Senate File 2128 - Introduced SENATE FILE 2128 BY BEALL , MATHIS , WILHELM , QUIRMBACH , SCHOENJAHN , SENG , BERTRAND , BOLKCOM , DVORSKY , DOTZLER , DANIELSON , HATCH , HORN , DEARDEN , FRAISE , SODDERS , KIBBIE , BLACK , JOCHUM , RAGAN , and ANDERSON A BILL FOR An Act requiring certain group health insurance policies, 1 contracts, or plans to provide coverage for autism spectrum 2 disorders for certain persons, providing for a repeal, and 3 including applicability and effective date provisions. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 TLSB 5713XS (4) 84 av/nh
S.F. 2128 Section 1. NEW SECTION . 514C.29 Autism spectrum disorders 1 coverage. 2 1. Notwithstanding the uniformity of treatment requirements 3 of section 514C.6, a group policy, contract, or plan providing 4 for third-party payment or prepayment of health, medical, and 5 surgical coverage benefits shall provide coverage benefits 6 to covered individuals under twenty-six years of age for 7 the screening, diagnosis, and treatment of autism spectrum 8 disorders if the policy, contract, or plan is either of the 9 following: 10 a. A policy, contract, or plan issued by a carrier, as 11 defined in section 513B.2, or an organized delivery system 12 authorized under 1993 Iowa Acts, chapter 158. 13 b. A plan established pursuant to chapter 509A for public 14 employees. 15 2. As used in this section, unless the context otherwise 16 requires: 17 a. “Applied behavior analysis” means the design, 18 implementation, and evaluation of environmental modifications, 19 using behavioral stimuli and consequences, to produce socially 20 significant improvement in human behavior or to prevent loss 21 of attained skill or function, including the use of direct 22 observation, measurement, and functional analysis of the 23 relations between environment and behavior. 24 b. “Autism spectrum disorder” means any of the pervasive 25 developmental disorders including autistic disorder, Asperger’s 26 disorder, and pervasive developmental disorders not otherwise 27 specified. The commissioner, by rule, shall define “autism 28 spectrum disorder” consistent with definitions provided in 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 c. “Behavioral health treatment” means counseling and 34 treatment programs, including applied behavior analysis, that 35 -1- LSB 5713XS (4) 84 av/nh 1/ 7
S.F. 2128 meet the following requirements: 1 (1) Are necessary to develop, maintain, or restore, to the 2 maximum extent practicable, the functioning of an individual. 3 (2) Are provided or supervised by a behavior analyst 4 certified by a nationally recognized board, or by a licensed 5 psychologist, so long as the services are performed 6 commensurate with the psychologist’s formal training and 7 supervised experience. 8 d. “Diagnosis of autism spectrum disorder” means the use 9 of medically necessary assessments, evaluations, or tests to 10 diagnose whether an individual has an autism spectrum disorder. 11 e. “Pharmacy care” means medications prescribed by a 12 licensed physician and any assessment, evaluation, or test 13 prescribed or ordered by a licensed physician to determine the 14 need for or effectiveness of such medications. 15 f. “Psychiatric care” means direct or consultative services 16 provided by a licensed physician who specializes in psychiatry. 17 g. “Psychological care” means direct or consultative 18 services provided by a licensed psychologist. 19 h. “Therapeutic care” means services provided by a licensed 20 speech pathologist, licensed occupational therapist, or 21 licensed physical therapist. 22 i. “Treatment for autism spectrum disorder” means 23 evidence-based care and related equipment prescribed or ordered 24 for an individual diagnosed with an autism spectrum disorder by 25 a licensed physician or a licensed psychologist who determines 26 that the treatment is medically necessary, including but not 27 limited to the following: 28 (1) Behavioral health treatment. 29 (2) Pharmacy care. 30 (3) Psychiatric care. 31 (4) Psychological care. 32 (5) Therapeutic care. 33 j. “Treatment plan” means a plan for the treatment of an 34 autism spectrum disorder developed by a licensed physician or 35 -2- LSB 5713XS (4) 84 av/nh 2/ 7
