S.F. 2072 Section 1. Section 225D.1, subsection 8, Code 2016, is 1 amended to read as follows: 2 8. “Eligible individual” means a child less than nine years 3 of age who has been diagnosed with autism based on a diagnostic 4 assessment of autism, is not otherwise eligible for coverage 5 for applied behavioral analysis treatment under the medical 6 assistance program, section 514C.28 514C.31 , or other private 7 insurance coverage, and whose household income does not exceed 8 four hundred percent of the federal poverty level. 9 Sec. 2. Section 225D.2, subsection 2, paragraph l, Code 10 2016, is amended to read as follows: 11 l. Proof of eligibility for the autism support program that 12 includes a written denial for coverage or a benefits summary 13 indicating that applied behavioral analysis treatment is not 14 a covered benefit for which the applicant is eligible, under 15 the Medicaid program, section 514C.28 514C.31 , or other private 16 insurance coverage. 17 Sec. 3. Section 225D.2, subsection 3, Code 2016, is amended 18 to read as follows: 19 3. Moneys in the autism support fund created under 20 subsection 5 shall be expended only for eligible individuals 21 who are not eligible for coverage for applied behavioral 22 analysis treatment under the medical assistance program, 23 section 514C.28 514C.31 , or other private insurance. Payment 24 for applied behavioral analysis treatment through the fund 25 shall be limited to only applied behavioral analysis treatment 26 that is clinically relevant and only to the extent approved 27 under the guidelines established by rule of the department. 28 Sec. 4. NEW SECTION . 514C.31 Autism spectrum disorders 29 coverage. 30 1. Notwithstanding the uniformity of treatment requirements 31 of section 514C.6, a group policy, contract, or plan providing 32 for third-party payment or prepayment of health, medical, and 33 surgical coverage benefits shall provide coverage benefits 34 to covered individuals under twenty-two years of age for 35 -1- LSB 5945XS (1) 86 av/nh 1/ 9

S.F. 2072 the screening, diagnosis, and treatment of autism spectrum 1 disorders if the policy, contract, or plan is either of the 2 following: 3 a. A policy, contract, or plan issued by a carrier, as 4 defined in section 513B.2, or an organized delivery system 5 authorized under 1993 Iowa Acts, chapter 158, to an employer 6 who on at least fifty percent of the employer’s working days 7 during the preceding calendar year employed more than fifty 8 full-time equivalent employees. In determining the number 9 of full-time equivalent employees of an employer, employers 10 who are affiliated or who are able to file a consolidated tax 11 return for purposes of state taxation shall be considered one 12 employer. 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 -2- LSB 5945XS (1) 86 av/nh 2/ 9

S.F. 2072 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 -3- LSB 5945XS (1) 86 av/nh 3/ 9

S.F. 2072 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 2020, the 8 commissioner shall, on or before July 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 for applied behavior analysis shall include the 22 services of persons working under the supervision of a behavior 23 analyst certified by a nationally recognized board or under 24 the supervision of a licensed psychologist, to provide applied 25 behavior analysis. 26 5. Coverage required pursuant to this section shall not be 27 subject to any limits on the number of visits an individual may 28 make for treatment of an autism spectrum disorder. 29 6. Coverage required pursuant to this section shall not 30 be subject to dollar limits, deductibles, copayments, or 31 coinsurance provisions, or any other general exclusions or 32 limitations of a group plan that are less favorable to an 33 insured than the dollar limits, deductibles, copayments, or 34 coinsurance provisions that apply to substantially all medical 35 -4- LSB 5945XS (1) 86 av/nh 4/ 9

