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H0644...........................................................by BUSINESS HEALTH INSURANCE - Amends existing law relating to insurance to require coverage for medically necessary care for children born with cleft lip or cleft palate. 02/10 House intro - 1st rdg - to printing 02/13 Rpt prt - to Bus
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]] Fifty-eighth Legislature Second Regular Session - 2006IN THE HOUSE OF REPRESENTATIVES HOUSE BILL NO. 644 BY BUSINESS COMMITTEE 1 AN ACT 2 RELATING TO INSURANCE; AMENDING SECTIONS 41-2140 AND 41-2210, IDAHO CODE, TO 3 REQUIRE COVERAGE FOR MEDICALLY NECESSARY CARE FOR CHILDREN BORN WITH CLEFT 4 LIP OR CLEFT PALATE; AMENDING SECTION 41-3437, IDAHO CODE, TO REQUIRE COV- 5 ERAGE FOR MEDICALLY NECESSARY CARE FOR CHILDREN BORN WITH CLEFT LIP OR 6 CLEFT PALATE AND TO MAKE TECHNICAL CORRECTIONS; AND AMENDING SECTIONS 7 41-3923 AND 41-4023, IDAHO CODE, TO REQUIRE COVERAGE FOR MEDICALLY NECES- 8 SARY CARE FOR CHILDREN BORN WITH CLEFT LIP OR CLEFT PALATE. 9 Be It Enacted by the Legislature of the State of Idaho: 10 SECTION 1. That Section 41-2140, Idaho Code, be, and the same is hereby 11 amended to read as follows: 12 41-2140. REQUIRED PROVISIONS. (1) Any disability insurance contract 13 delivered or issued for delivery in this state which provides coverage for 14 injury or sickness for newborn dependent children of the insured, shall pro- 15 vide such coverage for such newborn children, including adopted newborn chil- 16 dren that are placed with the adoptive insured within sixty (60) days of the 17 adopted child's date of birth, from and after the moment of birth. Coverage 18 under the contract for an adopted newborn child placed with the adoptive 19 insured more than sixty (60) days after the birth of the adopted child shall 20 be from and after the date the child is so placed. Coverage provided in accord 21 with this section shall include, but not be limited to, coverage for congeni- 22 tal anomalies, including coverage consistent with subsection (5) of this sec- 23 tion. For the purposes of this section, "child" means an individual who has 24 not attained age eighteen (18) years as of the date of the adoption or place- 25 ment for adoption. For the purposes of this section, "placed" shall mean phys- 26 ical placement in the care of the adoptive insured, or in those circumstances 27 in which such physical placement is prevented due to the medical needs of the 28 child requiring placement in a medical facility, it shall mean when the adop- 29 tive insured signs an agreement for adoption of such child and signs an agree- 30 ment assuming financial responsibility for such child. Prior to legal 31 finalization of adoption, the coverage required under the provisions of this 32 subsection (1) as to a child placed for adoption with an insured continues in 33 the same manner as it would with respect to a naturally born child of the 34 insured until the first to occur of the following events: 35 (a) Date the child is removed permanently from that placement and the 36 legal obligation terminates; or 37 (b) The date the insured rescinds, in writing, the agreement of adoption 38 or agreement assuming financial responsibility. 39 (2) An insurer shall not restrict coverage under a disability insurance 40 policy of any dependent child adopted by a participant or beneficiary, or 41 placed with a participant or beneficiary for adoption, solely on the basis of 42 a preexisting condition of the child at the time the child would otherwise 43 become eligible for coverage under the plan, if the adoption or placement for 2 1 adoption occurs which the participant or beneficiary is eligible for coverage 2 under the plan. 3 (3) No policy of disability insurance which provides maternity benefits 4 for a person covered continuously from conception shall be issued, amended, 5 delivered, or renewed in this state on or after January 1, 1977, if it con- 6 tains any exclusion, reduction, or other limitations as to coverage, 7 deductibles, or coinsurance provisions, as to involuntary complications of 8 pregnancy, unless such provisions apply generally to all benefits paid under 9 the policy. If a fixed amount is specified in such policy for surgery, the 10 fixed amounts for surgical procedures involving involuntary complications of 11 pregnancy shall be commensurate with other fixed amounts payable for proce- 12 dures of comparable difficulty and severity. In a case where a fixed amount 13 is payable for maternity benefits, involuntary complications of pregnancy 14 shall be deemed an illness and entitled to benefits otherwise provided by the 15 policy. Where the policy contains a maternity deductible, the maternity 16 deductible shall apply only to expenses resulting from normal delivery and 17 cesarean section delivery; however, expenses for cesarean section delivery in 18 excess of the deductible shall be treated as expenses for any other illness 19 under the policy. This section shall apply to all disability policies except 20 individual noncancelable or guaranteed renewable policies, issued or delivered 21 before January 1, 1977. 