SECTION 1. Chapter 175 of the General Laws as appearing in the 2012 Official Edition is hereby amended by inserting after section 47DD the following new section:-
Section 47EE. Coverage for Brain Injury Rehabilitation
(a) Applicability of Section
(1) Section 47EE applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is offered by:
(i) an insurance company operating under Chapter 175;
(ii) a group hospital service corporation operating under Chapter 175;
(iii) a fraternal benefit society operating under Chapter 176;
(iv) a small group health insurance operating under Chapter 176J
(v) a non-profit hospital service corporation operating under Chapter 176A
(vi) a Medical Service Corporation operating under Chapter 176B
(vii) a non-group health insurance company operating under 176M
(viii) a health maintenance organization operating under Chapter 176G;
(ix) an approved nonprofit health corporation that holds a certificate of authority under Chapter 176C.
(2)Section 47EE does not apply to:
(i) a plan that provides coverage:
(A) only for a specified disease or for another limited benefit other than an accident policy;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury;
(D) as a supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(i) Non-Profit Medical Service Plans operating under Chapter 176C
(ii) a workers' compensation insurance policy;
(iii) a long-term care insurance policy operating under Chapter 176U, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Chapter 175.
(iv) the Commonwealth Care Health Insurance Program as regulated under Chapter 118H.
(b) Required Coverages
(1) A health benefit plan must include, but is not limited to, coverage for cognitive rehabilitation therapy, cognitive communication therapy, neurocognitive therapy and rehabilitation, neurobehavioral, neurophysiological, neuropsychological, and psychophysiological testing and treatment, neuro feedback therapy, functional rehabilitation therapy and remediation required for and related to treatment of an acquired or traumatic brain injury.
(2) A health benefit plan shall include coverage for acute and post-acute:
(i) transition services
(ii) community reintegration services
(iii) residential services
(iv) inpatient services
(v) outpatient day treatment services
(vi) other post-acute care treatment services deemed necessary as a result of, or related to, an acquired or traumatic brain injury.
(3) A health benefit plan may not include any lifetime limitation, or unreasonable annual limitation on the number of days or sessions of acute care treatment. A health benefit plan may not include any lifetime limitation, or unreasonable annual limitation on the number of days or sessions of post-acute care treatment. Any limitations imposed under the plan for acute care treatment or post-acute care treatment must be separately stated in the plan.
(4) Except as provided by Subsection (c), a health benefit plan must include the same payment limitations, deductibles, copayments, and coinsurance factors for coverage required under this chapter as applicable to other similar coverage provided under the health benefit plan.
(5) To ensure that appropriate post-acute care treatment is provided, a health benefit plan must include coverage for reasonable expenses related to periodic reevaluation of the care of an individual covered under the plan who:
(i) has incurred an acquired or traumatic brain injury;
(ii) has been unresponsive to treatment; and
(iii) may become responsive to treatment at a later date.
(6) A determination of whether expenses, as described by Subsection (e), are reasonable may include consideration of factors including:
(ii) the time that has expired since the previous evaluation;
(iii) any significant difference in the specialization of the physician or practitioner performing the evaluation;
(iv) changes in technology; and
(v) advances in medicine.
(7) The commissioner shall adopt rules as necessary to implement this chapter.
(c) Training for Certain Personnel Required
(1) For its use in this section, "preauthorization" shall mean the provision of a reliable representation to a physician or health care provider of whether a health benefit plan issuer will pay the physician or provider for proposed medical or health care services if the physician or provider provides those services to the patient for whom the services are proposed. The term includes precertification, certification, recertification, or any other activity that involves providing a reliable representation by the issuer to a physician or health care provider.
(2) The commissioner by rule shall require a health benefit plan issuer to provide adequate training to personnel responsible for preauthorization of coverage or utilization review under the plan. The purpose of the training is to prevent denial of coverage in violation of Chapter 175, Section 47EE(b) to avoid confusion of medical benefits with mental health benefits. The commissioner, in consultation with the Massachusetts Brain Injury Advisory Board shall prescribe by rule the basic requirements for the training described by this subsection.
(d) Notice to Insured and Enrollees
(1) A health benefit plan issuer subject to this chapter must annually notify each insured or enrollee under the plan in writing about the coverages described by CHAPTER 175, SECTION 47EE(B).
(2) The commissioner, in consultation with the Massachusetts Brain Injury Advisory Board shall prescribe by rule the specific contents and wording of the notice required under this section.
(3) The notice required under this section must include:
(i) a description of the benefits listed under CHAPTER 175, SECTION 47EE(B);
(ii) a statement that the fact that an acquired or traumatic brain injury does not result in hospitalization or receipt of a specific treatment or service described by CHAPTER 175, SECTION 47EE(B) for acute care treatment does not affect the right of the insured or enrollee to receive benefits described by CHAPTER 175, SECTION 47EE(B) commensurate with the condition of the insured or enrollee; and
(4) a statement of the fact that benefits described by CHAPTER 175, SECTION 47EE(B) may be provided in a facility listed in Chapter 175, Section 47EE (f)
(e) Determination of Medical Necessity; Extension of Coverage
(1) In this section, "utilization review" is defined as "a system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual in this state. The term does not include a review in response to an elective request for clarification of coverage".
(2) A health benefit plan shall respond to a person requesting utilization review of a determination of medical necessity, or appealing for an extension of coverage based on an allegation of medical necessity not later than three business days after the date on which the person makes the request or submits the appeal. The person must make the request or submit the appeal in the manner prescribed by the terms of the plan's health insurance policy or agreement, contract, evidence of coverage, or similar coverage document. To comply with the requirements of this section, the health benefit plan issuer must respond through a direct telephone contact made by a representative of the issuer, and in writing to the person requesting review.
(f) Treatment Facilities
(1) A health benefit plan may not deny coverage under this chapter based solely on the fact that the treatment or services are provided at a facility other than a hospital. Treatment for an acquired or traumatic brain injury may be provided under the coverage required by this chapter, as appropriate, at a facility at which appropriate services may be provided, including, but not limited to:
(i) a hospital regulated under Chapter 111, including an acute or post-acute rehabilitation hospitals;
(ii) an assisted living facility regulated under Chapter 19D;
(iii) a Skilled Nursing and Rehabilitative Care Facility (Level I) or Skilled Nursing Care Facility (Level II) as designated under Department of Public Health regulations.
(2) Individual practitioners and treatment facilities will be qualified to provide acute care, and post-acute care rehabilitation services through possession of the appropriate licenses, accreditations, training and experience deemed customary and routine through trade practice.
(g) Consumer Information
(1) The commissioner shall prepare information for use by consumers, purchasers of health benefit plan coverage, and self-insurers regarding coverage recommended for acquired or traumatic brain injuries. The department shall publish information prepared under this section on the department's Internet website.
The information contained in this website is for general information purposes only. The General Court provides this information as a public service and while we endeavor to keep the data accurate and current to the best of our ability, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the website or the information contained on the website for any purpose. Any reliance you place on such information is therefore strictly at your own risk.