H.F. 2346 Section 1. NEW SECTION . 514C.26 Autism spectrum disorders 1 coverage. 2 1. As used in this section, unless the context otherwise 3 requires: 4 a. “Applied behavior analysis” means the design, 5 implementation, and evaluation of environmental modifications, 6 using behavioral stimuli and consequences, to produce socially 7 significant improvement in human behavior, including the use of 8 direct observation, measurement, and functional analysis of the 9 relationships between environment and behavior. 10 b. “Autism service provider” means any of the following: 11 (1) Any person, entity, or group that provides diagnostic 12 or treatment services for autism spectrum disorders who is 13 licensed or certified by the state of Iowa. 14 (2) Any person who is certified as a behavior analyst. 15 (3) Any person, if not licensed or certified, who is 16 supervised by a person who is certified as a behavior analyst, 17 whether such certified behavior analyst supervises as an 18 individual or as an employee of or in association with an 19 entity or group. However, an “autism service provider” does 20 not include parents and siblings of autistic persons to the 21 extent that such parents or siblings are providing diagnostic 22 or treatment services to their child or sibling. 23 c. “Autism spectrum disorder” means a neurobiological 24 disorder or an illness of the nervous system, which includes 25 autistic disorder, Asperger’s disorder, pervasive developmental 26 disorder not otherwise specified, Rett’s disorder, and 27 childhood disintegrative disorder. The commissioner, by rule, 28 shall define “autism spectrum disorder” consistent with the 29 most recent edition of the American psychiatric association’s 30 diagnostic and statistical manual of mental disorders, as such 31 definitions may be amended from time to time. The commissioner 32 may adopt the definitions provided in such manual by reference. 33 d. “Carrier” means the same as in 513B.2. 34 e. “Diagnosis of autism spectrum disorder” means medically 35 -1- LSB 5616YH (3) 83 av/rj 1/ 7

H.F. 2346 necessary assessments, evaluations, or tests in order to 1 diagnose whether an individual has an autism spectrum disorder. 2 f. “Habilitative or rehabilitative care” means professional, 3 counseling, or guidance services and treatment programs, 4 including applied behavior analysis, that are necessary to 5 develop and restore the functioning of an individual. 6 g. “Health insurance coverage” means the same as in 513B.2. 7 h. “Pharmacy care” means medications or nutritional 8 supplements used to address symptoms of an autism spectrum 9 disorder prescribed by a licensed physician, and any 10 health-related services deemed medically necessary to determine 11 the need for or effectiveness of the medications or nutritional 12 supplements prescribed. 13 i. “Psychiatric care” means direct or consultative services 14 provided by a psychiatrist licensed in the state in which the 15 psychiatrist practices. 16 j. “Psychological care” means direct or consultative 17 services provided by a psychologist licensed in the state in 18 which the psychologist practices. 19 k. “Therapeutic care” means services provided by a speech 20 therapist, occupational therapist, or physical therapist 21 licensed in the state in which the therapist practices. 22 l. “Treatment for autism spectrum disorder” means care 23 prescribed or ordered for an individual diagnosed with an 24 autism spectrum disorder by a licensed physician or licensed 25 psychologist, including but not limited to equipment necessary 26 for such care, pursuant to the powers granted under such 27 licensed physician’s or licensed psychologist’s license, 28 including but not limited to the following: 29 (1) Psychiatric care. 30 (2) Psychological care. 31 (3) Habilitative or rehabilitative care, including applied 32 behavior analysis therapy. 33 (4) Therapeutic care. 34 (5) Pharmacy care. 35 -2- LSB 5616YH (3) 83 av/rj 2/ 7

H.F. 2346 2. Notwithstanding the uniformity of treatment requirements 1 of section 514C.6, an individual or group policy, contract, or 2 plan providing for third-party payment or prepayment of health, 3 medical, and surgical coverage benefits shall provide benefits 4 for the diagnosis and treatment of autism spectrum disorders. 5 3. A carrier shall not deny or refuse to issue coverage, 6 refuse to contract with, refuse to renew, refuse to reissue, 7 or otherwise terminate or restrict coverage on an insured 8 solely because the insured is diagnosed with an autism spectrum 9 disorder or because the insured receives coverage under this 10 section. 11 4. a. Coverage required under this section is limited 12 to diagnosis and treatment that is ordered by the insured’s 13 treating physician or psychologist, pursuant to the powers 14 granted under such physician’s or psychologist’s license, in 15 accordance with a treatment plan. Service exclusions contained 16 in the health insurance coverage that are inconsistent with 17 the treatment plan shall be considered invalid as to autism 18 spectrum disorders. 19 b. The treatment plan, upon request of the carrier, shall 20 include all elements necessary for the carrier to review the 21 treatment plan. 22 c. Except for inpatient services, if an insured is receiving 23 treatment for an autism spectrum disorder, the carrier shall 24 have the right to review the treatment plan not more than once 25 every six months unless the carrier and the insured’s treating 26 physician or psychologist agree that a more frequent review is 27 necessary. The cost of obtaining any review shall be borne by 28 the carrier. 29 5. Coverage required under this section for applied 30 behavior analysis shall be subject to a maximum benefit 31 of seventy-two thousand dollars per calendar year and such 32 coverage shall only be afforded to insureds under the age of 33 twenty-one. Any coverage required under this section, other 34 than the coverage for applied behavior analysis, shall not be 35 -3- LSB 5616YH (3) 83 av/rj 3/ 7

