Senate File 1 - Introduced
SENATE FILE
BY BEALL
(COMPANION TO LSB 1118HH BY
ZIRKELBACH)
Passed Senate, Date Passed House, Date
Vote: Ayes Nays Vote: Ayes Nays
Approved
A BILL FOR
1 An Act requiring certain group health insurance policies,
2 contracts, or plans to provide coverage for autism spectrum
3 disorders for certain persons, requiring certification of
4 behavior specialists, and providing an applicability date.
5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
6 TLSB 1118XS 83
7 av/rj/14
PAG LIN
1 1 Section 1. NEW SECTION. 514C.24 AUTISM SPECTRUM
1 2 DISORDERS COVERAGE.
1 3 1. Notwithstanding the uniformity of treatment
1 4 requirements of section 514C.6, a group policy, contract, or
1 5 plan providing for third=party payment or prepayment of
1 6 health, medical, and surgical coverage benefits shall provide
1 7 coverage benefits to covered individuals under twenty=one
1 8 years of age for the diagnostic assessment of autism spectrum
1 9 disorders and for the treatment of autism spectrum disorders
1 10 if the policy, contract, or plan is either of the following:
1 11 a. A policy, contract, or plan issued by a carrier, as
1 12 defined in section 513B.2, or an organized delivery system
1 13 authorized under 1993 Iowa Acts, chapter 158, to an employer
1 14 who on at least fifty percent of the employer's working days
1 15 during the preceding calendar year employed more than fifty
1 16 full=time equivalent employees. In determining the number of
1 17 full=time equivalent employees of an employer, employers who
1 18 are affiliated or who are able to file a consolidated tax
1 19 return for purposes of state taxation shall be considered one
1 20 employer.
1 21 b. A plan established pursuant to chapter 509A for public
1 22 employees.
1 23 2. As used in this section, unless the context otherwise
1 24 requires:
1 25 a. "Applied behavioral analysis" means the design,
1 26 implementation, and evaluation of environmental modifications,
1 27 using behavioral stimuli and consequences, to produce socially
1 28 significant improvement in human behavior or to prevent loss
1 29 of attained skill or function, including the use of direct
1 30 observation, measurement, and functional analysis of the
1 31 relations between environment and behavior.
1 32 b. "Autism service provider" means a person, entity, or
1 33 group providing treatment of autism spectrum disorders,
1 34 pursuant to a treatment plan.
1 35 c. "Autism spectrum disorders" means any of the pervasive
2 1 developmental disorders including autistic disorder,
2 2 Asperger's disorder, and pervasive developmental disorders not
2 3 otherwise specified. The commissioner, by rule, shall define
2 4 "autism spectrum disorders" consistent with definitions
2 5 provided in the most recent edition of the American
2 6 psychiatric association's diagnostic and statistical manual of
2 7 mental disorders, as such definitions may be amended from time
2 8 to time. The commissioner may adopt the definitions provided
2 9 in such manual by reference.
2 10 d. "Behavior specialist" means an individual, certified by
2 11 the commissioner, who designs, implements, or evaluates a
2 12 behavior modification intervention component of a treatment
2 13 plan, including those based on applied behavioral analysis, to
2 14 produce socially significant improvements in human behavior or
2 15 to prevent loss of attained skill or function, through skill
2 16 acquisition and the reduction of problematic behavior.
2 17 e. "Diagnostic assessment of autism spectrum disorders"
2 18 means medically necessary assessment, evaluations, or tests
2 19 performed by a licensed physician, licensed physician
2 20 assistant, licensed psychologist, or licensed registered nurse
2 21 practitioner to diagnose whether an individual has an autism
2 22 spectrum disorder.
2 23 f. "Pharmacy care" means medications prescribed by a
2 24 licensed physician, licensed physician assistant, or licensed
2 25 registered nurse practitioner and any assessment, evaluation,
2 26 or test prescribed or ordered by a licensed physician,
2 27 licensed physician assistant, or licensed registered nurse
2 28 practitioner to determine the need for or effectiveness of
2 29 such medications.
2 30 g. "Psychiatric care" means direct or consultative
2 31 services provided by a licensed physician who specializes in
2 32 psychiatry.
2 33 h. "Psychological care" means direct or consultative
2 34 services provided by a licensed psychologist.
2 35 i. "Rehabilitative care" means professional services and
3 1 treatment programs, including applied behavioral analysis,
3 2 provided by an autism service provider to produce socially
3 3 significant improvement in human behavior or to prevent loss
3 4 of attained skill or function.
3 5 j. "Therapeutic care" means services provided by a
3 6 licensed speech pathologist, licensed occupational therapist,
3 7 or licensed physical therapist.
