HF 2196 (LSB 5575YH (3) 90)

HOUSE FILE 2196

BY  BEST

A BILL FOR

An Act relating to insurance coverage for the maintenance and repair of complex rehabilitation technology wheelchairs.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514M.1  Definitions.
   For purposes of this chapter, unless the context otherwise requires:
   1.  “Commissioner” means the commissioner of insurance.
   2.  “Complex rehabilitation technology wheelchair” means a complex rehabilitation manual or power wheelchair that is individually configured for a consumer to meet the consumer’s specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary, and includes the options and accessories related to the complex rehabilitation manual or power wheelchair.
   3.  “Consumer” means a covered person or a patient who uses a complex rehabilitation technology wheelchair.
   4.  “Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.
   5.  “Department” means the department of health and human services.
   6.  “Health care professional” means the same as defined in section 514J.102.
   7.  “Health carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, a plan established pursuant to chapter 509A for public employees, or any other entity providing a plan of health insurance, health care benefits, or health care services.
   8.  “Medical assistance” means the same as defined in section 249A.2.
   9.  “Patient” means an individual who resides in the state, who is a recipient, and who has a diagnosis or medical condition that results in significant physical impairment or functional limitation.
   10.  “Preventative maintenance” means the regular and routine maintenance of a complex rehabilitation technology wheelchair, as described in the owner’s manual, to ensure the complex rehabilitation technology wheelchair maintains its original design quality, function, and utility. “Preventative maintenance” may include but is not limited to:
   a.  An assessment and evaluation of the working condition of the complex rehabilitation technology wheelchair.
   b.  Any necessary adjustment or repairs, including necessary replacement parts, to the complex rehabilitation technology wheelchair.
   11.  “Qualified complex rehabilitation technology professional” means an individual who is certified as an assistive technology professional by the rehabilitation engineering and assistive technology society of North America.
   12.  “Qualified complex rehabilitation technology wheelchair supplier” or “qualified supplier” means an entity that meets all of the following criteria:
   a.  The entity is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology wheelchairs.
   b.  The entity employs at least one qualified complex rehabilitation technology professional to analyze the needs and capacities of a consumer in consultation with the consumer’s prescribing health care professional, to participate in the selection of an appropriate complex rehabilitation technology wheelchair for the needs and capacities of the consumer, and to provide training in the proper use of the complex rehabilitation technology wheelchair.
   c.  The entity has the capability to provide service and repairs, performed by trained technicians, for all complex rehabilitation technology wheelchairs sold by the qualified supplier.
   d.  At the time of delivery of a complex rehabilitation technology wheelchair to a consumer, the entity provides written information that explains how the consumer may receive service, repairs, and annual preventative maintenance for the complex rehabilitation technology wheelchair.
   13.  “Recipient” means a person who receives medical assistance under chapter 249A.
   14.  “Third-party payor” means health carriers and other entities that provide, administer, or perform prior authorization or claims processing for a plan of health insurance or health care benefits.
    Sec. 2.  NEW SECTION.  514M.2  Complex rehabilitation technology wheelchairs —— service and repairs.
   1.  Beginning January 1, 2025, a qualified complex rehabilitation technology wheelchair supplier that provides a complex rehabilitation technology wheelchair to a consumer shall be required to provide service and repairs of the complex rehabilitation technology wheelchair as requested by the consumer, or the consumer’s prescribing health care professional, in accordance with the consumer’s health carrier coverage and payment policies, except in the following circumstances:
   a.  The consumer moves out of the service area after receiving the complex rehabilitation technology wheelchair.
   b.  The consumer presents a safety risk to the qualified supplier.
   2.  A third-party payor shall not require any of the following in order for a qualified complex rehabilitation technology wheelchair supplier to provide service and repairs under this section:
   a.  Prior authorization.
   b.  Documentation of continued medical necessity by a health care professional.
   3.  Documentation of all service and repairs completed by a qualified complex rehabilitation technology wheelchair supplier under this section shall be maintained by the qualified supplier.
    Sec. 3.  NEW SECTION.  514M.3  Complex rehabilitation technology wheelchairs —— annual preventative maintenance.
   1.  Beginning July 1, 2025, a qualified complex rehabilitation technology wheelchair supplier that provides a complex rehabilitation technology wheelchair to a consumer may offer annual preventative maintenance on the complex rehabilitation technology wheelchair in accordance with manufacturer guidelines.
