Bill would require coverage for brain injury and dementia care

Health plans would cover medically necessary treatment related to or resulting from an acquired brain injury. This covers individual and group health policies and subscriber contracts, hospital, medical, or surgical expense policies, and self-funded employee plans where federal law allows. An acquired brain injury is an injury that happens after birth. The policy must be delivered, issued, or renewed in Nebraska. Specified-disease and other limited-benefit policies are excluded, and self-funded plans are covered only where federal law does not preempt the rule. Lifetime and yearly limits cannot conflict with accepted medical-necessity standards or brain-injury rehabilitation guidelines. Patient cost sharing cannot be greater than for other benefits under a comprehensive health policy. Coverage would be required no later than January 1, 2027.

The Nebraska Department of Insurance would set up a fast appeal process for denied brain-injury services and report on coverage decisions and appeals. The appeal process and annual online report concern denials of acquired brain-injury services covered by the bill. The department would have to resolve an expedited appeal within five business days after it is filed. Coverage for ongoing rehabilitation would continue until the appeal is resolved if the treating clinician determines that stopping it risks regression. The department would publish a report each year on coverage decisions, denials, and appeals.

Health plans and Nebraska’s medical assistance program would cover medically necessary testing and FDA-approved treatment or medication prescribed to slow Alzheimer’s disease or related dementia. The health-plan rule covers individual and group policies and subscriber contracts, hospital, medical, or surgical expense policies, and self-funded employee plans where federal law allows. The separate rule applies to the state medical assistance program. The health-plan rule excludes specified-disease and other limited-benefit policies; it covers self-funded plans only where federal law does not preempt it. Covered treatment and medication would not be subject to step therapy, which means patients would not have to try a different treatment first. Both coverage requirements would apply no later than January 1, 2028.