S.F. 64 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-one years of age for the 7 diagnostic assessment of autism spectrum disorders and for the 8 treatment of autism spectrum disorders if the policy, contract, 9 or plan is either of the 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, to an employer 13 who on at least fifty percent of the employer’s working days 14 during the preceding calendar year employed more than fifty 15 full-time equivalent employees. In determining the number 16 of full-time equivalent employees of an employer, employers 17 who are affiliated or who are able to file a consolidated tax 18 return for purposes of state taxation shall be considered one 19 employer. 20 b. A plan established pursuant to chapter 509A for public 21 employees. 22 2. As used in this section, unless the context otherwise 23 requires: 24 a. “Applied behavioral analysis” means the design, 25 implementation, and evaluation of environmental modifications, 26 using behavioral stimuli and consequences, to produce socially 27 significant improvement in human behavior or to prevent loss 28 of attained skill or function, including the use of direct 29 observation, measurement, and functional analysis of the 30 relations between environment and behavior. 31 b. “Autism service provider” means a person, entity, 32 or group providing treatment of autism spectrum disorders, 33 pursuant to a treatment plan. 34 c. “Autism spectrum disorders” means any of the pervasive 35 -1- LSB 1755XS (6) 84 av/nh 1/ 8

S.F. 64 developmental disorders including autistic disorder, Asperger’s 1 disorder, and pervasive developmental disorders not otherwise 2 specified. The commissioner, by rule, shall define “autism 3 spectrum disorders” consistent with definitions provided in the 4 most recent edition of the American psychiatric association’s 5 diagnostic and statistical manual of mental disorders, as such 6 definitions may be amended from time to time. The commissioner 7 may adopt the definitions provided in such manual by reference. 8 d. “Behavior specialist” means an individual, certified 9 by the commissioner, who designs, implements, or evaluates a 10 behavior modification intervention component of a treatment 11 plan, including those based on applied behavioral analysis, to 12 produce socially significant improvements in human behavior or 13 to prevent loss of attained skill or function, through skill 14 acquisition and the reduction of problematic behavior. 15 e. “Diagnostic assessment of autism spectrum disorders” means 16 medically necessary assessment, evaluations, or tests performed 17 by a licensed physician, licensed physician assistant, licensed 18 psychologist, or licensed registered nurse practitioner to 19 diagnose whether an individual has an autism spectrum disorder. 20 f. “Pharmacy care” means medications prescribed by a 21 licensed physician, licensed physician assistant, or licensed 22 registered nurse practitioner and any assessment, evaluation, 23 or test prescribed or ordered by a licensed physician, licensed 24 physician assistant, or licensed registered nurse practitioner 25 to determine the need for or effectiveness of such medications. 26 g. “Psychiatric care” means direct or consultative services 27 provided by a licensed physician who specializes in psychiatry. 28 h. “Psychological care” means direct or consultative 29 services provided by a licensed psychologist. 30 i. “Rehabilitative care” means professional services and 31 treatment programs, including applied behavioral analysis, 32 provided by an autism service provider to produce socially 33 significant improvement in human behavior or to prevent loss 34 of attained skill or function. 35 -2- LSB 1755XS (6) 84 av/nh 2/ 8

S.F. 64 j. “Therapeutic care” means services provided by a licensed 1 speech pathologist, licensed occupational therapist, or 2 licensed physical therapist. 3 k. “Treatment of autism spectrum disorders” means treatment 4 that is identified in a treatment plan and includes medically 5 necessary pharmacy care, psychiatric care, psychological care, 6 rehabilitative care, and therapeutic care that is one of the 7 following: 8 (1) Prescribed, ordered, or provided by a licensed 9 physician, licensed physician assistant, licensed psychologist, 10 licensed social worker, or licensed registered nurse 11 practitioner. 12 (2) Provided by an autism service provider. 13 (3) Provided by a person, entity, or group that works under 14 the direction of an autism service provider. 15 l. “Treatment plan” means a plan for the treatment of 16 autism spectrum disorders developed by a licensed physician or 17 licensed psychologist pursuant to a comprehensive evaluation 18 or reevaluation performed in a manner consistent with the most 19 recent clinical report or recommendations of the American 20 academy of pediatrics, as determined by the commissioner by 21 rule. 22 3. Coverage is required pursuant to this section in a 23 maximum benefit amount of not less than thirty-six thousand 24 dollars per year but shall not be subject to any limits on the 25 number of visits to an autism service provider for treatment of 26 autism spectrum disorders. Beginning in 2015, the commissioner 27 shall, on or before April 1 of each calendar year, publish 28 an adjustment to the maximum benefit required equal to the 29 percentage change in the United States department of labor 30 consumer price index for all urban consumers in the preceding 31 year, and the published adjusted maximum benefit shall be 32 applicable to group policies, contracts, or plans subject to 33 this section that are issued or renewed on or after January 1 34 of the following calendar year. Payments made under a group 35 -3- LSB 1755XS (6) 84 av/nh 3/ 8

