HF 2346 (LSB 5616YH (3) 83)

HOUSE FILE 2346

BY  HEATON

A BILL FOR

An Act requiring certain health insurance policies, contracts, or plans to provide coverage for the diagnosis and treatment of autism spectrum disorders, and providing an applicability date.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.26  Autism spectrum disorders coverage.
   1.  As used in this section, unless the context otherwise requires:
   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 relationships between environment and behavior.
   b.  “Autism service provider” means any of the following:
   (1)  Any person, entity, or group that provides diagnostic or treatment services for autism spectrum disorders who is licensed or certified by the state of Iowa.
   (2)  Any person who is certified as a behavior analyst.
   (3)  Any person, if not licensed or certified, who is supervised by a person who is certified as a behavior analyst, whether such certified behavior analyst supervises as an individual or as an employee of or in association with an entity or group. However, an “autism service provider” does not include parents and siblings of autistic persons to the extent that such parents or siblings are providing diagnostic or treatment services to their child or sibling.
   c.  “Autism spectrum disorder” means a neurobiological disorder or an illness of the nervous system, which includes autistic disorder, Asperger’s disorder, pervasive developmental disorder not otherwise specified, Rett’s disorder, and childhood disintegrative disorder. The commissioner, by rule, shall define “autism spectrum disorder” consistent with 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.
   d.  “Carrier” means the same as in 513B.2.
   e.  “Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests in order to diagnose whether an individual has an autism spectrum disorder.
   f.  “Habilitative or rehabilitative care” means professional, counseling, or guidance services and treatment programs, including applied behavior analysis, that are necessary to develop and restore the functioning of an individual.
   g.  “Health insurance coverage” means the same as in 513B.2.
   h.  “Pharmacy care” means medications or nutritional supplements used to address symptoms of an autism spectrum disorder prescribed by a licensed physician, and any health-related services deemed medically necessary to determine the need for or effectiveness of the medications or nutritional supplements prescribed.
   i.  “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
   j.  “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
   k.  “Therapeutic care” means services provided by a speech therapist, occupational therapist, or physical therapist licensed in the state in which the therapist practices.
   l.  “Treatment for autism spectrum disorder” means care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist, including but not limited to equipment necessary for such care, pursuant to the powers granted under such licensed physician’s or licensed psychologist’s license, including but not limited to the following:
   (1)  Psychiatric care.
   (2)  Psychological care.
   (3)  Habilitative or rehabilitative care, including applied behavior analysis therapy.
   (4)  Therapeutic care.
   (5)  Pharmacy care.
   2.  Notwithstanding the uniformity of treatment requirements of section 514C.6, an individual or group policy, contract, or plan providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide benefits for the diagnosis and treatment of autism spectrum disorders.
   3.  A carrier shall not deny or refuse to issue coverage, refuse to contract with, refuse to renew, refuse to reissue, or otherwise terminate or restrict coverage on an insured solely because the insured is diagnosed with an autism spectrum disorder or because the insured receives coverage under this section.
   4.  a.  Coverage required under this section is limited to diagnosis and treatment that is ordered by the insured’s treating physician or psychologist, pursuant to the powers granted under such physician’s or psychologist’s license, in accordance with a treatment plan. Service exclusions contained in the health insurance coverage that are inconsistent with the treatment plan shall be considered invalid as to autism spectrum disorders.
   b.  The treatment plan, upon request of the carrier, shall include all elements necessary for the carrier to review the treatment plan.
   c.  Except for inpatient services, if an insured is receiving treatment for an autism spectrum disorder, the carrier shall have the right to review the treatment plan not more than once every six months unless the carrier and the insured’s treating physician or psychologist agree that a more frequent review is necessary. The cost of obtaining any review shall be borne by the carrier.
   5.  Coverage required under this section for applied behavior analysis shall be subject to a maximum benefit of seventy-two thousand dollars per calendar year and such coverage shall only be afforded to insureds under the age of twenty-one. Any coverage required under this section, other than the coverage for applied behavior analysis, shall not be subject to this age limitation.
