Bill Text: OR HB2897 | 2013 | Regular Session | Introduced

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Bill Title: Relating to health insurance coverage of autism spectrum disorders; declaring an emergency.

Sponsorship: Moderate Partisan Bill (Democrat 5-1)

Status: (Failed) 2013-07-08 - In committee upon adjournment. [HB2897 Detail]

Download: Oregon-2013-HB2897-Introduced.html

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     77th OREGON LEGISLATIVE ASSEMBLY--2013 Regular Session

NOTE:  Matter within  { +  braces and plus signs + } in an
amended section is new. Matter within  { -  braces and minus
signs - } is existing law to be omitted. New sections are within
 { +  braces and plus signs + } .

LC 3268

                         House Bill 2897

Sponsored by Representative BUCKLEY, Senator EDWARDS;
  Representatives GELSER, GREENLICK, KENNEMER

                             SUMMARY

The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.

  Establishes requirements for health insurance coverage of
autism spectrum disorders.
  Declares emergency, effective on passage.

                        A BILL FOR AN ACT
Relating to health insurance coverage of autism spectrum
  disorders; creating new provisions; amending ORS 743A.190; and
  declaring an emergency.
Be It Enacted by the People of the State of Oregon:
  SECTION 1.  { + Sections 2 and 3 of this 2013 Act are added to
and made a part of the Insurance Code. + }
  SECTION 2.  { + As used in this section and section 3 of this
2013 Act:
  (1) 'Applied behavior analysis' means the design,
implementation and evaluation of environmental modifications,
using behavioral stimuli and consequences, to produce socially
significant improvement in human behavior, including the use of
direct observation, measurement and functional analysis of the
relationship between environment and behavior.
  (2) 'Autism line therapist' means an individual who:
  (a) Has completed:
  (A) A minimum of 12 semester hours, or the equivalent of 12
semester hours, of college coursework and is currently enrolled
in a course of study leading to an associate's or bachelor's
degree in psychology, education, social work, behavioral science,
human development or related fields; or
  (B) A minimum of 48 semester hours, or the equivalent of 48
semester hours, of college coursework in any field;
  (b) Has completed 40 hours of training by a board-certified
behavior analyst or licensed health care professional, that
covers the following topics:
  (A) Introduction to autism spectrum disorder, applied behavior
analysis, intensive behavioral programs and typical child
development;
  (B) Principles and application of applied behavior analysis or
other intensive behavioral programs;
  (C) Legal, ethical and safety issues in working with families
and vulnerable populations;
  (D) Professional standards and ethics; and

  (E) Additional topics as may be required under rules adopted by
a board or agency of this state;
  (c) Has completed 40 hours of work in the field supervised by a
board-certified behavior analyst or licensed health care
professional during a period of 12 weeks or less;
  (d) Has passed a criminal background check;
  (e) Receives ongoing, scheduled oversight by a board-certified
behavior analyst or licensed health care professional;
  (f) Has been approved by the Department of Human Services
pursuant to administrative rules adopted by the department or by
entering into a provider agreement with the department; and
  (g) Meets additional registration, supervision or credentialing
requirements as may be required by rules adopted by a board or
agency of this state.
  (3) 'Autism spectrum disorder' means a neurobiological
condition that includes autistic disorder, Asperger's disorder,
childhood disintegrative disorder and pervasive developmental
disorder not otherwise specified, as defined in the most recent
edition of the Diagnostic and Statistical Manual of Mental
Disorders published by the American Psychiatric Association.
  (4) 'Behavioral health treatment' means counseling and
treatment programs or applied behavior analysis and other
intensive behavioral programs that are necessary to develop,
improve, maintain or restore the functioning of an individual to
the maximum extent possible and are provided by:
  (a) A licensed health care professional;
  (b) A board-certified behavior analyst; or
  (c) An autism line therapist supervised by a board-certified
behavior analyst or licensed health care professional.
  (5) 'Board-certified behavior analyst' means an individual who:
  (a) Has been certified by the Behavior Analyst Certification
Board, Incorporated, as a 'Board Certified Behavior Analyst' or a
'Board Certified Assistant Behavior Analyst';
  (b) Has passed a criminal background check;
  (c) Has been approved by the Department of Human Services
pursuant to administrative rules adopted by the department or by
entering into a provider agreement with the department; and
  (d) Meets additional registration, supervision or credentialing
requirements as may be required by rules adopted by a board or
agency of this state.
  (6) 'Coordination of care' means a service that:
  (a) Facilitates linking patients with appropriate services and
resources in a coordinated effort to ensure that patient needs
are met and services are not duplicated by organizations involved
in providing care;
  (b) Assists patients and families to more effectively navigate
and use the health care system; or
  (c) Maximizes the value of services delivered to patients by
facilitating beneficial, efficient, safe and high-quality patient
experiences and improved health care outcomes.
  (7) 'Diagnosis' means medically necessary assessment,
evaluations or tests.
  (8) 'Medical accommodations for usual care' means medical
accommodations and services that are medically necessary in order
for an individual with an autism spectrum disorder to receive the
same medical or dental care that an individual without an autism
spectrum disorder would receive, including but not limited to
sedation.
  (9) 'Medically necessary' means in accordance with the
definition of medical necessity that is specified in the policy,
certificate or contract for the health benefit plan and that
applies uniformly to all covered services under the plan.
  (10) 'Pharmacy care' means medications prescribed by a licensed
physician or other health care professional licensed to prescribe
medications, and any health-related services deemed medically

