Bill Text: CT HB06847 | 2015 | General Assembly | Comm Sub

Connecticut House Bill 6847 (Prior Session Legislation)

Bill Title: An Act Enhancing Access To Behavioral Health Services And Services For Youths With Autism Spectrum Disorder.

Spectrum: Partisan Bill (Democrat 4-0)

Status: (Introduced - Dead) 2015-04-02 - File Number 417 [HB06847 Detail]

Download: Connecticut-2015-HB06847-Comm_Sub.html

General Assembly		*Substitute Bill No. 6847*
*January Session, 2015*		_____HB06847INS___031915____

AN ACT ENHANCING ACCESS TO BEHAVIORAL HEALTH SERVICES AND SERVICES FOR YOUTHS WITH AUTISM SPECTRUM DISORDER.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. Section 38a-514b of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2016):

(a) As used in this section:

(1) "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.

(2) ["Autism services provider"] "Autism spectrum disorder services provider" means any person, entity or group that provides treatment for autism spectrum disorder pursuant to this section.

(3) "Autism spectrum disorder" means [a pervasive developmental disorder] "autism spectrum disorder" as set forth in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". [, including, but not limited to, Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder and Pervasive Developmental Disorder Not Otherwise Specified.]

(4) "Behavioral therapy" means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Developmental Services pursuant to subsection (l) of section 17a-215c, as amended by this act, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with [an] autism spectrum disorder, that are: (A) Provided to children less than [fifteen] twenty-one years of age; and (B) provided or supervised by (i) a behavior analyst who is certified by the Behavior Analyst Certification Board, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is "supervised by" such behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.

(5) "Diagnosis" means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has [an] autism spectrum disorder.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorder. [, except that coverage for an insured under such policy who has been diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" shall be provided in accordance with subsection (i) of this section.] For the purposes of this section and section 38a-513c, [an] autism spectrum disorder shall be considered an illness.

(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with [an] autism spectrum disorder, in accordance with a treatment plan developed by a licensed physician, licensed psychologist or licensed clinical social worker pursuant to a comprehensive evaluation or reevaluation of the insured:

(A) Behavioral therapy;

(B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, licensed physician assistant or advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;

(D) Direct psychological or consultative services provided by a licensed psychologist;

(E) Physical therapy provided by a licensed physical therapist;

(F) Speech and language pathology services provided by a licensed speech and language pathologist; and

(G) Occupational therapy provided by a licensed occupational therapist.

[(d) Such policy may limit the coverage for behavioral therapy to a yearly benefit of fifty thousand dollars for a child who is less than nine years of age, thirty-five thousand dollars for a child who is at least nine years of age and less than thirteen years of age and twenty-five thousand dollars for a child who is at least thirteen years of age and less than fifteen years of age.]

[(e)] (d) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of [an] autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.

[(f)] (e) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan.

(2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless such insured's licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured's diagnosis.

[(g)] (f) Coverage required under this section may be subject to the other general exclusions and limitations of the group health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection [(f)] (e) of this section.

[(h)] (g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such group health insurance policy, (ii) section 38a-514, as amended by this act, or (iii) section 38a-516a, as amended by this act, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.

(2) Nothing in this section shall be construed to require such group health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.

[(i) Each such group health insurance policy shall maintain, for any insured diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", coverage as set forth in this section for the treatment of said disorder at the benefit levels, at a minimum, provided immediately preceding the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".]

Sec. 2. Section 38a-488b of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2016):

(a) As used in this section:

(2) "Autism spectrum disorder services provider" means any person, entity or group that provides treatment for an autism spectrum disorder pursuant to this section.

(3) "Autism spectrum disorder" means "autism spectrum disorder" as set forth in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".

(4) "Behavioral therapy" means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Developmental Services pursuant to subsection (l) of section 17a-215c, as amended by this act, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to children less than twenty-one years of age; and (B) provided or supervised by (i) a behavior analyst who is certified by the Behavior Analyst Certification Board, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is "supervised by" such behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.

[(a)] (b) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage [for physical therapy, speech therapy and occupational therapy services] for the diagnosis and treatment of autism spectrum disorder. [, as set forth in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", to the extent such services are a covered benefit for other diseases and conditions under such policy, except that coverage for an insured under such policy who has been diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" shall be provided in accordance with subsection (b) of this section.] For the purposes of this section and section 38a-482a, autism spectrum disorder shall be considered an illness.

