HB0556

HOUSE BILL 556

52nd legislature - STATE OF NEW MEXICO - first session, 2015

INTRODUCED BY

Deborah A. Armstrong

AN ACT

RELATING TO HEALTH COVERAGE; ENACTING SECTIONS OF THE HEALTH CARE PURCHASING ACT, THE NEW MEXICO INSURANCE CODE, THE HEALTH MAINTENANCE ORGANIZATION LAW AND THE NONPROFIT HEALTH CARE PLAN LAW TO REQUIRE COVERAGE FOR SERVICES AND PERSONNEL TRAINING RELATED TO BRAIN INJURY.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

SECTION 1. A new section of the Health Care Purchasing Act is enacted to read:

"[NEW MATERIAL] BRAIN INJURY TREATMENT--REHABILITATION--HABILITATION.--

A. Group health coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act shall include coverage for:

(1) cognitive rehabilitation therapy and rehabilitation;

(2) habilitation services;

(3) neurocognitive therapy and rehabilitation;

(4) neurobehavioral, neurophysiological and neuropsychological testing and treatment;

(5) neurofeedback therapy;

(6) remediation for treatment of a brain injury; and

(7) post-acute transition services and community reintegration services, including outpatient day treatment services or other post-acute care treatment services related to a brain injury.

B. Group health coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act shall not set a lifetime limit on post-acute care treatment related to a brain injury.

C. To ensure that appropriate post-acute care is provided, group health coverage shall include coverage for reasonable expenses related to periodic reevaluation of the care of an individual covered under a group coverage plan who:

(1) has incurred a brain injury;

(2) has been unresponsive to treatment provided at a time close to the acquisition of the brain injury; or

(3) becomes responsive to treatment at a date remote from the date of acquisition of the brain injury.

D. A determination of whether expenses described in Subsection C of this section are reasonable shall include consideration of the following factors:

(1) cost;

(2) the time that has transpired since the previous evaluation of necessity and reasonableness;

(3) any difference in the expertise of the physician or practitioner performing the evaluation;

(4) changes in technology; and

(5) advances in medicine.

E. Coverage offered pursuant to this section shall be subject to the payment limitations, deductibles, copayments and coinsurance as other non-preventive benefits and services covered pursuant to the Health Care Purchasing Act.

F. A group health plan shall not deny a claim for services or treatment required pursuant to this section on the sole basis that the treatment or services are provided at a facility other than a hospital. A group health plan shall provide coverage for the services described in Subsections A and C of this section at a hospital licensed by the department of health, including an acute care or rehabilitation hospital, or at an assisted living facility licensed by the department of health.

G. A group health plan that contracts with or approves admission to a service provider facility to provide services pursuant to this section shall not refuse to contract with or approve admission to that facility to provide covered services that are within the scope of the license of that facility and within the scope of services provided under a rehabilitation program for brain injury accredited by the commission on accreditation of rehabilitation facilities or another nationally recognized organization solely because that facility is licensed by the department of health as an assisted living facility or hospital.

H. A group health plan shall not consider services covered pursuant to this section to be custodial care solely based on the fact that those services are provided by an assisted living facility if:

(1) those services are provided through the assisted living facility's habilitation or rehabilitation program for brain injury; and

(2) the commission on accreditation of rehabilitation facilities or another nationally recognized organization has accredited the assisted living facility's habilitation or rehabilitation program.

I. The secretary of general services shall adopt and promulgate rules to require that a group health plan that provides coverage pursuant to this section shall ensure that personnel responsible for administering preauthorization of coverage or conducting utilization reviews receive training adequate to ensure that these personnel understand matters relating to brain injury and brain injury services in order to avoid confusion of medical benefits with behavioral health benefits.

