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House Study Bill 41 - IntroducedA Bill ForAn Act 1requiring certain health insurance policies, contracts,
2or plans to provide coverage of applied behavior analysis
3for treatment of autism spectrum disorder for certain
4individuals, and including applicability and effective date
5provisions.
6BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. Section 225D.1, subsection 8, Code 2017, is
2amended to read as follows:
38. “Eligible individual” means a child less than fourteen
4years of age who has been diagnosed with autism based on a
5diagnostic assessment of autism, is not otherwise eligible for
6coverage for applied behavioral analysis treatment or applied
7behavior analysis treatment under the medical assistance
8program, section 514C.28, 514C.31, or private insurance
9coverage, and whose household income does not exceed five
10hundred percent of the federal poverty level.
11 Sec. 2. Section 225D.2, subsection 2, paragraph l, Code
122017, is amended to read as follows:
13l. Proof of eligibility for the autism support program that
14includes a written denial for coverage or a benefits summary
15indicating that applied behavioral analysis treatment or
16applied behavior analysis treatment is not a covered benefit
17for which the applicant is eligible, under the Medicaid
18program, section 514C.28, 514C.31, or other private insurance
19coverage.
20 Sec. 3. Section 225D.2, subsection 3, Code 2017, is amended
21to read as follows:
223. Moneys in the autism support fund created under
23subsection 5 shall be expended only for eligible individuals
24who are not eligible for coverage for applied behavioral
25analysis treatment or applied behavior analysis treatment under
26the medical assistance program, section 514C.28, 514C.31,
27or other private insurance. Payment for applied behavioral
28analysis treatment through the fund shall be limited to only
29applied behavioral analysis treatment that is clinically
30relevant and only to the extent approved under the guidelines
31established by rule of the department.
32 Sec. 4. NEW SECTION. 514C.31 Applied behavior analysis for
33treatment of autism spectrum disorder — coverage.
341. Notwithstanding the uniformity of treatment requirements
35of section 514C.6, a group policy, contract, or plan providing
-1-1for third-party payment or prepayment of health, medical, and
2surgical coverage benefits shall provide coverage benefits for
3applied behavior analysis provided by a practitioner to covered
4individuals under nineteen years of age for the treatment of
5autism spectrum disorder pursuant to a treatment plan if the
6policy, contract, or plan is either of the following:
7a. A policy, contract, or plan issued by a carrier, as
8defined in section 513B.2, or an organized delivery system
9authorized under 1993 Iowa Acts, chapter 158, to an employer
10who on at least fifty percent of the employer’s working days
11during the preceding calendar year employed more than fifty
12full-time equivalent employees. In determining the number
13of full-time equivalent employees of an employer, employers
14who are affiliated or who are able to file a consolidated tax
15return for purposes of state taxation shall be considered one
16employer.
17b. A plan established pursuant to chapter 509A for public
18employees other than employees of the state.
192. As used in this section, unless the context otherwise
20requires:
21a. “Applied behavior analysis” means the design,
22implementation, and evaluation of environmental modifications,
23using behavioral stimuli and consequences, to produce socially
24significant improvement in human behavior, including the use
25of direct observation, measurement, and functional analysis of
26the relationship between environment and behavior. “Applied
27behavior analysis” does not include supervisory services.
28b. “Autism spectrum disorder” means a complex
29neurodevelopmental medical disorder characterized by social
30impairment, communication difficulties, and restricted,
31repetitive, and stereotyped patterns of behavior.
32c. “Practitioner” means any of the following:
33(1) A physician licensed pursuant to chapter 148.
34(2) A psychologist licensed pursuant to chapter 154B.
35(3) A person who holds a master’s degree or a doctoral
-2-1degree and is certified by a national behavior analyst
2certification board as a behavior analyst.
3d. “Treatment plan” means a plan for the treatment of an
4autism spectrum disorder developed by a licensed physician
5or licensed psychologist after a comprehensive evaluation or
6reevaluation performed in a manner consistent with the most
7recent clinical report or recommendations of the American
8academy of pediatrics, as determined by the commissioner by
9rule.
