Senate File 2019 - Introduced SENATE FILE 2019 BY McCOY A BILL FOR An Act relating to insurance coverage for the assessment and 1 treatment of eating disorders and including applicability 2 date provisions. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 5000XS (2) 86 av/rj

S.F. 2019 Section 1. NEW SECTION . 514C.31 Eating disorders —— 1 coverage. 2 1. Notwithstanding the uniformity of treatment requirements 3 of section 514C.6, a policy, contract, or plan providing for 4 third-party payment or prepayment of health or medical expenses 5 shall provide coverage benefits for the diagnostic assessment 6 and treatment of eating disorders. 7 2. As used in this section, unless the context otherwise 8 requires: 9 a. “Diagnostic assessment of eating disorders” means 10 medically necessary assessments, evaluations, or tests 11 performed by a physician or psychiatrist licensed pursuant to 12 chapter 148, a psychologist licensed pursuant to chapter 154B, 13 a social worker licensed pursuant to chapter 154C, or a mental 14 health counselor or marital and family therapist licensed 15 pursuant to chapter 154D, to diagnose whether an individual has 16 an eating disorder. 17 b. “Eating disorders” means pica, rumination disorder, 18 avoidant or restrictive food intake disorder, anorexia nervosa, 19 bulimia nervosa, binge eating disorder, other specified feeding 20 or eating disorder, or any other eating disorder not otherwise 21 specified. The commissioner, by rule, shall define “eating 22 disorders” consistent with definitions provided in the most 23 recent edition of the American psychiatric association’s 24 diagnostic and statistical manual of mental disorders, as such 25 definitions may be amended from time to time. The commissioner 26 may adopt the definitions provided in such manual by reference. 27 c. “Pharmacy care” means medications prescribed by 28 a licensed physician or psychiatrist and includes any 29 health-related services deemed medically necessary to determine 30 the need for or effectiveness of the medications prescribed, 31 but only to the extent that coverage of such medications is 32 included in the insured’s health coverage benefits. 33 d. “Psychiatric care” or “psychological care” means 34 direct or consultative services provided during inpatient 35 -1- LSB 5000XS (2) 86 av/rj 1/ 6

S.F. 2019 hospitalization, partial hospitalization, residential 1 care, intensive outpatient treatment, follow-up outpatient 2 care, or counseling, provided by a licensed psychiatrist or 3 psychologist. 4 e. “Therapeutic care” means medical care or behavioral 5 interventions provided by a licensed physician, psychiatrist, 6 psychologist, social worker, mental health counselor, or 7 marital and family therapist. 8 f. “Treatment of eating disorders” means treatment that 9 is identified in a treatment plan and includes medically 10 necessary pharmacy care, psychiatric or psychological care, or 11 therapeutic care, that is provided by a licensed physician, 12 psychiatrist, psychologist, social worker, mental health 13 counselor, or marital and family therapist. 14 g. “Treatment plan” means a plan for the treatment of eating 15 disorders developed by a licensed physician, psychiatrist, 16 psychologist, social worker, mental health counselor, 17 or marital and family therapist that includes all of the 18 following: 19 (1) A diagnosis. 20 (2) Proposed treatment by type, frequency, and duration of 21 treatment. 22 (3) Goals. 23 (4) All elements necessary for the third-party payment or 24 prepayment of claims. 25 3. Coverage required by this section is limited to 26 medically necessary diagnostic assessment and treatment of 27 eating disorders in accordance with a treatment plan, that is 28 provided by a licensed physician, psychiatrist, psychologist, 29 social worker, mental health counselor, or marital and family 30 therapist acting pursuant to that person’s applicable scope of 31 practice. 32 4. Coverage required pursuant to this section shall be 33 subject to copayment, deductible, and coinsurance provisions, 34 and any other general exclusions or limitations of a policy, 35 -2- LSB 5000XS (2) 86 av/rj 2/ 6