(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with autism spectrum disorder, in accordance with a treatment plan developed by a licensed physician, licensed psychologist or licensed clinical social worker pursuant to a comprehensive evaluation or reevaluation of the insured:

(A) Behavioral therapy;

(D) Direct psychological or consultative services provided by a licensed psychologist;

(E) Physical therapy provided by a licensed physical therapist;

(F) Speech and language pathology services provided by a licensed speech and language pathologist; and

(G) Occupational therapy provided by a licensed occupational therapist.

(d) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.

(e) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan.

(f) Coverage required under this section may be subject to the other general exclusions and limitations of the individual health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (e) of this section.

(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such individual health insurance policy, (ii) section 38a-488a, as amended by this act, or (iii) section 38a-490a, as amended by this act, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.

(2) Nothing in this section shall be construed to require such individual health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to section 10-76d, unless otherwise required by state or federal law.

[(b) Each such policy shall maintain, for any insured diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", coverage for physical therapy, speech therapy and occupational therapy services for the treatment of said disorder at the benefit levels, at a minimum, provided immediately preceding the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".]

Sec. 3. Section 38a-516a of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2016):

(a) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medically necessary early intervention services provided as part of an individualized family service plan pursuant to section 17a-248e. Such policy shall [(1)] provide coverage for such services provided by qualified personnel, as defined in section 17a-248, for a child from birth until the child's third birthday. [, and (2) maintain, for any insured diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", coverage for such services for the treatment of said disorder at the benefit levels, at a minimum, provided immediately preceding the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".]

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such services, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-520, shall not be subject to the deductible limits set forth in this section.

[(c) Such policy shall provide a maximum benefit of six thousand four hundred dollars per child per year and an aggregate benefit of nineteen thousand two hundred dollars per child over the total three-year period, except that for a child with autism spectrum disorder, as defined in section 38a-514b, who is receiving early intervention services as defined in section 17a-248, the maximum benefit available through early intervention providers shall be fifty thousand dollars per child per year and an aggregate benefit of one hundred fifty thousand dollars per child over the total three-year period as provided for in section 38a-514b. Nothing in this section shall be construed to increase the amount of coverage required for autism spectrum disorder for any child beyond the amounts set forth in section 38a-514b. Any coverage provided for autism spectrum disorder through an individualized family service plan pursuant to section 17a-248e shall be credited toward the coverage amounts required under section 38a-514b.]

[(d)] (c) No payment made under this section shall (1) [be applied by the insurer, health care center or plan administrator against or result in a loss of benefits due to any maximum lifetime or annual limits specified in the policy, (2)] adversely affect the availability of health insurance to the child, the child's parent or the child's family members insured under any such policy, or [(3)] (2) be a reason for the insurer, health care center or plan administrator to rescind or cancel such policy. Payments made under this section shall not be treated differently than other claim experience for purposes of premium rating.

Sec. 4. Section 38a-490a of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2016):

(a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for medically necessary early intervention services provided as part of an individualized family service plan pursuant to section 17a-248e. Such policy shall [(1)] provide coverage for such services provided by qualified personnel, as defined in section 17a-248, for a child from birth until the child's third birthday. [, and (2) maintain, for any insured diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", coverage for such services for the treatment of said disorder at the benefit levels, at a minimum, provided immediately preceding the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".]

(b) No such policy shall impose a coinsurance, copayment, deductible or other out-of-pocket expense for such services, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to the deductible limits set forth in this section.

Sec. 5. Section 17a-215c of the general statutes is amended by adding subsection (l) as follows (Effective from passage):

(NEW) (l) The Commissioner of Developmental Services, in consultation with the Autism Spectrum Disorder Advisory Council, shall designate services and interventions that demonstrate empirical effectiveness for the treatment of autism spectrum disorder. The commissioner shall update such designations periodically and whenever the commissioner deems it necessary to conform to changes generally recognized by the relevant medical community in evidence-based practices or research.

Sec. 6. Subdivision (3) of subsection (a) of section 38a-591c of the general statutes are repealed and the following is substituted in lieu thereof (Effective July 1, 2015):

(3) (A) Notwithstanding subdivision (2) of this subsection, for any utilization review for the treatment of a substance use disorder, as described in section 17a-458, the clinical review criteria used shall be: (i) The most recent edition of the American Society of Addiction [Medicine's Patient Placement Criteria] Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions; or (ii) clinical review criteria that the health carrier demonstrates is consistent with the most recent edition of the American Society of Addiction [Medicine's Patient Placement Criteria] Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, in accordance with subparagraph (B) of this subdivision.