103. a. The coverage for applied behavior analysis required
11pursuant to this section shall provide an annual maximum
12benefit of not less than the following:
13(1) For an individual through age six, thirty-six thousand
14dollars per year.
15(2) For an individual age seven through age thirteen,
16twenty-five thousand dollars per year.
17(3) For an individual age fourteen through age eighteen,
18twelve thousand five hundred dollars per year.
19b. Payments made under a group policy, contract, or plan
20subject to this section on behalf of a covered individual for
21any treatment other than applied behavior analysis shall not
22be applied toward the maximum benefit established under this
23subsection.
244. Coverage required pursuant to this section may be
25subject to dollar limits, deductibles, copayments, or
26coinsurance provisions that apply to other medical and surgical
27services under the policy, contract, or plan, subject to the
28requirements of subsection 3.
295. Coverage required pursuant to this section may be
30subject to care management provisions of the applicable
31policy, contract, or plan, including prior authorization,
32prior approval, and limits on the number of visits a covered
33individual may make for applied behavior analysis.
346. A carrier, organized delivery system, or plan may request
35a review of a treatment plan for a covered individual not more
-3-1than once every three months, unless the carrier, organized
2delivery system, or plan and the covered individual’s treating
3physician or psychologist execute an agreement that a more
4frequent review is necessary. An agreement giving a carrier,
5organized delivery system, or plan the right to review the
6treatment plan of a covered individual more frequently applies
7only to a particular covered individual receiving applied
8behavior analysis and does not apply to other individuals
9receiving applied behavior analysis from a practitioner. The
10cost of conducting a review under this section shall be paid by
11the carrier, organized delivery system, or plan.
127. Coverage required by this section shall be provided
13in coordination with coverage required for the treatment of
14autistic disorders pursuant to section 514C.22.
158. This section shall not be construed to limit benefits
16which are otherwise available to an individual under a group
17policy, contract, or plan.
189. This section shall not be construed as affecting any
19obligation to provide services to an individual under an
20individualized family service plan, an individualized education
21program, or an individualized service plan.
2210. This section shall not apply to accident-only,
23specified disease, short-term hospital or medical, hospital
24confinement indemnity, credit, dental, vision, Medicare
25supplement, long-term care, basic hospital and medical-surgical
26expense coverage as defined by the commissioner, disability
27income insurance coverage, coverage issued as a supplement
28to liability insurance, workers’ compensation or similar
29insurance, or automobile medical payment insurance, or
30individual accident and sickness policies issued to individuals
31or to individual members of a member association.
3211. The commissioner may adopt rules pursuant to chapter 17A
33to implement and administer this section.
3412. This section applies to third-party provider payment
35contracts, policies, or plans specified in subsection 1,
-4-1paragraph “a” or to plans established pursuant to chapter 509A
2for public employees other than employees of the state, that
3are delivered, issued for delivery, continued, or renewed in
4this state on or after January 1, 2018.
5 Sec. 5. EFFECTIVE DATE. The following provisions of this
6Act take effect January 1, 2018:
71. The sections of this Act amending sections 225D.1 and
8225D.2.
9EXPLANATION
10The inclusion of this explanation does not constitute agreement with
11the explanation’s substance by the members of the general assembly.
12This bill creates new Code section 514C.31, which requires
13certain individual and group health insurance policies,
14contracts, or plans and plans established pursuant to Code
15chapter 509A for public employees other than employees of
16the state to provide coverage benefits for applied behavior
17analysis for the treatment of autism spectrum disorder.
18“Autism spectrum disorder” means a complex
19neurodevelopmental medical disorder characterized by
20social impairment, communication difficulties, and restricted,
21repetitive, and stereotyped patterns of behavior.
22The bill requires coverage for applied behavior analysis
23that is provided by a board-certified behavior analyst or by
24a licensed physician or psychologist. The required maximum
25benefit for coverage for applied behavior analysis for an
26individual diagnosed with an autism spectrum disorder is
27$36,000 per year through age 6, $25,000 per year from age 7
28through age 13, and $12,500 per year from age 14 through age
2918.
