Bill Text: MI SB0353 | 2015-2016 | 98th Legislature | Introduced

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Bill Title: Insurance; health benefits; coverage of autism spectrum disorders; require insurers and health maintenance organizations to ensure timely diagnosis and treatment and adequate participating provider network. Amends sec. 3406s of 1956 PA 218 (MCL 500.3406s).

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2015-05-21 - Referred To Committee On Insurance [SB0353 Detail]

Download: Michigan-2015-SB0353-Introduced.html

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SENATE BILL No. 353

 

 

May 21, 2015, Introduced by Senator O'BRIEN and referred to the Committee on Insurance.

 

 

 

     A bill to amend 1956 PA 218, entitled

 

"The insurance code of 1956,"

 

by amending section 3406s (MCL 500.3406s), as added by 2012 PA 100.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 3406s. (1) Except as otherwise provided in this section,

 

an insurer that delivers, issues for delivery, or renews in this

 

state an expense-incurred hospital, medical, or surgical group or

 

individual policy or certificate delivered, issued for delivery, or

 

renewed in this state and or a health maintenance organization that

 

issues or renews a group or individual contract shall provide

 

coverage for the timely diagnosis of autism spectrum disorders and

 

timely treatment of autism spectrum disorders. An insurer or health

 

maintenance organization shall ensure that each insured or enrollee

 

has access to in-network participating providers that are a

 

reasonable distance from the residence of the insured or enrollee

 

and that do not require a waiting time that is longer than allowed

 

by the NCQA for an appointment to begin the process of obtaining a

 

diagnosis of autism spectrum disorders. For the purposes of this

 

subsection, a diagnosis or a treatment is considered to be timely

 

if it meets the definition of timely as provided by the NCQA. For

 

the purposes of this subsection, a distance is considered to be

 

reasonable if it meets the definition of reasonable distance

 

provided by the NCQA.

 

     (2) An insurer and or a health maintenance organization

 

subject to this section shall not do any of the following:

 

     (a) Terminate coverage or refuse to deliver, execute, issue,

 

amend, adjust, or renew coverage solely because an individual is

 

diagnosed with, or has received treatment for, an autism spectrum

 

disorder.

 

     (b) Limit the number of visits an insured or enrollee may use

 

for treatment of autism spectrum disorders covered under this

 

section.

 

     (c) Deny or limit coverage under this section on the basis

 

that treatment is educational or habilitative in nature.

 

     (d) Deny coverage under this section to, or limit coverage

 

under this section to only, an individual who exhibits problem

 

behaviors.

 

     (e) (d) Except as otherwise provided in this subdivision,

 

subject coverage under this section to dollar limits, copays,

 

deductibles, or coinsurance provisions that do not apply to

 

physical illness generally. Coverage Subject to subsection (8), an

 

insurer or health maintenance organization may limit coverage under

 

this section for treatment of autism spectrum disorders may be

 

limited to an insured or enrollee through 18 years of age and may

 

be subject the coverage to a maximum annual benefit as follows:

 

     (i) For a covered insured or enrollee through 6 years of age,

 

$50,000.00.

 

     (ii) For a covered insured or enrollee from 7 years of age

 

through 12 years of age, $40,000.00.

 

     (iii) For a covered insured or enrollee from 13 years of age

 

through 18 years of age, $30,000.00.

 

     (f) Establish a network of participating providers for the

 

diagnosis or treatment of autism spectrum disorders that only

 

includes autism evaluation centers approved by the insurer or

 

health maintenance organization. The insurer or health maintenance

 

organization shall establish a network of participating providers

 

for the timely diagnosis and timely treatment of autism spectrum

 

disorders that includes licensed physicians and licensed

 

psychologists whose scope of practice includes the diagnosis of

 

autism spectrum disorders or treatment of autism spectrum

 

disorders, as applicable, regardless of the physician's or

 

psychologist's affiliation with an approved autism evaluation

 

center.

 

     (3) (2) This section does not limit benefits that are

 

otherwise available to an insured or enrollee under a policy,

 

contract, or certificate. An insurer or health maintenance

 

organization shall utilize evidence-based care and managed care

 

cost-containment practices pursuant to the insurer's or health

 

maintenance organization's procedures so long as if that care and

 

those practices are consistent with this section. The An insurer or

 

health maintenance organization may subject coverage under this

 

section may be subject to other general exclusions and limitations

 

of the policy, contract, or certificate, including, but not limited

 

to, coordination of benefits, affiliated or participating provider

 

requirements, restrictions on services provided by family or

 

household members, utilization review of health care services

 

including review of medical necessity, case management, and other

 

managed care provisions.

 

     (4) (3) If an insured or enrollee is receiving treatment for

 

an autism spectrum disorder, an insurer or health maintenance

 

organization may, as a condition to providing the coverage under

 

this section, do all of the following:

 

     (a) Require a review of that treatment consistent with current

 

protocols and may require a treatment plan. If requested by the

 

insurer or health maintenance organization, the cost of treatment

 

review shall be borne by the insurer or health maintenance

 

organization.

 

     (b) Request the results of the autism diagnostic observation

 

schedule that has been used in the diagnosis of an autism spectrum

 

disorder for that insured or enrollee.

 

     (c) Request that the autism diagnostic observation schedule be

 

performed on that insured or enrollee not more frequently than once

 

every 3 years.

 

     (d) Request that an annual development evaluation be conducted

 

and the results of that annual development evaluation be submitted

 

to the insurer or health maintenance organization.

