Bill Text: OH SB381 | 2011-2012 | 129th General Assembly | Introduced

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Bill Title: To include pervasive developmental disorders in the mental health insurance parity law.

Spectrum: Partisan Bill (Republican 6-0)

Status: (Introduced - Dead) 2012-10-15 - To Health, Human Services, & Aging [SB381 Detail]

Download: Ohio-2011-SB381-Introduced.html

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As Introduced

129th General Assembly Regular Session 2011-2012

S. B. No. 381

Senator Seitz 

Cosponsors: Senators Balderson, Eklund, Patton, LaRose, Manning 

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A BILL

To amend sections 1751.01, 3923.281, and 3923.282 of

1

the Revised Code to include pervasive

2

developmental disorders in the mental health

3

insurance parity law.

4

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

Section 1. That sections 1751.01, 3923.281, and 3923.282 of	5
the Revised Code be amended to read as follows:	6

Sec. 1751.01.  As used in this chapter:

7

(A)(1) "Basic health care services" means the following	8
services when medically necessary:	9

(a) Physician's services, except when such services are	10
supplemental under division (B) of this section;	11

(b) Inpatient hospital services;

12

(c) Outpatient medical services;

13

(d) Emergency health services;

14

(e) Urgent care services;

15

(f) Diagnostic laboratory services and diagnostic and	16
therapeutic radiologic services;	17

(g) Diagnostic and treatment services, other than	18
prescription drug services, for biologically based mental	19
illnesses;	20

(h) Preventive health care services, including, but not	21
limited to, voluntary family planning services, infertility	22
services, periodic physical examinations, prenatal obstetrical	23
care, and well-child care;	24

(i) Routine patient care for patients enrolled in an eligible	25
cancer clinical trial pursuant to section 3923.80 of the Revised	26
Code.	27

"Basic health care services" does not include experimental	28
procedures.	29

Except as provided by divisions (A)(2) and (3) of this	30
section in connection with the offering of coverage for diagnostic	31
and treatment services for biologically based mental illnesses, a	32
health insuring corporation shall not offer coverage for a health	33
care service, defined as a basic health care service by this	34
division, unless it offers coverage for all listed basic health	35
care services. However, this requirement does not apply to the	36
coverage of beneficiaries enrolled in medicare pursuant to a	37
medicare contract, or to the coverage of beneficiaries enrolled in	38
the federal employee health benefits program pursuant to 5	39
U.S.C.A. 8905, or to the coverage of medicaid recipients, or to	40
the coverage of beneficiaries under any federal health care	41
program regulated by a federal regulatory body, or to the coverage	42
of beneficiaries under any contract covering officers or employees	43
of the state that has been entered into by the department of	44
administrative services.	45

(2)(a) A health insuring corporation may offer coverage for	46
diagnostic and treatment services for biologically based mental	47
illnesses without offering coverage for all other basic health	48
care services. A health insuring corporation may offer coverage	49
for diagnostic and treatment services for biologically based	50
mental illnesses alone or in combination with one or more	51
supplemental health care services. However, a health insuring	52
corporation that offers coverage for any other basic health care	53
service shall offer coverage for diagnostic and treatment services	54
for biologically based mental illnesses in combination with the	55
offer of coverage for all other listed basic health care services.	56

(b) Coverage for diagnostic and treatment services for	57
biologically based mental illnesses related to pervasive	58
developmental disorders shall include applied behavior analysis	59
when provided or supervised by an analyst certified by the	60
behavior analyst certification board or by a state licensed	61
physician or psychologist, or a mental health professional, as	62
defined in division (A)(1)(d) of section 2305.51 of the Revised	63
Code, so long as the services performed are commensurate with the	64
physician's, psychologist's, or mental health professional's	65
training and supervised experience. Such coverage shall include	66
the services of the personnel who work under the supervision of	67
the analyst certified by the behavior analyst certification board	68
or the licensed physician or psychologist or the mental health	69
professional.	70