H.F. 2346 subject to this age limitation. 1 6. Subject to the provisions of subsection 4, paragraph “c” , 2 coverage provided under this section shall not be subject to 3 any limits on the number of visits an insured may make to an 4 autism service provider. 5 7. This section shall not be construed as limiting benefits 6 which are otherwise available to an insured under a health 7 benefit policy, contract, or plan. Subject to the provisions 8 of subsection 5, the coverage required by this section shall 9 not be subject to any greater deductible, coinsurance, 10 copayment, or utilization review of health care services, 11 including review of medical necessity, than other coverage for 12 physical health care services provided by a health benefit 13 policy, contract, or plan. Coverage for treatment under this 14 section shall not be denied on the basis that it is educational 15 or habilitative in nature. 16 8. To the extent that any payments or reimbursements are 17 being made for applied behavior analysis, such payments or 18 reimbursements shall be made to any of the following: 19 a. An autism service provider. 20 b. The person who is supervising an autism service provider, 21 who is also certified as a behavior analyst. 22 c. The entity or group for whom such supervising person, who 23 is certified as a behavior analyst, works or is associated. 24 9. If a request for qualifications is made of a person who 25 is not an autism service provider, such person shall provide 26 documented evidence of the education and professional training, 27 if any, of such person. 28 10. The commissioner of insurance, in consultation with 29 the board of medicine, shall adopt rules providing for the 30 certification of autism service providers and behavior 31 analysts. 32 11. A carrier shall not be required to provide reimbursement 33 to a school district for treatment for autism spectrum 34 disorders provided by the school district. This section 35 -4- LSB 5616YH (3) 83 av/rj 4/ 7

H.F. 2346 shall not be construed as affecting any obligation to 1 provide services to an individual under an individualized 2 family service plan, an individualized education plan, or an 3 individualized service plan. 4 12. The provisions of this section shall not automatically 5 apply to individually underwritten health insurance coverage 6 but shall be offered as an option to any such policy, contract, 7 or plan. 8 13. This section shall not apply to accident-only, 9 specified disease, short-term hospital or medical, hospital 10 confinement indemnity, credit, dental, vision, Medicare 11 supplement, long-term care, basic hospital and medical-surgical 12 expense coverage as defined by the commissioner, disability 13 income insurance coverage, coverage issued as a supplement 14 to liability insurance, workers’ compensation or similar 15 insurance, automobile medical payment insurance, or individual 16 accident and sickness policies issued to individuals or to 17 individual members of a member association. 18 14. This section applies to third-party payment provider 19 policies, contracts, or plans, and to plans established 20 pursuant to chapter 509A that are delivered, issued for 21 delivery, continued, or renewed in this state on or after 22 January 1, 2011. 23 EXPLANATION 24 This bill creates new Code section 514C.26 which requires 25 certain health insurance policies, contracts, and plans to 26 provide coverage benefits for the diagnosis and treatment 27 of autism spectrum disorders. “Autism spectrum disorder” 28 means a neurobiological disorder or an illness of the nervous 29 system which includes autistic disorder, Asperger’s disorder, 30 pervasive developmental disorder not otherwise specified, 31 Rett’s disorder, and childhood disintegrative disorder, as 32 defined by the commissioner of insurance by rules consistent 33 with definitions provided in the most recent edition of the 34 American psychiatric association’s diagnostic and statistical 35 -5- LSB 5616YH (3) 83 av/rj 5/ 7

H.F. 2346 manual of mental disorders. 1 Coverage required under the bill is limited to diagnosis and 2 treatment that is ordered by an insured’s treating licensed 3 physician or psychologist in accordance with a treatment plan. 4 Exclusion of services in health insurance coverage that are 5 inconsistent with the treatment plan are invalid as to autism 6 spectrum disorders. The carrier is entitled to review the 7 treatment plan, but except for inpatient services, not more 8 than once every six months. Coverage required for applied 9 behavior analysis is subject to a maximum annual benefit of 10 $72,000 and is required only for individuals under the age of 11 21. 12 The bill shall not be construed to limit benefits which 13 are otherwise available to an insured under a health benefit 14 policy, contract, or plan and such benefits shall not be 15 subject to any greater deductible, coinsurance, copayment, or 16 utilization review than other coverage for physical health care 17 services. 18 Payments or reimbursements made for applied behavior 19 analysis must be made to an autism service provider, a person 20 who is supervising an autism service provider who is also 21 certified as a behavior analyst, or the entity or group for 22 whom the supervising person works or is associated. 23 The commissioner of insurance, in consultation with the 24 board of medicine, is required to adopt rules providing for 25 the certification of autism service providers and behavior 26 analysts. 27 A carrier is not required to provide reimbursement to a 28 school district for treatment for autism spectrum disorders 29 provided by the school district. Coverage required by the bill 30 is not required to be automatically applied to individually 31 underwritten health insurance coverage but shall instead be 32 offered as an option. The provisions of the bill do not apply 33 to specified limited-purpose insurance. 34 The new Code section applies to individual and group 35 -6- LSB 5616YH (3) 83 av/rj 6/ 7