Health care coverage: acquired brain injury.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires health care service plan contracts and health insurance policies to provide coverage for specified benefits. This bill would prohibit a health care service plan contract or a health insurance policy issued, amended, renewed, or delivered on or after January 1, 2014, from denying coverage for medically necessary medical or rehabilitation treatment for an acquired brain injury at a facility within the plan's or insurer's network that is properly licensed and accredited at which appropriate services may be provided, including specified facilities such as a hospital or a long-term acute care hospital, except as provided. The bill would additionally prohibit the contract or policy from denying the applicable coverage because the treating facility within the plan's or insurer's network is not near the enrollee's or insured's home. Because a willful violation of the bill's provisions by a health care service plan would be a crime, it would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.