(B) A health carrier that uses clinical review criteria as set forth in subparagraph (A)(ii) of this subdivision shall create and maintain a document in an easily accessible location on such health carrier's Internet web site that (i) compares each aspect of such clinical review criteria with the American Society of Addiction [Medicine's Patient Placement Criteria] Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, and (ii) provides citations to peer-reviewed medical literature generally recognized by the relevant medical community or to professional society guidelines that justify each deviation from the American Society of Addiction [Medicine's Patient Placement Criteria] Medicine Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions.

Sec. 7. (Effective from passage) (a) Not later than October 1, 2015, the Insurance Commissioner shall convene a working group to develop recommendations for behavioral health utilization and quality measures data that should be collected uniformly from state agencies that pay health care claims, group hospitalization and medical and surgical insurance plans established pursuant to section 5-259 of the general statutes, the state medical assistance program and health insurance companies and health care centers that write health insurance policies and health care contracts in this state. The purposes of such recommendations include, but are not limited to, protecting behavioral health parity for youths and other populations.

(b) The working group shall consist of the Insurance Commissioner, the Healthcare Advocate, the Commissioners of Social Services, Public Health, Mental Health and Addiction Services, Children and Families and Developmental Services and the Comptroller, or their designees, and may include representatives from health insurance companies or health care centers or any other members the Insurance Commissioner deems necessary and relevant to carry out the working group's duties under this section.

(c) (1) The working group shall determine the data that should be collected to inform analysis on (A) coverage for behavioral health services, (B) the adequacy of coverage for behavioral health conditions, including, but not limited to, autism spectrum disorders and substance use disorders, (C) the alignment of medical necessity criteria and utilization management procedures across such agencies, plans, program, companies and centers, (D) the adequacy of health care provider networks, (E) the overall availability of behavioral health care providers in this state, (F) the percentage of behavioral health care providers in this state that are participating providers under a group hospitalization and medical and surgical insurance plan established pursuant to section 5-259 of the general statutes, the state medical assistance program, or a health insurance policy or health care contract delivered, issued for delivery, renewed, amended or continued in this state, and (G) the adequacy of services available for behavioral health conditions, including, but not limited to, autism spectrum disorders and substance use disorders.

(2) The recommendations developed by the working group may include data such as (A) per member, per month claim expenses, (B) the median length of a covered treatment for an entire course of treatment by levels of care, (C) utilization review outcome data grouped by levels of care, age categories and levels of review as set forth in part VII of chapter 700c of the general statutes, (D) the number of in-network and out-of-network health care providers by location and provider type, (E) health care provider network management data by location and provider type, and (F) health care provider network fluctuations, the causes of such fluctuations and the decisions made by health insurance companies, health care centers and state agencies regarding the approval of health care providers to join a health care provider network.

(d) Not later than January 1, 2016, the Insurance Commissioner shall submit a report of the recommendations of the working group as set forth in subsection (a) of this section, in accordance with the provisions of section 11-4a of the general statutes, to the Governor and the joint standing committees of the General Assembly having cognizance of matters relating to insurance, human services, public health and children.

Sec. 8. Subsection (a) of section 38a-514 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2016):

(a) Except as provided in subsection (j) of this section, each group health insurance policy, providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469, delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. For the purposes of this section, "mental or nervous conditions" means mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". "Mental or nervous conditions" does not include (1) intellectual disabilities, (2) specific learning disorders, (3) motor disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) other conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". [, except that coverage for an insured under such policy who has been diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" shall be provided in accordance with subsection (i) of section 38a-514b.]

Sec. 9. Subsection (a) of section 38a-488a of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2016):

(a) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, renewed, amended or continued in this state shall provide benefits for the diagnosis and treatment of mental or nervous conditions. For the purposes of this section, "mental or nervous conditions" means mental disorders, as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". "Mental or nervous conditions" does not include (1) intellectual disabilities, (2) specific learning disorders, (3) motor disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) other conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". [, except that coverage for an insured under such policy who has been diagnosed with autism spectrum disorder prior to the release of the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" shall be provided in accordance with subsection (b) of section 38a-488b.]


This act shall take effect as follows and shall amend the following sections:
Section 1	January 1, 2016	38a-514b
Sec. 2	January 1, 2016	38a-488b
Sec. 3	January 1, 2016	38a-516a
Sec. 4	January 1, 2016	38a-490a
Sec. 5	from passage	17a-215c
Sec. 6	July 1, 2015	38a-591c(a)(3)
Sec. 7	from passage	New section
Sec. 8	January 1, 2016	38a-514(a)
Sec. 9	January 1, 2016	38a-488a(a)