PRINTER'S NO. 1410
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
1094
Session of
2024
INTRODUCED BY KEARNEY, J. WARD, TARTAGLIONE, KANE, FONTANA,
HUGHES, DILLON AND COSTA, MARCH 11, 2024
REFERRED TO BANKING AND INSURANCE, MARCH 11, 2024
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," in casualty insurance, providing
for coverage for postacute neurorehabilitation.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921, is amended by adding a
section to read:
Section 635.9. Coverage for Postacute Neurorehabilitation.--
(a) All group or individual health or sickness or accident
insurance policies providing hospital or medical/surgical
coverage and all group or individual subscriber contracts or
certificates issued by any entity subject to 40 Pa.C.S. Ch. 61
(relating to hospital plan corporations) or 63 (relating to
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professional health services plan corporations), this act, the
act of December 29, 1972 (P.L.1701, No.364), known as the Health
Maintenance Organization Act, or an employe welfare benefit plan
as defined in section 3 of the Employee Retirement Income
Security Act of 1974 (Public Law 93-406, 29 U.S.C. § 1001 et
seq.) providing hospital or medical/surgical coverage shall also
provide coverage for postacute neurorehabilitation for an
acquired brain injury. Coverage under this section shall include
medically necessary treatment related to or as a result of an
acquired brain injury, including cognitive communication
therapy, cognitive rehabilitation therapy, neurobehavioral
therapy, neurophysiological testing and treatment,
neuropsychological testing and treatment, functional
rehabilitation therapy, community reintegration services,
postacute transitional rehabilitation treatment, day
rehabilitation treatment and telerehab postacute rehabilitation
services and provide for such services as needed in facility and
home and community-based settings.
(b) Prior to payment for postacute neurorehabilitation
services, an insurer shall verify that the neurorehabilitation
individual practitioners and treatment facilities provide
services within the scope of the services provided under a
Commission on Accreditation of Rehabilitation Facilities
accredited rehabilitation program for brain injury or another
nationally recognized accredited rehabilitation program for
brain injury and are qualified to provide postacute care
rehabilitation services through possession of the appropriate
licenses, accreditation, training and experience deemed
customary and routine in the trade practice and according to
criteria set out in the Office of Long-Term Living's Home and
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Community-Based Community HealthChoices Waiver.
(c) Coverage under this section may not limit the number of
days of covered postacute care, including any therapy or
treatment or rehabilitation, testing, remediation or other
service described under this section, or the number of days of
covered inpatient care to the extent that the treatment or care
is determined to be medically necessary as a result of and
related to an acquired brain injury. The insured's or enrollee's
treating physician shall determine whether treatment or care is
medically necessary for purposes of this paragraph in
consultation with the treatment or care provider, the insured or
enrollee and, if appropriate, members of the insured's or
enrollee's family. Any limitations shall be separately stated by
the Insurance Department.
(d) Coverage under this section shall not be subject to any
greater deductible, coinsurance, copayments or out-of-pocket
limits than any other benefit provided by the Insurance
Department.
(e) The Insurance Department shall promulgate rules and
regulations that require an insurer to provide adequate training
to personnel responsible for preauthorization of coverage or
utilization review for services under this section.
(f) This section shall not apply to the following types of
policies:
(1) Accident only.
(2) Limited benefit.
(3) Credit.
(4) Dental.
(5) Vision.
(6) Specified disease.
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(7) Medicare supplement.
(8) Civilian Health and Medical Program of the Uniformed
Services (CHAMPUS) supplement.
(9) Long-term care or disability income.
(10) Workers' compensation.
(11) Automobile medical payment.
(12) Fixed indemnity.
(13) Hospital indemnity.
(g) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection unless
the context clearly indicates otherwise:
"Acquired brain injury" means an injury to the brain that
occurs after birth and can be caused by infectious diseases,
metabolic disorders, endocrine disorders or diminished oxygen,
brain tumors, toxins, disease that affects the blood supply to
the brain, stroke or a traumatic brain injury.
"Cognitive communication therapy" means the treatment of
problems with communication that have an underlying cause in a
cognitive deficit rather than a primary language or speech
deficit.
"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.
"Community reintegration services" means incremental guided
real-world therapeutic training to develop skills essential for
an individual to participate in life to re-enter employment, to
go to school and engage in other productive activity, to safely
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live independently and to participate in their community while
avoiding rehospitalization and long-term support needs.
"Day rehabilitation treatment" means a program that provides
assistance with acquisition, retention or improvement in self-
help, socialization and adaptive skills which is accomplished
through comprehensive day rehabilitation programming to acquire
more independent functioning and improved cognition,
communication and life skills.
"Functional rehabilitation therapy" means a structured
approach to rehabilitation for brain disorders which emphasizes
learning by doing and focuses relearning a specific task in a
prescribed format with maximum opportunity for repeated correct
practice. Compensatory strategies are developed for those skills
which are persistently impaired and individuals are trained on
daily implementation.
"Neurobehavioral therapy" means a set of medical and
therapeutic assessment and treatments focused on behavioral
impairments associated with brain disease or injury and the
amelioration of such impairments through the development of pro-
social behavior.
"Neurophysiological testing and treatment" means a set of
medical and therapeutic assessment and treatments focused on
psychophysiological disorders or physical disorders associated
with central nervous system dysfunction.
"Neuropsychological testing and treatment" means a set of
medical and therapeutic assessment and treatments focused on
evaluating the cognitive, emotional, psychosocial and behavioral
deficits caused by brain injury.
"Preauthorization" means the provision of a reliable
representation to a physician or health care provider of whether
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an insurer will pay the physician or health care provider for
proposed medical or health care services if the physician or
health care provider provides the 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.
"Postacute transitional rehabilitation treatment" means
integrated medical and therapeutic services, treatment,
education and skills training within a 24/7 real-world
environment of care in a home and community setting.
"Telerehab postacute rehabilitation services" means cognitive
rehabilitation and other neurorehabilitation services that can
be delivered through virtual methods in accordance with the
Health Insurance Portability and Accountability Act of 1996
(Public Law 104-191, 110 Stat. 1936) and allow for contextual
training in environments where an individual with a brain injury
needs to perform.
Section 2. This act shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the Federal Government
or the Insurance Department, the addition of section 635.9 of
the act shall apply to any policy for which a form or rate is
first filed on or after the effective date of this section.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the Federal
Government or the Insurance Department, the addition of
section 635.9 of the act shall apply to any policy issued or
renewed on or after 180 days after the effective date of this
section.
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Section 3. This act shall take effect in 60 days.
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