Senate File 2349 - Reprinted SENATE FILE 2349 BY COMMITTEE ON COMMERCE (SUCCESSOR TO SF 1) (As Amended and Passed by the Senate February 23, 2010 ) A BILL FOR An Act requiring certain group health insurance plans 1 established for employees of the state to provide coverage 2 for autism spectrum disorders for certain persons, requiring 3 certification of behavior specialists, and providing an 4 applicability date. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 6 SF 2349 (5) 83 av/rj/jh
S.F. 2349 Section 1. NEW SECTION . 514C.26 Autism spectrum disorders 1 coverage. 2 1. Notwithstanding the uniformity of treatment requirements 3 of section 514C.6, a group plan established pursuant to chapter 4 509A for employees of the state providing for third-party 5 payment or prepayment of health, medical, and surgical coverage 6 benefits shall provide coverage benefits to covered individuals 7 under twenty-one years of age for the diagnostic assessment 8 of autism spectrum disorders and for the treatment of autism 9 spectrum disorders. 10 2. As used in this section, unless the context otherwise 11 requires: 12 a. “Applied behavioral analysis” means the design, 13 implementation, and evaluation of environmental modifications, 14 using behavioral stimuli and consequences, to produce socially 15 significant improvement in human behavior or to prevent loss 16 of attained skill or function, including the use of direct 17 observation, measurement, and functional analysis of the 18 relations between environment and behavior. 19 b. “Autism service provider” means a person, entity, 20 or group providing treatment of autism spectrum disorders, 21 pursuant to a treatment plan. 22 c. “Autism spectrum disorders” means any of the pervasive 23 developmental disorders including autistic disorder, Asperger’s 24 disorder, and pervasive developmental disorders not otherwise 25 specified. The commissioner, by rule, shall define “autism 26 spectrum disorders” consistent with definitions provided in the 27 most recent edition of the American psychiatric association’s 28 diagnostic and statistical manual of mental disorders, as such 29 definitions may be amended from time to time. The commissioner 30 may adopt the definitions provided in such manual by reference. 31 d. “Behavior specialist” means an individual, certified by 32 the board of medicine, who designs, implements, or evaluates 33 a behavior modification intervention component of a treatment 34 plan, including those based on applied behavioral analysis, to 35 -1- SF 2349 (5) 83 av/rj/jh 1/ 6
S.F. 2349 produce socially significant improvements in human behavior or 1 to prevent loss of attained skill or function, through skill 2 acquisition and the reduction of problematic behavior. 3 e. “Diagnostic assessment of autism spectrum disorders” means 4 medically necessary assessment, evaluations, or tests performed 5 by a licensed physician, licensed physician assistant, licensed 6 psychologist, or licensed registered nurse practitioner to 7 diagnose whether an individual has an autism spectrum disorder. 8 f. “Pharmacy care” means medications prescribed by a 9 licensed physician, licensed physician assistant, or licensed 10 registered nurse practitioner and any assessment, evaluation, 11 or test prescribed or ordered by a licensed physician, licensed 12 physician assistant, or licensed registered nurse practitioner 13 to determine the need for or effectiveness of such medications. 14 g. “Psychiatric care” means direct or consultative services 15 provided by a licensed physician who specializes in psychiatry. 16 h. “Psychological care” means direct or consultative 17 services provided by a licensed psychologist. 18 i. “Rehabilitative care” means professional services and 19 treatment programs, including applied behavioral analysis, 20 provided by an autism service provider to produce socially 21 significant improvement in human behavior or to prevent loss 22 of attained skill or function. 23 j. “Therapeutic care” means services provided by a licensed 24 speech pathologist, licensed occupational therapist, or 25 licensed physical therapist. 26 k. “Treatment of autism spectrum disorders” means treatment 27 that is identified in a treatment plan and includes medically 28 necessary pharmacy care, psychiatric care, psychological care, 29 rehabilitative care, and therapeutic care that is one of the 30 following: 31 (1) Prescribed, ordered, or provided by a licensed 32 physician, licensed physician assistant, licensed psychologist, 33 licensed social worker, or licensed registered nurse 34 practitioner. 35 -2- SF 2349 (5) 83 av/rj/jh 2/ 6
S.F. 2349 (2) Provided by an autism service provider. 1 (3) Provided by a person, entity, or group that works under 2 the direction of an autism service provider. 3 l. “Treatment plan” means a plan for the treatment of 4 autism spectrum disorders developed by a licensed physician or 5 licensed psychologist pursuant to a comprehensive evaluation 6 or reevaluation performed in a manner consistent with the most 7 recent clinical report or recommendations of the American 8 academy of pediatrics, as determined by the commissioner by 9 rule. 10 3. Coverage is required pursuant to this section in a 11 maximum benefit amount of not more than thirty-six thousand 12 dollars per year but shall not be subject to any limits 13 on the number of visits to an autism service provider for 14 treatment of autism spectrum disorders. Beginning in 2014, 15 the commissioner shall, on or before April 1 of each calendar 16 year, publish an adjustment to the maximum benefit required 17 equal to the percentage change in the United States department 18 of labor consumer price index for all urban consumers in the 19 preceding year, and the published adjusted maximum benefit 20 shall be applicable to group policies, contracts, or plans 21 subject to this section that are issued or renewed on or after 22 January 1 of the following calendar year. Payments made under 23 a group plan subject to this section on behalf of a covered 24 individual for treatment of a health condition unrelated to or 25 distinguishable from the individual’s autism spectrum disorder 26 shall not be applied toward any maximum benefit established 27 under this subsection. 28 4. Coverage required pursuant to this section shall be 29 subject to copayment, deductible, and coinsurance provisions, 30 and any other general exclusions or limitations of a group 31 plan to the same extent as other medical or surgical services 32 covered by the group plan. 33 5. Coverage required by this section shall be provided 34 in coordination with coverage required for the treatment of 35 -3- SF 2349 (5) 83 av/rj/jh 3/ 6