3 8 k. "Treatment of autism spectrum disorders" means
3 9 treatment that is identified in a treatment plan and includes
3 10 medically necessary pharmacy care, psychiatric care,
3 11 psychological care, rehabilitative care, and therapeutic care
3 12 that is one of the following:
3 13 (1) Prescribed, ordered, or provided by a licensed
3 14 physician, licensed physician assistant, licensed
3 15 psychologist, licensed social worker, or licensed registered
3 16 nurse practitioner.
3 17 (2) Provided by an autism service provider.
3 18 (3) Provided by a person, entity, or group that works
3 19 under the direction of an autism service provider.
3 20 l. "Treatment plan" means a plan for the treatment of
3 21 autism spectrum disorders developed by a licensed physician or
3 22 licensed psychologist pursuant to a comprehensive evaluation
3 23 or reevaluation performed in a manner consistent with the most
3 24 recent clinical report or recommendations of the American
3 25 academy of pediatrics, as determined by the commissioner by
3 26 rule.
3 27 3. Coverage is required pursuant to this section in a
3 28 maximum benefit amount of not less than thirty=six thousand
3 29 dollars per year but shall not be subject to any limits on the
3 30 number of visits to an autism service provider for treatment
3 31 of autism spectrum disorders. Beginning in 2013, the
3 32 commissioner shall, on or before April 1 of each calendar
3 33 year, publish an adjustment to the maximum benefit required
3 34 equal to the percentage change in the United States department
3 35 of labor consumer price index for all urban consumers in the
4 1 preceding year, and the published adjusted maximum benefit
4 2 shall be applicable to group policies, contracts, or plans
4 3 subject to this section that are issued or renewed on or after
4 4 January 1 of the following calendar year. Payments made under
4 5 a group policy, contract, or plan subject to this section on
4 6 behalf of a covered individual for treatment of a health
4 7 condition unrelated to or distinguishable from the
4 8 individual's autism spectrum disorder shall not be applied
4 9 toward any maximum benefit established under this subsection.
4 10 4. Coverage required pursuant to this section shall be
4 11 subject to copayment, deductible, and coinsurance provisions,
4 12 and any other general exclusions or limitations of a group
4 13 policy, contract, or plan to the same extent as other medical
4 14 or surgical services covered by the group policy, contract, or
4 15 plan.
4 16 5. Coverage required by this section shall be provided in
4 17 coordination with coverage required for the treatment of
4 18 autistic disorders pursuant to section 514C.22.
4 19 6. This section shall not be construed to limit benefits
4 20 which are otherwise available to an individual under a group
4 21 policy, contract, or plan.
4 22 7. This section shall not be construed to require coverage
4 23 by a group policy, contract, or plan of any service solely
4 24 based on inclusion of the service in an individualized
4 25 education program. Consistent with federal or state law and
4 26 upon consent of the parent or guardian of a covered
4 27 individual, the treatment of autism spectrum disorders may be
4 28 coordinated with any services included in an individualized
4 29 education program. However, coverage for the treatment of
4 30 autism spectrum disorders shall not be contingent upon
4 31 coordination of services with an individualized education
4 32 program.
4 33 8. This section shall not apply to accident=only,
4 34 specified disease, short=term hospital or medical, hospital
4 35 confinement indemnity, credit, dental, vision, Medicare
5 1 supplement, long=term care, basic hospital and
5 2 medical=surgical expense coverage as defined by the
5 3 commissioner, disability income insurance coverage, coverage
5 4 issued as a supplement to liability insurance, workers'
5 5 compensation or similar insurance, or automobile medical
5 6 payment insurance, or individual accident and sickness
5 7 policies issued to individuals or to individual members of a
5 8 member association.
5 9 9. A carrier, organized delivery system, or plan
5 10 established pursuant to chapter 509A may manage the benefits
5 11 provided through common methods including but not limited to
5 12 providing payment of benefits or providing care and treatment
5 13 under a capitated payment system, prospective reimbursement
5 14 rate system, utilization control system, incentive system for
5 15 the use of least restrictive and costly levels of care, a
5 16 preferred provider contract limiting choice of specific
5 17 providers, or any other system, method, or organization
5 18 designed to assure services are medically necessary and
5 19 clinically appropriate.
5 20 10. An insurer may review a treatment plan for treatment
5 21 of autism spectrum disorders once every six months, subject to
5 22 its utilization review requirements, including case
5 23 management, concurrent review, and other managed care
5 24 provisions. A more or less frequent review may be agreed upon
5 25 by the insured and the licensed physician or licensed
5 26 psychologist developing the treatment plan.
5 27 11. For the purposes of this section, the results of a
5 28 diagnostic assessment of autism spectrum disorder shall be
5 29 valid for a period of not less than twelve months, unless a
5 30 licensed physician or licensed psychologist determines that a
5 31 more frequent assessment is necessary.