(c) A health insuring corporation may subject coverage for	71
applied behavior analysis to an annual maximum benefit of fifty	72
thousand dollars.	73

(d) On and after January 1, 2014, to the extent that division	74
(A)(2)(b) of this section results in the state paying the cost of	75
benefits that exceed the essential health benefits specified under	76
section 1302(b) of the "Patient Protection and Affordable Care	77
Act," 42 U.S.C. 18022(b), as amended, those benefits that exceed	78
the specified essential health benefits shall not be required of	79
health benefit plans in the individual market or in the small	80
group market that are offered by a health insuring corporation in	81
this state either through or outside a health insurance exchange	82
operated by the state or by the federal government.	83

(e) "Applied behavior analysis" means the design,	84
implementation, and evaluation of environmental modifications	85
using behavioral stimuli and consequences to produce socially	86
significant improvement in human behavior, that is delivered in a	87
home or clinic setting to address core deficits resulting from a	88
medical diagnosis of pervasive developmental disorder. "Applied	89
behavior analysis" includes the use of direct observation,	90
measurement, and functional analysis of the relationship between	91
environment and behavior.	92

(3) A health insuring corporation that offers coverage for	93
basic health care services is not required to offer coverage for	94
diagnostic and treatment services for biologically based mental	95
illnesses in combination with the offer of coverage for all other	96
listed basic health care services if all of the following apply:	97

(a) The health insuring corporation submits documentation	98
certified by an independent member of the American academy of	99
actuaries to the superintendent of insurance showing that incurred	100
claims for diagnostic and treatment services for biologically	101
based mental illnesses for a period of at least six months	102
independently caused the health insuring corporation's costs for	103
claims and administrative expenses for the coverage of basic	104
health care services to increase by more than one per cent per	105
year.	106

(b) The health insuring corporation submits a signed letter	107
from an independent member of the American academy of actuaries to	108
the superintendent of insurance opining that the increase in costs	109
described in division (A)(3)(a) of this section could reasonably	110
justify an increase of more than one per cent in the annual	111
premiums or rates charged by the health insuring corporation for	112
the coverage of basic health care services.	113

(c) The superintendent of insurance makes the following	114
determinations from the documentation and opinion submitted	115
pursuant to divisions (A)(3)(a) and (b) of this section:	116

(i) Incurred claims for diagnostic and treatment services for	117
biologically based mental illnesses for a period of at least six	118
months independently caused the health insuring corporation's	119
costs for claims and administrative expenses for the coverage of	120
basic health care services to increase by more than one per cent	121
per year.	122

(ii) The increase in costs reasonably justifies an increase	123
of more than one per cent in the annual premiums or rates charged	124
by the health insuring corporation for the coverage of basic	125
health care services.	126

Any determination made by the superintendent under this	127
division is subject to Chapter 119. of the Revised Code.	128

(B)(1) "Supplemental health care services" means any health	129
care services other than basic health care services that a health	130
insuring corporation may offer, alone or in combination with	131
either basic health care services or other supplemental health	132
care services, and includes:	133

(a) Services of facilities for intermediate or long-term	134
care, or both;	135

(b) Dental care services;

136

(c) Vision care and optometric services including lenses and	137
frames;	138

(d) Podiatric care or foot care services;

139

(e) Mental health services, excluding diagnostic and	140
treatment services for biologically based mental illnesses;	141

(f) Short-term outpatient evaluative and crisis-intervention	142
mental health services;	143

(g) Medical or psychological treatment and referral services	144
for alcohol and drug abuse or addiction;	145

(h) Home health services;

146

(i) Prescription drug services;

147

(j) Nursing services;

148

(k) Services of a dietitian licensed under Chapter 4759. of	149
the Revised Code;	150

(l) Physical therapy services;

151

(m) Chiropractic services;

152

(n) Any other category of services approved by the	153
superintendent of insurance.	154

(2) If a health insuring corporation offers prescription drug	155
services under this division, the coverage shall include	156
prescription drug services for the treatment of biologically based	157
mental illnesses on the same terms and conditions as other	158
physical diseases and disorders.	159

