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Below is a list of federal and state legislation recently passed in the legislature, along with brief descriptions of the enacted laws.
This mandate was signed into law on December 12, 2008, and applies to all of PersonalCare’s commercial plans, including both individual and group plans. It also applies to self-funded groups that are schools, municipalities and counties. It requires health plans to provide coverage for the following services for diagnosis and treatment of children (birth to 21) diagnosed with an autism spectrum disorder: psychiatric, psychological and habilitative care as well as behavioral, speech, occupational and physical therapies, up to an annual benefit maximum of $36,000. Implementation began in late 2008 and is currently ongoing.
This new law went into effect on June 1, 2009, as groups are issued or renewed. It applies to all of PersonalCare’s commercial plans, including both individual and group plans, as well as self-funded groups who are schools, municipalities and counties. Prior to this new law, the state did not regulate dependent age and left it to health plans’ discretion to determine dependent age status. This law now mandates that PersonalCare increase dependent age from the current 19/23 and cover unmarried non-military dependents up to age 26 whose parents’ policies provide for dependent coverage, and unmarried military veteran dependents up to age 30. It also provides for an initial 90-day enrollment period at the time a policy is issued or renewed to allow eligible dependent to enroll.
This law also does not allow a condition of eligibility for coverage on the dependent’s enrollment in an educational institution. Therefore, PersonalCare will no longer require full-time student status as a condition of continued eligibility.
This was signed into law on September 22, 2008 and was effective immediately. It mandates that health plans provide coverage of treatment by a licensed marriage and family therapist for mental, emotional or nervous disorders or conditions when an insurance policy covers mental, emotional, or nervous disorders or conditions.
While this law requires health plans allow their insured to select licensed marriage and family therapists to treat mental, emotional and nervous disorders and must cover those disorders, the law also provides that plans must cover these services “provided the disorder or condition treated is covered by the policy…” PersonalCare EOCs currently state that we do not cover “marriage or relationship counseling; vocational or employment counseling; and sex therapy.”
This new law became effective on January 1, 2009. It added anorexia nervosa and bulimia nervosa to the list of psychiatric illnesses identified as serious mental illnesses under Illinois law. Although these two conditions were not previously included as serious mental illnesses and, therefore, did not apply to that benefit, they were covered under other benefit provisions (i.e., non-serious, physician, medical).
This law was signed into law as an insurance mandate on April 7, 2009. It goes into effect as policies are issued or renewed after its effective date, which is January 1, 2010. This law applies to individual and group fully insured health plans as well as county, municipality and school district self-funded plans. It requires those plans to provide coverage for habilitative services for children under 19 years of age with congenital, genetic or early acquired disorders under certain conditions. Habilitative services under this section are occupational therapy, physical therapy, and other services to enhance a child’s ability to function with a congenital or genetic (such as hereditary disorders) or early acquired disorder (resulting from illness, trauma, injury or other event/condition suffered prior to developing functional life skills). It also includes autism or autism spectrum disorders, cerebral palsy, and other disorders resulting from early childhood. Clinical improvement and medical necessity can be required. Coverage under this section does not apply to the treatment of mental disorders or illnesses already covered under Section 370 of the Insurance Code.
This law was signed into law as an insurance mandate on March 27, 2009. It was effect immediately on the date of its passage. This law applies to individual and group fully insured health plans as well as county, municipality and school district self-funded plans. It requires coverage for all medically necessary pain medication and pain therapy related to the treatment of breast cancer on the same terms and conditions generally applicable to coverage for other conditions. It also modifies the term low-dose mammography to include digital mammography. It requires health plans to provide mammogram coverage at no cost to the insured when preventive mammograms are obtained from in-network providers. Health plans also cannot apply an annual or lifetime maximum but can apply participating/non-participating provider restrictions as stated. This law mandates coverage for such services in conjunction with the treatment of breast cancer.
On October 3, 2008, President Bush signed into law the “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008,” also known as the Mental Health Parity Act of 2008. This Act requires group health plans/group health insurers to apply the same treatment and financial limits ) as to medical/surgical benefits to mental health and substance use disorder benefits, including deductibles, copayments, coinsurance and out-of-pocket expenses, visit limits. Health plans also cannot apply lifetime financial or treatment limits, unless they apply those same limits to medical/surgical benefits. The plans can continue to apply medical management to these benefits. The law does only apply to large groups (51+), Medicare or FEHBP. It goes into effect for plan years that are new, or renew on or after October 3, 2009.
In order to determine correct coordination of benefits with Medicare, this new law requires payors to report subscribers and dependents to CMS This exchange of enrollment information should ensure that claims payments are made in the correct order by private payors and Medicare, and reduce incorrect payments and recovery costs. Coventry’s implementation plan began in the fourth quarter of 2008 and remains ongoing. The law requires health plans to have Social Security numbers for all members, including dependents.
On October 9, 2008, President Bush signed “Michelle’s Law.” This law provides that a group health plan may not terminate a college student’s health insurance coverage if a he/she takes a medically necessary leave of absence from college or changes to part-time status. To take advantage of the extension, the child must be enrolled in the plan with a full-time student status immediately before the first day of leave. Coverage must extend for one year after the first day of the leave (unless coverage would have otherwise terminated earlier for other reasons). Health plans can require the child’s physician to give written certification for the leave of absence. This law goes into effect for plan year beginning on or after October 9, 2009. There is already have a similar law in Illinois and PersonalCare has a similar policy similar in effect for fully insured business.
President Bush signed the Genetic Information Nondiscrimination Act of 2008, or “GINA”, into law on May 21, 2008. It applies to all group health plans (including small groups and medical supply plans) beginning one year after the Act’s date of enactment. This new law prohibits group health plans from requesting or requiring members to undergo genetic testing for health insurance purposes. In addition, health plans cannot deny coverage or apply a higher premium because a person may be more likely to have a disease or condition due to genetics. Finally, health plans cannot purchase genetic information from a third party in order to use it in their decision-making processes. PersonalCare does not engage in any activities prohibited by this new Act.