SSB 1050 (LSB 1597XC (5) 90)

SENATE FILE _____ 

BY  (PROPOSED COMMITTEE ON COMMERCE BILL BY CHAIRPERSON BROWN)

A BILL FOR

An Act relating to insurance coverage for covered individuals for the treatment of autism spectrum disorder.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  Section 514C.22, subsection 3, paragraph g, Code 2023, is amended to read as follows:
   g.  Autistic disorders Autism spectrum disorder, as that term is defined in section 514C.28, subsection 2.
    Sec. 2.  Section 514C.22, subsection 4, Code 2023, is amended to read as follows:
   4.  The commissioner, by rule, shall define the biologically based mental illnesses identified in subsection 3, paragraphs “a” through “f”. Definitions established by the commissioner shall be consistent with definitions provided in the most recent edition of the American psychiatric association’s diagnostic and statistical manual of mental disorders, as such definitions may be amended from time to time. The commissioner may adopt the definitions provided in such manual by reference.
    Sec. 3.  Section 514C.22, subsection 7, Code 2023, is amended by adding the following new paragraph:
   NEW PARAGRAPH.  c.  Notwithstanding paragraphs “a” and “b”, a group policy, contract, or plan covered under this section shall not impose an aggregate annual or lifetime limit on biologically based mental illness coverage benefits for autism spectrum disorder.
    Sec. 4.  Section 514C.22, subsection 8, unnumbered paragraph 1, Code 2023, is amended to read as follows:
   A group policy, contract, or plan covered under this section shall at a minimum allow for thirty inpatient days and fifty-two outpatient visits annually, and shall not limit the number of outpatient visits a covered individual may have with a practitioner for applied behavior analysis under section 514C.31, or with an autism service provider for treatment of autism spectrum disorder under section 514C.28. The policy, contract, or plan may also include deductibles, coinsurance, or copayments, provided the amounts and extent of such deductibles, coinsurance, or copayments applicable to other health, medical, or surgical services coverage under the policy, contract, or plan are the same. It is not a violation of this section if the policy, contract, or plan excludes entirely from coverage benefits for the cost of providing the following:
    Sec. 5.  Section 514C.22, subsection 9, Code 2023, is amended to read as follows:
   9.  This section applies to third-party payment provider policies or contracts and to plans established pursuant to chapter 509A that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2006 2024.
    Sec. 6.  Section 514C.28, subsections 1, 3, 5, and 13, Code 2023, are amended to read as follows:
   1.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a group plan established pursuant to chapter 509A for employees of the state providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide coverage benefits to covered individuals under twenty-one years of age for the diagnostic assessment of autism spectrum disorder and for the treatment of autism spectrum disorder.
   3.  Coverage is required pursuant to this section in a maximum benefit amount of not more than thirty-six thousand dollars per year but shall not be subject to any limits on the number of visits to a covered individual may have with an autism service provider for treatment of autism spectrum disorder. The commissioner shall, on or before April 1 of each calendar year, publish an adjustment to the maximum benefit required equal to the percentage change in the United States department of labor consumer price index for all urban consumers in the preceding year, and the published adjusted maximum benefit shall be applicable to group policies, contracts, or plans subject to this section that are issued or renewed on or after January 1 of the following calendar year. Payments made under a group plan subject to this section on behalf of a covered individual for treatment of a health condition unrelated to or distinguishable from the individual’s autism spectrum disorder shall not be applied toward any maximum benefit established under this subsection.
   5.  Coverage required by this section shall be provided in coordination with coverage required for the treatment of autistic disorders autism spectrum disorder pursuant to section 514C.22.
   13.   This section applies to plans established pursuant to chapter 509A for employees of the state that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011 2024.
    Sec. 7.  Section 514C.31, subsection 1, unnumbered paragraph 1, Code 2023, is amended to read as follows:
   Notwithstanding the uniformity of treatment requirements of section 514C.6, a group policy, contract, or plan providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide coverage benefits for applied behavior analysis provided by a practitioner to covered individuals under nineteen years of age for the treatment of autism spectrum disorder pursuant to a treatment plan if the policy, contract, or plan is either of the following:
    Sec. 8.  Section 514C.31, subsection 3, Code 2023, is amended by striking the subsection.
    Sec. 9.  Section 514C.31, subsections 4, 5, and 10, Code 2023, are amended to read as follows:
   4.  Coverage required pursuant to this section may be subject to dollar limits, deductibles, copayments, or coinsurance provisions that apply to other medical and surgical services under the policy, contract, or plan, subject to the requirements of subsection 3.
   5.  Coverage required pursuant to this section may be subject to care management provisions of the applicable policy, contract, or plan, including prior authorization, and prior approval, and limits on the number of visits a covered individual may make for applied behavior analysis.
   10.  This section applies to third-party provider payment contracts, policies, or plans specified in subsection 1, paragraph “a” or to plans established pursuant to chapter 509A for public employees other than employees of the state, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2018 2024.
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 covered individuals for the treatment of autism spectrum disorder (autism).
   Under current law, a group plan established pursuant to Code chapter 509A for employees of the state that provides for third-party payment or prepayment of health, medical, and surgical coverage benefits (coverage) shall provide coverage to covered individuals under 21 years of age for the diagnostic assessment and treatment of autism, and coverage is required in a maximum benefit amount of not more than $36,000 per year. The bill eliminates the 21-year maximum age limit and the maximum benefit amount.
   Under current law, a group policy, contract, or plan (policy) providing for third-party payment or prepayment of health, medical, and surgical coverage shall provide coverage for applied behavior analysis (analysis) provided by a practitioner to covered individuals under 19 years of age for the treatment of autism pursuant to a treatment plan if the policy is either a policy issued by a carrier to an employer who on at least 50 percent of the employer’s working days during the preceding calendar year employed more than 50 full-time equivalent employees, or the policy is established pursuant to Code chapter 509A for public employees other than employees of the state. Under the bill, the age restriction is eliminated. Current law requires that the coverage for analysis shall provide an annual maximum benefit of not less than $36,000 for individuals through age six, $25,000 for individuals age seven through 13, and $12,500 for individuals age 14 through 18. The bill eliminates the maximum benefit amounts and the age categories.
   The bill makes conforming changes to Code section 514C.22.
   The bill applies to third-party payment providers enumerated in the bill. The types of specialized health-related insurance which are not subject to the bill are specified in the bill. The bill applies to plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2024.