(C) "Specialty health care services" means one of the	160
supplemental health care services listed in division (B) of this	161
section, when provided by a health insuring corporation on an	162
outpatient-only basis and not in combination with other	163
supplemental health care services.	164

(D) "Biologically based mental illnesses" means	165
schizophrenia, schizoaffective disorder, major depressive	166
disorder, bipolar disorder, paranoia and other psychotic	167
disorders, obsessive-compulsive disorder, and panic disorder, as	168
these terms are defined in the most recent edition of the	169
diagnostic and statistical manual of mental disorders published by	170
the American psychiatric association, and pervasive developmental	171
disorders.	172

(E) "Closed panel plan" means a health care plan that	173
requires enrollees to use participating providers.	174

(F) "Compensation" means remuneration for the provision of	175
health care services, determined on other than a fee-for-service	176
or discounted-fee-for-service basis.	177

(G) "Contractual periodic prepayment" means the formula for	178
determining the premium rate for all subscribers of a health	179
insuring corporation.	180

(H) "Corporation" means a corporation formed under Chapter	181
1701. or 1702. of the Revised Code or the similar laws of another	182
state.	183

(I) "Emergency health services" means those health care	184
services that must be available on a seven-days-per-week,	185
twenty-four-hours-per-day basis in order to prevent jeopardy to an	186
enrollee's health status that would occur if such services were	187
not received as soon as possible, and includes, where appropriate,	188
provisions for transportation and indemnity payments or service	189
agreements for out-of-area coverage.	190

(J) "Enrollee" means any natural person who is entitled to	191
receive health care benefits provided by a health insuring	192
corporation.	193

(K) "Evidence of coverage" means any certificate, agreement,	194
policy, or contract issued to a subscriber that sets out the	195
coverage and other rights to which such person is entitled under a	196
health care plan.	197

(L) "Health care facility" means any facility, except a	198
health care practitioner's office, that provides preventive,	199
diagnostic, therapeutic, acute convalescent, rehabilitation,	200
mental health, mental retardation, intermediate care, or skilled	201
nursing services.	202

(M) "Health care services" means basic, supplemental, and	203
specialty health care services.	204

(N) "Health delivery network" means any group of providers or	205
health care facilities, or both, or any representative thereof,	206
that have entered into an agreement to offer health care services	207
in a panel rather than on an individual basis.	208

(O) "Health insuring corporation" means a corporation, as	209
defined in division (H) of this section, that, pursuant to a	210
policy, contract, certificate, or agreement, pays for, reimburses,	211
or provides, delivers, arranges for, or otherwise makes available,	212
basic health care services, supplemental health care services, or	213
specialty health care services, or a combination of basic health	214
care services and either supplemental health care services or	215
specialty health care services, through either an open panel plan	216
or a closed panel plan.	217

"Health insuring corporation" does not include a limited	218
liability company formed pursuant to Chapter 1705. of the Revised	219
Code, an insurer licensed under Title XXXIX of the Revised Code if	220
that insurer offers only open panel plans under which all	221
providers and health care facilities participating receive their	222
compensation directly from the insurer, a corporation formed by or	223
on behalf of a political subdivision or a department, office, or	224
institution of the state, or a public entity formed by or on	225
behalf of a board of county commissioners, a county board of	226
developmental disabilities, an alcohol and drug addiction services	227
board, a board of alcohol, drug addiction, and mental health	228
services, or a community mental health board, as those terms are	229
used in Chapters 340. and 5126. of the Revised Code. Except as	230
provided by division (D) of section 1751.02 of the Revised Code,	231
or as otherwise provided by law, no board, commission, agency, or	232
other entity under the control of a political subdivision may	233
accept insurance risk in providing for health care services.	234
However, nothing in this division shall be construed as	235
prohibiting such entities from purchasing the services of a health	236
insuring corporation or a third-party administrator licensed under	237
Chapter 3959. of the Revised Code.	238

