Bill Text: OR SB555 | 2011 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Relating to health insurance coverage for individuals with disabilities.

Spectrum: Slight Partisan Bill (Democrat 3-1)

Status: (Failed) 2011-06-30 - In committee upon adjournment. [SB555 Detail]

Download: Oregon-2011-SB555-Amended.html

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     76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session

SA to SB 555

LC 1979/SB 555-5

                      SENATE AMENDMENTS TO
                         SENATE BILL 555

  By COMMITTEE ON HEALTH CARE, HUMAN SERVICES AND RURAL HEALTH
                             POLICY

                              May 5

  On page 1 of the printed bill, line 5, delete 'Section 2 ' and
insert 'Sections 2 and 3' and delete 'is' and insert ' are'.
  In line 6, delete 'ORS 743A.190' and insert 'section 3 of this
2011 Act'.
  In line 8, after 'modifications' insert 'for an individual who
is 11 years of age or younger'.
  In line 13, before 'Diagnostic' insert 'most recent edition of
the'.
  Delete page 2 and insert 'cupational therapist, physical
therapist, certified behavior analyst, clinical autism spectrum
disorder specialist with an Autism Spectrum Disorder Specialist
Continuing Teacher License from the Teacher Standards and
Practices Commission or line therapists supervised by any of the
above.
  ' (7) '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.
  ' (8) 'Medically necessary' means reasonably expected to do the
following:
  ' (a) Prevent the onset of an illness, condition, injury or
disability;
  ' (b) Reduce or ameliorate the physical, mental or
developmental effects of an illness, condition, injury or
disability; or
  ' (c) Assist an individual in achieving or maintaining maximum
functional capacity to perform daily activities, taking into
account both the functional capacity of the individual and the
functional capacities that are appropriate for individuals of the
same age.
  ' (9) 'Pharmacy care' means medications prescribed by a
licensed physician and any health-related services deemed
medically necessary to determine the need or effectiveness of the
medications.
  ' (10) 'Psychiatric care' means direct or consultative services
provided by a psychiatrist licensed in the state where the
psychiatrist practices.
  ' (11) 'Psychological care' means direct or consultative
services provided by a psychologist licensed in the state where
the psychologist practices.
  ' (12) 'Therapeutic care' means services provided by licensed
or certified speech-language pathologists, occupational
therapists or physical therapists.
  ' (13) '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) Habilitative or rehabilitative care;
  ' (b) Pharmacy care;
  ' (c) Psychiatric care;
  ' (d) Psychological care;
  ' (e) Therapeutic care;
  ' (f) Augmentative communication devices and other assistive
technology devices;
  ' (g) Medical accommodations for usual care;
  ' (h) Coordination of care; and
  ' (i) Any other medically necessary care that meets a standard
of best available evidence no more restrictive than the standard
of evidence required for coverage of the prevailing medical or
surgical treatments.
  '  { +  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 not be subject to
utilization controls regarding the number or frequency of visits
or the duration of treatment except that applied behavioral
analysis may be limited to 87 hours per month.
  ' (3) Except as provided in subsection (8) of this section,
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.
  ' (7) Except for inpatient services, if an individual is
receiving treatment for an autism spectrum disorder, an insurer
may request a review of the treatment not more than once every
six months by a review panel appointed by the insurer and at the
expense of the insurer.
  ' (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.  The coverage may be subject to:
  ' (a) A separate annual deductible of up to $500.
  ' (b) A coinsurance requirement of up to 20 percent of the cost
of the care.
  ' (c) No annual limits on the individual's out-of-pocket
expenses.
  ' (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) 'Developmental disorder' means a neurological
condition that includes developmental delay, developmental
disability or intellectual disability. + }
  '  { - (a) - }  { +  (b) + } '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) 'Pervasive developmental disorder' means a
neurological condition that includes Asperger's syndrome, autism,
developmental delay, developmental disability or mental
retardation. - }
  ' (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.'.
  On page 3, delete lines 1 through 32.
  In line 33, delete '4' and insert '5' and delete ' Section 2'
and insert 'Sections 2 and 3'.
  In line 34, delete '3' and insert '4'.
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