H-3700.1 _______________________________________________
HOUSE BILL 2578
_______________________________________________
State of Washington 52nd Legislature 1992 Regular Session
By Representatives Ferguson, R. Meyers, Mitchell, Cooper, Paris, Kremen, Wynne, Sheldon, Miller, Dorn, Fraser, Horn, Sprenkle, Rasmussen, Moyer, Edmondson, Van Luven, Anderson and Dellwo
Read first time 01/22/92. Referred to Committee on Financial Institutions & Insurance.
AN ACT Relating to insurance coverage for neurodevelopmental therapies; and amending RCW 41.05.170, 48.21.310, 48.44.450, and 48.46.520.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:
Sec. 1. RCW 41.05.170 and 1989 c 345 s 4 are each amended to read as follows:
(1)(a)
Each health plan offered to public employees and their covered dependents under
this chapter which is not subject to the provisions of Title 48 RCW and is
established or renewed on or after twelve months after July 23, 1989, shall
include coverage for neurodevelopmental therapies for covered individuals ((age
six and under)) until the seventh birthday of the covered individual.
(b) Neurodevelopmental therapy is defined to be medically necessary speech, physical, or occupational therapy for the treatment of neurodevelopmental disorders. Neurodevelopmental disorders include structural or functional abnormalities of the central or peripheral nervous system that may be present before, during, or after birth.
(2)
Benefits provided under this section shall cover the services of those ((authorized))
licensed or certified to deliver occupational therapy, speech therapy,
and physical therapy. Benefits shall be payable only where the services have
been delivered pursuant to the referral and periodic review of a holder of a
license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services
have been rendered by such licensee. Nothing in this section shall preclude a
self-funded plan authorized under this chapter from negotiating rates with
qualified providers.
(3) Benefits provided under this section shall be for medically necessary services as determined by the self-funded plan authorized under this chapter. Benefits shall be payable for services for the maintenance of a covered individual in cases where significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore, maintain, and improve function.
(4) It is the intent of this section that the state, as an employer providing comprehensive health coverage including the benefits required by this section, retains the authority to design and employ utilization and cost controls. Therefore, benefits delivered under this section may be subject to the same contractual provisions regarding deductible amounts and/or copayments established by the self-funded plan authorized under this chapter for treatment of common major illnesses in the general coverages under the plan. Benefits provided under this section may be subject to standard waiting periods for preexisting conditions, and may be subject to the submission of written treatment plans.
(5) In
recognition of the intent expressed in subsection (4) of this section, benefits
provided under this section may be subject to contractual provisions establishing
annual benefit limits of not less than fifteen thousand dollars and/or
lifetime benefit limits((. Such limits may define the total dollar benefits
available, or may limit the number of services delivered as established by the
self-funded plan authorized under this chapter)) of not less than fifty
thousand dollars. The annual and lifetime benefit limits shall be calculated
on a per-contract basis.
Sec. 2. RCW 48.21.310 and 1989 c 345 s 2 are each amended to read as follows:
(1)(a)
Each employer-sponsored group policy for comprehensive health insurance ((which)),
including those negotiated through a collective bargaining process, that is
entered into, or renewed, on or after twelve months after July 23, 1989, shall
include coverage for neurodevelopmental therapies for covered individuals ((age
six and under)) until the seventh birthday of the covered individual.
(b) Neurodevelopmental therapy is defined to be medically necessary speech, physical, or occupational therapy for the treatment of neurodevelopmental disorders. Neurodevelopmental disorders include structural or functional abnormalities of the central or peripheral nervous system that may be present before, during, or after birth.
(2)
Benefits provided under this section shall cover the services of those ((authorized))
licensed or certified to deliver occupational therapy, speech therapy,
and physical therapy. Benefits shall be payable only where the services have
been delivered pursuant to the referral and periodic review of a holder of a
license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services
have been rendered by such licensee. Nothing in this section shall prohibit an
insurer from negotiating rates with qualified providers.
(3) Benefits provided under this section shall be for medically necessary services as determined by the insurer. Benefits shall be payable for services for the maintenance of an insured in cases where significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore, maintain, and improve function.
(4) It
is the intent of this section that ((employers purchasing)) purchasers
of group comprehensive health insurance, including the benefits required by
this section, together with the insurer, retain authority to design and employ
utilization and cost controls. Therefore, benefits delivered under this
section may be subject to the same contractual provisions regarding
deductible amounts and/or copayments established for treatment of common
major illnesses in the general coverages of the group policy by the ((employer
purchasing)) purchaser of group insurance and the insurer. Benefits
provided under this section may be subject to standard waiting periods for
preexisting conditions, and may be subject to the submission of written
treatment plans.
(5) In
recognition of the intent expressed in subsection (4) of this section, benefits
provided under this section may be subject to contractual provisions
establishing annual benefit limits not less than fifteen thousand dollars
and/or lifetime benefit limits((. Such limits may define the total dollar
benefits available or may limit the number of services delivered as agreed by
the employer purchasing insurance and the insurer)) not less than fifty
thousand dollars. The annual and lifetime benefit limits shall be calculated
on a per-contract basis.