30Required coverage can be subject to preauthorization, prior
31approval, or other care management requirements, including
32limits on the number of visits an individual may make for
33applied behavior analysis.
34Required coverage can be subject to dollar limits,
35deductibles, copayments, or coinsurance provisions, or any
-5-1other general exclusions or limitations of the coverage that
2apply to other covered medical or surgical services.
3Coverage of autism spectrum disorder under the new Code
4section is to be provided in coordination with coverage
5required for the treatment of autistic disorders pursuant to
6Code section 514C.22. The Code section shall not be construed
7to limit benefits otherwise available to an individual under a
8group policy, contract, or plan.
9The new Code section shall not be construed as affecting
10any obligation to provide services to an individual under an
11individualized family service plan, education program, or
12service plan.
13A carrier, organized delivery system, or plan may request
14to review a treatment plan not more than once every three
15months, unless the carrier, organized delivery system, or
16plan and the individual’s treating physician or psychologist
17execute an agreement that more frequent review is necessary.
18Such an agreement applies only to that individual and does not
19apply to other individuals receiving applied behavior analysis
20from a board-certified behavior analyst, a physician, or a
21psychologist. The cost of conducting the review of a treatment
22plan is to be borne by the carrier, organized delivery system,
23or plan.
24The new Code section does not apply to various specified
25types of insurance. The commissioner may adopt rules to
26implement and administer the provision.
27New Code section 514C.31 applies to third-party provider
28payment contracts, policies, or plans specified in the
29bill, or plans established pursuant to Code chapter 509A for
30public employees other than employees of the state, that are
31delivered, issued for delivery, continued, or renewed in this
32state on or after January 1, 2018.
33Coordinating changes are made in Code sections 225D.1 and
34225D.2 to provide that persons who are eligible for coverage
35of applied behavior analysis treatment under new Code section
-6-1514C.31 are not eligible to participate in the state autism
2support program. These changes also take effect January 1,
32018.
-7-av/nh
2or plans to provide coverage of applied behavior analysis
3for treatment of autism spectrum disorder for certain
4individuals, and including applicability and effective date
5provisions.
6BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1 Section 1. Section 225D.1, subsection 8, Code 2017, is
2amended to read as follows:
38. “Eligible individual” means a child less than fourteen
4years of age who has been diagnosed with autism based on a
5diagnostic assessment of autism, is not otherwise eligible for
6coverage for applied behavioral analysis treatment or applied
7behavior analysis treatment under the medical assistance
8program, section 514C.28, 514C.31, or private insurance
9coverage, and whose household income does not exceed five
10hundred percent of the federal poverty level.
11 Sec. 2. Section 225D.2, subsection 2, paragraph l, Code
122017, is amended to read as follows:
13l. Proof of eligibility for the autism support program that
14includes a written denial for coverage or a benefits summary
15indicating that applied behavioral analysis treatment or
16applied behavior analysis treatment is not a covered benefit
17for which the applicant is eligible, under the Medicaid
18program, section 514C.28, 514C.31, or other private insurance
19coverage.
20 Sec. 3. Section 225D.2, subsection 3, Code 2017, is amended
21to read as follows:
223. Moneys in the autism support fund created under
23subsection 5 shall be expended only for eligible individuals
24who are not eligible for coverage for applied behavioral
25analysis treatment or applied behavior analysis treatment under
26the medical assistance program, section 514C.28, 514C.31,
27or other private insurance. Payment for applied behavioral
28analysis treatment through the fund shall be limited to only
29applied behavioral analysis treatment that is clinically
30relevant and only to the extent approved under the guidelines
31established by rule of the department.
32 Sec. 4. NEW SECTION. 514C.31 Applied behavior analysis for
33treatment of autism spectrum disorder — coverage.