22 With respect to such individual noncancelable or guaranteed renewable pol- 23 icies issued or delivered before January 1, 1977, the insurer shall communi- 24 cate the availability of coverage of involuntary complications of pregnancy 25 when negotiating any changes in such policies. 26 For purposes of this section, involuntary complications of pregnancy shall 27 include, but not be limited to, puerperal infection, eclampsia, cesarean sec- 28 tion delivery, ectopic pregnancy, and toxemia. 29 All policies subject to this section and issued, amended, delivered, or 30 renewed in this state on or after January 1, 1977, shall be construed to be in 31 compliance with this section, and any provision in any such policy which is in 32 conflict with this section shall be of no force or effect. 33 (4) From and after January 1, 1998, no policy of disability insurance 34 which provides medical expense maternity benefits, shall restrict benefits for 35 any hospital length of stay in connection with childbirth for the mother or 36 newborn child in a manner that would be in conflict with the newborns' and 37 mothers' health protection act of 1996. 38 (5) With regard to newborn children born with cleft lip or cleft palate 39 or both, there shall be no age limit on benefits for such conditions, and care 40 and treatment shall include to the extent medically necessary, but shall not 41 be limited to, oral and facial surgery, surgical management and follow-up care 42 by plastic surgeons and oral surgeons, prosthetic treatment such as 43 obturators, speech appliances and feeding appliances, habilitative speech 44 therapy, otolaryngology treatment, and audiological assessments and treatment. 45 SECTION 2. That Section 41-2210, Idaho Code, be, and the same is hereby 46 amended to read as follows: 47 41-2210. REQUIRED PROVISION IN GROUP AND BLANKET POLICIES. (1) Any group 48 disability insurance contract or blanket disability insurance contract, deliv- 49 ered or issued for delivery in this state which provides coverage for injury 50 or sickness for newborn dependent children of subscribers or other members of 51 the covered group, shall provide coverage for such newborn children, including 52 adopted newborn children that are placed with the adoptive subscriber or other 53 member of the covered group within sixty (60) days of the adopted child's date 3 1 of birth, from and after the moment of birth. Coverage under the contract for 2 an adopted newborn child placed with the adoptive subscriber or other member 3 of the covered group more than sixty (60) days after the birth of the adopted 4 child shall be from and after the date the child is so placed. Coverage pro- 5 vided in accord with this section shall include, but not be limited to, cover- 6 age for congenital anomalies, including coverage consistent with subsection 7 (5) of this section. For the purposes of this section, "child" means an indi- 8 vidual who has not attained age eighteen (18) years as of the date of the 9 adoption or placement for adoption. For the purposes of this section, "placed" 10 shall mean physical placement in the care of the adoptive subscriber or other 11 member of the covered group, or in those circumstances in which such physical 12 placement is prevented due to the medical needs of the child requiring place- 13 ment in a medical facility, it shall mean when the adoptive subscriber or 14 other member of the covered group signs an agreement for adoption of such 15 child and signs an agreement assuming financial responsibility for such child. 16 Prior to legal finalization of adoption, the coverage required under the pro- 17 visions of this subsection (1) as to a child placed for adoption with a sub- 18 scriber or other member of the covered group continues in the same manner as 19 it would with respect to a naturally born child of the subscriber or other 20 member of the covered group until the first to occur of the following events: 21 (a) Date the child is removed permanently from that placement and the 22 legal obligation terminates; or 23 (b) The date the subscriber or other member of the covered group 24 rescinds, in writing, the agreement of adoption or agreement assuming 25 financial responsibility. 