Senate File 2128 - Reprinted SENATE FILE 2128 BY BEALL , MATHIS , WILHELM , QUIRMBACH , SCHOENJAHN , SENG , BERTRAND , BOLKCOM , DVORSKY , DOTZLER , DANIELSON , HATCH , HORN , DEARDEN , FRAISE , SODDERS , KIBBIE , BLACK , JOCHUM , RAGAN , and ANDERSON (As Amended and Passed by the Senate March 13, 2012 ) A BILL FOR An Act requiring certain group health insurance policies, 1 contracts, or plans to provide coverage for autism spectrum 2 disorders for certain persons, providing for a repeal, and 3 including applicability and effective date provisions. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 SF 2128 (6) 84 av/nh/jh
S.F. 2128 Section 1. NEW SECTION . 514C.29 Autism spectrum disorders 1 coverage. 2 1. Notwithstanding the uniformity of treatment requirements 3 of section 514C.6, a group policy, contract, or plan providing 4 for third-party payment or prepayment of health, medical, and 5 surgical coverage benefits shall provide coverage benefits 6 to covered individuals under twenty-six years of age for 7 the screening, diagnosis, and treatment of autism spectrum 8 disorders if the policy, contract, or plan is either of the 9 following: 10 a. A policy, contract, or plan issued by a carrier, as 11 defined in section 513B.2, or an organized delivery system 12 authorized under 1993 Iowa Acts, chapter 158. 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 service provider” means a person, group, or 25 entity that provides treatment for autism spectrum disorders. 26 c. “Autism spectrum disorder” means any of the pervasive 27 developmental disorders including autistic disorder, Asperger’s 28 disorder, and pervasive developmental disorders not otherwise 29 specified. The commissioner, by rule, shall define “autism 30 spectrum disorder” consistent with definitions provided in the 31 most recent edition of the American psychiatric association’s 32 diagnostic and statistical manual of mental disorders, as such 33 definitions may be amended from time to time. The commissioner 34 may adopt the definitions provided in such manual by reference. 35 -1- SF 2128 (6) 84 av/nh/jh 1/ 5
S.F. 2128 d. “Behavioral health treatment” means counseling and 1 treatment programs, including applied behavior analysis, that 2 meet the following requirements: 3 (1) Are necessary to develop, maintain, or restore, to the 4 maximum extent practicable, the functioning of an individual. 5 (2) Are provided by an applied behavior analysis direct 6 service provider under the supervision of an assistant behavior 7 analyst certified by a nationally recognized board, with 8 overall clinical direction by a behavior analyst certified by 9 a nationally recognized board, or by a licensed psychologist, 10 so long as the services are performed commensurate with the 11 psychologist’s formal training and supervised experience. 12 e. “Diagnosis of autism spectrum disorder” means the use 13 of medically necessary assessments, evaluations, or tests 14 performed by a licensed physician or licensed psychologist to 15 diagnose whether an individual has an autism spectrum disorder. 16 f. “Pharmacy care” means medications prescribed by a 17 licensed physician and any assessment, evaluation, or test 18 prescribed or ordered by a licensed physician to determine the 19 need for or effectiveness of such medications. 20 g. “Psychiatric care” means direct or consultative services 21 provided by a licensed physician who specializes in psychiatry. 22 h. “Psychological care” means direct or consultative 23 services provided by a licensed psychologist. 24 i. “Rehabilitative care” means professional services and 25 treatment programs, including applied behavior analysis, that 26 are provided by an autism service provider to produce socially 27 significant improvements in human behavior or to prevent loss 28 of attained skills or functions. 29 j. “Therapeutic care” means services provided by a licensed 30 speech pathologist, licensed occupational therapist, or 31 licensed physical therapist. 32 k. “Treatment for autism spectrum disorder” means treatment 33 that is identified in a treatment plan as prescribed by a 34 licensed physician or a licensed psychologist and includes 35 -2- SF 2128 (6) 84 av/nh/jh 2/ 5
