Bill > S485

This bill mandates that health benefit plans, which are insurance policies or agreements covering medical or surgical expenses for various conditions, must provide coverage for cognitive rehabilitation therapy and related services for individuals with acquired or traumatic brain injuries. This coverage includes acute and post-acute care services like transition, community reintegration, residential, inpatient, outpatient day treatment, and other necessary post-acute treatments. The bill prohibits lifetime or unreasonable annual limitations on the number of days or sessions for both acute and post-acute care, and requires that any limitations be clearly stated. It also ensures that payment limitations, deductibles, copayments, and coinsurance for this coverage are consistent with other similar benefits. Furthermore, health plans must cover periodic reevaluations for individuals unresponsive to treatment but who may become responsive later, with the reasonableness of expenses determined by factors like cost, time since previous evaluation, and advancements in medicine. The bill also requires health plan issuers to provide adequate training to personnel involved in preauthorization (a process where an issuer confirms payment for proposed services) and utilization review (a system for reviewing the necessity and appropriateness of healthcare services) to prevent improper denials of coverage. Issuers must also annually notify insured individuals about this coverage, detailing the benefits and clarifying that the absence of hospitalization or specific treatments for acute care does not affect their right to receive benefits commensurate with their condition. Importantly, coverage cannot be denied solely because treatment is provided at a facility other than a hospital, and services can be rendered at various qualified facilities, including hospitals, assisted living facilities, and skilled nursing facilities. The commissioner will also develop and publish information for consumers about this coverage.