S.F. 2072 and surgical benefits under the policy, contract, or plan, 1 except as provided in subsection 3. 2 7. Coverage required by this section shall be provided 3 in coordination with coverage required for the treatment of 4 autistic disorders pursuant to section 514C.22. 5 8. This section shall not be construed to limit benefits 6 which are otherwise available to an individual under a group 7 policy, contract, or plan. 8 9. This section shall not be construed as affecting any 9 obligation to provide services to an individual under an 10 individualized family service plan, an individualized education 11 program, or an individualized service plan. 12 10. Except for inpatient services, if an insured is 13 receiving treatment for an autism spectrum disorder, an insurer 14 is entitled to review the treatment plan annually, unless the 15 insurer and the insured’s treating physician or psychologist 16 agree that a more frequent review is necessary. An agreement 17 giving an insurer the right to review the treatment plan of 18 an insured more frequently applies only to that insured and 19 does not apply to other individuals being treated for autism 20 spectrum disorders by a physician or psychologist. The cost of 21 conducting a review of a treatment plan shall be borne by the 22 insurer. 23 11. This section shall not apply to accident-only, 24 specified disease, short-term hospital or medical, hospital 25 confinement indemnity, credit, dental, vision, Medicare 26 supplement, long-term care, basic hospital and medical-surgical 27 expense coverage as defined by the commissioner, disability 28 income insurance coverage, coverage issued as a supplement 29 to liability insurance, workers’ compensation or similar 30 insurance, or automobile medical payment insurance, or 31 individual accident and sickness policies issued to individuals 32 or to individual members of a member association. 33 12. The commissioner shall adopt rules pursuant to chapter 34 17A to implement and administer this section. 35 -5- LSB 5945XS (1) 86 av/nh 5/ 9

S.F. 2072 13. An insurer shall not terminate coverage of an individual 1 solely because the individual is diagnosed with or has received 2 treatment for an autism spectrum disorder. 3 14. a. By February 1, 2018, and every February 1 4 thereafter, the commissioner shall submit a report to the 5 general assembly regarding implementation of the coverage 6 required under this section. The report shall include 7 information concerning but not limited to all of the following: 8 (1) The total number of insureds diagnosed with autism 9 spectrum disorder in the immediately preceding calendar year. 10 (2) The total cost of all claims paid out in the immediately 11 preceding calendar year for coverage required under this 12 section. 13 (3) The cost of such coverage per insured per month. 14 (4) The average cost per insured per month for coverage of 15 applied behavior analysis required under this section. 16 b. All third-party payment provider policies, contracts, 17 or plans, as specified in subsection 1, and plans established 18 pursuant to chapter 509A shall provide the commissioner with 19 data requested by the commissioner for inclusion in the annual 20 report. 21 15. If any provision of this section or its application 22 to any person or circumstance is held invalid, the invalidity 23 does not affect other provisions or application of this section 24 which can be given effect without the invalid provision or 25 application, and to this end the provisions of this section are 26 severable. 27 16. This section applies to third-party payment provider 28 policies, contracts, or plans, as specified in subsection 1, 29 and to plans established pursuant to chapter 509A, that are 30 delivered, issued for delivery, continued, or renewed in this 31 state on or after January 1, 2017. 32 Sec. 5. REPEAL. Section 514C.28, Code 2016, is repealed. 33 Sec. 6. EFFECTIVE DATE. The following provisions of this 34 Act take effect January 1, 2017: 35 -6- LSB 5945XS (1) 86 av/nh 6/ 9

S.F. 2072 1. The sections of this Act amending sections 225D.1 and 1 225D.2. 2 2. The section of this Act repealing section 514C.28. 3 EXPLANATION 4 The inclusion of this explanation does not constitute agreement with 5 the explanation’s substance by the members of the general assembly. 6 This bill creates new Code section 514C.31 which requires 7 certain group health insurance policies, contracts, or plans 8 to provide coverage benefits for the screening, diagnosis, and 9 treatment of autism spectrum disorders. The new provision 10 is applicable to group health policies, contracts, or plans 11 issued to employers with more than 50 employees and to health 12 plans established under Code chapter 509A for public employees. 13 Coverage benefits are required for covered individuals under 22 14 years of age. 15 “Autism spectrum disorder” includes autistic disorder, 16 Asperger’s disorder, and pervasive developmental disorders 17 not otherwise specified, as defined by the commissioner of 18 insurance by rule consistent with definitions provided in the 19 most recent edition of the American psychiatric association’s 20 diagnostic and statistical manual of mental disorders. 21 The required maximum benefit for coverage for applied 22 behavior analysis is $36,000 per year. Beginning in 2020, 23 the commissioner is required to make and publish annual 24 adjustments for inflation to the maximum benefit required equal 25 to the percentage change in the medical care component of the 26 United States department of labor consumer price index for 27 all consumers in the previous year. The published adjusted 28 maximum benefit is applicable to specified group policies, 29 contracts, or plans delivered, issued for delivery, continued, 30 or renewed during the following calendar year. Payments made 31 on behalf of a covered individual for any treatment other than 32 applied behavior analysis cannot be applied toward this maximum 33 benefit. 34 Coverage for applied behavior analysis must include 35 -7- LSB 5945XS (1) 86 av/nh 7/ 9

