House File 2460 H-8229 Amend House File 2460 as follows: 1 1. Page 112, after line 5 by inserting: 2 < DIVISION ___ 3 AUTISM SPECTRUM DISORDERS COVERAGE 4 Sec. ___. Section 225D.1, subsection 8, Code 5 2016, as otherwise amended by this Act, if enacted, is 6 amended to read as follows: 7 8. “Eligible individual” means a child less than 8 fourteen years of age who has been diagnosed with 9 autism based on a diagnostic assessment of autism, 10 is not otherwise eligible for coverage for applied 11 behavioral analysis treatment under the medical 12 assistance program, section 514C.28 514C.31 , or other 13 private insurance coverage, and whose household income 14 does not exceed five hundred percent of the federal 15 poverty level. 16 Sec. ___. Section 225D.2, subsection 2, paragraph 17 l, Code 2016, is amended to read as follows: 18 l. Proof of eligibility for the autism support 19 program that includes a written denial for coverage or 20 a benefits summary indicating that applied behavioral 21 analysis treatment is not a covered benefit for which 22 the applicant is eligible, under the Medicaid program, 23 section 514C.28 514C.31 , or other private insurance 24 coverage. 25 Sec. ___. Section 225D.2, subsection 3, Code 2016, 26 is amended to read as follows: 27 3. Moneys in the autism support fund created under 28 subsection 5 shall be expended only for eligible 29 individuals who are not eligible for coverage for 30 applied behavioral analysis treatment under the medical 31 assistance program, section 514C.28 514C.31 , or other 32 private insurance. Payment for applied behavioral 33 analysis treatment through the fund shall be limited 34 to only applied behavioral analysis treatment that is 35 -1- HF2460.3512 (1) 86 pf/rn 1/ 8 #1.

clinically relevant and only to the extent approved 1 under the guidelines established by rule of the 2 department. 3 Sec. ___. NEW SECTION . 514C.31 Autism spectrum 4 disorders coverage. 5 1. Notwithstanding the uniformity of treatment 6 requirements of section 514C.6, a group policy, 7 contract, or plan providing for third-party payment or 8 prepayment of health, medical, and surgical coverage 9 benefits shall provide coverage benefits to covered 10 individuals under twenty-two years of age for the 11 screening, diagnosis, and treatment of autism spectrum 12 disorders if the policy, contract, or plan is either 13 of the following: 14 a. A policy, contract, or plan issued by a carrier, 15 as defined in section 513B.2, or an organized delivery 16 system authorized under 1993 Iowa Acts, chapter 158, 17 to an employer who on at least fifty percent of the 18 employer’s working days during the preceding calendar 19 year employed more than fifty full-time equivalent 20 employees. In determining the number of full-time 21 equivalent employees of an employer, employers who 22 are affiliated or who are able to file a consolidated 23 tax return for purposes of state taxation shall be 24 considered one employer. 25 b. A plan established pursuant to chapter 509A for 26 public employees. 27 2. As used in this section, unless the context 28 otherwise requires: 29 a. “Applied behavior analysis” means the design, 30 implementation, and evaluation of environmental 31 modifications, using behavioral stimuli and 32 consequences, to produce socially significant 33 improvement in human behavior or to prevent loss of 34 attained skill or function, including the use of direct 35 -2- HF2460.3512 (1) 86 pf/rn 2/ 8

