Bill Text: OH HB376 | 2011-2012 | 129th General Assembly | Introduced

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Bill Title: To prohibit health insurers from excluding coverage for specified services for individuals diagnosed with an autism spectrum disorder.

Spectrum: Partisan Bill (Democrat 37-0)

Status: (Introduced - Dead) 2011-11-15 - To Health & Aging [HB376 Detail]

Download: Ohio-2011-HB376-Introduced.html

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As Introduced

129th General Assembly Regular Session 2011-2012

H. B. No. 376

Representatives Celeste, Garland 

Cosponsors: Representatives Antonio, Ashford, Barnes, Boyd, Carney, Clyde, DeGeeter, Driehaus, Fedor, Fende, Foley, Gentile, Gerberry, Goyal, Hagan, R., Heard, Letson, Lundy, Mallory, Milkovich, Murray, O'Brien, Okey, Patmon, Phillips, Pillich, Ramos, Reece, Slesnick, Stinziano, Sykes, Szollosi, Weddington, Winburn, Yuko 

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A BILL

To amend section 1739.05 and to enact sections

1

1751.68 and 3923.84 of the Revised Code to

2

prohibit health insurers from excluding coverage

3

for specified services for individuals diagnosed

4

with an autism spectrum disorder.

5

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1. That section 1739.05 be amended and sections	6
1751.68 and 3923.84 of the Revised Code be enacted to read as	7
follows:	8

Sec. 1739.05.  (A) A multiple employer welfare arrangement	9
that is created pursuant to sections 1739.01 to 1739.22 of the	10
Revised Code and that operates a group self-insurance program may	11
be established only if any of the following applies:	12

(1) The arrangement has and maintains a minimum enrollment of	13
three hundred employees of two or more employers.	14

(2) The arrangement has and maintains a minimum enrollment of	15
three hundred self-employed individuals.	16

(3) The arrangement has and maintains a minimum enrollment of	17
three hundred employees or self-employed individuals in any	18
combination of divisions (A)(1) and (2) of this section.	19

(B) A multiple employer welfare arrangement that is created	20
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	21
that operates a group self-insurance program shall comply with all	22
laws applicable to self-funded programs in this state, including	23
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	24
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	25
3923.24, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63,	26
3923.80, 3923.84, 3924.031, 3924.032, and 3924.27 of the Revised	27
Code.	28

(C) A multiple employer welfare arrangement created pursuant	29
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	30
enrollments only through agents or solicitors licensed pursuant to	31
Chapter 3905. of the Revised Code to sell or solicit sickness and	32
accident insurance.	33

(D) A multiple employer welfare arrangement created pursuant	34
to sections 1739.01 to 1739.22 of the Revised Code shall provide	35
benefits only to individuals who are members, employees of	36
members, or the dependents of members or employees, or are	37
eligible for continuation of coverage under section 1751.53 or	38
3923.38 of the Revised Code or under Title X of the "Consolidated	39
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	40
U.S.C.A. 1161, as amended.	41

Sec. 1751.68.  (A) Notwithstanding section 3901.71 of the	42
Revised Code, no health insuring corporation policy, contract, or	43
agreement that provides basic health care services that is	44
delivered, issued for delivery, or renewed in this state shall	45
exclude coverage for the screening and diagnosis of autism	46
spectrum disorders or for any of the following services when those	47
services are medically necessary and are prescribed, provided, or	48
ordered for an individual diagnosed with an autism spectrum	49
disorder by a health care professional licensed or certified under	50
the laws of this state to prescribe, provide, or order such	51
services:	52

(1) Habilitative or rehabilitative care;

53

(2) Pharmacy care if the policy, contract, or agreement	54
provides coverage for other prescription drug services;	55

(3) Psychiatric care;

56

(4) Psychological care;

57

(5) Therapeutic care;

58

(6) Counseling services;

59

(7) Any additional treatments or therapies adopted by the	60
director of developmental disabilities pursuant to division (I)(4)	61
of section 3923.84 of the Revised Code.	62

