Bill Text: IA SF2254 | 2015-2016 | 86th General Assembly | Introduced
Bill Title: A bill for an act requiring certain group health insurance policies, contracts, or plans to provide coverage for autism spectrum disorders for certain persons, providing for a repeal, and including applicability and effective date provisions. (Formerly SF 2072.)
Spectrum: Committee Bill
Status: (Engrossed - Dead) 2016-03-01 - Read first time, referred to Commerce. H.J. 355. [SF2254 Detail]
Download: Iowa-2015-SF2254-Introduced.html
Senate File 2254 - Introduced SENATE FILE BY COMMITTEE ON COMMERCE (SUCCESSOR TO SF 2072) A BILL FOR 1 An Act requiring certain group health insurance policies, 2 contracts, or plans to provide coverage for autism spectrum 3 disorders for certain persons, providing for a repeal, and 4 including applicability and effective date provisions. 5 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 5945SV (1) 86 av/nh PAG LIN 1 1 Section 1. Section 225D.1, subsection 8, Code 2016, is 1 2 amended to read as follows: 1 3 8. "Eligible individual" means a child less than nine years 1 4 of age who has been diagnosed with autism based on a diagnostic 1 5 assessment of autism, is not otherwise eligible for coverage 1 6 for applied behavioral analysis treatment under the medical 1 7 assistance program, section514C.28514C.31, or other private 1 8 insurance coverage, and whose household income does not exceed 1 9 four hundred percent of the federal poverty level. 1 10 Sec. 2. Section 225D.2, subsection 2, paragraph l, Code 1 11 2016, is amended to read as follows: 1 12 l. Proof of eligibility for the autism support program that 1 13 includes a written denial for coverage or a benefits summary 1 14 indicating that applied behavioral analysis treatment is not 1 15 a covered benefit for which the applicant is eligible, under 1 16 the Medicaid program, section514C.28514C.31, or other private 1 17 insurance coverage. 1 18 Sec. 3. Section 225D.2, subsection 3, Code 2016, is amended 1 19 to read as follows: 1 20 3. Moneys in the autism support fund created under 1 21 subsection 5 shall be expended only for eligible individuals 1 22 who are not eligible for coverage for applied behavioral 1 23 analysis treatment under the medical assistance program, 1 24 section514C.28514C.31, or other private insurance. Payment 1 25 for applied behavioral analysis treatment through the fund 1 26 shall be limited to only applied behavioral analysis treatment 1 27 that is clinically relevant and only to the extent approved 1 28 under the guidelines established by rule of the department. 1 29 Sec. 4. NEW SECTION. 514C.31 Autism spectrum disorders 1 30 coverage. 1 31 1. Notwithstanding the uniformity of treatment requirements 1 32 of section 514C.6, a group policy, contract, or plan providing 1 33 for third=party payment or prepayment of health, medical, and 1 34 surgical coverage benefits shall provide coverage benefits 1 35 to covered individuals under twenty=two years of age for 2 1 the screening, diagnosis, and treatment of autism spectrum 2 2 disorders if the policy, contract, or plan is either of the 2 3 following: 2 4 a. A policy, contract, or plan issued by a carrier, as 2 5 defined in section 513B.2, or an organized delivery system 2 6 authorized under 1993 Iowa Acts, chapter 158, to an employer 2 7 who on at least fifty percent of the employer's working days 2 8 during the preceding calendar year employed more than fifty 2 9 full=time equivalent employees. In determining the number 2 10 of full=time equivalent employees of an employer, employers 2 11 who are affiliated or who are able to file a consolidated tax 2 12 return for purposes of state taxation shall be considered one 2 13 employer. 2 14 b. A plan established pursuant to chapter 509A for public 2 15 employees. 2 16 2. As used in this section, unless the context otherwise 2 17 requires: 2 18 a. "Applied behavior analysis" means the design, 2 19 implementation, and evaluation of environmental modifications, 2 20 using behavioral stimuli and consequences, to produce socially 2 21 significant improvement in human behavior or to prevent loss 2 22 of attained skill or function, including the use of direct 2 23 observation, measurement, and functional analysis of the 2 24 relations between environment and behavior. 2 25 b. "Autism spectrum disorder" means any of the pervasive 2 26 developmental disorders including autistic disorder, Asperger's 2 27 disorder, and pervasive developmental disorders not otherwise 2 28 specified. The commissioner, by rule, shall define "autism 2 29 spectrum disorder" consistent with definitions provided in the 2 30 most recent edition of the American psychiatric association's 2 31 diagnostic and statistical manual of mental disorders, as such 2 32 definitions may be amended from time to time. The commissioner 2 33 may adopt the definitions provided in such manual by reference. 