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House File 243 - IntroducedA Bill ForAn Act 1relating to insurance coverage for covered individuals
2for the treatment of autism spectrum disorder.
3BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. Section 514C.22, subsection 3, paragraph g, Code
22023, is amended to read as follows:
3g. Autistic disorders Autism spectrum disorder, as that term
4is defined in section 514C.28, subsection 2.
5 Sec. 2. Section 514C.22, subsection 4, Code 2023, is amended
6to read as follows:
74. The commissioner, by rule, shall define the biologically
8based mental illnesses identified in subsection 3, paragraphs
9“a” through “f”. Definitions established by the commissioner
10shall be consistent with definitions provided in the most
11recent edition of the American psychiatric association’s
12diagnostic and statistical manual of mental disorders, as such
13definitions may be amended from time to time. The commissioner
14may adopt the definitions provided in such manual by reference.
15 Sec. 3. Section 514C.22, subsection 7, Code 2023, is amended
16by adding the following new paragraph:
17 NEW PARAGRAPH. c. Notwithstanding paragraphs “a” and “b”,
18a group policy, contract, or plan covered under this section
19shall not impose an aggregate annual or lifetime limit on
20biologically based mental illness coverage benefits for autism
21spectrum disorder.
22 Sec. 4. Section 514C.22, subsection 8, unnumbered paragraph
231, Code 2023, is amended to read as follows:
24A group policy, contract, or plan covered under this
25section shall at a minimum allow for thirty inpatient days
26and fifty-two outpatient visits annually, and shall not
27limit the number of outpatient visits a covered individual
28may have with a practitioner for applied behavior analysis
29under section 514C.31, or with an autism service provider for
30treatment of autism spectrum disorder under section 514C.28.
31The policy, contract, or plan may also include deductibles,
32coinsurance, or copayments, provided the amounts and extent
33of such deductibles, coinsurance, or copayments applicable to
34other health, medical, or surgical services coverage under the
35policy, contract, or plan are the same. It is not a violation
-1-1of this section if the policy, contract, or plan excludes
2entirely from coverage benefits for the cost of providing the
3following:
4 Sec. 5. Section 514C.22, subsection 9, Code 2023, is amended
5to read as follows:
69. This section applies to third-party payment provider
7policies or contracts and to plans established pursuant
8to chapter 509A that are delivered, issued for delivery,
9continued, or renewed in this state on or after January 1, 2006
10 2024.
11 Sec. 6. Section 514C.28, subsections 1, 3, 5, and 13, Code
122023, are amended to read as follows:
131. Notwithstanding the uniformity of treatment requirements
14of section 514C.6, a group plan established pursuant to chapter
15509A for employees of the state providing for third-party
16payment or prepayment of health, medical, and surgical coverage
17benefits shall provide coverage benefits to covered individuals
18under twenty-one years of age for the diagnostic assessment
19of autism spectrum disorder and for the treatment of autism
20spectrum disorder.
213. Coverage is required pursuant to this section in a
22maximum benefit amount of not more than thirty-six thousand
23dollars per year but shall not be subject to any limits on
24the number of visits to a covered individual may have with
25 an autism service provider for treatment of autism spectrum
26disorder. The commissioner shall, on or before April 1 of
27each calendar year, publish an adjustment to the maximum
28benefit required equal to the percentage change in the United
29States department of labor consumer price index for all urban
30consumers in the preceding year, and the published adjusted
31maximum benefit shall be applicable to group policies,
32contracts, or plans subject to this section that are issued
33or renewed on or after January 1 of the following calendar
34year. Payments made under a group plan subject to this section
35 on behalf of a covered individual for treatment of a health
-2-1condition unrelated to or distinguishable from the individual’s
2autism spectrum disorder shall not be applied toward any
3maximum benefit established under this subsection.
45. Coverage required by this section shall be provided
5in coordination with coverage required for the treatment of
6autistic disorders autism spectrum disorder pursuant to section
7514C.22.
813. This section applies to plans established pursuant to
9chapter 509A for employees of the state that are delivered,
10issued for delivery, continued, or renewed in this state on or
11after January 1, 2011 2024.
12 Sec. 7. Section 514C.31, subsection 1, unnumbered paragraph
131, Code 2023, is amended to read as follows:
14Notwithstanding the uniformity of treatment requirements of
15section 514C.6, a group policy, contract, or plan providing
16for third-party payment or prepayment of health, medical, and
17surgical coverage benefits shall provide coverage benefits for
18applied behavior analysis provided by a practitioner to covered
19individuals under nineteen years of age for the treatment of
20autism spectrum disorder pursuant to a treatment plan if the
21policy, contract, or plan is either of the following:
22 Sec. 8. Section 514C.31, subsection 3, Code 2023, is amended
23by striking the subsection.
24 Sec. 9. Section 514C.31, subsections 4, 5, and 10, Code
252023, are amended to read as follows:
264. Coverage required pursuant to this section may be
27subject to dollar limits, deductibles, copayments, or
28coinsurance provisions that apply to other medical and surgical
29services under the policy, contract, or plan, subject to the
30requirements of subsection 3.