(B) Coverage provided under this section shall be delineated	63
in a treatment plan developed by the attending psychologist or	64
physician and shall not be subject to any limits on the number or	65
duration of visits an individual may make to any autism services	66
provider, except as delineated in the treatment plan, if the	67
services are medically necessary.	68

(C) Coverage provided under this section may be subject to	69
any copayment, deductible, and coinsurance provisions of the	70
policy, contract, or agreement to the extent that other medical	71
services covered by the policy, contract, or agreement are subject	72
to those provisions. Coverage provided under this section may be	73
subject to a yearly maximum limitation of thirty-six thousand	74
dollars on claims paid for services related to coverage provided	75
under this section.	76

(D)(1) Not more than once every six months, a health insuring	77
corporation may request a review of any treatment provided under	78
this section unless the insured's licensed physician or licensed	79
psychologist agrees that more frequent review is necessary. The	80
health insuring corporation shall pay for any review requested	81
under division (D)(1) of this section.	82

(2) If requested by the health insuring corporation, the	83
provider shall provide the health insuring corporation with an	84
annual treatment plan.	85

(3) Inpatient services are not subject to the six-month	86
review limitations under division (D)(1) of this section.	87

(E) This section shall not be construed as limiting benefits	88
otherwise available under an individual's policy, contract, or	89
agreement.	90

(F) This section shall not be construed as affecting any	91
obligation to provide services to an individual under an	92
individualized family service plan developed under 20 U.S.C. 1436	93
or individualized service plan developed under section 5126.31 of	94
the Revised Code, or affecting the duty of a public school to	95
provide a child with a disability with a free appropriate public	96
education under the "Individuals with Disabilities Education	97
Improvement Act of 2004," 20 U.S.C. 1400 et seq., as amended, and	98
Chapter 3323. of the Revised Code.	99

(G) A health insuring corporation that offers coverage for	100
basic health care services is not required to offer the coverage	101
required under division (A) of this section in combination with	102
the offer of coverage for basic health care services if all of the	103
following apply:	104

(1) The health insuring corporation submits documentation	105
certified by an independent member of the American academy of	106
actuaries to the superintendent of insurance showing that incurred	107
claims for the coverage required under division (A) of this	108
section for a period of at least six months independently caused	109
the health insuring corporation's costs for claims and	110
administrative expenses for the coverage of all covered services	111
to increase by more than one per cent per year.	112

(2) The health insuring corporation submits a signed letter	113
from an independent member of the American academy of actuaries to	114
the superintendent opining that the increase in costs described in	115
division (G)(1) of this section could reasonably justify an	116
increase of more than one per cent in the annual premiums or rates	117
charged by the health insuring corporation for the coverage of	118
basic health care services.	119

(3) The superintendent makes both of the following	120
determinations from the documentation and opinion submitted	121
pursuant to divisions (G)(1) and (2) of this section:	122

(a) Incurred claims for the coverage required under division	123
(A) of this section for a period of at least six months	124
independently caused the health insuring corporation's costs for	125
claims and administrative expenses for the coverage of all covered	126
services to increase by more than one per cent per year.	127

(b) The increase in costs reasonably justifies an increase of	128
more than one per cent in the annual premiums or rates charged by	129
the health insuring corporation for the coverage of basic health	130
care services.	131

Any determination made by the superintendent under division	132
(G)(3) of this section is subject to Chapter 119. of the Revised	133
Code.	134

(H) The services covered under this section shall not be	135
considered supplemental health care services under division (B)(1)	136
of section 1751.01 of the Revised Code.	137

(I) As used in this section:

138

(1) "Applied behavior analysis" means the design,	139
implementation, and evaluation of environmental modifications	140
using behavioral stimuli and consequences to produce socially	141
significant improvement in human behavior, including, but not	142
limited to, the use of direct observation, measurement, and	143
functional analysis of the relationship between environment and	144
behavior.	145

