SF 2128 (LSB 5713XS (6) 84)

SENATE FILE 2128

BY  BEALL, MATHIS, WILHELM, QUIRMBACH, SCHOENJAHN, SENG, BERTRAND, BOLKCOM, DVORSKY, DOTZLER, DANIELSON, HATCH, HORN, DEARDEN, FRAISE, SODDERS, KIBBIE, BLACK, JOCHUM, RAGAN, and ANDERSON

(As Amended and Passed by the Senate 2012-03-13)

A BILL FOR

An Act requiring certain group health insurance policies, contracts, or plans to provide coverage for autism spectrum disorders for certain persons, providing for a repeal, and including applicability and effective date provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.29  Autism spectrum disorders 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 to covered individuals under twenty-six years of age for the screening, diagnosis, and treatment of autism spectrum disorders 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.
   b.  A plan established pursuant to chapter 509A for public employees.
   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 or to prevent loss of attained skill or function, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
   b.  “Autism service provider” means a person, group, or entity that provides treatment for autism spectrum disorders.
   c.  “Autism spectrum disorder” means any of the pervasive developmental disorders including autistic disorder, Asperger’s disorder, and pervasive developmental disorders not otherwise specified. The commissioner, by rule, shall define “autism spectrum disorder” consistent with definitions provided in the most recent edition of the American psychiatric association’s diagnostic and statistical manual of mental disorders, as such definitions may be amended from time to time. The commissioner may adopt the definitions provided in such manual by reference.

   d.  “Behavioral health treatment” means counseling and treatment programs, including applied behavior analysis, that meet the following requirements:
   (1)  Are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.
   (2)  Are provided by an applied behavior analysis direct service provider under the supervision of an assistant behavior analyst certified by a nationally recognized board, with overall clinical direction by a behavior analyst certified by a nationally recognized board, or by a licensed psychologist, so long as the services are performed commensurate with the psychologist’s formal training and supervised experience.
   e.  “Diagnosis of autism spectrum disorder” means the use of medically necessary assessments, evaluations, or tests performed by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder.
   f.  “Pharmacy care” means medications prescribed by a licensed physician and any assessment, evaluation, or test prescribed or ordered by a licensed physician to determine the need for or effectiveness of such medications.
   g.  “Psychiatric care” means direct or consultative services provided by a licensed physician who specializes in psychiatry.
   h.  “Psychological care” means direct or consultative services provided by a licensed psychologist.
   i.  “Rehabilitative care” means professional services and treatment programs, including applied behavior analysis, that are provided by an autism service provider to produce socially significant improvements in human behavior or to prevent loss of attained skills or functions.
   j.  “Therapeutic care” means services provided by a licensed speech pathologist, licensed occupational therapist, or licensed physical therapist.
   k.  “Treatment for autism spectrum disorder” means treatment that is identified in a treatment plan as prescribed by a licensed physician or a licensed psychologist and includes medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care, and therapeutic care that is provided by one of the following:
   (1)  A mental health professional as defined in section 228.1.
   (2)  An autism service provider.
   l.  “Treatment plan” means a plan for the treatment of an autism spectrum disorder developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendations of the American academy of pediatrics or the American academy of child and adolescent psychiatry, as determined by the commissioner by rule.
   3.  Coverage for applied behavior analysis is required pursuant to this section for a maximum benefit amount of thirty-six thousand dollars per year. Beginning in 2014, the commissioner shall, on or before April 1 of each calendar year, publish an adjustment for inflation to the maximum benefit required equal to the percentage change in the medical care component of the United States department of labor consumer price index for all urban consumers in the preceding year, and the published adjusted maximum benefit shall be applicable to group policies, contracts, or plans subject to this section that are delivered, issued for delivery, continued, or renewed on or after January 1 of the following calendar year. 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 shall not be subject to any limits on the number of visits an individual may make for treatment of an autism spectrum disorder.
   5.  Coverage required pursuant to this section shall not be subject to dollar limits, deductibles, copayments, or coinsurance provisions, or any other general exclusions or limitations of a group plan that are less favorable to an insured than the dollar limits, deductibles, copayments, or coinsurance provisions that apply to physical illness generally under the policy, contract, or plan, except as provided in subsection 3.
   6.  Coverage required by this section shall be provided in coordination with coverage required for the treatment of autistic disorders pursuant to section 514C.22.
   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 to require coverage by a group policy, contract, or plan of any service solely based on inclusion of the service in an individualized education program. Consistent with federal or state law and upon consent of the parent or guardian of a covered individual, the treatment of autism spectrum disorders may be coordinated with any services included in an individualized education program. However, coverage for the treatment of autism spectrum disorders shall not be contingent upon coordination of services with an individualized education program.
   9.  Except for inpatient services, if an insured is receiving treatment for an autism spectrum disorder, an insurer is entitled to review the treatment plan annually, unless the insurer and the insured’s treating physician or psychologist agree that a more frequent review is necessary. An agreement giving an insurer the right to review the treatment plan of an insured more frequently applies only to that insured and does not apply to other individuals being treated for autism spectrum disorders by a physician or psychologist. The cost of conducting a review of a treatment plan shall be borne by the insurer.
   10.  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.
   11.  The commissioner shall adopt rules pursuant to chapter 17A to implement and administer this section.
   12.  An insurer shall not terminate coverage of an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder.
   13.  This section applies to third-party payment provider policies, contracts, or plans, and to plans established pursuant to chapter 509A, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2013. 
    Sec. 2.  REPEAL.  Section 514C.28, Code 2011, is repealed.
    Sec. 3.  EFFECTIVE DATE.  The following provision of this Act takes effect January 1, 2013:
   1.  The section of this Act repealing section 514C.28.