S.F. 2072 services rendered by persons working under the supervision of 1 a certified behavior analyst or a licensed psychologist to 2 provide applied behavior analysis. 3 Required coverage cannot be subject to any limits on the 4 number of visits an individual may make for treatment of an 5 autism spectrum disorder. 6 Required coverage cannot be subject to dollar limits, 7 deductibles, copayments, or coinsurance provisions, or any 8 other general exclusions or limitations of a group plan that 9 are less favorable to an insured than those that apply to 10 physical illness generally under the policy, contract, or 11 plan, except as to the maximum benefit limitation for applied 12 behavior analysis coverage. 13 Coverage of autism spectrum disorders under the new Code 14 section is to be provided in coordination with coverage 15 required for the treatment of autistic disorders pursuant to 16 Code section 514C.22. The Code section shall not be construed 17 to limit benefits otherwise available to an individual under a 18 group policy, contract, or plan. 19 The new Code section shall not be construed as affecting 20 any obligation to provide services to an individual under an 21 individualized family service plan, education program, or 22 service plan. 23 Except for inpatient services, if an insured is receiving 24 treatment for an autism spectrum disorder, an insurer is 25 entitled to review the treatment plan annually, unless the 26 insurer and the insured’s treating physician or psychologist 27 agree that more frequent review is necessary. Such an 28 agreement applies only to that insured and does not apply to 29 other individuals being treated for autism spectrum disorder by 30 a physician or psychologist. The cost of conducting the review 31 of a treatment plan is to be borne by the insurer. 32 The new Code section does not apply to various specified 33 types of insurance. The commissioner is required to adopt 34 rules to implement and administer the provision. 35 -8- LSB 5945XS (1) 86 av/nh 8/ 9

S.F. 2072 An insurer shall not terminate coverage of an individual 1 solely because the individual is diagnosed with or has received 2 treatment for an autism spectrum disorder. 3 By February 1, 2018, and every February 1 thereafter, the 4 commissioner of insurance is required to submit a report to 5 the general assembly regarding implementation of the coverage 6 required under the new Code section. The annual report 7 must include information about the total number of insureds 8 diagnosed with autism spectrum disorders in the preceding 9 calendar year, the total cost of all claims paid out for the 10 required coverage, the cost of such coverage per insured per 11 month, and the average cost per insured per month for the 12 required coverage of applied behavior analysis. 13 The new Code section is severable if any portion of the Code 14 section or its application to any person or circumstance is 15 held to be invalid. 16 The new Code section applies to specified third-party 17 payment provider policies, contracts, or plans, and to plans 18 established pursuant to Code chapter 509A, that are delivered, 19 issued for delivery, continued, or renewed in this state on or 20 after January 1, 2017. 21 Code section 514C.28, which currently mandates coverage 22 for autism spectrum disorders only in group plans established 23 pursuant to Code chapter 509A for state employees, is repealed 24 effective January 1, 2017. 25 Coordinating changes are made in Code sections 225D.1 and 26 225D.2 to provide that persons who are eligible for coverage 27 of applied behavior analysis treatment under new Code section 28 514C.31 are not eligible to participate in the state autism 29 support program. These changes also take effect January 1, 30 2017. 31 -9- LSB 5945XS (1) 86 av/nh 9/ 9