Bill Text: IA SSB1043 | 2017-2018 | 87th General Assembly | Introduced
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.
Spectrum: Committee Bill
Status: (N/A - Dead) 2017-02-22 - Subcommittee recommends amendment and passage. [SSB1043 Detail]
Download: Iowa-2017-SSB1043-Introduced.html
Senate
Study
Bill
1043
-
Introduced
SENATE
FILE
_____
BY
(PROPOSED
COMMITTEE
ON
COMMERCE
BILL
BY
CHAIRPERSON
ANDERSON)
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
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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
other
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
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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
24
of
direct
observation,
measurement,
and
functional
analysis
of
25
the
relationship
between
environment
and
behavior.
“Applied
26
behavior
analysis”
does
not
include
supervisory
services.
27
b.
“Autism
spectrum
disorder”
means
a
complex
28
neurodevelopmental
medical
disorder
characterized
by
social
29
impairment,
communication
difficulties,
and
restricted,
30
repetitive,
and
stereotyped
patterns
of
behavior.
31
c.
“Practitioner”
means
any
of
the
following:
32
(1)
A
physician
licensed
pursuant
to
chapter
148.
33
(2)
A
psychologist
licensed
pursuant
to
chapter
154B.
34
(3)
A
person
who
holds
a
master’s
degree
or
a
doctoral
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degree
and
is
certified
by
a
national
behavior
analyst
1
certification
board
as
a
behavior
analyst.
2
d.
“Treatment
plan”
means
a
plan
for
the
treatment
of
an
3
autism
spectrum
disorder
developed
by
a
licensed
physician
4
or
licensed
psychologist
after
a
comprehensive
evaluation
or
5
reevaluation
performed
in
a
manner
consistent
with
the
most
6
recent
clinical
report
or
recommendations
of
the
American
7
academy
of
pediatrics,
as
determined
by
the
commissioner
by
8
rule.
9
3.
a.
The
coverage
for
applied
behavior
analysis
required
10
pursuant
to
this
section
shall
provide
an
annual
maximum
11
benefit
of
not
less
than
the
following:
12
(1)
For
an
individual
through
age
six,
thirty-six
thousand
13
dollars
per
year.
14
(2)
For
an
individual
age
seven
through
age
thirteen,
15
twenty-five
thousand
dollars
per
year.
16
(3)
For
an
individual
age
fourteen
through
age
eighteen,
17
twelve
thousand
five
hundred
dollars
per
year.
18
b.
Payments
made
under
a
group
policy,
contract,
or
plan
19
subject
to
this
section
on
behalf
of
a
covered
individual
for
20
any
treatment
other
than
applied
behavior
analysis
shall
not
21
be
applied
toward
the
maximum
benefit
established
under
this
22
subsection.
23
4.
Coverage
required
pursuant
to
this
section
may
be
24
subject
to
dollar
limits,
deductibles,
copayments,
or
25
coinsurance
provisions
that
apply
to
other
medical
and
surgical
26
services
under
the
policy,
contract,
or
plan,
subject
to
the
27
requirements
of
subsection
3.
28
5.
Coverage
required
pursuant
to
this
section
may
be
29
subject
to
care
management
provisions
of
the
applicable
30
policy,
contract,
or
plan,
including
prior
authorization,
31
prior
approval,
and
limits
on
the
number
of
visits
a
covered
32
individual
may
make
for
applied
behavior
analysis.
33
6.
A
carrier,
organized
delivery
system,
or
plan
may
request
34
a
review
of
a
treatment
plan
for
a
covered
individual
not
more
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than
once
every
three
months,
unless
the
carrier,
organized
1
delivery
system,
or
plan
and
the
covered
individual’s
treating
2
physician
or
psychologist
execute
an
agreement
that
a
more
3
frequent
review
is
necessary.
An
agreement
giving
a
carrier,
4
organized
delivery
system,
or
plan
the
right
to
review
the
5
treatment
plan
of
a
covered
individual
more
frequently
applies
6
only
to
a
particular
covered
individual
receiving
applied
7
behavior
analysis
and
does
not
apply
to
other
individuals
8
receiving
applied
behavior
analysis
from
a
practitioner.
The
9
cost
of
conducting
a
review
under
this
section
shall
be
paid
by
10
the
carrier,
organized
delivery
system,
or
plan.
11
7.
This
section
shall
not
be
construed
to
limit
benefits
12
which
are
otherwise
available
to
an
individual
under
a
group
13
policy,
contract,
or
plan.
14
8.
This
section
shall
not
be
construed
as
affecting
any
15
obligation
to
provide
services
to
an
individual
under
an
16
individualized
family
service
plan,
an
individualized
education
17
program,
or
an
individualized
service
plan.
18
9.