S.F. 2349 autistic disorders pursuant to section 514C.22. 1 6. This section shall not be construed to limit benefits 2 which are otherwise available to an individual under a group 3 plan. 4 7. This section shall not be construed to require coverage 5 by a group plan of any service solely based on inclusion of the 6 service in an individualized education program. Consistent 7 with federal or state law and upon consent of the parent or 8 guardian of a covered individual, the treatment of autism 9 spectrum disorders may be coordinated with any services 10 included in an individualized education program. However, 11 coverage for the treatment of autism spectrum disorders 12 shall not be contingent upon coordination of services with an 13 individualized education program. 14 8. This section shall not apply to accident-only, 15 specified disease, short-term hospital or medical, hospital 16 confinement indemnity, credit, dental, vision, Medicare 17 supplement, long-term care, basic hospital and medical-surgical 18 expense coverage as defined by the commissioner, disability 19 income insurance coverage, coverage issued as a supplement 20 to liability insurance, workers’ compensation or similar 21 insurance, or automobile medical payment insurance, or 22 individual accident and sickness policies issued to individuals 23 or to individual members of a member association. 24 9. A plan established pursuant to chapter 509A for employees 25 of the state may manage the benefits provided through common 26 methods including but not limited to providing payment of 27 benefits or providing care and treatment under a capitated 28 payment system, prospective reimbursement rate system, 29 utilization control system, incentive system for the use of 30 least restrictive and costly levels of care, a preferred 31 provider contract limiting choice of specific providers, or 32 any other system, method, or organization designed to assure 33 services are medically necessary and clinically appropriate. 34 10. An insurer may review a treatment plan for treatment 35 -4- SF 2349 (5) 83 av/rj/jh 4/ 6
S.F. 2349 of autism spectrum disorders once every six months, subject to 1 its utilization review requirements, including case management, 2 concurrent review, and other managed care provisions. A more 3 or less frequent review may be agreed upon by the insured and 4 the licensed physician or licensed psychologist developing the 5 treatment plan. 6 11. For the purposes of this section, the results of a 7 diagnostic assessment of autism spectrum disorder shall be 8 valid for a period of not less than twelve months, unless a 9 licensed physician or licensed psychologist determines that a 10 more frequent assessment is necessary. 11 12. The board of medicine shall adopt rules providing for 12 the certification of behavior specialists. 13 a. An applicant for a certificate as a behavior specialist 14 shall submit a written application on forms provided by the 15 board of medicine evidencing and insuring that the applicant 16 meets all of the following requirements: 17 (1) Is of good moral character. 18 (2) Has received a master’s or higher degree from a 19 board-approved, accredited college or university, including 20 a major course of study in school, clinical, or counseling 21 psychology, special education, social work, speech therapy, 22 occupational therapy, or another related field. 23 (3) Has at least one year of experience involving 24 functional behavior assessments, including the development and 25 implementation of behavioral supports or treatment plans. 26 (4) Has completed at least one thousand hours in direct 27 clinical experience with individuals with behavioral challenges 28 or at least one thousand hours experience in a related field 29 with individuals with autism spectrum disorders. 30 (5) Has completed relevant training programs, including 31 professional ethics, autism-specific training, assessments 32 training, instructional strategies and best practices, 33 crisis intervention, comorbidity and medications, family 34 collaboration, and addressing specific skill deficits training. 35 -5- SF 2349 (5) 83 av/rj/jh 5/ 6
S.F. 2349 b. The board of medicine shall not issue a certificate to an 1 applicant who has been convicted of a felony, of a controlled 2 substance-related offense under chapter 124 or of the laws of 3 another jurisdiction unless all of the following requirements 4 have been met: 5 (1) At least ten years have elapsed from the date of 6 conviction of such an offense. 7 (2) The applicant satisfactorily demonstrates to the board 8 of medicine that the applicant has made significant progress 9 in personal rehabilitation since the conviction such that 10 certification of the applicant would not be expected to create 11 a substantial risk of harm to the health and safety of patients 12 or the public, or a substantial risk of further criminal 13 violations. 14 (3) The applicant otherwise satisfies the requirements of 15 this subsection. 16 13. The commissioner shall adopt rules pursuant to chapter 17 17A to implement and administer this section. 18 14. This section applies to plans established pursuant to 19 chapter 509A for employees of the state that are delivered, 20 issued for delivery, continued, or renewed in this state on or 21 after January 1, 2011. 22 -6- SF 2349 (5) 83 av/rj/jh 6/ 6