(2) "Autism services provider" means any person whose	146
professional scope of practice allows treatment of autism spectrum	147
disorders, whose services are delineated in the treatment plan	148
under division (B) of this section, and of whom one of the	149
following is true:	150

(a) The person is licensed, certified, or registered by an	151
appropriate agency of this state to perform the services assigned	152
to the person in the treatment plan.	153

(b) The person is directly supervised by an individual who is	154
licensed, certified, or registered by an appropriate agency of	155
this state to perform the services assigned to the person in the	156
treatment plan.	157

(3) "Autism spectrum disorder" means any of the pervasive	158
developmental disorders as defined by the most recent edition of	159
the diagnostic and statistical manual of mental disorders,	160
published by the American psychiatric association, or if that	161
manual is no longer published, a similar diagnostic manual. Autism	162
spectrum disorder includes, but is not limited to, autistic	163
disorder, Asperger's disorder, Rett's disorder, childhood	164
disintegrative disorder, and pervasive developmental disorder.	165

(4) "Diagnosis of autism spectrum disorders" means medically	166
necessary assessments, evaluations, or tests, including, but not	167
limited to, genetic and psychological tests to determine whether	168
an individual has an autism spectrum disorder.	169

(5) "Habilitative or rehabilitative care" means professional,	170
counseling, and guidance services and treatment programs,	171
including applied behavior analysis, that are necessary to	172
develop, maintain, or restore the functioning of an individual to	173
the maximum extent practicable.	174

(6) "Medically necessary" means the service is based upon	175
evidence; is prescribed, provided, or ordered by a health care	176
professional licensed or certified under the laws of this state to	177
prescribe, provide, or order autism-related services in accordance	178
with accepted standards of practice; and will or is reasonably	179
expected to do any of the following:	180

(a) Prevent the onset of an illness, condition, injury, or	181
disability;	182

(b) Reduce or ameliorate the physical, mental, or	183
developmental effects of an illness, condition, injury, or	184
disability;	185

(c) Assist in achieving or maintaining maximum functional	186
capacity for performing daily activities, taking into account both	187
the functional capacity of the individual and the appropriate	188
functional capacities of individuals of the same age.	189

(7) "Pharmacy care" means prescribed medications and any	190
medically necessary health-related services used to determine the	191
need or effectiveness of the medications.	192

(8) "Psychiatric care" means direct or consultative services	193
provided by a psychiatrist licensed in the state in which the	194
psychiatrist practices psychiatry.	195

(9) "Psychological care" means direct or consultative	196
services provided by a psychologist licensed in the state in which	197
the psychologist practices psychology.	198

(10) "Therapeutic care" means services, communication	199
devices, or other adaptive devices or equipment provided by a	200
licensed speech-language pathologist, licensed occupational	201
therapist, or licensed physical therapist.	202

Sec. 3923.84.  (A) Notwithstanding section 3901.71 of the	203
Revised Code, no individual or group policy of sickness and	204
accident insurance that is delivered, issued for delivery, or	205
renewed in this state or public employee benefit plan established	206
or modified in this state shall exclude coverage for the screening	207
and diagnosis of autism spectrum disorders or for any of the	208
following services when those services are medically necessary and	209
are prescribed, provided, or ordered for an individual diagnosed	210
with an autism spectrum disorder by a health care professional	211
licensed or certified under the laws of this state to prescribe,	212
provide, or order such services:	213

(1) Habilitative or rehabilitative care;

214

(2) Pharmacy care if the policy or plan provides coverage for	215
other prescription drug services;	216

(3) Psychiatric care;

217

(4) Psychological care;

218

(5) Therapeutic care;

219

(6) Counseling services;

220

(7) Any additional treatments or therapies adopted by the	221
director of developmental disabilities pursuant to division (I)(4)	222
of this section.	223

(B) Coverage provided under this section shall be delineated	224
in a treatment plan developed by the attending psychologist or	225
physician and shall not be subject to any limits on the number or	226
duration of visits an individual may make to any autism services	227
provider, except as delineated in the treatment plan, if the	228
services are medically necessary.	229

