SF 400 (LSB 1738SV (2) 87)

SENATE FILE 400

BY  COMMITTEE ON COMMERCE

(SUCCESSOR TO SSB 1043)

A BILL FOR

An Act requiring certain health insurance policies, contracts, or plans to provide coverage of applied behavior analysis for treatment of autism spectrum disorder for certain individuals, and including applicability and effective date provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  Section 225D.1, subsection 8, Code 2017, is amended to read as follows:
   8.  “Eligible individual” means a child less than fourteen years of age who has been diagnosed with autism based on a diagnostic assessment of autism, is not otherwise eligible for coverage for applied behavioral analysis treatment or applied behavior analysis treatment under the medical assistance program, section 514C.28, 514C.31, or other private insurance coverage, and whose household income does not exceed five hundred percent of the federal poverty level.
    Sec. 2.  Section 225D.2, subsection 2, paragraph l, Code 2017, is amended to read as follows:
   l.  Proof of eligibility for the autism support program that includes a written denial for coverage or a benefits summary indicating that applied behavioral analysis treatment or applied behavior analysis treatment is not a covered benefit for which the applicant is eligible, under the Medicaid program, section 514C.28, 514C.31, or other private insurance coverage.
    Sec. 3.  Section 225D.2, subsection 3, Code 2017, is amended to read as follows:
   3.  Moneys in the autism support fund created under subsection 5 shall be expended only for eligible individuals who are not eligible for coverage for applied behavioral analysis treatment or applied behavior analysis treatment under the medical assistance program, section 514C.28, 514C.31, or other private insurance. Payment for applied behavioral analysis treatment through the fund shall be limited to only applied behavioral analysis treatment that is clinically relevant and only to the extent approved under the guidelines established by rule of the department.
    Sec. 4.  NEW SECTION.  514C.31  Applied behavior analysis for treatment of autism spectrum disorder —— coverage.
   1.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a group policy, contract, or plan providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide coverage benefits for applied behavior analysis provided by a practitioner to covered individuals under nineteen years of age for the treatment of autism spectrum disorder pursuant to a treatment plan if the policy, contract, or plan is either of the following:
   a.  A policy, contract, or plan issued by a carrier, as defined in section 513B.2, or an organized delivery system authorized under 1993 Iowa Acts, chapter 158, to an employer who on at least fifty percent of the employer’s working days during the preceding calendar year employed more than fifty full-time equivalent employees. In determining the number of full-time equivalent employees of an employer, employers who are affiliated or who are able to file a consolidated tax return for purposes of state taxation shall be considered one employer.
   b.  A plan established pursuant to chapter 509A for public employees other than employees of the state.
   2.  As used in this section, unless the context otherwise requires:
   a.  “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.
   b.  “Autism spectrum disorder” means a complex neurodevelopmental medical disorder characterized by social impairment, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior.
   c.  “Practitioner” means any of the following:
   (1)  A physician licensed pursuant to chapter 148.
   (2)  A psychologist licensed pursuant to chapter 154B.
   (3)  A person who holds a master’s degree or a doctoral degree and is certified by a national behavior analyst certification board as a behavior analyst.
   d.  “Treatment plan” means a plan for the treatment of an autism spectrum disorder developed by a licensed physician or licensed psychologist after a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendations of the American academy of pediatrics. “Treatment plan” includes supervisory services, subject to the provisions of subsection 5.
   3.  a.  The coverage for applied behavior analysis required pursuant to this section shall provide an annual maximum benefit of not less than the following:
   (1)  For an individual through age six, thirty-six thousand dollars per year.
   (2)  For an individual age seven through age thirteen, twenty-five thousand dollars per year.
   (3)  For an individual age fourteen through age eighteen, twelve thousand five hundred dollars per year.
   b.  Payments made under a group policy, contract, or plan subject to this section on behalf of a covered individual for any treatment other than applied behavior analysis shall not be applied toward the maximum benefit established under this subsection.
   4.  Coverage required pursuant to this section may be subject to dollar limits, deductibles, copayments, or coinsurance provisions that apply to other medical and surgical services under the policy, contract, or plan, subject to the requirements of subsection 3.
