Senate File 400 - Introduced SENATE FILE 400 BY COMMITTEE ON COMMERCE (SUCCESSOR TO SSB 1043) A BILL FOR An Act requiring certain health insurance policies, contracts, 1 or plans to provide coverage of applied behavior analysis 2 for treatment of autism spectrum disorder for certain 3 individuals, and including applicability and effective date 4 provisions. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 6 TLSB 1738SV (2) 87 av/nh

S.F. 400 Section 1. Section 225D.1, subsection 8, Code 2017, is 1 amended to read as follows: 2 8. “Eligible individual” means a child less than fourteen 3 years of age who has been diagnosed with autism based on a 4 diagnostic assessment of autism, is not otherwise eligible for 5 coverage for applied behavioral analysis treatment or applied 6 behavior analysis treatment under the medical assistance 7 program, section 514C.28 , 514C.31 , or other private insurance 8 coverage, and whose household income does not exceed five 9 hundred percent of the federal poverty level. 10 Sec. 2. Section 225D.2, subsection 2, paragraph l, Code 11 2017, is amended to read as follows: 12 l. Proof of eligibility for the autism support program that 13 includes a written denial for coverage or a benefits summary 14 indicating that applied behavioral analysis treatment or 15 applied behavior analysis treatment is not a covered benefit 16 for which the applicant is eligible, under the Medicaid 17 program, section 514C.28 , 514C.31 , or other private insurance 18 coverage. 19 Sec. 3. Section 225D.2, subsection 3, Code 2017, is amended 20 to read as follows: 21 3. Moneys in the autism support fund created under 22 subsection 5 shall be expended only for eligible individuals 23 who are not eligible for coverage for applied behavioral 24 analysis treatment or applied behavior analysis treatment under 25 the medical assistance program, section 514C.28 , 514C.31 , 26 or other private insurance. Payment for applied behavioral 27 analysis treatment through the fund shall be limited to only 28 applied behavioral analysis treatment that is clinically 29 relevant and only to the extent approved under the guidelines 30 established by rule of the department. 31 Sec. 4. NEW SECTION . 514C.31 Applied behavior analysis for 32 treatment of autism spectrum disorder —— coverage. 33 1. Notwithstanding the uniformity of treatment requirements 34 of section 514C.6, a group policy, contract, or plan providing 35 -1- LSB 1738SV (2) 87 av/nh 1/ 7

S.F. 400 for third-party payment or prepayment of health, medical, and 1 surgical coverage benefits shall provide coverage benefits for 2 applied behavior analysis provided by a practitioner to covered 3 individuals under nineteen years of age for the treatment of 4 autism spectrum disorder pursuant to a treatment plan if the 5 policy, contract, or plan is either of the following: 6 a. A policy, contract, or plan issued by a carrier, as 7 defined in section 513B.2, or an organized delivery system 8 authorized under 1993 Iowa Acts, chapter 158, to an employer 9 who on at least fifty percent of the employer’s working days 10 during the preceding calendar year employed more than fifty 11 full-time equivalent employees. In determining the number 12 of full-time equivalent employees of an employer, employers 13 who are affiliated or who are able to file a consolidated tax 14 return for purposes of state taxation shall be considered one 15 employer. 16 b. A plan established pursuant to chapter 509A for public 17 employees other than employees of the state. 18 2. As used in this section, unless the context otherwise 19 requires: 20 a. “Applied behavior analysis” means the design, 21 implementation, and evaluation of environmental modifications, 22 using behavioral stimuli and consequences, to produce socially 23 significant improvement in human behavior, including the use of 24 direct observation, measurement, and functional analysis of the 25 relationship between environment and behavior. 26 b. “Autism spectrum disorder” means a complex 27 neurodevelopmental medical disorder characterized by social 28 impairment, communication difficulties, and restricted, 29 repetitive, and stereotyped patterns of behavior. 30 c. “Practitioner” means any of the following: 31 (1) A physician licensed pursuant to chapter 148. 32 (2) A psychologist licensed pursuant to chapter 154B. 33 (3) A person who holds a master’s degree or a doctoral 34 degree and is certified by a national behavior analyst 35 -2- LSB 1738SV (2) 87 av/nh 2/ 7

S.F. 400 certification board as a behavior analyst. 1 d. “Treatment plan” means a plan for the treatment of an 2 autism spectrum disorder developed by a licensed physician 3 or licensed psychologist after a comprehensive evaluation or 4 reevaluation performed in a manner consistent with the most 5 recent clinical report or recommendations of the American 6 academy of pediatrics. “Treatment plan” includes supervisory 7 services, subject to the provisions of subsection 5. 8 3. a. The coverage for applied behavior analysis required 9 pursuant to this section shall provide an annual maximum 10 benefit of not less than the following: 11 (1) For an individual through age six, thirty-six thousand 12 dollars per year. 13 (2) For an individual age seven through age thirteen, 14 twenty-five thousand dollars per year. 15 (3) For an individual age fourteen through age eighteen, 16 twelve thousand five hundred dollars per year. 17 b. Payments made under a group policy, contract, or plan 18 subject to this section on behalf of a covered individual for 19 any treatment other than applied behavior analysis shall not 20 be applied toward the maximum benefit established under this 21 subsection. 22 4. Coverage required pursuant to this section may be 23 subject to dollar limits, deductibles, copayments, or 24 coinsurance provisions that apply to other medical and surgical 25 services under the policy, contract, or plan, subject to the 26 requirements of subsection 3. 27 5. Coverage required pursuant to this section may be 28 subject to care management provisions of the applicable 29 policy, contract, or plan, including prior authorization, 30 prior approval, and limits on the number of visits a covered 31 individual may make for applied behavior analysis. 32 6. A carrier, organized delivery system, or plan may request 33 a review of a treatment plan for a covered individual not 34 more than once every three months during the first year of 35 -3- LSB 1738SV (2) 87 av/nh 3/ 7