5 32 12. The commissioner, in consultation with the board of
5 33 medicine, shall adopt rules providing for the certification of
5 34 behavior specialists.
5 35 a. An applicant for a certificate as a behavior specialist
6 1 shall submit a written application on forms provided by the
6 2 commissioner evidencing and insuring that the applicant meets
6 3 all of the following requirements:
6 4 (1) Is of good moral character.
6 5 (2) Has received a master's or higher degree from a
6 6 board=approved, accredited college or university, including a
6 7 major course of study in school, clinical, or counseling
6 8 psychology, special education, social work, speech therapy,
6 9 occupational therapy, or another related field.
6 10 (3) Has at least one year of experience involving
6 11 functional behavior assessments, including the development and
6 12 implementation of behavioral supports or treatment plans.
6 13 (4) Has completed at least one thousand hours in direct
6 14 clinical experience with individuals with behavioral
6 15 challenges or at least one thousand hours experience in a
6 16 related field with individuals with autism spectrum disorders.
6 17 (5) Has completed relevant training programs, including
6 18 professional ethics, autism=specific training, assessments
6 19 training, instructional strategies and best practices, crisis
6 20 intervention, comorbidity and medications, family
6 21 collaboration, and addressing specific skill deficits
6 22 training.
6 23 b. The commissioner shall not issue a certificate to an
6 24 applicant who has been convicted of a felony, of a controlled
6 25 substance=related offense under chapter 124 or of the laws of
6 26 another jurisdiction unless all of the following requirements
6 27 have been met:
6 28 (1) At least ten years have elapsed from the date of
6 29 conviction of such an offense.
6 30 (2) The applicant satisfactorily demonstrates to the
6 31 commissioner that the applicant has made significant progress
6 32 in personal rehabilitation since the conviction such that
6 33 certification of the applicant would not be expected to create
6 34 a substantial risk of harm to the health and safety of
6 35 patients or the public, or a substantial risk of further
7 1 criminal violations.
7 2 (3) The applicant otherwise satisfies the requirements of
7 3 this subsection.
7 4 13. The commissioner shall adopt rules pursuant to chapter
7 5 17A to implement and administer this section.
7 6 14. This section applies to third=party payment provider
7 7 policies, contracts, or plans, and to plans established
7 8 pursuant to chapter 509A that are delivered, issued for
7 9 delivery, continued, or renewed in this state on or after
7 10 January 1, 2010.
7 11 EXPLANATION
7 12 This bill creates new Code section 514C.24 which requires
7 13 certain group health insurance policies, contracts, or plans
7 14 to provide coverage benefits for the diagnosis and treatment
7 15 of autism spectrum disorders. The new provision is applicable
7 16 to group health policies, contracts, or plans issued to
7 17 employers with more than 50 employees and to health plans
7 18 established under Code chapter 509A for public employees.
7 19 Coverage benefits are required for covered individuals under
7 20 21 years of age.
7 21 "Autism spectrum disorders" includes autistic disorder,
7 22 Asperger's disorder, and pervasive developmental disorder not
7 23 otherwise specified, as defined by the commissioner of
7 24 insurance by rule consistent with definitions provided in the
7 25 most recent edition of the American psychiatric association's
7 26 diagnostic and statistical manual of mental disorders.
7 27 Required coverage for the diagnosis and treatment of autism
7 28 spectrum disorders must be not less than $36,000 per year and
7 29 without limits on the number of visits to an autism service
7 30 provider. Beginning in 2013, the commissioner is required to
7 31 make annual adjustments to the maximum benefit required equal
7 32 to the change in the United States department of labor
7 33 consumer price index. Payments made on behalf of a covered
7 34 individual that are unrelated to or distinguishable from the
7 35 individual's autism spectrum disorder cannot be applied toward
8 1 this maximum benefit.
8 2 Coverage of autism spectrum disorders under the new Code
8 3 section is to be provided in coordination with coverage
8 4 required for the treatment of autistic disorders pursuant to
8 5 Code section 514C.22. The section shall not be construed to
8 6 limit benefits otherwise available to an individual under a
8 7 group health policy, contract, or plan.
8 8 The commissioner, in consultation with the board of
8 9 medicine, is required to adopt rules for the certification of
8 10 behavior specialists who design, implement, or evaluate
8 11 behavior modification intervention components of treatment
8 12 plans for autism spectrum disorders that are developed by a
8 13 licensed physician or licensed psychologist.
8 14 The new Code section applies to third=party payment
8 15 provider policies, contracts, or plans, and to plans
8 16 established pursuant to Code chapter 509A that are delivered,
8 17 issued for delivery, continued, or renewed in this state on or
8 18 after January 1, 2010.
8 19 LSB 1118XS 83
8 20 av/rj/14