2 34 c. "Behavioral health treatment" means counseling and 2 35 treatment programs, including applied behavior analysis, that 3 1 meet the following requirements: 3 2 (1) Are necessary to develop, maintain, or restore, to the 3 3 maximum extent practicable, the functioning of an individual. 3 4 (2) Are provided or supervised by a behavior analyst 3 5 certified by a nationally recognized board, or by a licensed 3 6 psychologist, so long as the services are performed 3 7 commensurate with the psychologist's formal training and 3 8 supervised experience. 3 9 d. "Diagnosis of autism spectrum disorder" means the use 3 10 of medically necessary assessments, evaluations, or tests to 3 11 diagnose whether an individual has an autism spectrum disorder. 3 12 e. "Pharmacy care" means medications prescribed by a 3 13 licensed physician and any assessment, evaluation, or test 3 14 prescribed or ordered by a licensed physician to determine the 3 15 need for or effectiveness of such medications. 3 16 f. "Psychiatric care" means direct or consultative services 3 17 provided by a licensed physician who specializes in psychiatry. 3 18 g. "Psychological care" means direct or consultative 3 19 services provided by a licensed psychologist. 3 20 h. "Therapeutic care" means services provided by a licensed 3 21 speech pathologist, licensed occupational therapist, or 3 22 licensed physical therapist. 3 23 i. "Treatment for autism spectrum disorder" means 3 24 evidence=based care and related equipment prescribed or ordered 3 25 for an individual diagnosed with an autism spectrum disorder by 3 26 a licensed physician or a licensed psychologist who determines 3 27 that the treatment is medically necessary, including but not 3 28 limited to the following: 3 29 (1) Behavioral health treatment. 3 30 (2) Pharmacy care. 3 31 (3) Psychiatric care. 3 32 (4) Psychological care. 3 33 (5) Therapeutic care. 3 34 j. "Treatment plan" means a plan for the treatment of an 3 35 autism spectrum disorder developed by a licensed physician or 4 1 licensed psychologist pursuant to a comprehensive evaluation 4 2 or reevaluation performed in a manner consistent with the most 4 3 recent clinical report or recommendations of the American 4 4 academy of pediatrics, as determined by the commissioner by 4 5 rule. 4 6 3. Coverage for applied behavior analysis is required 4 7 pursuant to this section for a maximum benefit amount of 4 8 thirty=six thousand dollars per year. Beginning in 2020, the 4 9 commissioner shall, on or before July 1 of each calendar year, 4 10 publish an adjustment for inflation to the maximum benefit 4 11 required equal to the percentage change in the medical care 4 12 component of the United States department of labor consumer 4 13 price index for all urban consumers in the preceding year, and 4 14 the published adjusted maximum benefit shall be applicable to 4 15 group policies, contracts, or plans subject to this section 4 16 that are delivered, issued for delivery, continued, or renewed 4 17 on or after January 1 of the following calendar year. Payments 4 18 made under a group policy, contract, or plan subject to this 4 19 section on behalf of a covered individual for any treatment 4 20 other than applied behavior analysis shall not be applied 4 21 toward the maximum benefit established under this subsection. 4 22 4. Coverage for applied behavior analysis shall include the 4 23 services of persons working under the supervision of a behavior 4 24 analyst certified by a nationally recognized board or under 4 25 the supervision of a licensed psychologist, to provide applied 4 26 behavior analysis. 4 27 5. Coverage required pursuant to this section shall not be 4 28 subject to any limits on the number of visits an individual may 4 29 make for treatment of an autism spectrum disorder. 4 30 6. Coverage required pursuant to this section shall not 4 31 be subject to dollar limits, deductibles, copayments, or 4 32 coinsurance provisions, or any other general exclusions or 4 33 limitations of a group plan that are less favorable to an 4 34 insured than the dollar limits, deductibles, copayments, or 4 35 coinsurance provisions that apply to substantially all medical 5 1 and surgical benefits under the policy, contract, or plan, 5 2 except as provided in subsection 3. 5 3 7. Coverage required by this section shall be provided 5 4 in coordination with coverage required for the treatment of 5 5 autistic disorders pursuant to section 514C.22. 