J. A group health plan shall provide annual notice to each enrollee in writing about the availability of the coverages required pursuant to this section. The notice issued pursuant to this subsection shall include:

(1) a description of the benefits listed in Subsections A and C of this section; and

(2) a statement that a brain injury that does not result in hospitalization or receipt of a specific treatment or service described in Subsection A or C of this section for acute care treatment does not affect the right of an enrollee to receive benefits described in Subsections A and C of this section commensurate with the condition of the enrollee.

K. Each publicly funded health care agency shall prepare information for enrollees regarding the coverages required pursuant to this section. The publicly funded health care agencies shall publish this information in a publicly accessible manner on the web site of the risk management division of the general services department.

L. The secretary of general services shall adopt and promulgate rules as necessary for the implementation of this section.

M. The provisions of this section do not apply to group health coverage intended to supplement major medical group-type coverage, such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or any other limited-benefit health insurance policy.

N. As used in this section, "brain injury" means brain damage caused by events involving an internal or external source at or after birth that may result in cognitive, physical, emotional or behavioral impairments that lead to permanent or temporary changes in functioning."

SECTION 2. A new section of Chapter 59A, Article 22

NMSA 1978 is enacted to read:

"[NEW MATERIAL] BRAIN INJURY TREATMENT--REHABILITATION--HABILITATION.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state shall include coverage for:

(1) cognitive rehabilitation therapy and rehabilitation;

(2) habilitation services;

(3) neurocognitive therapy and rehabilitation;

(4) neurobehavioral, neurophysiological and neuropsychological testing and treatment;

(5) neurofeedback therapy;

(6) remediation for treatment of a brain injury; and

(7) post-acute transition services and community reintegration services, including outpatient day treatment services or other post-acute care treatment services related to a brain injury.

B. An individual or group health insurance policy, health care plan or certificate of health insurance shall not set a lifetime limit on post-acute care treatment related to a brain injury.

C. To ensure that appropriate post-acute care is provided, a health insurance policy, health care plan or certificate of health insurance shall include coverage for reasonable expenses related to periodic reevaluation of the care of an individual covered under a health insurance policy, health care plan or certificate of health insurance who:

(1) has incurred a brain injury;

(2) has been unresponsive to treatment provided at a time close to the acquisition of the brain injury; or

(3) becomes responsive to treatment at a date remote from the date of acquisition of the brain injury.

D. A determination of whether expenses described in Subsection C of this section are reasonable shall include consideration of the following factors:

(1) cost;

(2) the time that has transpired since the previous evaluation of necessity and reasonableness;

(3) any difference in the expertise of the physician or practitioner performing the evaluation;

(4) changes in technology; and

(5) advances in medicine.

F. A carrier shall not deny a claim for services or treatment required pursuant to this section on the sole basis that the treatment or services are provided at a facility other than a hospital licensed by the department of health. A carrier shall provide coverage for the services described in Subsections A and C of this section at a hospital, including an acute care or rehabilitation hospital, or at an assisted living facility licensed by the department of health.

G. An insurer that contracts with or approves admission to a service provider facility to provide services pursuant to this section shall not refuse to contract with or approve admission to that facility to provide covered services that are within the scope of the license of that facility and within the scope of services provided under a rehabilitation program for brain injury accredited by the commission on accreditation of rehabilitation facilities or another nationally recognized organization solely because that facility is licensed by the department of health as an assisted living facility or hospital.

H. An insurer shall not consider services covered pursuant to this section to be custodial care solely based on the fact that those services are provided by an assisted living facility if:

(1) those services are provided through the assisted living facility's habilitation or rehabilitation program for brain injury; and

(2) the commission on accreditation of rehabilitation facilities or another nationally recognized organization has accredited the assisted living facility's habilitation or rehabilitation program.

I. The superintendent shall adopt and promulgate rules to require that an insurer that provides coverage pursuant to this section shall ensure that personnel responsible for administering preauthorization of coverage or conducting utilization reviews receive training adequate to ensure that these personnel understand matters relating to brain injury and brain injury services in order to avoid confusion of medical benefits with behavioral health benefits.