26 (2) An insurer shall not restrict coverage under a group disability 27 insurance contract or a blanket disability insurance contract of any dependent 28 child adopted by a participant or beneficiary, or placed with a participant or 29 beneficiary for adoption, solely on the basis of a preexisting condition of a 30 child at the time the child would otherwise become eligible for coverage under 31 the plan, if the adoption or placement for adoption occurs while the partici- 32 pant or beneficiary is eligible for coverage under the plan. 33 (3) No policy of disability insurance which provides maternity benefits 34 for a person covered continuously from conception shall be issued, amended, 35 delivered, or renewed in this state on or after January 1, 1977, if it con- 36 tains any exclusion, reduction, or other limitations as to coverage, 37 deductibles, or coinsurance provisions, as to involuntary complications of 38 pregnancy, unless such provisions apply generally to all benefits paid under 39 the policy. If a fixed amount is specified in such policy for surgery, the 40 fixed amounts for surgical procedures involving involuntary complications of 41 pregnancy shall be commensurate with other fixed amounts payable for proce- 42 dures of comparable difficulty and severity. In a case where a fixed amount is 43 payable for maternity benefits, involuntary complications of pregnancy shall 44 be deemed an illness and entitled to benefits otherwise provided by the pol- 45 icy. Where the policy contains a maternity deductible, the maternity deduct- 46 ible shall apply only to expenses resulting from normal delivery and cesarean 47 section delivery; however, expenses for cesarean section delivery in excess of 48 the deductible shall be treated as expenses for any other illness under the 49 policy. This section shall apply to all disability policies except any group 50 disability policy made subject to an applicable collective-bargaining agree- 51 ment in effect before January 1, 1977. 52 For purposes of this section, involuntary complications of pregnancy shall 53 include, but not be limited to, puerperal infection, eclampsia, cesarean sec- 54 tion delivery, ectopic pregnancy, and toxemia. 55 All policies subject to this section and issued, amended, delivered, or 4 1 renewed in this state on or after January 1, 1977, shall be construed to be in 2 compliance with this section, and any provision in any such policy which is in 3 conflict with this section shall be of no force or effect. 4 (4) From and after January 1, 1998, no policy of disability insurance 5 which provides medical expense maternity benefits, shall restrict benefits for 6 any hospital length of stay in connection with childbirth for the mother or 7 newborn child in a manner that would be in conflict with the newborns' and 8 mothers' health protection act of 1996. 9 (5) With regard to newborn children born with cleft lip or cleft palate 10 or both, there shall be no age limit on benefits for such conditions, and care 11 and treatment shall include to the extent medically necessary, but shall not 12 be limited to, oral and facial surgery, surgical management and follow-up care 13 by plastic surgeons and oral surgeons, prosthetic treatment such as 14 obturators, speech appliances and feeding appliances, habilitative speech 15 therapy, otolaryngology treatment, and audiological assessments and treatment. 16 SECTION 3. That Section 41-3437, Idaho Code, be, and the same is hereby 17 amended to read as follows: 18 41-3437. REQUIRED PROVISIONS -- INFANTS. (a1) A subscriber's contract, 19 delivered or issued for delivery in this state which provides coverage for 20 injury or sickness for newborn dependent children of subscribers or other mem- 21 bers of the covered group, shall provide coverage for such newborn children, 22 including adopted newborn children that are placed with the adoptive sub- 23 scriber or other member of the covered group within sixty (60) days of the 24 adopted child's date of birth, from and after the moment of birth. Coverage 25 under the contract for an adopted newborn child placed with the adoptive sub- 26 scriber or other member of the covered group more than sixty (60) days after 27 the birth of the adopted child shall be from and after the date the child is 28 so placed. Coverage provided in accord with this section shall include, but 29 not be limited to, coverage for congenital anomalies, including coverage con- 30 sistent with subsection (3) of this section. For the purposes of this section, 31 "child" means an individual who has not attained age eighteen (18) years as of 32 the date of the adoption or placement for adoption. For the purposes of this 33 section, "placed" shall mean physical placement in the care of the adoptive 34 subscriber or other member of the covered group, or in those circumstances in 35 which such physical placement is prevented due to the