S.F. 400 the treatment plan and not more than once every six months 1 during every year thereafter, unless the carrier, organized 2 delivery system, or plan and the covered individual’s treating 3 physician or psychologist execute an agreement that a more 4 frequent review is necessary. An agreement giving a carrier, 5 organized delivery system, or plan the right to review the 6 treatment plan of a covered individual more frequently applies 7 only to a particular covered individual receiving applied 8 behavior analysis and does not apply to other individuals 9 receiving applied behavior analysis from a practitioner. 10 The cost of conducting a review under this section shall be 11 paid by the carrier, organized delivery system, or plan. A 12 carrier, organized delivery system, or plan shall not change 13 the provisions of a treatment plan until the completion of a 14 review of the treatment plan. 15 7. This section shall not be construed to limit benefits 16 which are otherwise available to an individual under a group 17 policy, contract, or plan. 18 8. This section shall not be construed as affecting any 19 obligation to provide services to an individual under an 20 individualized family service plan, an individualized education 21 program, or an individualized service plan. 22 9. This section shall not apply to accident-only, 23 specified disease, short-term hospital or medical, hospital 24 confinement indemnity, credit, dental, vision, Medicare 25 supplement, long-term care, basic hospital and medical-surgical 26 expense coverage as defined by the commissioner, disability 27 income insurance coverage, coverage issued as a supplement 28 to liability insurance, workers’ compensation or similar 29 insurance, or automobile medical payment insurance, or 30 individual accident and sickness policies issued to individuals 31 or to individual members of a member association. 32 10. This section applies to third-party provider payment 33 contracts, policies, or plans specified in subsection 1, 34 paragraph “a” or to plans established pursuant to chapter 509A 35 -4- LSB 1738SV (2) 87 av/nh 4/ 7

S.F. 400 for public employees other than employees of the state, that 1 are delivered, issued for delivery, continued, or renewed in 2 this state on or after January 1, 2018. 3 Sec. 5. EFFECTIVE DATE. The following provisions of this 4 Act take effect January 1, 2018: 5 1. The sections of this Act amending sections 225D.1 and 6 225D.2. 7 EXPLANATION 8 The inclusion of this explanation does not constitute agreement with 9 the explanation’s substance by the members of the general assembly. 10 This bill creates new Code section 514C.31, which requires 11 certain individual and group health insurance policies, 12 contracts, or plans and plans established pursuant to Code 13 chapter 509A for public employees other than employees of 14 the state to provide coverage benefits for applied behavior 15 analysis for the treatment of autism spectrum disorder. 16 “Autism spectrum disorder” means a complex 17 neurodevelopmental medical disorder characterized by 18 social impairment, communication difficulties, and restricted, 19 repetitive, and stereotyped patterns of behavior. 20 The bill requires coverage for applied behavior analysis 21 that is provided by a board-certified behavior analyst or by 22 a licensed physician or psychologist. The required maximum 23 benefit for coverage for applied behavior analysis for an 24 individual diagnosed with an autism spectrum disorder is 25 $36,000 per year through age 6, $25,000 per year from age 7 26 through age 13, and $12,500 per year from age 14 through age 27 18. 28 Required coverage can be subject to preauthorization, prior 29 approval, or other care management requirements, including 30 limits on the number of visits an individual may make for 31 applied behavior analysis. 32 Required coverage can be subject to dollar limits, 33 deductibles, copayments, or coinsurance provisions, or any 34 other general exclusions or limitations of the coverage that 35 -5- LSB 1738SV (2) 87 av/nh 5/ 7

S.F. 400 apply to other covered medical or surgical services. 1 The new Code section shall not be construed to limit benefits 2 otherwise available to an individual under a group policy, 3 contract, or plan. 4 The new Code section shall not be construed as affecting 5 any obligation to provide services to an individual under an 6 individualized family service plan, education program, or 7 service plan. 8 A carrier, organized delivery system, or plan may request 9 to review a treatment plan not more than once every three 10 months during the first year of the treatment plan and not 11 more than once every six months during every year thereafter, 12 unless the carrier, organized delivery system, or plan and 13 the individual’s treating physician or psychologist execute 14 an agreement that more frequent review is necessary. Such 15 an agreement applies only to that individual and does not 16 apply to other individuals receiving applied behavior analysis 17 from a board-certified behavior analyst, a physician, or a 18 psychologist. The cost of conducting the review of a treatment 19 plan is to be borne by the carrier, organized delivery system, 20 or plan. A carrier, organized delivery system, or plan 21 shall not change the provisions of a treatment plan until the 22 completion of a review of the plan. 23 The new Code section does not apply to various specified 24 types of insurance. 25 New Code section 514C.31 applies to third-party provider 26 payment contracts, policies, or plans specified in the 27 bill, or plans established pursuant to Code chapter 509A for 28 public employees other than employees of the state, that are 29 delivered, issued for delivery, continued, or renewed in this 30 state on or after January 1, 2018. 31 Coordinating changes are made in Code sections 225D.1 and 32 225D.2 to provide that persons who are eligible for coverage 33 of applied behavior analysis treatment under new Code section 34 514C.31 are not eligible to participate in the state autism 35 -6- LSB 1738SV (2) 87 av/nh 6/ 7