S.F. 2019 contract, or plan to the same extent as other health or medical 1 services covered by the policy, contract, or plan. 2 5. This section shall not be construed to limit benefits 3 which are otherwise available to an individual under a policy, 4 contract, or plan. 5 6. a. Coverage of the diagnosis and treatment of eating 6 disorders may be subject to other general exclusions and 7 limitations of the policy, contract, or plan providing for 8 third-party payment or prepayment of health or medical expenses 9 not in conflict with the provisions of this section, such 10 as coordination of benefits, and utilization of health care 11 services, which include reviews of medical necessity and care 12 management. 13 b. Medical necessity determinations and care management 14 for the treatment of eating disorders shall do all of the 15 following: 16 (1) Consider the overall medical and mental health needs of 17 the individual diagnosed with an eating disorder. 18 (2) Not be based solely on the weight of the individual 19 diagnosed with an eating disorder. 20 (3) Take into consideration the most recent practice 21 guideline for the treatment of patients with eating disorders 22 adopted by the American psychiatric association in addition to 23 current standards based upon the medical literature generally 24 recognized as authoritative in the medical community. 25 7. The commissioner shall adopt rules pursuant to chapter 26 17A to implement and administer this section. 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 -3- LSB 5000XS (2) 86 av/rj 3/ 6

S.F. 2019 individual accident and sickness policies issued to individuals 1 or to individual members of a member association. 2 9. This section applies to the following classes of 3 third-party payment provider policies, contracts, or plans 4 delivered, issued for delivery, continued, or renewed in this 5 state on or after January 1, 2017: 6 a. Individual or group accident and sickness insurance 7 providing coverage on an expense-incurred basis. 8 b. An individual or group hospital or medical service 9 contract issued pursuant to chapter 509, 514, or 514A. 10 c. An individual or group health maintenance organization 11 contract regulated under chapter 514B. 12 d. Any other entity engaged in the business of insurance, 13 risk transfer, or risk retention, which is subject to the 14 jurisdiction of the commissioner. 15 e. A plan established pursuant to chapter 509A for public 16 employees. 17 f. An organized delivery system licensed by the director of 18 public health. 19 EXPLANATION 20 The inclusion of this explanation does not constitute agreement with 21 the explanation’s substance by the members of the general assembly. 22 This bill provides that a policy, contract, or plan 23 providing for third-party payment or prepayment of health 24 or medical expenses shall provide coverage benefits for the 25 diagnostic assessment and treatment of eating disorders. 26 “Eating disorders” is defined to mean pica, rumination 27 disorder, avoidant or restrictive food intake disorder, 28 anorexia nervosa, bulimia nervosa, binge eating disorder, 29 other specified feeding or eating disorder, or any other 30 eating disorder not otherwise specified. The commissioner, by 31 rule, is required to define “eating disorders” consistent with 32 definitions provided in the most recent edition of the American 33 psychiatric association’s diagnostic and statistical manual of 34 mental disorders. 35 -4- LSB 5000XS (2) 86 av/rj 4/ 6

S.F. 2019 Coverage required by the bill is limited to medically 1 necessary diagnostic assessment and treatment of eating 2 disorders in accordance with a treatment plan, that is 3 provided by a licensed physician, psychiatrist, psychologist, 4 social worker, mental health counselor, or marital and 5 family therapist acting pursuant to that person’s applicable 6 scope of practice. The treatment plan must include a 7 diagnosis; proposed treatment by type, frequency, and duration 8 of treatment; goals; and all elements necessary for the 9 third-party payment or prepayment of claims. “Treatment of 10 eating disorders” includes medically necessary pharmacy care, 11 psychiatric or psychological care, or therapeutic care. 12 Coverage required is subject to copayment, deductible, and 13 coinsurance provisions, and any other general exclusions or 14 limitations of a policy, contract, or plan to the same extent 15 as other health or medical services that are covered. The 16 required coverage shall not be construed to limit benefits 17 which are otherwise available to an individual under a policy, 18 contract, or plan. 19 The required coverage may be subject to other general 20 exclusions and limitations of the contract, policy, or plan 21 that are not in conflict with the provisions of the bill, 22 such as coordination of benefits, and utilization of health 23 care services, which include reviews of medical necessity 24 and care management. Medical necessity determinations and 25 care management for the treatment of eating disorders must 26 consider the overall medical and mental health needs of the 27 individual diagnosed with the disorder; not be based solely 28 on the weight of the individual diagnosed with the disorder; 29 and take into consideration the most recent practice guideline 30 for the treatment of patients with eating disorders adopted 31 by the American psychiatric association in addition to 32 current standards based upon the medical literature generally 33 recognized as authoritative in the medical community. 34 The commissioner is directed to adopt rules pursuant to Code 35 -5- LSB 5000XS (2) 86 av/rj 5/ 6

S.F. 2019 chapter 17A to implement and administer the provisions of the 1 bill. 2 The bill applies to specified individual and group policies, 3 contracts, and plans that are delivered, issued for delivery, 4 continued, or renewed in this state on or after January 1, 5 2017. 6 -6- LSB 5000XS (2) 86 av/rj 6/ 6