medical needs of the 36 child requiring placement in a medical facility, it shall mean when the adop- 37 tive subscriber or other member of the covered group signs an agreement for 38 adoption of such child and signs an agreement assuming financial responsibil- 39 ity for such child. Prior to legal finalization of adoption, the coverage 40 required under the provisions of this subsection as to a child placed for 41 adoption with a subscriber or other member of the covered group continues in 42 the same manner as it would with respect to a naturally born child of the sub- 43 scriber or other member of the covered group until the first to occur of the 44 following events: 45 (1a) Date the child is removed permanently from that placement and the 46 legal obligation terminates; or 47 (2b) The date the subscriber or other member of the covered group 48 rescinds, in writing, the agreement of adoption or agreement assuming 49 financial responsibility. 50 (b2) A service corporation shall not restrict coverage under a 51 subscriber's contract of any dependent child adopted by a participant or bene- 52 ficiary, or placed with a participant or beneficiary for adoption, solely on 53 the basis of a preexisting condition of the child at the time the child would 5 1 otherwise become eligible for coverage under the plan, if the adoption or 2 placement for adoption occurs while the participant or beneficiary is eligible 3 for coverage under the plan. 4 (3) With regard to newborn children born with cleft lip or cleft palate 5 or both, there shall be no age limit on benefits for such conditions, and care 6 and treatment shall include to the extent medically necessary, but shall not 7 be limited to, oral and facial surgery, surgical management and follow-up 8 care by plastic surgeons and oral surgeons, prosthetic treatment such as 9 obturators, speech appliances and feeding appliances, habilitative speech 10 therapy, otolaryngology treatment, and audiological assessments and treatment. 11 SECTION 4. That Section 41-3923, Idaho Code, be, and the same is hereby 12 amended to read as follows: 13 41-3923. COVERAGE OF ADOPTED NEWBORN CHILDREN -- COVERAGE OF MATERNITY 14 AND COMPLICATIONS OF PREGNANCY. (1) Any contract delivered or issued for 15 delivery in this state by an organization offering a managed care plan for 16 which a certificate of authority is required, which provides coverage for 17 injury or sickness for newborn dependent children of the members of the cov- 18 ered group, shall provide such coverage for such newborn children and infants, 19 including adopted newborn children that are placed with the adoptive member of 20 the covered group within sixty (60) days of the adopted child's date of birth, 21 from and after the moment of birth. Coverage under the contract for an adopted 22 newborn child placed with the adoptive member of the covered group more than 23 sixty (60) days after the birth of the adopted child shall be from and after 24 the date the child is so placed. Coverage provided in accord with this section 25 shall include, but not be limited to, coverage for congenital anomalies, 26 including coverage consistent with subsection (5) of this section. For the 27 purposes of this section, "child" means an individual who has not reached 28 eighteen (18) years as of the date of the adoption or placement for adoption. 29 For the purposes of this section, "placed" shall mean physical placement in 30 the care of the adoptive member of the covered group, or in those circum- 31 stances in which such physical placement is prevented due to the medical needs 32 of the child requiring placement in a medical facility, it shall mean when the 33 adoptive member of the covered group signs an agreement for adoption of such 34 child and signs an agreement assuming financial responsibility for such child. 35 Prior to legal finalization of adoption, the coverage required under the pro- 36 visions of this subsection (1) as to a child placed for adoption with a member 37 of the covered group continues in the same manner as it would with respect to 38 a naturally born child of the member of the covered group until the first to 39 occur of the following events: 40 (a) Date the child is removed permanently from that placement and the 41 legal obligation terminates; or 42 (b) The date the member of the covered group rescinds, in writing, the 43 agreement of adoption or agreement assuming financial responsibility. 