(P) "Intermediary organization" means a health delivery	239
network or other entity that contracts with licensed health	240
insuring corporations or self-insured employers, or both, to	241
provide health care services, and that enters into contractual	242
arrangements with other entities for the provision of health care	243
services for the purpose of fulfilling the terms of its contracts	244
with the health insuring corporations and self-insured employers.	245

(Q) "Intermediate care" means residential care above the	246
level of room and board for patients who require personal	247
assistance and health-related services, but who do not require	248
skilled nursing care.	249

(R) "Medicaid" has the same meaning as in section 5111.01 of	250
the Revised Code.	251

(S) "Medical record" means the personal information that	252
relates to an individual's physical or mental condition, medical	253
history, or medical treatment.	254

(T) "Medicare" means the program established under Title	255
XVIII of the "Social Security Act" 49 Stat. 620 (1935), 42 U.S.C.	256
1395, as amended.	257

(U)(1) "Open panel plan" means a health care plan that	258
provides incentives for enrollees to use participating providers	259
and that also allows enrollees to use providers that are not	260
participating providers.	261

(2) No health insuring corporation may offer an open panel	262
plan, unless the health insuring corporation is also licensed as	263
an insurer under Title XXXIX of the Revised Code, the health	264
insuring corporation, on June 4, 1997, holds a certificate of	265
authority or license to operate under Chapter 1736. or 1740. of	266
the Revised Code, or an insurer licensed under Title XXXIX of the	267
Revised Code is responsible for the out-of-network risk as	268
evidenced by both an evidence of coverage filing under section	269
1751.11 of the Revised Code and a policy and certificate filing	270
under section 3923.02 of the Revised Code.	271

(V) "Osteopathic hospital" means a hospital registered under	272
section 3701.07 of the Revised Code that advocates osteopathic	273
principles and the practice and perpetuation of osteopathic	274
medicine by doing any of the following:	275

(1) Maintaining a department or service of osteopathic	276
medicine or a committee on the utilization of osteopathic	277
principles and methods, under the supervision of an osteopathic	278
physician;	279

(2) Maintaining an active medical staff, the majority of	280
which is comprised of osteopathic physicians;	281

(3) Maintaining a medical staff executive committee that has	282
osteopathic physicians as a majority of its members.	283

(W) "Panel" means a group of providers or health care	284
facilities that have joined together to deliver health care	285
services through a contractual arrangement with a health insuring	286
corporation, employer group, or other payor.	287

(X) "Person" has the same meaning as in section 1.59 of the	288
Revised Code, and, unless the context otherwise requires, includes	289
any insurance company holding a certificate of authority under	290
Title XXXIX of the Revised Code, any subsidiary and affiliate of	291
an insurance company, and any government agency.	292

(Y) "Pervasive developmental disorder" means all of the	293
following as they are defined in the most recent edition of the	294
diagnostic and statistical manual of mental disorders as published	295
by the American psychiatric association:	296

(1) Autistic disorder;

297

(2) Asperger's disorder;

298

(3) Pervasive developmental disorder-not otherwise specified;

299

(4) Rett's syndrome;

300

(5) Childhood disintegrative disorder.

301

(Z) "Premium rate" means any set fee regularly paid by a	302
subscriber to a health insuring corporation. A "premium rate" does	303
not include a one-time membership fee, an annual administrative	304
fee, or a nominal access fee, paid to a managed health care system	305
under which the recipient of health care services remains solely	306
responsible for any charges accessed for those services by the	307
provider or health care facility.	308

(Z)(AA) "Primary care provider" means a provider that is	309
designated by a health insuring corporation to supervise,	310
coordinate, or provide initial care or continuing care to an	311
enrollee, and that may be required by the health insuring	312
corporation to initiate a referral for specialty care and to	313
maintain supervision of the health care services rendered to the	314
enrollee.	315