J. A carrier shall provide annual notice to each enrollee in writing about the availability of the coverages required pursuant to this section. The notice issued pursuant to this subsection shall include:

(1) a description of the benefits listed in Subsections A and C of this section; and

(2) a statement that a brain injury that does not result in hospitalization or receipt of a specific treatment or service described in Subsection A or C of this section for acute care treatment does not affect the right of an insured or beneficiary to receive benefits described in Subsections A and C of this section commensurate with the condition of the insured or beneficiary.

K. A carrier shall prepare information for insureds and beneficiaries regarding the coverages required pursuant to this section. The carrier shall publish this information in a publicly accessible manner on the carrier's web site.

L. The superintendent shall adopt and promulgate rules as necessary for the implementation of this section.

M. The provisions of this section do not apply to an individual policy, plan or contract intended to supplement major medical group-type coverage, such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or any other limited-benefit health insurance policy.

SECTION 3. A new section of Chapter 59A, Article 23

NMSA 1978 is enacted to read:

"[NEW MATERIAL] BRAIN INJURY TREATMENT--REHABILITATION--HABILITATION.--

A. A blanket or group health insurance policy that is delivered, issued for delivery or renewed in this state shall include coverage for:

(1) cognitive rehabilitation therapy and rehabilitation;

(2) habilitation services;

(3) neurocognitive therapy and rehabilitation;

(4) neurobehavioral, neurophysiological and neuropsychological testing and treatment;

(5) neurofeedback therapy;

(6) remediation for treatment of a brain injury; and

(7) post-acute transition services and community reintegration services, including outpatient day treatment services or other post-acute care treatment services related to a brain injury.

B. A blanket or group health insurance policy shall not set a lifetime limit on post-acute care treatment related to a brain injury.

C. To ensure that appropriate post-acute care is provided, a blanket or group health insurance policy shall include coverage for reasonable expenses related to periodic reevaluation of the care of an individual covered under a blanket or group health insurance policy who:

(1) has incurred a brain injury;

(2) has been unresponsive to treatment provided at a time close to the acquisition of the brain injury; or

(3) becomes responsive to treatment at a date remote from the date of acquisition of the brain injury.

D. A determination of whether expenses described in Subsection C of this section are reasonable shall include consideration of the following factors:

(1) cost;

(2) the time that has transpired since the previous evaluation of necessity and reasonableness;

(3) any difference in the expertise of the physician or practitioner performing the evaluation;

(4) changes in technology; and

(5) advances in medicine.

F. A carrier shall not deny a claim for services or treatment required pursuant to this section on the sole basis that the treatment or services are provided at a facility other than a hospital. A carrier shall provide coverage for the services described in Subsections A and C of this section at a hospital licensed by the department of health, including an acute care or rehabilitation hospital, or at an assisted living facility licensed by the department of health.

G. An insurer that contracts with or approves admission to a service provider facility to provide services pursuant to this section shall not refuse to contract with or approve admission to that facility to provide covered services that are within the scope of the license of that facility and within the scope of services provided under a rehabilitation program for brain injury accredited by the commission of accreditation on rehabilitation facilities or another nationally recognized organization solely because that facility is licensed by the department of health as an assisted living facility or hospital.

H. An insurer shall not consider services covered pursuant to this section to be custodial care solely based on the fact that those services are provided by an assisted living facility if:

(1) those services are provided through the assisted living facility's habilitation or rehabilitation program for brain injury; and

(2) the commission on accreditation of rehabilitation facilities or another nationally recognized organization has accredited the assisted living facility's habilitation or rehabilitation program.

(1) a description of the benefits listed in Subsections A and C of this section; and

(2) a statement that a brain injury that does not result in hospitalization or receipt of a specific treatment or service described in Subsection A or C of this section for acute care treatment does not affect the right of an insured or beneficiary to receive benefits described in Subsections A and C of this section commensurate with the condition of the insured or beneficiary.