44 (2) The managed care organization shall not restrict coverage under a 45 health care contract of any dependent child adopted by a member, or placed 46 with a member for adoption, solely on the basis of a preexisting condition of 47 the child at the time the child would otherwise become eligible for coverage 48 under the plan, if the adoption or placement for adoption occurs while the 49 member is eligible for coverage under the plan. 50 (3) No health care contract which provides maternity benefits for a per- 51 son covered continuously from conception shall be issued, amended, delivered, 52 or renewed in this state if it contains any exclusion, reduction, or other 53 limitations as to coverage, deductibles, copayments, or coinsurance provisions 6 1 as to involuntary complications of pregnancy, unless such provisions apply 2 generally to all benefits paid under the plan. If a fixed amount is specified 3 in such plan for surgery, the fixed amounts for surgical procedures involving 4 involuntary complications of pregnancy shall be commensurate with other fixed 5 amounts payable for procedures of comparable difficulty and severity. In a 6 case where a fixed amount is payable for maternity benefits, involuntary 7 complications of pregnancy shall be deemed an illness and entitled to benefits 8 otherwise provided by the plan. Where the plan contains a maternity deduct- 9 ible, the maternity deductible shall apply only to expenses resulting from 10 normal delivery and cesarean section delivery; however, expenses for cesarean 11 section delivery in excess of the deductible shall be treated as expenses for 12 any other illness under the plan. 13 Where a plan which provides or arranges direct health care services for 14 its members contains a maternity deductible, the maternity deductible shall 15 apply only to expenses resulting from prenatal care and delivery. However, 16 expenses resulting from any delivery in excess of the deductible amount shall 17 be treated as expenses for any other illness under the plan. If the pregnancy 18 is interrupted, the maternity deductible charged for prenatal care and deliv- 19 ery shall be based on the value of the medical services received, providing 20 that it is never more than two-thirds (2/3) of the plan's maternity deduct- 21 ible. 22 This section shall apply to all health care contracts except any group 23 health care contracts made subject to an applicable collective-bargaining 24 agreement in effect before January 1, 1977. 25 For purposes of this section, involuntary complications of pregnancy shall 26 include, but not be limited to, puerperal infection, eclampsia, cesarean sec- 27 tion delivery, ectopic pregnancy, and toxemia. 28 All health care contracts subject to this section and issued, amended, 29 delivered, or renewed in this state on or after January 1, 1977, shall be con- 30 strued to be in compliance with this section, and any provision in any such 31 plan which is in conflict with this section shall be of no force or effect. 32 (4) From and after January 1, 1998, no policy of disability insurance 33 which provides medical expense maternity benefits shall restrict benefits for 34 any hospital length of stay in connection with childbirth for the mother or 35 newborn child in a manner that would be in conflict with the newborns' and 36 mothers' health protection act of 1996. 37 (5) With regard to newborn children born with cleft lip or cleft palate 38 or both, there shall be no age limit on benefits for such conditions, and care 39 and treatment shall include to the extent medically necessary, but shall not 40 be limited to, oral and facial surgery, surgical management and follow-up care 41 by plastic surgeons and oral surgeons, prosthetic treatment such as 42 obturators, speech appliances and feeding appliances, habilitative speech 43 therapy, otolaryngology treatment, and audiological assessments and treatment. 44 SECTION 5. That Section 41-4023, Idaho Code, be, and the same is hereby 45 amended to read as follows: 46 41-4023. COVERAGE FROM MOMENT OF BIRTH -- COMPLICATIONS OF PREGNANCY. (1) 47 Every self-funded plan issued in this state or providing coverage to any cov- 48 ered family residing within this state, shall contain a provision granting 49 immediate accident and sickness coverage, from and after the moment of birth, 50 to each newborn child or infant of any covered family covered, including a 51 newborn child placed with the adoptive covered family within sixty (60) days 52 of the adopted child's date of birth. Coverage under the self-funded plan for 53 an adopted newborn child placed with the adoptive covered family more than 7 1 sixty (60) days after the birth of the adopted child shall be from and after 2 the date the child is so placed. Coverage provided in accord with this section 3 shall include, but not be limited to, coverage for congenital anomalies, 4 including coverage consistent with subsection (4) of this section. For the 5 purposes of this section, "child" means an individual who has not reached 6 eighteen (18) years as of the date of the adoption or placement for adoption. 