   6.  Subject to the provisions of subsection 4, paragraph “c”, coverage provided under this section shall not be subject to any limits on the number of visits an insured may make to an autism service provider.
   7.  This section shall not be construed as limiting benefits which are otherwise available to an insured under a health benefit policy, contract, or plan. Subject to the provisions of subsection 5, the coverage required by this section shall not be subject to any greater deductible, coinsurance, copayment, or utilization review of health care services, including review of medical necessity, than other coverage for physical health care services provided by a health benefit policy, contract, or plan. Coverage for treatment under this section shall not be denied on the basis that it is educational or habilitative in nature.
   8.  To the extent that any payments or reimbursements are being made for applied behavior analysis, such payments or reimbursements shall be made to any of the following:
   a.  An autism service provider.
   b.  The person who is supervising an autism service provider, who is also certified as a behavior analyst.
   c.  The entity or group for whom such supervising person, who is certified as a behavior analyst, works or is associated.
   9.  If a request for qualifications is made of a person who is not an autism service provider, such person shall provide documented evidence of the education and professional training, if any, of such person.
   10.  The commissioner of insurance, in consultation with the board of medicine, shall adopt rules providing for the certification of autism service providers and behavior analysts.
   11.  A carrier shall not be required to provide reimbursement to a school district for treatment for autism spectrum disorders provided by the school district. 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 plan, or an individualized service plan.
   12.  The provisions of this section shall not automatically apply to individually underwritten health insurance coverage but shall be offered as an option to any such policy, contract, or plan.
   13.  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, automobile medical payment insurance, or individual accident and sickness policies issued to individuals or to individual members of a member association.
   14.  This section applies to third-party payment provider policies, contracts, or plans, and to plans established pursuant to chapter 509A that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011.
EXPLANATION
   This bill creates new Code section 514C.26 which requires certain health insurance policies, contracts, and plans to provide coverage benefits for the diagnosis and treatment of autism spectrum disorders. “Autism spectrum disorder” means a neurobiological disorder or an illness of the nervous system which includes autistic disorder, Asperger’s disorder, pervasive developmental disorder not otherwise specified, Rett’s disorder, and childhood disintegrative disorder, as defined by the commissioner of insurance by rules consistent with definitions provided in the most recent edition of the American psychiatric association’s diagnostic and statistical manual of mental disorders.
   Coverage required under the bill is limited to diagnosis and treatment that is ordered by an insured’s treating licensed physician or psychologist in accordance with a treatment plan. Exclusion of services in health insurance coverage that are inconsistent with the treatment plan are invalid as to autism spectrum disorders. The carrier is entitled to review the treatment plan, but except for inpatient services, not more than once every six months. Coverage required for applied behavior analysis is subject to a maximum annual benefit of $72,000 and is required only for individuals under the age of 21.
   The bill shall not be construed to limit benefits which are otherwise available to an insured under a health benefit policy, contract, or plan and such benefits shall not be subject to any greater deductible, coinsurance, copayment, or utilization review than other coverage for physical health care services.
   Payments or reimbursements made for applied behavior analysis must be made to an autism service provider, a person who is supervising an autism service provider who is also certified as a behavior analyst, or the entity or group for whom the supervising person works or is associated.
   The commissioner of insurance, in consultation with the board of medicine, is required to adopt rules providing for the certification of autism service providers and behavior analysts.
   A carrier is not required to provide reimbursement to a school district for treatment for autism spectrum disorders provided by the school district. Coverage required by the bill is not required to be automatically applied to individually underwritten health insurance coverage but shall instead be offered as an option. The provisions of the bill do not apply to specified limited-purpose insurance.
   The new Code section applies to individual and group third-party payment provider policies, contracts, or plans, and to plans that are established pursuant to chapter 509A, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011.