpairedwithindividualstrainedondaily implementation.
To ensure acquisition and use, the focus of functional rehabilitation therapy is set on relearning those skills essential for safe daily living in home- and community-based settings.
(8) "Health coverage plan" means any hospital, health, or medical Page 3 of 5 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
295 ENROLLED expenseinsurancepolicy,hospitalormedicalservicecontract,employeewelfare benefit plan, contract, or other agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type in this state, including a group insurance plan or a self-insurance plan.
"Health coverage plan" does not include a plan providing coverage for excepted benefits as defined in R.S.
22:1061, limited benefit health insurance plans, short-term policies that have a term of less than twelve months, Medicare, Medicaid, and the Office of Group Benefits programs.
(9)"Medicallynecessarytreatment"means healthcareservicesthatare consistent with generally accepted principles of professional medical practice.
Medically necessary treatment includes but is not limited to cognitive rehabilitation therapy;
cognitive communication therapy;
neurocognitive therapy and rehabilitation;
neurobehavioral;
neurophysiological;
and neuropsychological testing;
neurofeedback therapy;
functional rehabilitation therapy;
community reintegration services;
post-acute residential treatment services;
inpatient services;
outpatient and day treatment services;
and home- and community-based treatment.
(10)"Neurobehavioraltherapy"meansasetofmedicalandtherapeutic assessmentsandtreatmentsfocusedonbehavioralimpairmentsassociatedwith brain disease or injury and the amelioration of these impairments through the development of prosocial behavior.
(11) "Neurocognitive therapy" means treatment of disorders in which the primary clinical deficit is in cognitive function which has not been present since birth and is a decline from a previously attained level of function.
(12) "Neuropsychological testing" means a set of medical and therapeutic assessments and treatments focused on amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by brain injury.
(13) "Post-acute residential treatment" means integrated medical and therapeutic services, treatment, education, and skills training provided in a Page 4 of 5 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.
SB NO.
295 ENROLLED home- and community-based setting and designed to create the maximum opportunity for correct practice of skill in the context of use to develop new neural pathways to enable the person to avoid rehospitalization and long-term care.
I.
18031(d)(3)(B)(ii),§18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 CFRC.F.R. Part 155.20, shall not be required toprovideabenefitunderthis Sectionthat exceedstheessentialhealthbenefits specified under 42 U.S.C.
18022(b).§155.20, shall not be required to provide a benefit under this Section that exceeds the essential health benefits specified under 42 U.S.C.
Section§18022(b)." 2.AMENDMENT NO.
The2 provisionsOn ofpage this5, Actdelete applytolines anynew18 policy,and contract,19 program,in ortheir healthentirety coverageAMENDMENT planNO. issued on and after January 1, 2027.
Any3 policy,On contract,page or5, healthline coverage20, planchange in"Section effect2." prior to January1,"Section 2027,3." shallPage convert1 to conform to the provisions of this1 ActCODING: on or before the renewal date, but no later than January 1, 2028.
PRESIDENTWordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored OFare THEadditions. SENATE SPEAKER OF THE HOUSE OF REPRESENTATIVES GOVERNOR OF THE STATE OF LOUISIANA APPROVED:
Page 5 of 5 Coding:
Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.