   2.  At a minimum, a third-party payor shall provide coverage and payment for complex rehabilitation technology wheelchair preventative maintenance services on an annual basis, including any labor, part, diagnostic evaluation, travel, or other related costs.
   3.  A third-party payor shall not require prior authorization or medical necessity documentation to cover the cost of preventative maintenance services for a consumer’s complex rehabilitation technology wheelchair.
   4.  Documentation of all preventative maintenance services performed by a qualified complex rehabilitation technology wheelchair supplier pursuant to this section shall be maintained by the qualified supplier.
   5.  All preventative maintenance shall be performed by a trained technician who is an employee of the qualified complex rehabilitation technology wheelchair supplier.
    Sec. 4.  NEW SECTION.  514M.4  Third-party payors —— applicability.
   1.  This chapter applies to the following classes of third-party payor contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2025:
   a.  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   b.  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   c.  An individual or group health maintenance organization contract regulated under chapter 514B.
   d.  A plan established for public employees pursuant to chapter 509A.
   e.  The medical assistance program under chapter 249A including all managed care organizations acting pursuant to a contract with the department of health and human services to administer the medical assistance program.
   2.  This chapter shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
    Sec. 5.  NEW SECTION.  514M.5  Task force —— reimbursement rates.
   1.  The division and the department shall form a task force whose members shall include the commissioner or the commissioner’s designee, the director or the director’s designee, two representatives from qualified complex rehabilitation technology wheelchair suppliers, two representatives from rehabilitation technology wheelchair manufacturers, two consumers or the consumers’ legal representatives, and two representatives from third-party payors. All members of the task force shall be reimbursed for all actual and necessary expenses incurred in the performance of duties as a member of the task force.
   2.  The task force shall annually review and determine all of the following:
   a.  The coverage and reimbursement of service and repairs under section 514M.2. The coverage and reimbursement shall include all related diagnostic and evaluation time, related labor, necessary parts, and reasonable travel time.
   b.  The reimbursement for preventative maintenance under section 514M.3. The reimbursement shall include all related diagnostic and evaluation time, related labor, necessary parts, and reasonable travel time.
   c.  The scope of the preventative maintenance required under section 514M.3.
    Sec. 6.  NEW SECTION.  514M.6  Rules.
   The division and the department shall adopt joint rules pursuant to chapter 17A as necessary to administer this chapter.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to insurance coverage for the maintenance and repair of complex rehabilitation technology wheelchairs.
   Beginning January 1, 2025, the bill requires a qualified complex rehabilitation technology wheelchair supplier (qualified supplier) that provides a complex rehabilitation technology wheelchair (wheelchair) to a consumer to provide service and repairs on the wheelchair as requested by the consumer, or the consumer’s prescribing health care professional, except in the circumstances detailed in the bill. “Qualified supplier”, “consumer”, and “complex rehabilitation technology wheelchair” are defined in the bill.
   The bill prohibits a third-party payor from requiring prior authorization or documentation of continued medical necessity in order for a qualified supplier to provide service and repairs under the bill. “Third-party payor” is defined in the bill.
   Documentation of all service and repairs completed by a qualified supplier under the bill shall be maintained by the qualified supplier.
   Beginning July 1, 2025, a qualified supplier that provides a wheelchair to a consumer may offer annual preventative maintenance (PM) on the wheelchair, in accordance with manufacturer guidelines. A third-party payor shall not require prior authorization or documentation of continued medical necessity in order for a qualified supplier to perform annual PM. Documentation of all PM shall be maintained by the qualified supplier.
   The bill applies to third-party payment providers enumerated in the bill, including the medical assistance program (program) under Code chapter 249A and managed care organizations acting pursuant to a contract with the department of health and human services (HHS) to administer the program. The bill specifies the types of specialized health-related insurance which are not subject to the bill.
   The bill requires the division of insurance (division) and HHS to form a task force made up of members as detailed in the bill. All members of the task force shall be reimbursed for all actual and necessary expenses incurred in the performance of duties as a member of the task force. The task force shall annually review and determine the coverage and reimbursement for service and repairs completed under the bill, and the rates shall include all related evaluation and diagnostic time, labor, necessary parts, and reasonable travel time.
   The division and HHS shall adopt joint rules as necessary to administer the bill.