315. Coverage required pursuant to this section may be
32subject to care management provisions of the applicable
33policy, contract, or plan, including prior authorization, and
34 prior approval, and limits on the number of visits a covered
35individual may make for applied behavior analysis.
-3- 110. This section applies to third-party provider payment
2contracts, policies, or plans specified in subsection 1,
3paragraph “a” or to plans established pursuant to chapter 509A
4for public employees other than employees of the state, that
5are delivered, issued for delivery, continued, or renewed in
6this state on or after January 1, 2018 2024.
7EXPLANATION
8The inclusion of this explanation does not constitute agreement with
9the explanation’s substance by the members of the general assembly.
10This bill relates to insurance coverage for covered
11individuals for the treatment of autism spectrum disorder
12(autism).
13Under current law, a group plan established pursuant to
14Code chapter 509A for employees of the state that provides
15for third-party payment or prepayment of health, medical, and
16surgical coverage benefits (coverage) shall provide coverage to
17covered individuals under 21 years of age for the diagnostic
18assessment and treatment of autism, and coverage is required
19in a maximum benefit amount of not more than $36,000 per year.
20The bill eliminates the 21-year maximum age limit and the
21maximum benefit amount.
22Under current law, a group policy, contract, or plan
23(policy) providing for third-party payment or prepayment
24of health, medical, and surgical coverage shall provide
25coverage for applied behavior analysis (analysis) provided
26by a practitioner to covered individuals under 19 years of
27age for the treatment of autism pursuant to a treatment plan
28if the policy is either a policy issued by a carrier to an
29employer who on at least 50 percent of the employer’s working
30days during the preceding calendar year employed more than 50
31full-time equivalent employees, or the policy is established
32pursuant to Code chapter 509A for public employees other than
33employees of the state. Under the bill, the age restriction
34is eliminated. Current law requires that the coverage for
35analysis shall provide an annual maximum benefit of not less
-4-1than $36,000 for individuals through age six, $25,000 for
2individuals age seven through 13, and $12,500 for individuals
3age 14 through 18. The bill eliminates the maximum benefit
4amounts and the age categories.
5The bill makes conforming changes to Code section 514C.22.
6The bill applies to third-party payment providers enumerated
7in the bill. The types of specialized health-related insurance
8which are not subject to the bill are specified in the bill.
9The bill applies to plans delivered, issued for delivery,
10continued, or renewed in this state on or after January 1,
112024.
-5-ko/rn
2for the treatment of autism spectrum disorder.
3BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. Section 514C.22, subsection 3, paragraph g, Code
22023, is amended to read as follows:
3g. Autistic disorders Autism spectrum disorder, as that term
4is defined in section 514C.28, subsection 2.
5 Sec. 2. Section 514C.22, subsection 4, Code 2023, is amended
6to read as follows:
74. The commissioner, by rule, shall define the biologically
8based mental illnesses identified in subsection 3, paragraphs
9“a” through “f”. Definitions established by the commissioner
10shall be consistent with definitions provided in the most
11recent edition of the American psychiatric association’s
12diagnostic and statistical manual of mental disorders, as such
13definitions may be amended from time to time. The commissioner
14may adopt the definitions provided in such manual by reference.
15 Sec. 3. Section 514C.22, subsection 7, Code 2023, is amended
16by adding the following new paragraph:
17 NEW PARAGRAPH. c. Notwithstanding paragraphs “a” and “b”,
18a group policy, contract, or plan covered under this section
19shall not impose an aggregate annual or lifetime limit on
20biologically based mental illness coverage benefits for autism
21spectrum disorder.
22 Sec. 4. Section 514C.22, subsection 8, unnumbered paragraph
231, Code 2023, is amended to read as follows:
24A group policy, contract, or plan covered under this
25section shall at a minimum allow for thirty inpatient days
26and fifty-two outpatient visits annually, and shall not
27limit the number of outpatient visits a covered individual
28may have with a practitioner for applied behavior analysis
29under section 514C.31, or with an autism service provider for
30treatment of autism spectrum disorder under section 514C.28.
31The policy, contract, or plan may also include deductibles,
32coinsurance, or copayments, provided the amounts and extent
33of such deductibles, coinsurance, or copayments applicable to
34other health, medical, or surgical services coverage under the
35policy, contract, or plan are the same. It is not a violation
-1-1of this section if the policy, contract, or plan excludes
2entirely from coverage benefits for the cost of providing the
3following:
4 Sec. 5. Section 514C.22, subsection 9, Code 2023, is amended
5to read as follows:
69. This section applies to third-party payment provider
7policies or contracts and to plans established pursuant
8to chapter 509A that are delivered, issued for delivery,
9continued, or renewed in this state on or after January 1, 2006
10 2024.
