House
File
215
-
Enrolled
House
File
215
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
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
House
File
215,
p.
2
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:
House
File
215,
p.
3
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
House
File
215,
p.
4
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
House
File
215,
p.
5
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.
______________________________
LINDA
UPMEYER
Speaker
of
the
House
______________________________
JACK
WHITVER
President
of
the
Senate
I
hereby
certify
that
this
bill
originated
in
the
House
and
is
known
as
House
File
215,
Eighty-seventh
General
Assembly.
______________________________
CARMINE
BOAL
Chief
Clerk
of
the
House
Approved
_______________,
2017
______________________________
TERRY
E.
BRANSTAD
Governor