(C) Coverage provided under this section may be subject to	230
any copayment, deductible, and coinsurance provisions of the	231
policy or plan to the extent that other medical services covered	232
by the policy or plan are subject to those provisions. Coverage	233
provided under this section may be subject to a yearly maximum	234
limitation of thirty-six thousand dollars on claims paid for	235
services related to coverage provided under this section.	236

(D)(1) Not more than once every six months, an insurer or	237
public employee benefit plan may request a review of any treatment	238
provided under this section unless the insured's licensed	239
physician or licensed psychologist agrees that more frequent	240
review is necessary. The insurer or public employee benefit plan	241
shall pay for any review requested under division (D)(1) of this	242
section.	243

(2) If requested by the insurer or public employee benefit	244
plan, the provider shall provide the insurer or public employee	245
benefit plan with an annual treatment plan.	246

(3) Inpatient services are not subject to the six-month	247
review limitations under division (D)(1) of this section.	248

(E) This section shall not be construed as limiting benefits	249
otherwise available under an individual's policy or plan.	250

(F) This section shall not be construed as affecting any	251
obligation to provide services to an individual under an	252
individualized family service plan developed under 20 U.S.C. 1436	253
or individualized service plan developed under section 5126.31 of	254
the Revised Code, or affecting the duty of a public school to	255
provide a child with a disability with a free appropriate public	256
education under the "Individuals with Disabilities Education	257
Improvement Act of 2004," 20 U.S.C. 1400 et seq., as amended, and	258
Chapter 3323. of the Revised Code.	259

(G) This section does not apply to the offer or renewal of	260
any individual or group policy of sickness and accident insurance	261
that provides coverage for specific diseases or accidents only, or	262
to any hospital indemnity, medicare supplement, medicare, tricare,	263
long-term care, disability income, one-time limited duration	264
policy of not longer than six months, or other policy that offers	265
only supplemental benefits.	266

(H) A public employee benefit plan or insurer that offers a	267
policy of sickness and accident insurance is not required to offer	268
the coverage required under division (A) of this section if all of	269
the following apply:	270

(1) The insurer or public employee benefit plan submits	271
documentation certified by an independent member of the American	272
academy of actuaries to the superintendent of insurance showing	273
that incurred claims for the coverage required under division (A)	274
of this section for a period of at least six months independently	275
caused the costs for claims and administrative expenses for the	276
coverage of all covered services to increase by more than one per	277
cent per year.	278

(2) The insurer or public employee benefit plan submits a	279
signed letter from an independent member of the American academy	280
of actuaries to the superintendent opining that the increase in	281
costs described in division (H)(1) of this section could	282
reasonably justify an increase of more than one per cent in the	283
annual premiums or rates charged by the insurer or public employee	284
benefit plan for the coverage of all covered services.	285

(3) The superintendent makes both of the following	286
determinations from the documentation and opinion submitted	287
pursuant to divisions (H)(1) and (2) of this section:	288

(a) Incurred claims for the coverage required under division	289
(A) of this section for a period of at least six months	290
independently caused the costs for claims and administrative	291
expenses for the coverage of all covered services to increase by	292
more than one per cent per year.	293

(b) The increase in costs reasonably justifies an increase of	294
more than one per cent in the annual premiums or rates charged by	295
the insurer or public employee benefit plan for the coverage of	296
all covered services.	297

Any determination made by the superintendent under division	298
(H)(3) of this section is subject to Chapter 119. of the Revised	299
Code.	300

(I)(1) The director of developmental disabilities shall	301
convene a committee on the coverage of autism spectrum disorders	302
to investigate and recommend treatments or therapies for autism	303
spectrum disorders that the committee believes should be included	304
in the services that health benefit plans and public employee	305
benefit plans are required to cover under division (A) of this	306
section and the qualifications of the providers of those	307
treatments or therapies.	308