   5.  Coverage required pursuant to this section may be subject to care management provisions of the applicable policy, contract, or plan, including prior authorization, prior approval, and limits on the number of visits a covered individual may make for applied behavior analysis.
   6.  A carrier, organized delivery system, or plan may request a review of a treatment plan for a covered individual not more than once every three months during the first year of the treatment plan and not more than once every six months during every year thereafter, unless the carrier, organized delivery system, or plan and the covered individual’s treating physician or psychologist execute an agreement that a more frequent review is necessary. An agreement giving a carrier, organized delivery system, or plan the right to review the treatment plan of a covered individual more frequently applies only to a particular covered individual receiving applied behavior analysis and does not apply to other individuals receiving applied behavior analysis from a practitioner. The cost of conducting a review under this section shall be paid by the carrier, organized delivery system, or plan. A carrier, organized delivery system, or plan shall not change the provisions of a treatment plan until the completion of a review of the treatment plan.
   7.  This section shall not be construed to limit benefits which are otherwise available to an individual under a group policy, contract, or plan.
   8.  This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.
   9.  This section 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, or individual accident and sickness policies issued to individuals or to individual members of a member association.
   10.  This section applies to third-party provider payment contracts, policies, or plans specified in subsection 1, paragraph “a” or to plans established pursuant to chapter 509A for public employees other than employees of the state, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2018.
    Sec. 5.  EFFECTIVE DATE.  The following provisions of this Act take effect January 1, 2018:
   1.  The sections of this Act amending sections 225D.1 and 225D.2.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill creates new Code section 514C.31, which requires certain individual and group health insurance policies, contracts, or plans and plans established pursuant to Code chapter 509A for public employees other than employees of the state to provide coverage benefits for applied behavior analysis for the treatment of autism spectrum disorder. 
   “Autism spectrum disorder” means a complex neurodevelopmental medical disorder characterized by social impairment, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior.
   The bill requires coverage for applied behavior analysis that is provided by a board-certified behavior analyst or by a licensed physician or psychologist. The required maximum benefit for coverage for applied behavior analysis for an individual diagnosed with an autism spectrum disorder is $36,000 per year through age 6, $25,000 per year from age 7 through age 13, and $12,500 per year from age 14 through age 18.
   Required coverage can be subject to preauthorization, prior approval, or other care management requirements, including limits on the number of visits an individual may make for applied behavior analysis.
   Required coverage can be subject to dollar limits, deductibles, copayments, or coinsurance provisions, or any other general exclusions or limitations of the coverage that apply to other covered medical or surgical services.
   The new Code section shall not be construed to limit benefits otherwise available to an individual under a group policy, contract, or plan.
   The new Code section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, education program, or service plan.
   A carrier, organized delivery system, or plan may request to review a treatment plan not more than once every three months during the first year of the treatment plan and not more than once every six months during every year thereafter, unless the carrier, organized delivery system, or plan and the individual’s treating physician or psychologist execute an agreement that more frequent review is necessary. Such an agreement applies only to that individual and does not apply to other individuals receiving applied behavior analysis from a board-certified behavior analyst, a physician, or a psychologist. The cost of conducting the review of a treatment plan is to be borne by the carrier, organized delivery system, or plan. A carrier, organized delivery system, or plan shall not change the provisions of a treatment plan until the completion of a review of the plan.
   The new Code section does not apply to various specified types of insurance.
   New Code section 514C.31 applies to third-party provider payment contracts, policies, or plans specified in the bill, or plans established pursuant to Code chapter 509A for public employees other than employees of the state, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2018.
   Coordinating changes are made in Code sections 225D.1 and 225D.2 to provide that persons who are eligible for coverage of applied behavior analysis treatment under new Code section 514C.31 are not eligible to participate in the state autism support program. These changes also take effect January 1, 2018.