Bill Text: IA HF215 | 2017-2018 | 87th General Assembly | Enrolled
Bill Title: A bill for an act requiring certain health insurance policies, contracts, or plans to provide coverage of applied behavior analysis for treatment of autism spectrum disorder for certain individuals, and including applicability and effective date provisions. (Formerly HSB 41.) Effective 7-1-17, with exception of sections 1, 2 and 3 effective 1-1-18.
Spectrum: Committee Bill
Status: (Passed) 2017-03-30 - Signed by Governor. H.J. 825. [HF215 Detail]
Download: Iowa-2017-HF215-Enrolled.html
House File 215 - Enrolled
HOUSE FILE
BY COMMITTEE ON COMMERCE
(SUCCESSOR TO HSB 41)
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A BILL FOR
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House File 215
AN ACT
REQUIRING CERTAIN HEALTH INSURANCE POLICIES, CONTRACTS,
OR PLANS TO PROVIDE COVERAGE OF APPLIED BEHAVIOR ANALYSIS
FOR TREATMENT OF AUTISM SPECTRUM DISORDER FOR CERTAIN
INDIVIDUALS, AND INCLUDING APPLICABILITY AND EFFECTIVE DATE
PROVISIONS.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
Section 1. Section 225D.1, subsection 8, Code 2017, is
amended to read as follows:
8. "Eligible individual" means a child less than fourteen
years of age who has been diagnosed with autism based on a
diagnostic assessment of autism, is not otherwise eligible for
coverage for applied behavioral analysis treatment or applied
behavior analysis treatment under the medical assistance
program, section 514C.28, 514C.31, or private insurance
coverage, and whose household income does not exceed five
hundred percent of the federal poverty level.
Sec. 2. Section 225D.2, subsection 2, paragraph l, Code
2017, is amended to read as follows:
l. Proof of eligibility for the autism support program that
includes a written denial for coverage or a benefits summary
indicating that applied behavioral analysis treatment or
applied behavior analysis treatment is not a covered benefit
for which the applicant is eligible, under the Medicaid
program, section 514C.28, 514C.31, or other private insurance
coverage.
Sec. 3. Section 225D.2, subsection 3, Code 2017, is amended
to read as follows:
3. Moneys in the autism support fund created under
subsection 5 shall be expended only for eligible individuals
who are not eligible for coverage for applied behavioral
analysis treatment or applied behavior analysis treatment under
the medical assistance program, section 514C.28, 514C.31,
or other private insurance. Payment for applied behavioral
analysis treatment through the fund shall be limited to only
applied behavioral analysis treatment that is clinically
relevant and only to the extent approved under the guidelines
established by rule of the department.
Sec. 4. NEW SECTION. 514C.31 Applied behavior analysis for
treatment of autism spectrum disorder ==== coverage.
1. Notwithstanding the uniformity of treatment requirements
of section 514C.6, a group policy, contract, or plan providing
for third=party payment or prepayment of health, medical, and
surgical coverage benefits shall provide coverage benefits for
applied behavior analysis provided by a practitioner to covered
individuals under nineteen years of age for the treatment of
autism spectrum disorder pursuant to a treatment plan if the
policy, contract, or plan is either of the following:
a. A policy, contract, or plan issued by a carrier, as
defined in section 513B.2, or an organized delivery system
authorized under 1993 Iowa Acts, chapter 158, to an employer
who on at least fifty percent of the employer's working days
during the preceding calendar year employed more than fifty
full=time equivalent employees. In determining the number
of full=time equivalent employees of an employer, employers
who are affiliated or who are able to file a consolidated tax
return for purposes of state taxation shall be considered one
employer.
b. A plan established pursuant to chapter 509A for public
employees other than employees of the state.