S.F. 64 policy, contract, or plan subject to this section on behalf 1 of a covered individual for treatment of a health condition 2 unrelated to or distinguishable from the individual’s autism 3 spectrum disorder shall not be applied toward any maximum 4 benefit established under this subsection. 5 4. Coverage required pursuant to this section shall be 6 subject to copayment, deductible, and coinsurance provisions, 7 and any other general exclusions or limitations of a group 8 policy, contract, or plan to the same extent as other medical 9 or surgical services covered by the group policy, contract, or 10 plan. 11 5. Coverage required by this section shall be provided 12 in coordination with coverage required for the treatment of 13 autistic disorders pursuant to section 514C.22. 14 6. This section shall not be construed to limit benefits 15 which are otherwise available to an individual under a group 16 policy, contract, or plan. 17 7. This section shall not be construed to require coverage 18 by a group policy, contract, or plan of any service solely 19 based on inclusion of the service in an individualized 20 education program. Consistent with federal or state law and 21 upon consent of the parent or guardian of a covered individual, 22 the treatment of autism spectrum disorders may be coordinated 23 with any services included in an individualized education 24 program. However, coverage for the treatment of autism 25 spectrum disorders shall not be contingent upon coordination of 26 services with an individualized education program. 27 8. This section shall not apply to accident-only, 28 specified disease, short-term hospital or medical, hospital 29 confinement indemnity, credit, dental, vision, Medicare 30 supplement, long-term care, basic hospital and medical-surgical 31 expense coverage as defined by the commissioner, disability 32 income insurance coverage, coverage issued as a supplement 33 to liability insurance, workers’ compensation or similar 34 insurance, or automobile medical payment insurance, or 35 -4- LSB 1755XS (6) 84 av/nh 4/ 8

S.F. 64 individual accident and sickness policies issued to individuals 1 or to individual members of a member association. 2 9. A carrier, organized delivery system, or plan 3 established pursuant to chapter 509A may manage the benefits 4 provided through common methods including but not limited to 5 providing payment of benefits or providing care and treatment 6 under a capitated payment system, prospective reimbursement 7 rate system, utilization control system, incentive system 8 for the use of least restrictive and costly levels of care, 9 a preferred provider contract limiting choice of specific 10 providers, or any other system, method, or organization 11 designed to assure services are medically necessary and 12 clinically appropriate. 13 10. An insurer may review a treatment plan for treatment 14 of autism spectrum disorders once every six months, subject to 15 its utilization review requirements, including case management, 16 concurrent review, and other managed care provisions. A more 17 or less frequent review may be agreed upon by the insured and 18 the licensed physician or licensed psychologist developing the 19 treatment plan. 20 11. For the purposes of this section, the results of a 21 diagnostic assessment of autism spectrum disorder shall be 22 valid for a period of not less than twelve months, unless a 23 licensed physician or licensed psychologist determines that a 24 more frequent assessment is necessary. 25 12. The commissioner, in consultation with the board of 26 medicine, shall adopt rules providing for the certification of 27 behavior specialists. 28 a. An applicant for a certificate as a behavior specialist 29 shall submit a written application on forms provided by the 30 commissioner evidencing and insuring that the applicant meets 31 all of the following requirements: 32 (1) Is of good moral character. 33 (2) Has received a master’s or higher degree from a 34 board-approved, accredited college or university, including 35 -5- LSB 1755XS (6) 84 av/nh 5/ 8