341. Notwithstanding the uniformity of treatment requirements
35of section 514C.6, a group policy, contract, or plan providing
-1-1for third-party payment or prepayment of health, medical, and
2surgical coverage benefits shall provide coverage benefits for
3applied behavior analysis provided by a practitioner to covered
4individuals under nineteen years of age for the treatment of
5autism spectrum disorder pursuant to a treatment plan if the
6policy, contract, or plan is either of the following:
7a. A policy, contract, or plan issued by a carrier, as
8defined in section 513B.2, or an organized delivery system
9authorized under 1993 Iowa Acts, chapter 158, to an employer
10who on at least fifty percent of the employer’s working days
11during the preceding calendar year employed more than fifty
12full-time equivalent employees. In determining the number
13of full-time equivalent employees of an employer, employers
14who are affiliated or who are able to file a consolidated tax
15return for purposes of state taxation shall be considered one
16employer.
17b. A plan established pursuant to chapter 509A for public
18employees other than employees of the state.
192. As used in this section, unless the context otherwise
20requires:
21a. “Applied behavior analysis” means the design,
22implementation, and evaluation of environmental modifications,
23using behavioral stimuli and consequences, to produce socially
24significant improvement in human behavior, including the use
25of direct observation, measurement, and functional analysis of
26the relationship between environment and behavior. “Applied
27behavior analysis” does not include supervisory services.
28b. “Autism spectrum disorder” means a complex
29neurodevelopmental medical disorder characterized by social
30impairment, communication difficulties, and restricted,
31repetitive, and stereotyped patterns of behavior.
32c. “Practitioner” means any of the following:
33(1) A physician licensed pursuant to chapter 148.
34(2) A psychologist licensed pursuant to chapter 154B.
35(3) A person who holds a master’s degree or a doctoral
-2-1degree and is certified by a national behavior analyst
2certification board as a behavior analyst.
3d. “Treatment plan” means a plan for the treatment of an
4autism spectrum disorder developed by a licensed physician
5or licensed psychologist after a comprehensive evaluation or
6reevaluation performed in a manner consistent with the most
7recent clinical report or recommendations of the American
8academy of pediatrics, as determined by the commissioner by
9rule.
103. a. The coverage for applied behavior analysis required
11pursuant to this section shall provide an annual maximum
12benefit of not less than the following:
13(1) For an individual through age six, thirty-six thousand
14dollars per year.
15(2) For an individual age seven through age thirteen,
16twenty-five thousand dollars per year.
17(3) For an individual age fourteen through age eighteen,
18twelve thousand five hundred dollars per year.
19b. Payments made under a group policy, contract, or plan
20subject to this section on behalf of a covered individual for
21any treatment other than applied behavior analysis shall not
22be applied toward the maximum benefit established under this
23subsection.
244. Coverage required pursuant to this section may be
25subject to dollar limits, deductibles, copayments, or
26coinsurance provisions that apply to other medical and surgical
27services under the policy, contract, or plan, subject to the
28requirements of subsection 3.
295. Coverage required pursuant to this section may be
30subject to care management provisions of the applicable
31policy, contract, or plan, including prior authorization,
32prior approval, and limits on the number of visits a covered
33individual may make for applied behavior analysis.
346. A carrier, organized delivery system, or plan may request
35a review of a treatment plan for a covered individual not more
-3-1than once every three months, unless the carrier, organized
2delivery system, or plan and the covered individual’s treating
3physician or psychologist execute an agreement that a more
4frequent review is necessary. An agreement giving a carrier,
5organized delivery system, or plan the right to review the
6treatment plan of a covered individual more frequently applies
7only to a particular covered individual receiving applied
8behavior analysis and does not apply to other individuals
9receiving applied behavior analysis from a practitioner. The
10cost of conducting a review under this section shall be paid by
11the carrier, organized delivery system, or plan.
127. Coverage required by this section shall be provided
13in coordination with coverage required for the treatment of
14autistic disorders pursuant to section 514C.22.
158. This section shall not be construed to limit benefits
16which are otherwise available to an individual under a group
17policy, contract, or plan.
189. This section shall not be construed as affecting any
19obligation to provide services to an individual under an
20individualized family service plan, an individualized education
21program, or an individualized service plan.