L. The superintendent shall adopt and promulgate rules as necessary for the implementation of this section.

M. The provisions of this section do not apply to a group or blanket policy, plan or contract intended to supplement major medical group-type coverage, such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or any other limited-benefit health insurance policy.

SECTION 4. A new section of the Health Maintenance Organization Law is enacted to read:

"[NEW MATERIAL] BRAIN INJURY TREATMENT--REHABILITATION--HABILITATION.--

A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state shall include coverage for:

(1) cognitive rehabilitation therapy and rehabilitation;

(2) habilitation services;

(3) neurocognitive therapy and rehabilitation;

(4) neurobehavioral, neurophysiological and neuropsychological testing and treatment;

(5) neurofeedback therapy;

(6) remediation for treatment of a brain injury; and

(7) post-acute transition services and community reintegration services, including outpatient day treatment services or other post-acute care treatment services related to a brain injury.

B. A health maintenance organization contract shall not set a lifetime limit on post-acute care treatment related to a brain injury.

C. To ensure that appropriate post-acute care is provided, a health maintenance organization contract shall include coverage for reasonable expenses related to periodic reevaluation of the care of an individual covered under a health maintenance organization contract who:

(1) has incurred a brain injury;

(2) has been unresponsive to treatment provided at a time close to the acquisition of the brain injury; or

(3) becomes responsive to treatment at a date remote from the date of acquisition of the brain injury.

D. A determination of whether expenses described in Subsection C of this section are reasonable shall include consideration of the following factors:

(1) cost;

(2) the time that has transpired since the previous evaluation of necessity and reasonableness;

(3) any difference in the expertise of the physician or practitioner performing the evaluation;

(4) changes in technology; and

(5) advances in medicine.

F. A health maintenance organization shall not deny a claim for services or treatment required pursuant to this section on the sole basis that the treatment or services are provided at a facility other than a hospital. A health maintenance organization shall provide coverage for the services described in Subsections A and C of this section at a hospital licensed by the department of health, including an acute care or rehabilitation hospital, or at an assisted living facility licensed by the department of health.

G. A health maintenance organization that contracts with or approves admission to a service provider facility to provide services pursuant to this section shall not refuse to contract with or approve admission to that facility to provide covered services that are within the scope of the license of that facility and within the scope of services provided under a rehabilitation program for brain injury accredited by the commission on accreditation of rehabilitation facilities or another nationally recognized organization solely because that facility is licensed by the department of health as an assisted living facility or hospital.

H. A health maintenance organization shall not consider services covered pursuant to this section to be custodial care solely based on the fact that those services are provided by an assisted living facility if:

(1) those services are provided through the assisted living facility's habilitation or rehabilitation program for brain injury; and

(2) the commission on accreditation of rehabilitation facilities or another nationally recognized organization has accredited the assisted living facility's habilitation or rehabilitation program.

I. The superintendent shall adopt and promulgate rules to require that a health maintenance organization that provides coverage pursuant to this section shall ensure that personnel responsible for administering preauthorization of coverage or conducting utilization reviews receive training adequate to ensure that these personnel understand matters relating to brain injury and brain injury services in order to avoid confusion of medical benefits with behavioral health benefits.

J. A health maintenance organization shall provide annual notice to each subscriber in writing about the availability of the coverages required pursuant to this section. The notice issued pursuant to this subsection shall include:

(1) a description of the benefits listed in Subsections A and C of this section; and

(2) a statement that a brain injury that does not result in hospitalization or receipt of a specific treatment or service described in Subsection A or C of this section for acute care treatment does not affect the right of a subscriber to receive benefits described in Subsections A and C of this section commensurate with the condition of the subscriber.

K. A health maintenance organization shall prepare information for subscribers regarding the coverages required pursuant to this section. The health maintenance organization shall publish this information in a publicly accessible manner on the health maintenance organization's web site.

L. The superintendent shall adopt and promulgate rules as necessary for the implementation of this section.

M. The provisions of this section do not apply to an individual or group health maintenance organization contract intended to supplement major medical group-type coverage, such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or any other limited-benefit health insurance policy.