This
section
shall
not
apply
to
accident-only,
19
specified
disease,
short-term
hospital
or
medical,
hospital
20
confinement
indemnity,
credit,
dental,
vision,
Medicare
21
supplement,
long-term
care,
basic
hospital
and
medical-surgical
22
expense
coverage
as
defined
by
the
commissioner,
disability
23
income
insurance
coverage,
coverage
issued
as
a
supplement
24
to
liability
insurance,
workers’
compensation
or
similar
25
insurance,
or
automobile
medical
payment
insurance,
or
26
individual
accident
and
sickness
policies
issued
to
individuals
27
or
to
individual
members
of
a
member
association.
28
10.
The
commissioner
may
adopt
rules
pursuant
to
chapter
17A
29
to
implement
and
administer
this
section.
30
11.
This
section
applies
to
third-party
provider
payment
31
contracts,
policies,
or
plans
specified
in
subsection
1,
32
paragraph
“a”
or
to
plans
established
pursuant
to
chapter
509A
33
for
public
employees
other
than
employees
of
the
state,
that
34
are
delivered,
issued
for
delivery,
continued,
or
renewed
in
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this
state
on
or
after
January
1,
2018.
1
Sec.
5.
EFFECTIVE
DATE.
The
following
provisions
of
this
2
Act
take
effect
January
1,
2018:
3
1.
The
sections
of
this
Act
amending
sections
225D.1
and
4
225D.2.
5
EXPLANATION
6
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
7
the
explanation’s
substance
by
the
members
of
the
general
assembly.
8
This
bill
creates
new
Code
section
514C.31,
which
requires
9
certain
individual
and
group
health
insurance
policies,
10
contracts,
or
plans
and
plans
established
pursuant
to
Code
11
chapter
509A
for
public
employees
other
than
employees
of
12
the
state
to
provide
coverage
benefits
for
applied
behavior
13
analysis
for
the
treatment
of
autism
spectrum
disorder.
14
“Autism
spectrum
disorder”
means
a
complex
15
neurodevelopmental
medical
disorder
characterized
by
16
social
impairment,
communication
difficulties,
and
restricted,
17
repetitive,
and
stereotyped
patterns
of
behavior.
18
The
bill
requires
coverage
for
applied
behavior
analysis
19
that
is
provided
by
a
board-certified
behavior
analyst
or
by
20
a
licensed
physician
or
psychologist.
The
required
maximum
21
benefit
for
coverage
for
applied
behavior
analysis
for
an
22
individual
diagnosed
with
an
autism
spectrum
disorder
is
23
$36,000
per
year
through
age
6,
$25,000
per
year
from
age
7
24
through
age
13,
and
$12,500
per
year
from
age
14
through
age
25
18.
26
Required
coverage
can
be
subject
to
preauthorization,
prior
27
approval,
or
other
care
management
requirements,
including
28
limits
on
the
number
of
visits
an
individual
may
make
for
29
applied
behavior
analysis.
30
Required
coverage
can
be
subject
to
dollar
limits,
31
deductibles,
copayments,
or
coinsurance
provisions,
or
any
32
other
general
exclusions
or
limitations
of
the
coverage
that
33
apply
to
other
covered
medical
or
surgical
services.
34
The
new
Code
section
shall
not
be
construed
to
limit
benefits
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otherwise
available
to
an
individual
under
a
group
policy,
1
contract,
or
plan.
2
The
new
Code
section
shall
not
be
construed
as
affecting
3
any
obligation
to
provide
services
to
an
individual
under
an
4
individualized
family
service
plan,
education
program,
or
5
service
plan.
6
A
carrier,
organized
delivery
system,
or
plan
may
request
7
to
review
a
treatment
plan
not
more
than
once
every
three
8
months,
unless
the
carrier,
organized
delivery
system,
or
9
plan
and
the
individual’s
treating
physician
or
psychologist
10
execute
an
agreement
that
more
frequent
review
is
necessary.
11
Such
an
agreement
applies
only
to
that
individual
and
does
not
12
apply
to
other
individuals
receiving
applied
behavior
analysis
13
from
a
board-certified
behavior
analyst,
a
physician,
or
a
14
psychologist.
The
cost
of
conducting
the
review
of
a
treatment
15
plan
is
to
be
borne
by
the
carrier,
organized
delivery
system,
16
or
plan.
17
The
new
Code
section
does
not
apply
to
various
specified
18
types
of
insurance.
The
commissioner
may
adopt
rules
to
19
implement
and
administer
the
provision.
20
New
Code
section
514C.31
applies
to
third-party
provider
21
payment
contracts,
policies,
or
plans
specified
in
the
22
bill,
or
plans
established
pursuant
to
Code
chapter
509A
for
23
public
employees
other
than
employees
of
the
state,
that
are
24
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
25
state
on
or
after
January
1,
2018.
26
Coordinating
changes
are
made
in
Code
sections
225D.1
and
27
225D.2
to
provide
that
persons
who
are
eligible
for
coverage
28
of
applied
behavior
analysis
treatment
under
new
Code
section
29
514C.31
are
not
eligible
to
participate
in
the
state
autism
30
support
program.
These
changes
also
take
effect
January
1,
31
2018.
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