(AA)(BB) "Provider" means any natural person or partnership	316
of natural persons who are licensed, certified, accredited, or	317
otherwise authorized in this state to furnish health care	318
services, or any professional association organized under Chapter	319
1785. of the Revised Code, provided that nothing in this chapter	320
or other provisions of law shall be construed to preclude a health	321
insuring corporation, health care practitioner, or organized	322
health care group associated with a health insuring corporation	323
from employing certified nurse practitioners, certified nurse	324
anesthetists, clinical nurse specialists, certified nurse	325
midwives, dietitians, physician assistants, dental assistants,	326
dental hygienists, optometric technicians, or other allied health	327
personnel who are licensed, certified, accredited, or otherwise	328
authorized in this state to furnish health care services.	329

(BB)(CC) "Provider sponsored organization" means a	330
corporation, as defined in division (H) of this section, that is	331
at least eighty per cent owned or controlled by one or more	332
hospitals, as defined in section 3727.01 of the Revised Code, or	333
one or more physicians licensed to practice medicine or surgery or	334
osteopathic medicine and surgery under Chapter 4731. of the	335
Revised Code, or any combination of such physicians and hospitals.	336
Such control is presumed to exist if at least eighty per cent of	337
the voting rights or governance rights of a provider sponsored	338
organization are directly or indirectly owned, controlled, or	339
otherwise held by any combination of the physicians and hospitals	340
described in this division.	341

(CC)(DD) "Solicitation document" means the written materials	342
provided to prospective subscribers or enrollees, or both, and	343
used for advertising and marketing to induce enrollment in the	344
health care plans of a health insuring corporation.	345

(DD)(EE) "Subscriber" means a person who is responsible for	346
making payments to a health insuring corporation for participation	347
in a health care plan, or an enrollee whose employment or other	348
status is the basis of eligibility for enrollment in a health	349
insuring corporation.	350

(EE)(FF) "Urgent care services" means those health care	351
services that are appropriately provided for an unforeseen	352
condition of a kind that usually requires medical attention	353
without delay but that does not pose a threat to the life, limb,	354
or permanent health of the injured or ill person, and may include	355
such health care services provided out of the health insuring	356
corporation's approved service area pursuant to indemnity payments	357
or service agreements.	358

Sec. 3923.281.  (A) As used in this section:

359

(1) "Biologically based mental illness" means schizophrenia,	360
schizoaffective disorder, major depressive disorder, bipolar	361
disorder, paranoia and other psychotic disorders,	362
obsessive-compulsive disorder, and panic disorder, as these terms	363
are defined in the most recent edition of the diagnostic and	364
statistical manual of mental disorders published by the American	365
psychiatric association, and pervasive developmental disorders.	366

(2) "Policy of sickness and accident insurance" has the same	367
meaning as in section 3923.01 of the Revised Code, but excludes	368
any hospital indemnity, medicare supplement, long-term care,	369
disability income, one-time-limited-duration policy of not longer	370
than six months, supplemental benefit, or other policy that	371
provides coverage for specific diseases or accidents only; any	372
policy that provides coverage for workers' compensation claims	373
compensable pursuant to Chapters 4121. and 4123. of the Revised	374
Code; and any policy that provides coverage to beneficiaries	375
enrolled in Title XIX of the "Social Security Act," 49 Stat. 620	376
(1935), 42 U.S.C.A. 301, as amended, known as the medical	377
assistance program or medicaid, as provided by the Ohio department	378
of job and family services under Chapter 5111. of the Revised	379
Code.	380

(3) "Applied behavior analysis" means the design,	381
implementation, and evaluation of environmental modifications	382
using behavioral stimuli and consequences to produce socially	383
significant improvement in human behavior, that is delivered in a	384
home or clinic setting to address core deficits resulting from a	385
medical diagnosis of pervasive developmental disorder. "Applied	386
behavior analysis" includes the use of direct observation,	387
measurement, and functional analysis of the relationship between	388
environment and behavior.	389

(4) "Pervasive developmental disorder" means all of the	390
following as they are defined in the most recent edition of the	391
diagnostic and statistical manual of mental disorders as published	392
by the American psychiatric association:	393

(a) Autistic disorder;

394

(b) Asperger's disorder;

395

(c) Pervasive developmental disorder-not otherwise specified;

396

(d) Rett's syndrome;

397

(e) Childhood disintegrative disorder.