5 6 8. This section shall not be construed to limit benefits 5 7 which are otherwise available to an individual under a group 5 8 policy, contract, or plan. 5 9 9. This section shall not be construed as affecting any 5 10 obligation to provide services to an individual under an 5 11 individualized family service plan, an individualized education 5 12 program, or an individualized service plan. 5 13 10. Except for inpatient services, if an insured is 5 14 receiving treatment for an autism spectrum disorder, an insurer 5 15 is entitled to review the treatment plan annually, unless the 5 16 insurer and the insured's treating physician or psychologist 5 17 agree that a more frequent review is necessary. An agreement 5 18 giving an insurer the right to review the treatment plan of 5 19 an insured more frequently applies only to that insured and 5 20 does not apply to other individuals being treated for autism 5 21 spectrum disorders by a physician or psychologist. The cost of 5 22 conducting a review of a treatment plan shall be borne by the 5 23 insurer. 5 24 11. This section shall not apply to accident=only, 5 25 specified disease, short=term hospital or medical, hospital 5 26 confinement indemnity, credit, dental, vision, Medicare 5 27 supplement, long=term care, basic hospital and medical=surgical 5 28 expense coverage as defined by the commissioner, disability 5 29 income insurance coverage, coverage issued as a supplement 5 30 to liability insurance, workers' compensation or similar 5 31 insurance, or automobile medical payment insurance, or 5 32 individual accident and sickness policies issued to individuals 5 33 or to individual members of a member association. 5 34 12. The commissioner shall adopt rules pursuant to chapter 5 35 17A to implement and administer this section. 6 1 13. An insurer shall not terminate coverage of an individual 6 2 solely because the individual is diagnosed with or has received 6 3 treatment for an autism spectrum disorder. 6 4 14. a. By February 1, 2018, and every February 1 6 5 thereafter, the commissioner shall submit a report to the 6 6 general assembly regarding implementation of the coverage 6 7 required under this section. The report shall include 6 8 information concerning but not limited to all of the following: 6 9 (1) The total number of insureds diagnosed with autism 6 10 spectrum disorder in the immediately preceding calendar year. 6 11 (2) The total cost of all claims paid out in the immediately 6 12 preceding calendar year for coverage required under this 6 13 section. 6 14 (3) The cost of such coverage per insured per month. 6 15 (4) The average cost per insured per month for coverage of 6 16 applied behavior analysis required under this section. 6 17 b. All third=party payment provider policies, contracts, 6 18 or plans, as specified in subsection 1, and plans established 6 19 pursuant to chapter 509A shall provide the commissioner with 6 20 data requested by the commissioner for inclusion in the annual 6 21 report. 6 22 15. If any provision of this section or its application 6 23 to any person or circumstance is held invalid, the invalidity 6 24 does not affect other provisions or application of this section 6 25 which can be given effect without the invalid provision or 6 26 application, and to this end the provisions of this section are 6 27 severable. 6 28 16. This section applies to third=party payment provider 6 29 policies, contracts, or plans, as specified in subsection 1, 6 30 and to plans established pursuant to chapter 509A, that are 6 31 delivered, issued for delivery, continued, or renewed in this 6 32 state on or after January 1, 2017. 6 33 Sec. 5. REPEAL. Section 514C.28, Code 2016, is repealed. 6 34 Sec. 6. EFFECTIVE DATE. The following provisions of this 6 35 Act take effect January 1, 2017: 7 1 1. The sections of this Act amending sections 225D.1 and 7 2 225D.2. 7 3 2. The section of this Act repealing section 514C.28. 7 4 EXPLANATION 7 5 The inclusion of this explanation does not constitute agreement with 7 6 the explanation's substance by the members of the general assembly. 7 7 This bill creates new Code section 514C.31 which requires 7 8 certain group health insurance policies, contracts, or plans 7 9 to provide coverage benefits for the screening, diagnosis, and 7 10 treatment of autism spectrum disorders. The new provision 7 11 is applicable to group health policies, contracts, or plans 7 12 issued to employers with more than 50 employees and to health 7 13 plans established under Code chapter 509A for public employees. 7 14 Coverage benefits are required for covered individuals under 22 7 15 years of age. 7 16 "Autism spectrum disorder" includes autistic disorder, 7 17 Asperger's disorder, and pervasive developmental disorders 7 18 not otherwise specified, as defined by the commissioner of 7 19 insurance by rule consistent with definitions provided in the 7 20 most recent edition of the American psychiatric association's 7 21 diagnostic and statistical manual of mental disorders. 