observation, measurement, and functional analysis of 1 the relations between environment and behavior. 2 b. “Autism spectrum disorder” means any of 3 the pervasive developmental disorders including 4 autistic disorder, Asperger’s disorder, and pervasive 5 developmental disorders not otherwise specified. The 6 commissioner, by rule, shall define “autism spectrum 7 disorder” consistent with definitions provided in 8 the most recent edition of the American psychiatric 9 association’s diagnostic and statistical manual of 10 mental disorders, as such definitions may be amended 11 from time to time. The commissioner may adopt the 12 definitions provided in such manual by reference. 13 c. “Behavioral health treatment” means counseling 14 and treatment programs, including applied behavior 15 analysis, that meet the following requirements: 16 (1) Are necessary to develop, maintain, or restore, 17 to the maximum extent practicable, the functioning of 18 an individual. 19 (2) Are provided or supervised by a behavior 20 analyst certified by a nationally recognized board, or 21 by a licensed psychologist, so long as the services are 22 performed commensurate with the psychologist’s formal 23 training and supervised experience. 24 d. “Diagnosis of autism spectrum disorder” means the 25 use of medically necessary assessments, evaluations, or 26 tests to diagnose whether an individual has an autism 27 spectrum disorder. 28 e. “Pharmacy care” means medications prescribed by 29 a licensed physician and any assessment, evaluation, 30 or test prescribed or ordered by a licensed physician 31 to determine the need for or effectiveness of such 32 medications. 33 f. “Psychiatric care” means direct or consultative 34 services provided by a licensed physician who 35 -3- HF2460.3512 (1) 86 pf/rn 3/ 8

specializes in psychiatry. 1 g. “Psychological care” means direct or consultative 2 services provided by a licensed psychologist. 3 h. “Therapeutic care” means services provided by 4 a licensed speech pathologist, licensed occupational 5 therapist, or licensed physical therapist. 6 i. “Treatment for autism spectrum disorder” means 7 evidence-based care and related equipment prescribed 8 or ordered for an individual diagnosed with an autism 9 spectrum disorder by a licensed physician or a licensed 10 psychologist who determines that the treatment is 11 medically necessary, including but not limited to the 12 following: 13 (1) Behavioral health treatment. 14 (2) Pharmacy care. 15 (3) Psychiatric care. 16 (4) Psychological care. 17 (5) Therapeutic care. 18 j. “Treatment plan” means a plan for the treatment 19 of an autism spectrum disorder developed by a licensed 20 physician or licensed psychologist pursuant to a 21 comprehensive evaluation or reevaluation performed 22 in a manner consistent with the most recent clinical 23 report or recommendations of the American academy of 24 pediatrics, as determined by the commissioner by rule. 25 3. Coverage for applied behavior analysis is 26 required pursuant to this section for a maximum 27 benefit amount of thirty-six thousand dollars per year. 28 Beginning in 2020, the commissioner shall, on or before 29 July 1 of each calendar year, publish an adjustment for 30 inflation to the maximum benefit required equal to the 31 percentage change in the medical care component of the 32 United States department of labor consumer price index 33 for all urban consumers in the preceding year, and the 34 published adjusted maximum benefit shall be applicable 35 -4- HF2460.3512 (1) 86 pf/rn 4/ 8

to group policies, contracts, or plans subject to 1 this section that are delivered, issued for delivery, 2 continued, or renewed on or after January 1 of the 3 following calendar year. Payments made under a group 4 policy, contract, or plan subject to this section on 5 behalf of a covered individual for any treatment other 6 than applied behavior analysis shall not be applied 7 toward the maximum benefit established under this 8 subsection. 9 4. Coverage for applied behavior analysis shall 10 include the services of persons working under the 11 supervision of a behavior analyst certified by a 12 nationally recognized board or under the supervision of 13 a licensed psychologist, to provide applied behavior 14 analysis. 15 5. Coverage required pursuant to this section shall 16 not be subject to any limits on the number of visits an 17 individual may make for treatment of an autism spectrum 18 disorder. 19 6. Coverage required pursuant to this section 20 shall not be subject to dollar limits, deductibles, 21 copayments, or coinsurance provisions, or any other 22 general exclusions or limitations of a group plan 23 that are less favorable to an insured than the dollar 24 limits, deductibles, copayments, or coinsurance 25 provisions that apply to substantially all medical and 26 surgical benefits under the policy, contract, or plan, 27 except as provided in subsection 3. 28 7. Coverage required by this section shall be 29 provided in coordination with coverage required for the 30 treatment of autistic disorders pursuant to section 31 514C.22. 32 8. This section shall not be construed to limit 33 benefits which are otherwise available to an individual 34 under a group policy, contract, or plan. 35 -5- HF2460.3512 (1) 86 pf/rn 5/ 8