11 Sec. 6. Section 514C.28, subsections 1, 3, 5, and 13, Code
122023, are amended to read as follows:
131. Notwithstanding the uniformity of treatment requirements
14of section 514C.6, a group plan established pursuant to chapter
15509A for employees of the state providing for third-party
16payment or prepayment of health, medical, and surgical coverage
17benefits shall provide coverage benefits to covered individuals
18under twenty-one years of age for the diagnostic assessment
19of autism spectrum disorder and for the treatment of autism
20spectrum disorder.
213. Coverage is required pursuant to this section in a
22maximum benefit amount of not more than thirty-six thousand
23dollars per year but shall not be subject to any limits on
24the number of visits to a covered individual may have with
25 an autism service provider for treatment of autism spectrum
26disorder. The commissioner shall, on or before April 1 of
27each calendar year, publish an adjustment to the maximum
28benefit required equal to the percentage change in the United
29States department of labor consumer price index for all urban
30consumers in the preceding year, and the published adjusted
31maximum benefit shall be applicable to group policies,
32contracts, or plans subject to this section that are issued
33or renewed on or after January 1 of the following calendar
34year. Payments made under a group plan subject to this section
35 on behalf of a covered individual for treatment of a health
-2-1condition unrelated to or distinguishable from the individual’s
2autism spectrum disorder shall not be applied toward any
3maximum benefit established under this subsection.
45. Coverage required by this section shall be provided
5in coordination with coverage required for the treatment of
6autistic disorders autism spectrum disorder pursuant to section
7514C.22.
813. This section applies to plans established pursuant to
9chapter 509A for employees of the state that are delivered,
10issued for delivery, continued, or renewed in this state on or
11after January 1, 2011 2024.
12 Sec. 7. Section 514C.31, subsection 1, unnumbered paragraph
131, Code 2023, is amended to read as follows:
14Notwithstanding the uniformity of treatment requirements of
15section 514C.6, a group policy, contract, or plan providing
16for third-party payment or prepayment of health, medical, and
17surgical coverage benefits shall provide coverage benefits for
18applied behavior analysis provided by a practitioner to covered
19individuals under nineteen years of age for the treatment of
20autism spectrum disorder pursuant to a treatment plan if the
21policy, contract, or plan is either of the following:
22 Sec. 8. Section 514C.31, subsection 3, Code 2023, is amended
23by striking the subsection.
24 Sec. 9. Section 514C.31, subsections 4, 5, and 10, Code
252023, are amended to read as follows:
264. Coverage required pursuant to this section may be
27subject to dollar limits, deductibles, copayments, or
28coinsurance provisions that apply to other medical and surgical
29services under the policy, contract, or plan, subject to the
30requirements of subsection 3.
315. Coverage required pursuant to this section may be
32subject to care management provisions of the applicable
33policy, contract, or plan, including prior authorization, and
34 prior approval, and limits on the number of visits a covered
35individual may make for applied behavior analysis.
-3- 110. This section applies to third-party provider payment
2contracts, policies, or plans specified in subsection 1,
3paragraph “a” or to plans established pursuant to chapter 509A
4for public employees other than employees of the state, that
5are delivered, issued for delivery, continued, or renewed in
6this state on or after January 1, 2018 2024.
7EXPLANATION
8The inclusion of this explanation does not constitute agreement with
9the explanation’s substance by the members of the general assembly.
10This bill relates to insurance coverage for covered
11individuals for the treatment of autism spectrum disorder
12(autism).
13Under current law, a group plan established pursuant to
14Code chapter 509A for employees of the state that provides
15for third-party payment or prepayment of health, medical, and
16surgical coverage benefits (coverage) shall provide coverage to
17covered individuals under 21 years of age for the diagnostic
18assessment and treatment of autism, and coverage is required
19in a maximum benefit amount of not more than $36,000 per year.
20The bill eliminates the 21-year maximum age limit and the
21maximum benefit amount.
22Under current law, a group policy, contract, or plan
23(policy) providing for third-party payment or prepayment
24of health, medical, and surgical coverage shall provide
25coverage for applied behavior analysis (analysis) provided
26by a practitioner to covered individuals under 19 years of
27age for the treatment of autism pursuant to a treatment plan
28if the policy is either a policy issued by a carrier to an
29employer who on at least 50 percent of the employer’s working
30days during the preceding calendar year employed more than 50
31full-time equivalent employees, or the policy is established
32pursuant to Code chapter 509A for public employees other than
33employees of the state. Under the bill, the age restriction
34is eliminated. Current law requires that the coverage for
35analysis shall provide an annual maximum benefit of not less
-4-1than $36,000 for individuals through age six, $25,000 for
2individuals age seven through 13, and $12,500 for individuals
3age 14 through 18. The bill eliminates the maximum benefit
4amounts and the age categories.
5The bill makes conforming changes to Code section 514C.22.
6The bill applies to third-party payment providers enumerated
7in the bill. The types of specialized health-related insurance
8which are not subject to the bill are specified in the bill.
9The bill applies to plans delivered, issued for delivery,
10continued, or renewed in this state on or after January 1,
112024.
-5-ko/rn