S.F. 2128 licensed psychologist pursuant to a comprehensive evaluation 1 or reevaluation performed in a manner consistent with the most 2 recent clinical report or recommendations of the American 3 academy of pediatrics, as determined by the commissioner by 4 rule. 5 3. Coverage for applied behavior analysis is required 6 pursuant to this section for a maximum benefit amount of 7 thirty-six thousand dollars per year. Beginning in 2014, the 8 commissioner shall, on or before April 1 of each calendar year, 9 publish an adjustment for inflation to the maximum benefit 10 required equal to the percentage change in the medical care 11 component of the United States department of labor consumer 12 price index for all urban consumers in the preceding year, and 13 the published adjusted maximum benefit shall be applicable to 14 group policies, contracts, or plans subject to this section 15 that are delivered, issued for delivery, continued, or renewed 16 on or after January 1 of the following calendar year. Payments 17 made under a group policy, contract, or plan subject to this 18 section on behalf of a covered individual for any treatment 19 other than applied behavior analysis shall not be applied 20 toward the maximum benefit established under this subsection. 21 4. Coverage required pursuant to this section shall not be 22 subject to any limits on the number of visits an individual may 23 make for treatment of an autism spectrum disorder. 24 5. Coverage required pursuant to this section shall not 25 be subject to dollar limits, deductibles, copayments, or 26 coinsurance provisions, or any other general exclusions or 27 limitations of a group plan that are less favorable to an 28 insured than the dollar limits, deductibles, copayments, or 29 coinsurance provisions that apply to physical illness generally 30 under the policy, contract, or plan, except as provided in 31 subsection 3. 32 6. Coverage required by this section shall be provided 33 in coordination with coverage required for the treatment of 34 autistic disorders pursuant to section 514C.22. 35 -3- LSB 5713XS (4) 84 av/nh 3/ 7
S.F. 2128 7. This section shall not be construed to limit benefits 1 which are otherwise available to an individual under a group 2 policy, contract, or plan. 3 8. This section shall not be construed as affecting any 4 obligation to provide services to an individual under an 5 individualized family service plan, an individualized education 6 program, or an individualized service plan. 7 9. Except for inpatient services, if an insured is receiving 8 treatment for an autism spectrum disorder, an insurer is 9 entitled to review the treatment plan annually, unless the 10 insurer and the insured’s treating physician or psychologist 11 agree that a more frequent review is necessary. An agreement 12 giving an insurer the right to review the treatment plan of 13 an insured more frequently applies only to that insured and 14 does not apply to other individuals being treated for autism 15 spectrum disorders by a physician or psychologist. The cost of 16 conducting a review of a treatment plan shall be borne by the 17 insurer. 18 10. This section shall not apply to accident-only, 19 specified disease, short-term hospital or medical, hospital 20 confinement indemnity, credit, dental, vision, Medicare 21 supplement, long-term care, basic hospital and medical-surgical 22 expense coverage as defined by the commissioner, disability 23 income insurance coverage, coverage issued as a supplement 24 to liability insurance, workers’ compensation or similar 25 insurance, or automobile medical payment insurance, or 26 individual accident and sickness policies issued to individuals 27 or to individual members of a member association. 28 11. The commissioner shall adopt rules pursuant to chapter 29 17A to implement and administer this section. 30 12. An insurer shall not terminate coverage of an individual 31 solely because the individual is diagnosed with or has received 32 treatment for an autism spectrum disorder. 33 13. This section applies to third-party payment provider 34 policies, contracts, or plans, and to plans established 35 -4- LSB 5713XS (4) 84 av/nh 4/ 7