9. This section shall not be construed as affecting 1 any obligation to provide services to an individual 2 under an individualized family service plan, an 3 individualized education program, or an individualized 4 service plan. 5 10. Except for inpatient services, if an insured is 6 receiving treatment for an autism spectrum disorder, 7 an insurer is entitled to review the treatment plan 8 annually, unless the insurer and the insured’s treating 9 physician or psychologist agree that a more frequent 10 review is necessary. An agreement giving an insurer 11 the right to review the treatment plan of an insured 12 more frequently applies only to that insured and does 13 not apply to other individuals being treated for autism 14 spectrum disorders by a physician or psychologist. The 15 cost of conducting a review of a treatment plan shall 16 be borne by the insurer. 17 11. This section shall not apply to accident-only, 18 specified disease, short-term hospital or medical, 19 hospital confinement indemnity, credit, dental, vision, 20 Medicare supplement, long-term care, basic hospital 21 and medical-surgical expense coverage as defined 22 by the commissioner, disability income insurance 23 coverage, coverage issued as a supplement to liability 24 insurance, workers’ compensation or similar insurance, 25 or automobile medical payment insurance, or individual 26 accident and sickness policies issued to individuals or 27 to individual members of a member association. 28 12. The commissioner shall adopt rules pursuant to 29 chapter 17A to implement and administer this section. 30 13. An insurer shall not terminate coverage of an 31 individual solely because the individual is diagnosed 32 with or has received treatment for an autism spectrum 33 disorder. 34 14. a. By February 1, 2018, and every February 1 35 -6- HF2460.3512 (1) 86 pf/rn 6/ 8

thereafter, the commissioner shall submit a report to 1 the general assembly regarding implementation of the 2 coverage required under this section. The report shall 3 include information concerning but not limited to all 4 of the following: 5 (1) The total number of insureds diagnosed with 6 autism spectrum disorder in the immediately preceding 7 calendar year. 8 (2) The total cost of all claims paid out in the 9 immediately preceding calendar year for coverage 10 required under this section. 11 (3) The cost of such coverage per insured per 12 month. 13 (4) The average cost per insured per month for 14 coverage of applied behavior analysis required under 15 this section. 16 b. All third-party payment provider policies, 17 contracts, or plans, as specified in subsection 1, 18 and plans established pursuant to chapter 509A shall 19 provide the commissioner with data requested by the 20 commissioner for inclusion in the annual report. 21 15. If any provision of this section or its 22 application to any person or circumstance is held 23 invalid, the invalidity does not affect other 24 provisions or application of this section which can 25 be given effect without the invalid provision or 26 application, and to this end the provisions of this 27 section are severable. 28 16. This section applies to third-party payment 29 provider policies, contracts, or plans, as specified 30 in subsection 1, and to plans established pursuant to 31 chapter 509A, that are delivered, issued for delivery, 32 continued, or renewed in this state on or after January 33 1, 2017. 34 Sec. ___. REPEAL. Section 514C.28, Code 2016, is 35 -7- HF2460.3512 (1) 86 pf/rn 7/ 8

repealed. 1 Sec. ___. EFFECTIVE DATE. The following provisions 2 of this division of this Act take effect January 1, 3 2017: 4 1. The sections of this division of this Act 5 amending sections 225D.1 and 225D.2. 6 2. The section of this division of this Act 7 repealing section 514C.28. > 8 2. By renumbering as necessary. 9 ______________________________ HALL of Woodbury -8- HF2460.3512 (1) 86 pf/rn 8/ 8 #2.