House File 215 - Reprinted HOUSE FILE 215 BY COMMITTEE ON COMMERCE (SUCCESSOR TO HSB 41) (As Amended and Passed by the House March 15, 2017 ) 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 HF 215 (2) 87 av/nh/md

H.F. 215 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 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- HF 215 (2) 87 av/nh/md 1/ 5

H.F. 215 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- HF 215 (2) 87 av/nh/md 2/ 5

H.F. 215 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- HF 215 (2) 87 av/nh/md 3/ 5

H.F. 215 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- HF 215 (2) 87 av/nh/md 4/ 5