398

(B)(1) Notwithstanding section 3901.71 of the Revised Code,	399
and subject to division (E) of this section, every policy of	400
sickness and accident insurance shall provide benefits for the	401
diagnosis and treatment of biologically based mental illnesses on	402
the same terms and conditions as, and shall provide benefits no	403
less extensive than, those provided under the policy of sickness	404
and accident insurance for the treatment and diagnosis of all	405
other physical diseases and disorders, if both of the following	406
apply:	407

(1)(a) The biologically based mental illness is clinically	408
diagnosed by a physician authorized under Chapter 4731. of the	409
Revised Code to practice medicine and surgery or osteopathic	410
medicine and surgery; a psychologist licensed under Chapter 4732.	411
of the Revised Code; a professional clinical counselor,	412
professional counselor, or independent social worker licensed	413
under Chapter 4757. of the Revised Code; or a clinical nurse	414
specialist licensed under Chapter 4723. of the Revised Code whose	415
nursing specialty is mental health.	416

(2)(b) The prescribed treatment is not experimental or	417
investigational, having proven its clinical effectiveness in	418
accordance with generally accepted medical standards.	419

(2) Coverage for diagnostic and treatment services for	420
biologically based mental illnesses related to pervasive	421
developmental disorders shall include applied behavior analysis	422
when provided or supervised by an analyst certified by the	423
behavior analyst certification board or by a state licensed	424
physician or psychologist, or a mental health professional, as	425
defined under division (A)(1)(d) of section 2305.51 of the Revised	426
Code, so long as the services performed are commensurate with the	427
physician's, psychologist's, or mental health professional's	428
training and supervised experience. Such coverage shall include	429
the services of the personnel who work under the supervision of	430
the analyst certified by the behavior analyst certification board	431
or the licensed physician or psychologist or the mental health	432
professional.	433

(3) An insurer may subject coverage for applied behavior	434
analysis to an annual maximum benefit of fifty thousand dollars.	435

(4) On and after January 1, 2014, to the extent that the	436
requirement of division (B)(2) of this section results in the	437
state paying the cost of benefits that exceed the essential health	438
benefits specified under section 1302(b) of the "Patient	439
Protection and Affordable Care Act," 42 U.S.C. 300gg-11, as	440
amended, the specific benefits that exceed the specified essential	441
health benefits shall not be required of health benefit plans in	442
the individual market or the small group market that are offered	443
by a health care insurer in this state either through or outside a	444
health insurance exchange operated by the state or by the federal	445
government.	446

(C) Division (B) of this section applies to all coverages and	447
terms and conditions of the policy of sickness and accident	448
insurance, including, but not limited to, coverage of inpatient	449
hospital services, outpatient services, and medication; maximum	450
lifetime benefits; copayments; and individual and family	451
deductibles.	452

(D) Nothing in this section shall be construed as prohibiting	453
a sickness and accident insurance company from taking any of the	454
following actions:	455

(1) Negotiating separately with mental health care providers	456
with regard to reimbursement rates and the delivery of health care	457
services;	458

(2) Offering policies that provide benefits solely for the	459
diagnosis and treatment of biologically based mental illnesses;	460

(3) Managing the provision of benefits for the diagnosis or	461
treatment of biologically based mental illnesses through the use	462
of pre-admission screening, by requiring beneficiaries to obtain	463
authorization prior to treatment, or through the use of any other	464
mechanism designed to limit coverage to that treatment determined	465
to be necessary;	466

(4) Enforcing the terms and conditions of a policy of	467
sickness and accident insurance.	468

(E) An insurer that offers any policy of sickness and	469
accident insurance is not required to provide benefits for the	470
diagnosis and treatment of biologically based mental illnesses	471
pursuant to division (B) of this section if all of the following	472
apply:	473