S.F. 2128 medically necessary pharmacy care, psychiatric care, 1 psychological care, rehabilitative care, and therapeutic care 2 that is provided by one of the following: 3 (1) A mental health professional as defined in section 4 228.1. 5 (2) An autism service provider. 6 l. “Treatment plan” means a plan for the treatment of an 7 autism spectrum disorder developed by a licensed physician or 8 licensed psychologist pursuant to a comprehensive evaluation 9 or reevaluation performed in a manner consistent with the most 10 recent clinical report or recommendations of the American 11 academy of pediatrics or the American academy of child and 12 adolescent psychiatry, as determined by the commissioner by 13 rule. 14 3. Coverage for applied behavior analysis is required 15 pursuant to this section for a maximum benefit amount of 16 thirty-six thousand dollars per year. Beginning in 2014, the 17 commissioner shall, on or before April 1 of each calendar year, 18 publish an adjustment for inflation to the maximum benefit 19 required equal to the percentage change in the medical care 20 component of the United States department of labor consumer 21 price index for all urban consumers in the preceding year, and 22 the published adjusted maximum benefit shall be applicable to 23 group policies, contracts, or plans subject to this section 24 that are delivered, issued for delivery, continued, or renewed 25 on or after January 1 of the following calendar year. Payments 26 made under a group policy, contract, or plan subject to this 27 section on behalf of a covered individual for any treatment 28 other than applied behavior analysis shall not be applied 29 toward the maximum benefit established under this subsection. 30 4. Coverage required pursuant to this section shall not be 31 subject to any limits on the number of visits an individual may 32 make for treatment of an autism spectrum disorder. 33 5. Coverage required pursuant to this section shall not 34 be subject to dollar limits, deductibles, copayments, or 35 -3- SF 2128 (6) 84 av/nh/jh 3/ 5
S.F. 2128 coinsurance provisions, or any other general exclusions or 1 limitations of a group plan that are less favorable to an 2 insured than the dollar limits, deductibles, copayments, or 3 coinsurance provisions that apply to physical illness generally 4 under the policy, contract, or plan, except as provided in 5 subsection 3. 6 6. Coverage required by this section shall be provided 7 in coordination with coverage required for the treatment of 8 autistic disorders pursuant to section 514C.22. 9 7. This section shall not be construed to limit benefits 10 which are otherwise available to an individual under a group 11 policy, contract, or plan. 12 8. This section shall not be construed to require coverage 13 by a group policy, contract, or plan of any service solely 14 based on inclusion of the service in an individualized 15 education program. Consistent with federal or state law and 16 upon consent of the parent or guardian of a covered individual, 17 the treatment of autism spectrum disorders may be coordinated 18 with any services included in an individualized education 19 program. However, coverage for the treatment of autism 20 spectrum disorders shall not be contingent upon coordination of 21 services with an individualized education program. 22 9. Except for inpatient services, if an insured is receiving 23 treatment for an autism spectrum disorder, an insurer is 24 entitled to review the treatment plan annually, unless the 25 insurer and the insured’s treating physician or psychologist 26 agree that a more frequent review is necessary. An agreement 27 giving an insurer the right to review the treatment plan of 28 an insured more frequently applies only to that insured and 29 does not apply to other individuals being treated for autism 30 spectrum disorders by a physician or psychologist. The cost of 31 conducting a review of a treatment plan shall be borne by the 32 insurer. 33 10. This section shall not apply to accident-only, 34 specified disease, short-term hospital or medical, hospital 35 -4- SF 2128 (6) 84 av/nh/jh 4/ 5
S.F. 2128 confinement indemnity, credit, dental, vision, Medicare 1 supplement, long-term care, basic hospital and medical-surgical 2 expense coverage as defined by the commissioner, disability 3 income insurance coverage, coverage issued as a supplement 4 to liability insurance, workers’ compensation or similar 5 insurance, or automobile medical payment insurance, or 6 individual accident and sickness policies issued to individuals 7 or to individual members of a member association. 8 11. The commissioner shall adopt rules pursuant to chapter 9 17A to implement and administer this section. 10 12. An insurer shall not terminate coverage of an individual 11 solely because the individual is diagnosed with or has received 12 treatment for an autism spectrum disorder. 13 13. This section applies to third-party payment provider 14 policies, contracts, or plans, and to plans established 15 pursuant to chapter 509A, that are delivered, issued for 16 delivery, continued, or renewed in this state on or after 17 January 1, 2013. 18 Sec. 2. REPEAL. Section 514C.28, Code 2011, is repealed. 19 Sec. 3. EFFECTIVE DATE. The following provision of this Act 20 takes effect January 1, 2013: 21 1. The section of this Act repealing section 514C.28. 22 -5- SF 2128 (6) 84 av/nh/jh 5/ 5