SECTION 5. A new section of the Nonprofit Health Care

Plan Law is enacted to read:

"[NEW MATERIAL] BRAIN INJURY TREATMENT--REHABILITATION--HABILITATION.--

A. An individual or group health care plan that is delivered, issued for delivery or renewed in this state shall include coverage for:

(1) cognitive rehabilitation therapy and rehabilitation;

(2) habilitation services;

(3) neurocognitive therapy and rehabilitation;

(4) neurobehavioral, neurophysiological and neuropsychological testing and treatment;

(5) neurofeedback therapy;

(6) remediation for treatment of a brain injury; and

(7) post-acute transition services and community reintegration services, including outpatient day treatment services or other post-acute care treatment services related to a brain injury.

B. A health care plan shall not set a lifetime limit on post-acute care treatment related to a brain injury.

C. To ensure that appropriate post-acute care is provided, a health care plan shall include coverage for reasonable expenses related to periodic reevaluation of the care of an individual covered under a health care plan who:

(1) has incurred a brain injury;

(2) has been unresponsive to treatment provided at a time close to the acquisition of the brain injury; or

(3) becomes responsive to treatment at a date remote from the date of acquisition of the brain injury.

D. A determination of whether expenses described in Subsection C of this section are reasonable shall include consideration of the following factors:

(1) cost;

(2) the time that has transpired since the previous evaluation of necessity and reasonableness;

(3) any difference in the expertise of the physician or practitioner performing the evaluation;

(4) changes in technology; and

(5) advances in medicine.

F. A health care plan shall not deny a claim for services or treatment required pursuant to this section on the sole basis that the treatment or services are provided at a facility other than a hospital. A health care plan shall provide coverage for the services described in Subsections A and C of this section at a hospital licensed by the department of health, including an acute care or rehabilitation hospital, or at an assisted living facility licensed by the department of health.

G. A health care plan that contracts with or approves admission to a service provider facility to provide services pursuant to this section shall not refuse to contract with or approve admission to that facility to provide covered services that are within the scope of the license of that facility and within the scope of services provided under a rehabilitation program for brain injury accredited by the commission of accreditation on rehabilitation facilities or another nationally recognized organization solely because that facility is licensed by the department of health as an assisted living facility or hospital.

H. A health care plan shall not consider services covered pursuant to this section to be custodial care solely based on the fact that those services are provided by an assisted living facility if:

(1) those services are provided through the assisted living facility's habilitation or rehabilitation program for brain injury; and

(2) the commission on accreditation of rehabilitation facilities or another nationally recognized organization has accredited the assisted living facility's habilitation or rehabilitation program.

I. The superintendent shall adopt and promulgate rules to require that a health care plan that provides coverage pursuant to this section shall ensure that personnel responsible for administering preauthorization of coverage or conducting utilization reviews receive training adequate to ensure that these personnel understand matters relating to brain injury and brain injury services in order to avoid confusion of medical benefits with behavioral health benefits.

J. A health care plan shall provide annual notice to each subscriber in writing about the availability of the coverages required pursuant to this section. The notice issued pursuant to this subsection shall include:

(1) a description of the benefits listed in Subsections A and C of this section; and

(2) a statement that a brain injury that does not result in hospitalization or receipt of a specific treatment or service described in Subsection A or C of this section for acute care treatment does not affect the right of a subscriber to receive benefits described in Subsections A and C of this section commensurate with the condition of the subscriber.

K. A health care plan shall prepare information for subscribers regarding the coverages required pursuant to this section. The health care plan shall publish this information in a publicly accessible manner on the health care plan's web site.

L. The superintendent shall adopt and promulgate rules as necessary for the implementation of this section.

M. The provisions of this section do not apply to an individual or group health care plan intended to supplement major medical group-type coverage, such as medicare supplement, long-term care, disability income, specified disease, accident-only, hospital indemnity or any other limited-benefit health insurance policy.

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