 

     (5) (4) Beginning January 1, 2014, a A qualified health plan

 

offered through an American health benefit exchange established in

 

this state pursuant to the federal act is not required to provide

 

coverage under this section to the extent that it exceeds coverage

 

that is included in the essential health benefits as required

 

pursuant to the federal act. As used in this subsection, "federal

 

act" means the federal patient protection and affordable care act,

 

Public Law 111-148, as amended by the federal health care and

 

education reconciliation act of 2010, Public Law 111-152, and any

 

regulations promulgated under those acts.

 

     (6) (5) This section does not apply to a short-term or 1-time

 

limited duration policy or certificate of no longer than 6 months

 

as described in section 2213b.

 

     (7) (6) This section does not require the coverage of

 

prescription drugs and related services unless the insured or

 

enrollee is covered by a prescription drug plan. This section does

 

not require an insurer or health maintenance organization to

 

provide coverage for autism spectrum disorders to an insured or

 

enrollee under more than 1 of its policies, certificates, or

 

contracts. If an insured or enrollee has more than 1 policy,

 

certificate, or contract that covers autism spectrum disorders, the

 

benefits provided are subject to the limits of this section when

 

coordinating benefits.

 

     (8) The department shall adjust the coverage limits allowed

 

under subsection (2)(e) by March 31 each year in accordance with

 

the annual average percentage increase or decrease in the United

 

States consumer price index for the 12-month period ending the

 

preceding December 31.

 

     (9) (7) As used in this section:

 

     (a) "Applied behavior analysis" means the design,

 

implementation, and evaluation of environmental modifications,

 

using behavioral stimuli and consequences, to produce significant

 

improvement in human behavior, including the use of direct

 

observation, measurement, and functional analysis of the

 

relationship between environment and behavior.

 

     (b) "Autism diagnostic observation schedule" means the

 

protocol available through western psychological services for

 

diagnosing and assessing autism spectrum disorders or any other

 

standardized diagnostic measure for autism spectrum disorders that

 

is approved by the commissioner, director if the commissioner

 

director determines that the diagnostic measure is recognized by

 

the health care industry and is an evidence-based diagnostic tool.

 

     (c) "Autism spectrum disorders" means any of the following

 

pervasive developmental disorders as defined by the diagnostic and

 

statistical manual:

 

     (i) Autistic disorder.

 

     (ii) Asperger's disorder.

 

     (iii) Pervasive developmental disorder not otherwise specified.

 

     (d) "Behavioral health treatment" means evidence-based

 

counseling and treatment programs, including applied behavior

 

analysis, that meet both of the following requirements:

 

     (i) Are necessary to develop, maintain, or restore, to the

 

maximum extent practicable, the functioning of an individual.

 

     (ii) Are provided or supervised by a board certified behavior

 

analyst or a licensed psychologist so long as if the services

 

performed are commensurate with the psychologist's formal

 

university training and supervised experience.

 

     (e) "Diagnosis of autism spectrum disorders" means

 

assessments, evaluations, or tests, including the autism diagnostic

 

observation schedule, performed by a licensed physician or a

 

licensed psychologist to diagnose whether an individual has 1 of

 

the autism spectrum disorders.

 

     (f) "Diagnostic and statistical manual" or "DSM" means the

 

diagnostic and statistical manual of mental disorders published by

 

the American psychiatric association Psychiatric Association or

 

other manual that contains common language and standard criteria

 

for the classification of mental disorders and that is approved by

 

the commissioner, director if the commissioner director determines

 

that the manual is recognized by the health care industry and the

 

classification of mental disorders is at least as comprehensive as

 

the manual published by the American psychiatric association

 

Psychiatric Association on the effective date of this section.April

 

18, 2012.

 

     (g) "NCQA" means the National Committee for Quality Assurance.

 

     (h) (g) "Pharmacy care" means medications prescribed by a

 

licensed physician and related services performed by a licensed

 

pharmacist and any health-related services considered medically

 

necessary to determine the need or effectiveness of the

 

medications.

 

     (i) (h) "Psychiatric care" means evidence-based direct or

 

consultative services provided by a psychiatrist licensed in the

 

state in which the psychiatrist practices.

 

     (j) (i) "Psychological care" means evidence-based direct or

 

consultative services provided by a psychologist licensed in the

 

state in which the psychologist practices.

 

     (k) (j) "Therapeutic care" means evidence-based services

 

provided by a licensed or certified speech therapist, occupational

 

therapist, physical therapist, or social worker.

 

     (l) (k) "Treatment of autism spectrum disorders" means

 

evidence-based treatment that includes the following care

 

prescribed or ordered for an individual diagnosed with 1 of the

 

autism spectrum disorders by a licensed physician or a licensed

 

psychologist who determines the care to be medically necessary:

 

     (i) Behavioral health treatment.

 

     (ii) Pharmacy care.

 

     (iii) Psychiatric care.

 

     (iv) Psychological care.

 

     (v) Therapeutic care.

 

     (m) (l) "Treatment plan" means a written, comprehensive, and

 

individualized intervention plan that incorporates specific

 

treatment goals and objectives and that is developed by a board

 

certified or licensed provider who has the appropriate credentials

 

and who is operating within his or her scope of practice, when if

 

the treatment of an autism spectrum disorder is first prescribed or

 

ordered by a licensed physician or licensed psychologist as

 

described in subdivision (k).(l).

 

     Enacting section 1. This amendatory act takes effect 90 days

 

after the date it is enacted into law.