HF 50 (LSB 1090YH (3) 90)

HOUSE FILE 50

BY  JONES

A BILL FOR

An Act relating to insurance coverage for the treatment of eating disorders.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.36  Eating disorders —— coverage.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense obligation imposed on a covered person by a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses.
   b.  “Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.
   c.  “Eating disorder” means pica, rumination disorder, avoidant or restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent edition of the diagnostic and statistical manual of mental disorders as published by the American psychiatric association.
   d.  “Facility” means an institution providing health care services or a health care setting, including but not limited to hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic centers, laboratory and imaging centers, rehabilitation centers, and other therapeutic settings.
   e.  “Health care professional” means a physician, a psychologist, a psychiatrist, a nutritionist, or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law.
   f.  “Health care provider” means a health care professional or a facility.
   g.  “Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease including services for mental health conditions, illnesses, injuries, or diseases. “Health care services” also includes dental care services.
   h.  “Health carrier” means the same as defined in section 514J.102.
   i.  “Treatment plan” means a plan for the treatment of a covered person’s eating disorder developed by a health care professional pursuant to a comprehensive evaluation or reevaluation performed in consultation with the covered person or the covered person’s representative. The plan may include but is not limited to cognitive behavioral therapy, family-based therapy, group cognitive behavioral therapy, nutrition education, prescription drugs, hospitalization, day treatment programs, residential treatment programs, and other health care services.
   2.  a.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a health carrier that offers individual, group, or small group contracts, policies, or plans in this state that provide for third-party payment or prepayment of health or medical expenses shall offer coverage for the treatment of eating disorders including all of the following:
   (1)  Health care services pursuant to a covered person’s treatment plan.
   (2)  Health care services pursuant to a covered person’s treatment plan that are provided to the covered person out-of-network or out-of-state if such health care services are unavailable in this state and are determined to be medically necessary by the covered person’s health care provider.
   b.  Coverage required under this section shall not be less favorable than coverage a health carrier offers for general physical illness.
   c.  Cost-sharing requirements imposed for coverage required under this section shall not be less favorable than cost-sharing requirements imposed by a health carrier for general physical illness.
   3.  a.  This section applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2024:
   (1)  Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
   (2)  An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
   (3)  An individual or group health maintenance organization contract regulated under chapter 514B.
   (4)  A plan established for public employees pursuant to chapter 509A.
   (5)  The medical assistance program under chapter 249A including all managed care organizations acting pursuant to a contract with the department of health and human services to administer the medical assistance program.
   b.  This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.
   4.  The commissioner of insurance shall adopt rules pursuant to chapter 17A to administer this section.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to insurance coverage for eating disorders. “Eating disorder” is defined in the bill as pica, rumination disorder, avoidant or restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating disorder, and any other eating disorder contained in the most recent edition of the diagnostic and statistical manual of mental disorders as published by the American psychiatric association.
   The bill requires a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses to provide coverage for health care services (services) pursuant to a covered person’s treatment plan (plan), and services pursuant to a covered person’s plan that are provided to the covered person out-of-network or out-of-state if such services are unavailable in this state and are determined to be medically necessary by the covered person’s health care provider. “Treatment plan” is defined in the bill as a plan for the treatment of a covered person’s eating disorder developed by a health care professional pursuant to a comprehensive evaluation or reevaluation performed in consultation with the covered person or the covered person’s representative. The plan may include but is not limited to cognitive behavioral therapy, family-based therapy, group cognitive behavioral therapy, nutrition education, prescription drugs, hospitalization, day treatment programs, residential treatment programs, and other health care services.
   The bill applies to third-party payment providers enumerated in the bill, including the medical assistance program (program) under Code chapter 249A and managed care organizations acting pursuant to a contract with the department of health and human services to administer the program. The bill specifies the types of specialized health-related insurance which are not subject to the bill.
   The commissioner of insurance is required to adopt rules to administer the bill.
   The bill applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2024.