(1) The insurer submits documentation certified by an	474
independent member of the American academy of actuaries to the	475
superintendent of insurance showing that incurred claims for	476
diagnostic and treatment services for biologically based mental	477
illnesses for a period of at least six months independently caused	478
the insurer's costs for claims and administrative expenses for the	479
coverage of all other physical diseases and disorders to increase	480
by more than one per cent per year.	481

(2) The insurer submits a signed letter from an independent	482
member of the American academy of actuaries to the superintendent	483
of insurance opining that the increase described in division	484
(E)(1) of this section could reasonably justify an increase of	485
more than one per cent in the annual premiums or rates charged by	486
the insurer for the coverage of all other physical diseases and	487
disorders.	488

(3) The superintendent of insurance makes the following	489
determinations from the documentation and opinion submitted	490
pursuant to divisions (E)(1) and (2) of this section:	491

(a) Incurred claims for diagnostic and treatment services for	492
biologically based mental illnesses for a period of at least six	493
months independently caused the insurer's costs for claims and	494
administrative expenses for the coverage of all other physical	495
diseases and disorders to increase by more than one per cent per	496
year.	497

(b) The increase in costs reasonably justifies an increase of	498
more than one per cent in the annual premiums or rates charged by	499
the insurer for the coverage of all other physical diseases and	500
disorders.	501

Any determination made by the superintendent under this	502
division is subject to Chapter 119. of the Revised Code.	503

Sec. 3923.282. (A) As used in this section:

504

(1) "Biologically based mental illness" means schizophrenia,	505
schizoaffective disorder, major depressive disorder, bipolar	506
disorder, paranoia and other psychotic disorders,	507
obsessive-compulsive disorder, and panic disorder, as these terms	508
are defined in the most recent edition of the diagnostic and	509
statistical manual of mental disorders published by the American	510
psychiatric association, and pervasive developmental disorders.	511

(2) "Plan of health coverage" includes any private or public	512
employer group self-insurance plan that provides payment for	513
health care benefits for other than specific diseases or accidents	514
only, which benefits are not provided by contract with a sickness	515
and accident insurer or health insuring corporation.	516

(3) "Applied behavior analysis" means the design,	517
implementation, and evaluation of environmental modifications	518
using behavioral stimuli and consequences to produce socially	519
significant improvement in human behavior, that is delivered in a	520
home or clinic setting to address core deficits resulting from a	521
medical diagnosis of pervasive developmental disorder. "Applied	522
behavior analysis" includes the use of direct observation,	523
measurement, and functional analysis of the relationship between	524
environment and behavior.	525

(4) "Pervasive developmental disorder" means all of the	526
following as they are defined in the most recent edition of the	527
diagnostic and statistical manual of mental disorders as published	528
by the American psychiatric association:	529

(a) Autistic disorder;

530

(b) Asperger's disorder;

531

(c) Pervasive developmental disorder-not otherwise specified;

532

(d) Rett's syndrome;

533

(e) Childhood disintegrative disorder.

534

(B)(1) Notwithstanding section 3901.71 of the Revised Code,	535
and subject to division (F) of this section, each plan of health	536
coverage shall provide benefits for the diagnosis and treatment of	537
biologically based mental illnesses on the same terms and	538
conditions as, and shall provide benefits no less extensive than,	539
those provided under the plan of health coverage for the treatment	540
and diagnosis of all other physical diseases and disorders, if	541
both of the following apply:	542

(1)(a) The biologically based mental illness is clinically	543
diagnosed by a physician authorized under Chapter 4731. of the	544
Revised Code to practice medicine and surgery or osteopathic	545
medicine and surgery; a psychologist licensed under Chapter 4732.	546
of the Revised Code; a professional clinical counselor,	547
professional counselor, or independent social worker licensed	548
under Chapter 4757. of the Revised Code; or a clinical nurse	549
specialist licensed under Chapter 4723. of the Revised Code whose	550
nursing specialty is mental health.	551