S.F. 64 a major course of study in school, clinical, or counseling 1 psychology, special education, social work, speech therapy, 2 occupational therapy, or another related field. 3 (3) Has at least one year of experience involving 4 functional behavior assessments, including the development and 5 implementation of behavioral supports or treatment plans. 6 (4) Has completed at least one thousand hours in direct 7 clinical experience with individuals with behavioral challenges 8 or at least one thousand hours of experience in a related field 9 with individuals with autism spectrum disorders. 10 (5) Has completed relevant training programs, including 11 professional ethics, autism-specific training, assessments 12 training, instructional strategies and best practices, 13 crisis intervention, comorbidity and medications, family 14 collaboration, and addressing specific skill deficits training. 15 b. The commissioner shall not issue a certificate to an 16 applicant who has been convicted of a felony, of a controlled 17 substance-related offense under chapter 124 or of the laws of 18 another jurisdiction unless all of the following requirements 19 have been met: 20 (1) At least ten years have elapsed from the date of 21 conviction of such an offense. 22 (2) The applicant satisfactorily demonstrates to the 23 commissioner that the applicant has made significant progress 24 in personal rehabilitation since the conviction such that 25 certification of the applicant would not be expected to create 26 a substantial risk of harm to the health and safety of patients 27 or the public, or a substantial risk of further criminal 28 violations. 29 (3) The applicant otherwise satisfies the requirements of 30 this subsection. 31 13. The commissioner shall adopt rules pursuant to chapter 32 17A to implement and administer this section. 33 14. This section applies to third-party payment provider 34 policies, contracts, or plans, and to plans established 35 -6- LSB 1755XS (6) 84 av/nh 6/ 8

S.F. 64 pursuant to chapter 509A that are delivered, issued for 1 delivery, continued, or renewed in this state on or after 2 January 1, 2012. 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, 2012: 6 1. The section of this Act repealing section 514C.28. 7 EXPLANATION 8 This bill creates new Code section 514C.24 which requires 9 certain group health insurance policies, contracts, or plans to 10 provide coverage benefits for the diagnosis and treatment of 11 autism spectrum disorders. The new provision is applicable to 12 group health policies, contracts, or plans issued to employers 13 with more than 50 employees and to health plans established 14 under Code chapter 509A for public employees. Coverage 15 benefits are required for covered individuals under 21 years 16 of age. 17 “Autism spectrum disorders” includes autistic disorder, 18 Asperger’s disorder, and pervasive developmental disorders 19 not otherwise specified, as defined by the commissioner of 20 insurance by rule consistent with definitions provided in the 21 most recent edition of the American psychiatric association’s 22 diagnostic and statistical manual of mental disorders. 23 Required coverage for the diagnosis and treatment of autism 24 spectrum disorders must be not less than $36,000 per year and 25 without limits on the number of visits to an autism service 26 provider. Beginning in 2015, the commissioner is required to 27 make annual adjustments to the maximum benefit required equal 28 to the change in the United States department of labor consumer 29 price index. Payments made on behalf of a covered individual 30 that are unrelated to or distinguishable from the individual’s 31 autism spectrum disorder cannot be applied toward this maximum 32 benefit. 33 Coverage of autism spectrum disorders under the new Code 34 section is to be provided in coordination with coverage 35 -7- LSB 1755XS (6) 84 av/nh 7/ 8

S.F. 64 required for the treatment of autistic disorders pursuant to 1 Code section 514C.22. The Code section shall not be construed 2 to limit benefits otherwise available to an individual under a 3 group health policy, contract, or plan. 4 The commissioner, in consultation with the board of 5 medicine, is required to adopt rules for the certification 6 of behavior specialists who design, implement, or evaluate 7 behavior modification intervention components of treatment 8 plans for autism spectrum disorders that are developed by a 9 licensed physician or licensed psychologist. 10 The new Code section applies to third-party payment provider 11 policies, contracts, or plans, and to plans established 12 pursuant to Code chapter 509A that are delivered, issued for 13 delivery, continued, or renewed in this state on or after 14 January 1, 2012. 15 Code section 514C.28, which currently mandates coverage 16 for autism spectrum disorders only in group plans established 17 pursuant to Code chapter 509A for state employees, is repealed 18 effective January 1, 2012. 19 -8- LSB 1755XS (6) 84 av/nh 8/ 8