SECOND REGULAR SESSION
HOUSE BILL NO. 1810
95TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE SANDER.
3170L.01I D. ADAM CRUMBLISS, Chief Clerk
To amend chapter 376, RSMo, by adding thereto one new section relating to health insurance coverage for habilitative services.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be known as section 376.1195, to read as follows:
376.1195. 1. Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011, shall provide coverage for habilitative services for children less than eighteen years of age with a neurologic, congenital, genetic, or early acquired disorder, including all such prenatal, perinatal, and postnatal disorders, when all of the following conditions are met:
(1) A licensed physician has diagnosed the child's neurologic, congenital, genetic, or early acquired disorder;
(2) The treatment is administered by a licensed speech-language pathologist, licensed occupational therapist, or licensed physical therapist upon the referral of a licensed physician;
(3) The initial or continued treatment is medically necessary, as determined by the appropriate licensed health care professional, and is therapeutic and not experimental or investigational.
2. For the purposes of this section, the following terms shall mean:
(1) "Congenital or genetic disorder", includes but is not limited to hereditary disorders;
(2) "Early acquired disorder", a disorder resulting from illness, trauma, injury, or some other event or condition occurring prior to such child developing functional life skills such as, but not limited to, walking, talking, or self-help skills;
(3) "Habilitative services", occupational therapy, physical therapy, and speech therapy prescribed by the insured's treating physician to enhance the ability of a child to function with a neurologic, congenital, genetic, or early acquired disorder;
(4) "Health carrier", the same meaning as such term is defined in section 376.1350;
(5) "Health benefit plan", the same meaning as such term is defined in section 376.1350;
(6) "Neurologic, congenital, genetic, and early acquired disorder", include but is not limited to autism or an autism spectrum disorder, cerebral palsy, Downs Syndrome, and other disorders resulting from early childhood illness, trauma, or injury;
(7) "Neurologic disorder", any disorder affecting a child's nervous system.
3. A health carrier or health benefit plan subject to the provisions of this section shall not be required to provide reimbursement for habilitative services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Nothing in this subsection shall be construed as exempting a health carrier, health benefit plan, or similar third party from an otherwise valid obligation to provide or to pay for services provided to a child with a disability.
4. Health carriers and health benefit plans subject to the provisions of this section shall provide notice annually to its insureds and enrollees about the coverage required under this section.
5. A determination by a health carrier or health benefit plan subject to the provisions of this section denying a request for habilitative services or denying payment for habilitative services on the grounds that a condition or disease is not a neurologic, congenital, genetic, or early acquired disorder is considered an adverse determination under section 376.1350.
6. The coverage required by this section shall not be subject to any greater deductibles, co-payments, or coinsurance than services provided by the health benefit plan for physical illness.
7. The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months' or less duration, or any other supplemental policy as determined by the director of the department of insurance, financial institutions and professional registration.