S.F. 2128 pursuant to chapter 509A, that are delivered, issued for 1 delivery, continued, or renewed in this state on or after 2 January 1, 2013. 3 Sec. 2. REPEAL. Section 514C.28, Code 2011, is repealed. 4 Sec. 3. EFFECTIVE DATE. The following provision of this Act 5 takes effect January 1, 2013: 6 1. The section of this Act repealing section 514C.28. 7 EXPLANATION 8 This bill creates new Code section 514C.29 which requires 9 certain group health insurance policies, contracts, or plans 10 to provide coverage benefits for the screening, diagnosis, and 11 treatment of autism spectrum disorders. The new provision 12 is applicable to group health policies, contracts, or plans 13 and to health plans established under Code chapter 509A for 14 public employees. Coverage benefits are required for covered 15 individuals under 26 years of age. 16 “Autism spectrum disorder” includes autistic disorder, 17 Asperger’s disorder, and pervasive developmental disorders 18 not otherwise specified, as defined by the commissioner of 19 insurance by rule consistent with definitions provided in the 20 most recent edition of the American psychiatric association’s 21 diagnostic and statistical manual of mental disorders. 22 The required maximum benefit for coverage for applied 23 behavior analysis is $36,000 per year. Beginning in 2014, 24 the commissioner is required to make and publish annual 25 adjustments for inflation to the maximum benefit required equal 26 to the percentage change in the medical care component of the 27 United States department of labor consumer price index for 28 all consumers in the previous year. The published adjusted 29 maximum benefit is applicable to group policies, contracts, or 30 plans delivered, issued for delivery, continued, or renewed 31 during the following calendar year. Payments made on behalf 32 of a covered individual for any treatment other than applied 33 behavior analysis cannot be applied toward this maximum 34 benefit. 35 -5- LSB 5713XS (4) 84 av/nh 5/ 7
S.F. 2128 Required coverage cannot be subject to any limits on the 1 number of visits an individual may make for treatment of an 2 autism spectrum disorder. 3 Required coverage cannot be subject to dollar limits, 4 deductibles, copayments, or coinsurance provisions, or any 5 other general exclusions or limitations of a group plan that 6 are less favorable to an insured than those that apply to 7 physical illness generally under the policy, contract, or 8 plan, except as to the maximum benefit limitation for applied 9 behavior analysis coverage. 10 Coverage of autism spectrum disorders under the new Code 11 section is to be provided in coordination with coverage 12 required for the treatment of autistic disorders pursuant to 13 Code section 514C.22. The Code section shall not be construed 14 to limit benefits otherwise available to an individual under a 15 group policy, contract, or plan. 16 The new Code section shall not be construed as affecting 17 any obligation to provide services to an individual under an 18 individualized family service plan, education program, or 19 service plan. 20 Except for inpatient services, if an insured is receiving 21 treatment for an autism spectrum disorder, an insurer is 22 entitled to review the treatment plan annually, unless the 23 insurer and the insured’s treating physician or psychologist 24 agree that more frequent review is necessary. Such an 25 agreement applies only to that insured and does not apply to 26 other individuals being treated for autism spectrum disorder by 27 a physician or psychologist. The cost of conducting the review 28 of a treatment plan is to be borne by the insurer. 29 The new Code section does not apply to various specified 30 types of insurance. The commissioner is required to adopt 31 rules to implement and administer the provision. 32 An insurer shall not terminate coverage of an individual 33 solely because the individual is diagnosed with or has received 34 treatment for an autism spectrum disorder. 35 -6- LSB 5713XS (4) 84 av/nh 6/ 7
S.F. 2128 The new Code section applies to third-party payment provider 1 policies, contracts, or plans, and to plans established 2 pursuant to Code chapter 509A, that are delivered, issued for 3 delivery, continued, or renewed in this state on or after 4 January 1, 2013. 5 Code section 514C.28, which currently mandates coverage 6 for autism spectrum disorders only in group plans established 7 pursuant to Code chapter 509A for state employees, is repealed 8 effective January 1, 2013. 9 -7- LSB 5713XS (4) 84 av/nh 7/ 7