7 For the purposes of this section, "placed" shall mean physical placement in 8 the care of the adoptive covered family, or in those circumstances in which 9 such physical placement is prevented due to the medical needs of the child 10 requiring placement in a medical facility, it shall mean when the adoptive 11 covered family signs an agreement for adoption of such child and signs an 12 agreement assuming financial responsibility for such child. Prior to legal 13 finalization of adoption, the coverage required under the provisions of this 14 subsection (1) as to a child placed for adoption with a covered family contin- 15 ues in the same manner as it would with respect to a naturally born child of 16 the covered family until the first to occur of the following events: 17 (a) Date the child is removed permanently from that placement and the 18 legal obligation terminates; or 19 (b) The date the covered family rescinds, in writing, the agreement of 20 adoption or agreement assuming financial responsibility. No such plan may 21 be issued or amended if it contains any disclaimer, waiver, or other limi- 22 tation of coverage relative to the coverage or insurability of newborn or 23 adopted children or infants of a covered family covered from and after the 24 moment of birth that is inconsistent with the provisions of this section. 25 (2) An insurer shall not restrict coverage under a self-funded plan of 26 any dependent child adopted by a participant or beneficiary, or placed with a 27 participant or beneficiary for adoption, solely on the basis of a preexisting 28 condition of the child at the time the child would otherwise become eligible 29 for coverage under the plan, if the adoption or placement for adoption occurs 30 while the participant or beneficiary is eligible for coverage under the plan. 31 (3) No self-funded plan which provides maternity benefits for a person 32 covered continuously from conception shall be issued, amended, delivered, or 33 renewed in this state on or after January 1, 1977, if it contains any exclu- 34 sion, reduction, or other limitations as to coverage, deductibles, or coinsur- 35 ance provisions as to involuntary complications of pregnancy, unless such pro- 36 visions apply generally to all benefits paid under the plan. If a fixed amount 37 is specified in such plan for surgery, the fixed amounts for surgical proce- 38 dures involving involuntary complications of pregnancy shall be commensurate 39 with other fixed amounts payable for procedures of comparable difficulty and 40 severity. In a case where a fixed amount is payable for maternity benefits, 41 involuntary complications of pregnancy shall be deemed an illness and entitled 42 to benefits otherwise provided by the plan. Where the plan contains a mater- 43 nity deductible, the maternity deductible shall apply only to expenses result- 44 ing from normal delivery and cesarean section delivery; however, expenses for 45 cesarean section delivery in excess of the deductible shall be treated as 46 expenses for any other illness under the plan. This subdivision shall apply to 47 all self-funded plans except any such plan made subject to an applicable 48 collective-bargaining agreement in effect before January 1, 1977. 49 For purposes of this subdivision, involuntary complications of pregnancy 50 shall include, but not be limited to, puerperal infection, eclampsia, cesarean 51 section delivery, ectopic pregnancy, and toxemia. 52 All plans subject to this subdivision and issued, amended, delivered, or 53 renewed in this state on or after January 1, 1977, shall be construed to be in 54 compliance with this section, and any provision in any such plan which is in 55 conflict with this section shall be of no force or effect. 8 1 (4) With regard to newborn children born with cleft lip or cleft palate 2 or both, there shall be no age limit on benefits for such conditions, and care 3 and treatment shall include to the extent medically necessary, but shall not 4 be limited to, oral and facial surgery, surgical management and follow-up care 5 by plastic surgeons and oral surgeons, prosthetic treatment such as 6 obturators, speech appliances and feeding appliances, habilitative speech 7 therapy, otolaryngology treatment, and audiological assessments and treatment.
STATEMENT OF PURPOSE RS 15692 This legislation proposes amending multiple sections of the Idaho Code to require coverage for medically necessary care for children born with cleft lip or cleft palate. FISCAL NOTE This legislation will result in an estimated savings of over $100,000 to the Children's Special Health Program funded through the Division of Health. Contact Name: Rep. Margaret Henbest Phone: 332-1000 STATEMENT OF PURPOSE/FISCAL NOTE H 644