necessary to determine the need or effectiveness of the
medications.
  (11) 'Psychiatric care' means direct or consultative services
provided by a licensed psychiatrist or psychiatric mental health
nurse practitioner.
  (12) 'Psychological care' means direct or consultative services
provided by a licensed psychologist, clinical social worker or
professional counselor.
  (13) 'Rehabilitative care' means services provided by a
licensed speech-language pathologist, occupational therapist,
physical therapist, speech-language pathology assistant,
occupational therapy assistant or physical therapist assistant.
  (14) 'Treatment for autism spectrum disorders' includes, but is
not limited to, the following care prescribed, provided or
ordered for an individual diagnosed with one of the autism
spectrum disorders by a licensed physician or licensed
psychologist who determines the care to be medically necessary:
  (a) Behavioral health treatment;
  (b) Pharmacy care to the same extent that pharmacy care is
covered by the health benefit plan for other medical conditions;
  (c) Psychiatric care;
  (d) Psychological care;
  (e) Rehabilitative care;
  (f) Augmentative communication devices and other assistive
technology devices to the same extent that medical devices are
covered by the health benefit plan for other medical conditions;
  (g) Medical accommodations for usual care;
  (h) Coordination of care; and
  (i) Any other medical services that are medically necessary and
are otherwise covered by the health benefit plan. + }
  SECTION 3.  { + (1) A health benefit plan, as defined in ORS
743.730, that provides coverage for hospital, surgical or medical
care shall provide coverage for the screening for, diagnosis of
and treatment for autism spectrum disorders. An insurer may not
terminate coverage or refuse to issue or renew coverage for an
individual solely because the individual is diagnosed with one of
the autism spectrum disorders or has received treatment for an
autism spectrum disorder.
  (2) Coverage under this section may be subject to utilization
controls that are reasonable in the context of individual
determinations of medical necessity.
  (3) Coverage under this section may not be subject to dollar
limits, deductibles, copayments or coinsurance provisions that
are less favorable to an insured than the dollar limits,
deductibles, copayments or coinsurance provisions that apply to
physical illness generally under the health benefit plan.
  (4) This section does not limit coverage that is otherwise
available to an individual under a health benefit plan or reduce
benefits required under ORS 743A.168.
  (5) A claim for services described in this section may not be
denied on the basis that the service is habilitative or
rehabilitative and does not fully restore function.
  (6) Coverage required by this section includes medically
necessary treatment provided in the home and in the community,
except that health benefit plans may impose limits on coverage
for specialized education and related services provided by
schools as required by federal or state law.
  (7) Except for inpatient services, if an individual is
receiving treatment for an autism spectrum disorder, an insurer
may request a review of the determination that the treatment is
medically necessary in a manner consistent with the insurer's
review process for other conditions, provided that the frequency
of review is not unreasonably burdensome on the insured. The
insurer may require the treatment plan to include the diagnosis,
the proposed treatment by type and frequency, the anticipated

duration of treatment, the anticipated outcomes stated as goals
and the reasons the treatment is medically necessary.
  (8) Subsections (1) to (7) of this section apply to health
benefit plans and to self-insurance programs offered by the
Public Employees' Benefit Board and the Oregon Educators Benefit
Board.
  (9) ORS 743A.001 does not apply to this section.
  (10) The Department of Consumer and Business Services, after
notice, hearing and consultation with a panel of experts with
expertise in diagnosing and treating autism spectrum disorders,
may adopt rules necessary to carry out the provisions of this
section. + }
  SECTION 4. ORS 743A.190 is amended to read:
  743A.190. (1) A health benefit plan, as defined in ORS 743.730,
must cover for a child enrolled in the plan who is under 18 years
of age and who has been diagnosed with a pervasive developmental
disorder all medical services, including rehabilitation services,
that are medically necessary and are otherwise covered under the
plan.
  (2) The coverage required under subsection (1) of this section,
including rehabilitation services, may be made subject to other
provisions of the health benefit plan that apply to covered
services, including but not limited to:
  (a) Deductibles, copayments or coinsurance;
  (b) Prior authorization or utilization review requirements; or
  (c) Treatment limitations regarding the number of visits or the
duration of treatment.
  (3) As used in this section:
  (a) 'Medically necessary' means in accordance with the
definition of medical necessity that is specified in the policy,
certificate or contract for the health benefit plan and that
applies uniformly to all covered services under the health
benefit plan.
  (b) { + (A) + } 'Pervasive developmental disorder' means a
neurological condition that includes   { - Asperger's syndrome,
autism, - }  developmental delay, developmental disability or
mental retardation.
   { +  (B) 'Pervasive developmental disorder' does not include
autism spectrum disorders as defined in section 2 of this 2013
Act. + }
  (c) 'Rehabilitation services' means physical therapy,
occupational therapy or speech therapy services to restore or
improve function.
  (4) The provisions of ORS 743A.001 do not apply to this
section.
  (5) The definition of 'pervasive developmental disorder' is not
intended to apply to coverage required under ORS 743A.168.
  SECTION 5.  { + Sections 2 and 3 of this 2013 Act and the
amendments to ORS 743A.190 by section 4 of this 2013 Act apply to
policies or certificates issued or renewed on or after the
effective date of this 2013 Act. + }
  SECTION 6.  { + This 2013 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2013 Act takes effect on its
passage. + }
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