2210. This section shall not apply to accident-only,
23specified disease, short-term hospital or medical, hospital
24confinement indemnity, credit, dental, vision, Medicare
25supplement, long-term care, basic hospital and medical-surgical
26expense coverage as defined by the commissioner, disability
27income insurance coverage, coverage issued as a supplement
28to liability insurance, workers’ compensation or similar
29insurance, or automobile medical payment insurance, or
30individual accident and sickness policies issued to individuals
31or to individual members of a member association.
3211. The commissioner may adopt rules pursuant to chapter 17A
33to implement and administer this section.
3412. This section applies to third-party provider payment
35contracts, policies, or plans specified in subsection 1,
-4-1paragraph “a” or to plans established pursuant to chapter 509A
2for public employees other than employees of the state, that
3are delivered, issued for delivery, continued, or renewed in
4this state on or after January 1, 2018.
5 Sec. 5. EFFECTIVE DATE. The following provisions of this
6Act take effect January 1, 2018:
71. The sections of this Act amending sections 225D.1 and
8225D.2.
9EXPLANATION
10The inclusion of this explanation does not constitute agreement with
11the explanation’s substance by the members of the general assembly.
12This bill creates new Code section 514C.31, which requires
13certain individual and group health insurance policies,
14contracts, or plans and plans established pursuant to Code
15chapter 509A for public employees other than employees of
16the state to provide coverage benefits for applied behavior
17analysis for the treatment of autism spectrum disorder.
18“Autism spectrum disorder” means a complex
19neurodevelopmental medical disorder characterized by
20social impairment, communication difficulties, and restricted,
21repetitive, and stereotyped patterns of behavior.
22The bill requires coverage for applied behavior analysis
23that is provided by a board-certified behavior analyst or by
24a licensed physician or psychologist. The required maximum
25benefit for coverage for applied behavior analysis for an
26individual diagnosed with an autism spectrum disorder is
27$36,000 per year through age 6, $25,000 per year from age 7
28through age 13, and $12,500 per year from age 14 through age
2918.
30Required coverage can be subject to preauthorization, prior
31approval, or other care management requirements, including
32limits on the number of visits an individual may make for
33applied behavior analysis.
34Required coverage can be subject to dollar limits,
35deductibles, copayments, or coinsurance provisions, or any
-5-1other general exclusions or limitations of the coverage that
2apply to other covered medical or surgical services.
3Coverage of autism spectrum disorder under the new Code
4section is to be provided in coordination with coverage
5required for the treatment of autistic disorders pursuant to
6Code section 514C.22. The Code section shall not be construed
7to limit benefits otherwise available to an individual under a
8group policy, contract, or plan.
9The new Code section shall not be construed as affecting
10any obligation to provide services to an individual under an
11individualized family service plan, education program, or
12service plan.
13A carrier, organized delivery system, or plan may request
14to review a treatment plan not more than once every three
15months, unless the carrier, organized delivery system, or
16plan and the individual’s treating physician or psychologist
17execute an agreement that more frequent review is necessary.
18Such an agreement applies only to that individual and does not
19apply to other individuals receiving applied behavior analysis
20from a board-certified behavior analyst, a physician, or a
21psychologist. The cost of conducting the review of a treatment
22plan is to be borne by the carrier, organized delivery system,
23or plan.
24The new Code section does not apply to various specified
25types of insurance. The commissioner may adopt rules to
26implement and administer the provision.
27New Code section 514C.31 applies to third-party provider
28payment contracts, policies, or plans specified in the
29bill, or plans established pursuant to Code chapter 509A for
30public employees other than employees of the state, that are
31delivered, issued for delivery, continued, or renewed in this
32state on or after January 1, 2018.
33Coordinating changes are made in Code sections 225D.1 and
34225D.2 to provide that persons who are eligible for coverage
35of applied behavior analysis treatment under new Code section
-6-1514C.31 are not eligible to participate in the state autism
2support program. These changes also take effect January 1,
32018.
-7-av/nh