SF 2204 (LSB 5000SV (2) 86)

SENATE FILE 2204

BY  COMMITTEE ON COMMERCE

(SUCCESSOR TO SF 2019)

(As Amended and Passed by the Senate 2016-03-08)

A BILL FOR

An Act relating to insurance coverage for the assessment and treatment of eating disorders and including applicability date provisions.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.31  Eating disorders —— coverage.
   1.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall provide coverage benefits for the diagnostic assessment and treatment of eating disorders.
   2.  As used in this section, unless the context otherwise requires:
   a.  “Diagnostic assessment of eating disorders” means medically necessary assessments, evaluations, or tests performed by a physician or psychiatrist licensed pursuant to chapter 148, a psychologist licensed pursuant to chapter 154B, an advanced registered nurse practitioner licensed pursuant to chapter 152 or 152E, a dietician licensed pursuant to chapter 152A, a social worker licensed pursuant to chapter 154C, or a mental health counselor or marital and family therapist licensed pursuant to chapter 154D, to diagnose whether an individual has an eating disorder.
   b.  “Eating disorders” means pica, rumination disorder, avoidant or restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, or any other eating disorder not otherwise specified. The commissioner, by rule, shall define “eating disorders” 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.
   c.  “Pharmacy care” means medications prescribed by a licensed physician or psychiatrist and includes any health-related services deemed medically necessary to determine the need for or effectiveness of the medications prescribed, but only to the extent that coverage of such medications is included in the insured’s health coverage benefits.
   d.  “Psychiatric care” or “psychological care” means direct or consultative services provided during inpatient hospitalization, partial hospitalization, residential care, intensive outpatient treatment, follow-up outpatient care, or counseling, provided by a licensed psychiatrist or psychologist.
   e.  “Therapeutic care” means medical care or behavioral interventions provided by a licensed physician, psychiatrist, psychologist, advanced registered nurse practitioner, dietician, social worker, mental health counselor, or marital and family therapist.
   f.  “Treatment of eating disorders” means treatment that is identified in a treatment plan and includes medically necessary pharmacy care, psychiatric or psychological care, or therapeutic care, that is provided by a licensed physician, psychiatrist, psychologist, advanced registered nurse practitioner, dietician, social worker, mental health counselor, or marital and family therapist.
   g.  “Treatment plan” means a plan for the treatment of eating disorders developed by a licensed physician, psychiatrist, psychologist, advanced registered nurse practitioner, dietician, social worker, mental health counselor, or marital and family therapist that includes all of the following:
   (1)  A diagnosis.
   (2)  Proposed treatment by type, frequency, and duration of treatment.
   (3)  Goals.
   (4)  All elements necessary for the third-party payment or prepayment of claims.
   3.  Coverage required by this section is limited to medically necessary diagnostic assessment and treatment of eating disorders in accordance with a treatment plan, that is provided by a licensed physician, psychiatrist, psychologist, advanced registered nurse practitioner, dietician, social worker, mental health counselor, or marital and family therapist acting pursuant to that person’s applicable scope of practice.
   4.  Coverage required pursuant to this section shall be subject to copayment, deductible, and coinsurance provisions, and any other general exclusions or limitations of a policy, contract, or plan to the same extent as other health or medical services covered by the policy, contract, or plan.
   5.  This section shall not be construed to limit benefits which are otherwise available to an individual under a policy, contract, or plan.
   6.  a.  Coverage of the diagnosis and treatment of eating disorders may be subject to other general exclusions and limitations of the policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses not in conflict with the provisions of this section, such as coordination of benefits, and utilization of health care services, which include reviews of medical necessity and care management.
   b.  Medical necessity determinations and care management for the treatment of eating disorders shall do all of the following:
   (1)  Consider the overall medical and mental health needs of the individual diagnosed with an eating disorder.
   (2)  Not be based solely on the weight of the individual diagnosed with an eating disorder.
   (3)  Take into consideration the most recent practice guideline for the treatment of patients with eating disorders adopted by the American psychiatric association in addition to current standards based upon the medical literature generally recognized as authoritative in the medical community.
   7.  The commissioner shall adopt rules pursuant to chapter 17A to implement and administer this section.
   8.  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.
   9.  This section applies to the following classes of third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2017:
   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.  Any other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.
   e.  A plan established pursuant to chapter 509A for public employees.
   f.  An organized delivery system licensed by the director of public health.