Sec. 3. RCW 48.44.450 and 1989 c 345 s 1 are each amended to read as follows:
(1)(a)
Each employer-sponsored group contract for comprehensive health care service ((which)),
including those negotiated through a collective bargaining process, that is
entered into, or renewed, on or after twelve months after July 23, 1989, shall
include coverage for neurodevelopmental therapies for covered individuals ((age
six and under)) until the seventh birthday of the covered individual.
(b) Neurodevelopmental therapy is defined to be medically necessary speech, physical, or occupational therapy for the treatment of neurodevelopmental disorders. Neurodevelopmental disorders include structural or functional abnormalities of the central or peripheral nervous system that may be present before, during, or after birth.
(2)
Benefits provided under this section shall cover the services of those ((authorized))
licensed or certified to deliver occupational therapy, speech therapy,
and physical therapy. Benefits shall be payable only where the services have
been delivered pursuant to the referral and periodic review of a holder of a
license issued pursuant to chapter 18.71 or 18.57 RCW or where covered services
have been rendered by such licensee. Nothing in this section shall prohibit a
health care service contractor from requiring that covered services be
delivered by a provider who participates by contract with the health care
service contractor unless no participating provider is available to deliver
covered services. Nothing in this section shall prohibit a health care service
contractor from negotiating rates with qualified providers.
(3) Benefits provided under this section shall be for medically necessary services as determined by the health care service contractor. Benefits shall be payable for services for the maintenance of a covered individual in cases where significant deterioration in the patient's condition would result without the service. Benefits shall be payable to restore, maintain, and improve function.
(4) It
is the intent of this section that ((employers purchasing)) purchasers
of comprehensive group coverage including the benefits required by this
section, together with the health care service contractor, retain authority to
design and employ utilization and cost controls. Therefore, benefits delivered
under this section may be subject to the same contractual provisions
regarding deductible amounts and/or copayments established for treatment of
common major illnesses in the general coverages of the group contract by
the ((employer purchasing)) purchaser of the group coverage and
the health care service contractor. Benefits provided under this section may
be subject to standard waiting periods for preexisting conditions, and may be
subject to the submission of written treatment plans.
(5) In
recognition of the intent expressed in subsection (4) of this section, benefits
provided under this section may be subject to contractual provisions
establishing annual benefit limits of not less than fifteen thousand dollars
and/or lifetime benefit limits((. Such limits may define the total dollar
benefits available or may limit the number of services delivered as agreed by
the employer purchasing coverage and the health care service contractor)) of
not less than fifty thousand dollars. The annual and lifetime benefit limits
shall be calculated on a per-contract basis.
Sec. 4. RCW 48.46.520 and 1989 c 345 s 3 are each amended to read as follows:
(1)(a)
Each employer-sponsored group contract for comprehensive health care service ((which)),
including those negotiated through a collective bargaining process, that is
entered into, or renewed, on or after twelve months after July 23, 1989, shall
include coverage for neurodevelopmental therapies for covered individuals ((age
six and under)) until the seventh birthday of the covered individual.
(b) Neurodevelopmental therapy is defined to be medically necessary speech, physical, or occupational therapy for the treatment of neurodevelopmental disorders. Neurodevelopmental disorders include structural or functional abnormalities of the central or peripheral nervous system that may be present before, during, or after birth.
(2)
Benefits provided under this section shall cover the services of those ((authorized))
licensed or certified to deliver occupational therapy, speech therapy,
and physical therapy. Covered benefits and treatment must be rendered or
referred by the health maintenance organization, and delivered pursuant to the
referral and periodic review of a holder of a license issued pursuant to
chapter 18.71 or 18.57 RCW or where treatment is rendered by such licensee.
Nothing in this section shall prohibit a health maintenance organization from
negotiating rates with qualified providers.
(3) Benefits provided under this section shall be for medically necessary services as determined by the health maintenance organization. Benefits shall be provided for the maintenance of a covered enrollee in cases where significant deterioration in the patient's condition would result without the service. Benefits shall be provided to restore, maintain, and improve function.
(4) It
is the intent of this section that ((employers purchasing)) purchasers
of comprehensive group coverage including the benefits required by this
section, together with the health maintenance organization, retain authority to
design and employ utilization and cost controls. Therefore, benefits provided
under this section may be subject to the same contractual provisions
regarding deductible amounts and/or copayments established for treatment of
common major illnesses in the general coverages of the group agreement by
the ((employer purchasing)) purchaser of the group coverage and
the health maintenance organization. Benefits provided under this section may
be subject to standard waiting periods for preexisting conditions, and may be
subject to the submission of written treatment plans.
(5) In
recognition of the intent expressed in subsection (4) of this section, benefits
provided under this section may be subject to contractual provisions
establishing annual benefit limits of not less than fifteen thousand dollars
and/or lifetime benefit limits((. Such limits may define the total dollar
benefits available, or may limit the number of services delivered as agreed by
the employer purchasing coverage and the health maintenance organization)) of
not less than fifty thousand dollars. The annual and lifetime benefit limits
shall be calculated on a per-contract basis.