2. As used in this section, unless the context otherwise
requires:
a. "Applied behavior analysis" means the design,
implementation, and evaluation of environmental modifications,
using behavioral stimuli and consequences, to produce socially
significant improvement in human behavior, including the use of
direct observation, measurement, and functional analysis of the
relationship between environment and behavior.
b. "Autism spectrum disorder" means a complex
neurodevelopmental medical disorder characterized by social
impairment, communication difficulties, and restricted,
repetitive, and stereotyped patterns of behavior.
c. "Practitioner" means any of the following:
(1) A physician licensed pursuant to chapter 148.
(2) A psychologist licensed pursuant to chapter 154B.
(3) A person who holds a master's degree or a doctoral
degree and is certified by a national behavior analyst
certification board as a behavior analyst.
d. "Treatment plan" means a plan for the treatment of an
autism spectrum disorder developed by a licensed physician
or licensed psychologist after a comprehensive evaluation or
reevaluation performed in a manner consistent with the most
recent clinical report or recommendations of the American
academy of pediatrics. "Treatment plan" includes supervisory
services, subject to the provisions of subsection 5.
3. a. The coverage for applied behavior analysis required
pursuant to this section shall provide an annual maximum
benefit of not less than the following:
(1) For an individual through age six, thirty=six thousand
dollars per year.
(2) For an individual age seven through age thirteen,
twenty=five thousand dollars per year.
(3) For an individual age fourteen through age eighteen,
twelve thousand five hundred dollars per year.
b. Payments made under a group policy, contract, or plan
subject to this section on behalf of a covered individual for
any treatment other than applied behavior analysis shall not
be applied toward the maximum benefit established under this
subsection.
4. Coverage required pursuant to this section may be
subject to dollar limits, deductibles, copayments, or
coinsurance provisions that apply to other medical and surgical
services under the policy, contract, or plan, subject to the
requirements of subsection 3.
5. Coverage required pursuant to this section may be
subject to care management provisions of the applicable
policy, contract, or plan, including prior authorization,
prior approval, and limits on the number of visits a covered
individual may make for applied behavior analysis.
6. A carrier, organized delivery system, or plan may request
a review of a treatment plan for a covered individual not
more than once every three months during the first year of
the treatment plan and not more than once every six months
during every year thereafter, unless the carrier, organized
delivery system, or plan and the covered individual's treating
physician or psychologist execute an agreement that a more
frequent review is necessary. An agreement giving a carrier,
organized delivery system, or plan the right to review the
treatment plan of a covered individual more frequently applies
only to a particular covered individual receiving applied
behavior analysis and does not apply to other individuals
receiving applied behavior analysis from a practitioner.
The cost of conducting a review under this section shall be
paid by the carrier, organized delivery system, or plan. A
carrier, organized delivery system, or plan shall not change
the provisions of a treatment plan until the completion of a
review of the treatment plan.
7. This section shall not be construed to limit benefits
which are otherwise available to an individual under a group
policy, contract, or plan.
8. This section shall not be construed as affecting any
obligation to provide services to an individual under an
individualized family service plan, an individualized education
program, or an individualized service plan.
9. This section shall not apply to accident=only,
specified disease, short=term hospital or medical, hospital
confinement indemnity, credit, dental, vision, Medicare
supplement, long=term care, basic hospital and medical=surgical
expense coverage as defined by the commissioner, disability
income insurance coverage, coverage issued as a supplement
to liability insurance, workers' compensation or similar
insurance, or automobile medical payment insurance, or
individual accident and sickness policies issued to individuals
or to individual members of a member association.
10. This section applies to third=party provider payment
contracts, policies, or plans specified in subsection 1,
paragraph "a" or to plans established pursuant to chapter 509A
for public employees other than employees of the state, that
are delivered, issued for delivery, continued, or renewed in
this state on or after January 1, 2018.
Sec. 5. EFFECTIVE DATE. The following provisions of this
Act take effect January 1, 2018:
1. The sections of this Act amending sections 225D.1 and
225D.2.
LINDA UPMEYER
JACK WHITVER
CARMINE BOAL
TERRY E. BRANSTA
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