(2) The committee shall consist of nine members appointed by	309
the director of developmental disabilities including the director	310
of developmental disabilities, the director of health, and at	311
least one licensed physician, licensed psychologist, and parent of	312
an individual diagnosed with an autism spectrum disorder.	313

(3) The committee shall serve at the pleasure of the	314
director.	315

(4) The committee shall submit its recommendations to the	316
director of developmental disabilities. The director may adopt	317
rules in accordance with Chapter 119. of the Revised Code to	318
include additional treatments or therapies for autism spectrum	319
disorders in the services that health benefit plans and public	320
employee benefit plans are required to cover under division (A) of	321
this section.	322

(J) As used in this section:

323

(1) "Applied behavior analysis" means the design,	324
implementation, and evaluation of environmental modifications	325
using behavioral stimuli and consequences to produce socially	326
significant improvement in human behavior, including, but not	327
limited to, the use of direct observation, measurement, and	328
functional analysis of the relationship between environment and	329
behavior.	330

(2) "Autism services provider" means any person whose	331
professional scope of practice allows treatment of autism spectrum	332
disorders, whose services are delineated in the treatment plan	333
under division (B) of this section, and of whom one of the	334
following is true:	335

(a) The person is licensed, certified, or registered by an	336
appropriate agency of this state to perform the services assigned	337
to the person in the treatment plan.	338

(b) The person is directly supervised by an individual who is	339
licensed, certified, or registered by an appropriate agency of	340
this state to perform the services assigned to the person in the	341
treatment plan.	342

(3) "Autism spectrum disorder" means any of the pervasive	343
developmental disorders as defined by the most recent edition of	344
the diagnostic and statistical manual of mental disorders,	345
published by the American psychiatric association, or if that	346
manual is no longer published, a similar diagnostic manual. Autism	347
spectrum disorder includes, but is not limited to, autistic	348
disorder, Asperger's disorder, Rett's disorder, childhood	349
disintegrative disorder, and pervasive developmental disorder.	350

(4) "Diagnosis of autism spectrum disorders" means medically	351
necessary assessments, evaluations, or tests, including, but not	352
limited to, genetic and psychological tests to determine whether	353
an individual has an autism spectrum disorder.	354

(5) "Habilitative or rehabilitative care" means professional,	355
counseling, and guidance services and treatment programs,	356
including applied behavior analysis, that are necessary to	357
develop, maintain, or restore the functioning of an individual to	358
the maximum extent practicable.	359

(6) "Health benefit plan" has the same meaning as in section	360
3924.01 of the Revised Code.	361

(7) "Medically necessary" means the service is based upon	362
evidence; is prescribed, provided, or ordered by a health care	363
professional licensed or certified under the laws of this state to	364
prescribe, provide, or order autism-related services in accordance	365
with accepted standards of practice; and will or is reasonably	366
expected to do any of the following:	367

(a) Prevent the onset of an illness, condition, injury, or	368
disability;	369

(b) Reduce or ameliorate the physical, mental, or	370
developmental effects of an illness, condition, injury, or	371
disability;	372

(c) Assist in achieving or maintaining maximum functional	373
capacity for performing daily activities, taking into account both	374
the functional capacity of the individual and the appropriate	375
functional capacities of individuals of the same age.	376

(8) "Pharmacy care" means prescribed medications and any	377
medically necessary health-related services used to determine the	378
need or effectiveness of the medications.	379

(9) "Psychiatric care" means direct or consultative services	380
provided by a psychiatrist licensed in the state in which the	381
psychiatrist practices psychiatry.	382

(10) "Psychological care" means direct or consultative	383
services provided by a psychologist licensed in the state in which	384
the psychologist practices psychology.	385

(11) "Therapeutic care" means services, communication	386
devices, or other adaptive devices or equipment provided by a	387
licensed speech-language pathologist, licensed occupational	388
therapist, or licensed physical therapist.	389

Section 2.  That existing section 1739.05 of the Revised Code	390
is hereby repealed.	391