7 22 The required maximum benefit for coverage for applied 7 23 behavior analysis is $36,000 per year. Beginning in 2020, 7 24 the commissioner is required to make and publish annual 7 25 adjustments for inflation to the maximum benefit required equal 7 26 to the percentage change in the medical care component of the 7 27 United States department of labor consumer price index for 7 28 all consumers in the previous year. The published adjusted 7 29 maximum benefit is applicable to specified group policies, 7 30 contracts, or plans delivered, issued for delivery, continued, 7 31 or renewed during the following calendar year. Payments made 7 32 on behalf of a covered individual for any treatment other than 7 33 applied behavior analysis cannot be applied toward this maximum 7 34 benefit. 7 35 Coverage for applied behavior analysis must include 8 1 services rendered by persons working under the supervision of 8 2 a certified behavior analyst or a licensed psychologist to 8 3 provide applied behavior analysis. 8 4 Required coverage cannot be subject to any limits on the 8 5 number of visits an individual may make for treatment of an 8 6 autism spectrum disorder. 8 7 Required coverage cannot be subject to dollar limits, 8 8 deductibles, copayments, or coinsurance provisions, or any 8 9 other general exclusions or limitations of a group plan that 8 10 are less favorable to an insured than those that apply to 8 11 physical illness generally under the policy, contract, or 8 12 plan, except as to the maximum benefit limitation for applied 8 13 behavior analysis coverage. 8 14 Coverage of autism spectrum disorders under the new Code 8 15 section is to be provided in coordination with coverage 8 16 required for the treatment of autistic disorders pursuant to 8 17 Code section 514C.22. The Code section shall not be construed 8 18 to limit benefits otherwise available to an individual under a 8 19 group policy, contract, or plan. 8 20 The new Code section shall not be construed as affecting 8 21 any obligation to provide services to an individual under an 8 22 individualized family service plan, education program, or 8 23 service plan. 8 24 Except for inpatient services, if an insured is receiving 8 25 treatment for an autism spectrum disorder, an insurer is 8 26 entitled to review the treatment plan annually, unless the 8 27 insurer and the insured's treating physician or psychologist 8 28 agree that more frequent review is necessary. Such an 8 29 agreement applies only to that insured and does not apply to 8 30 other individuals being treated for autism spectrum disorder by 8 31 a physician or psychologist. The cost of conducting the review 8 32 of a treatment plan is to be borne by the insurer. 8 33 The new Code section does not apply to various specified 8 34 types of insurance. The commissioner is required to adopt 8 35 rules to implement and administer the provision. 9 1 An insurer shall not terminate coverage of an individual 9 2 solely because the individual is diagnosed with or has received 9 3 treatment for an autism spectrum disorder. 9 4 By February 1, 2018, and every February 1 thereafter, the 9 5 commissioner of insurance is required to submit a report to 9 6 the general assembly regarding implementation of the coverage 9 7 required under the new Code section. The annual report 9 8 must include information about the total number of insureds 9 9 diagnosed with autism spectrum disorders in the preceding 9 10 calendar year, the total cost of all claims paid out for the 9 11 required coverage, the cost of such coverage per insured per 9 12 month, and the average cost per insured per month for the 9 13 required coverage of applied behavior analysis. 9 14 The new Code section is severable if any portion of the Code 9 15 section or its application to any person or circumstance is 9 16 held to be invalid. 9 17 The new Code section applies to specified third=party 9 18 payment provider policies, contracts, or plans, and to plans 9 19 established pursuant to Code chapter 509A, that are delivered, 9 20 issued for delivery, continued, or renewed in this state on or 9 21 after January 1, 2017. 9 22 Code section 514C.28, which currently mandates coverage 9 23 for autism spectrum disorders only in group plans established 9 24 pursuant to Code chapter 509A for state employees, is repealed 9 25 effective January 1, 2017. 9 26 Coordinating changes are made in Code sections 225D.1 and 9 27 225D.2 to provide that persons who are eligible for coverage 9 28 of applied behavior analysis treatment under new Code section 9 29 514C.31 are not eligible to participate in the state autism 9 30 support program. These changes also take effect January 1, 9 31 2017.