(2)(b) The prescribed treatment is not experimental or	552
investigational, having proven its clinical effectiveness in	553
accordance with generally accepted medical standards.	554

(2) Coverage for diagnostic and treatment services for	555
biologically based mental illnesses related to pervasive	556
developmental disorders shall include applied behavior analysis	557
when provided or supervised by an analyst certified by the	558
behavior analyst certification board or by a state licensed	559
physician or psychologist, or a mental health professional, as	560
defined under division (A)(1)(d) of section 2305.51 of the Revised	561
Code, so long as the services performed are commensurate with the	562
physician's, psychologist's, or mental health professional's	563
training and supervised experience. Such coverage shall include	564
the services of the personnel who work under the supervision of	565
the analyst certified by the behavior analyst certification board	566
or the licensed physician or psychologist or the mental health	567
professional.	568

(3) An employer may subject coverage for applied behavior	569
analysis to an annual maximum benefit of fifty thousand dollars.	570

(4) On and after January 1, 2014, to the extent that the	571
requirement of division (B)(2) of this section results in the	572
state paying the cost of benefits that exceed the essential health	573
benefits specified under section 1302(b) of the "Patient	574
Protection and Affordable Care Act," 42 U.S.C. 300gg-11, as	575
amended, the specific benefits that exceed the specified essential	576
health benefits shall not be required of health benefit plans in	577
the individual market or small group market that are offered by a	578
health care insurer in this state either through or outside a	579
health insurance exchange operated by the state or by the federal	580
government.	581

(C) Division (B) of this section applies to all coverages and	582
terms and conditions of the plan of health coverage, including,	583
but not limited to, coverage of inpatient hospital services,	584
outpatient services, and medication; maximum lifetime benefits;	585
copayments; and individual and family deductibles.	586

(D) This section does not apply to a plan of health coverage	587
if federal law supersedes, preempts, prohibits, or otherwise	588
precludes its application to such plans. This section does not	589
apply to long-term care, hospital indemnity, disability income, or	590
medicare supplement plans of health coverage, or to any other	591
supplemental benefit plans of health coverage.	592

(E) Nothing in this section shall be construed as prohibiting	593
an employer from taking any of the following actions in connection	594
with a plan of health coverage:	595

(1) Negotiating separately with mental health care providers	596
with regard to reimbursement rates and the delivery of health care	597
services;	598

(2) Managing the provision of benefits for the diagnosis or	599
treatment of biologically based mental illnesses through the use	600
of pre-admission screening, by requiring beneficiaries to obtain	601
authorization prior to treatment, or through the use of any other	602
mechanism designed to limit coverage to that treatment determined	603
to be necessary;	604

(3) Enforcing the terms and conditions of a plan of health	605
coverage.	606

(F) An employer that offers a plan of health coverage is not	607
required to provide benefits for the diagnosis and treatment of	608
biologically based mental illnesses in combination with benefits	609
for the treatment and diagnosis of all other physical diseases and	610
disorders as described in division (B) of this section if both of	611
the following apply:	612

(1) The employer submits documentation certified by an	613
independent member of the American academy of actuaries to the	614
superintendent of insurance showing that incurred claims for	615
diagnostic and treatment services for biologically based mental	616
illnesses for a period of at least six months independently caused	617
the employer's costs for claims and administrative expenses for	618
the coverage of all other physical diseases and disorders to	619
increase by more than one per cent per year.	620

(2) The superintendent of insurance determines from the	621
documentation and opinion submitted pursuant to division (F) of	622
this section, that incurred claims for diagnostic and treatment	623
services for biologically based mental illnesses for a period of	624
at least six months independently caused the employer's costs for	625
claims and administrative expenses for the coverage of all other	626
physical diseases and disorders to increase by more than one per	627
cent per year.	628

Any determination made by the superintendent under this	629
division is subject to Chapter 119. of the Revised Code.	630

Section 2. That existing sections 1751.01, 3923.281, and	631
3923.282 of the Revised Code are hereby repealed.	632