Read 1st time March 5, 2008 and copies ordered printed.





To amend chapter 376, RSMo, by adding thereto one new section relating to mandatory insurance for autism.

Be it enacted by the General Assembly of the state of Missouri, as follows:

            Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be known as section 376.1224, to read as follows:

            376.1224. 1. For purposes of this section, the following terms shall mean:

            (1) "Applied behavior analysis", 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 relations between environment and behavior;

            (2) "Autism service provider", any person, entity, or group that provides treatment of autism spectrum disorders;

            (3) "Autism spectrum disorders", a neurobiological disorder that includes any of the pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including Autistic Disorder, Asperger's Disorder, Rett's Syndrome, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified;

            (4) "Carrier", shall have the meaning ascribed to such term in subdivision (6) of subsection 2 of section 379.930, RSMo;

            (5) "Diagnosis of autism spectrum disorders", medically necessary assessments, evaluations, or tests in order to diagnose whether an individual has an autism spectrum disorder;

            (6) "Evidence-based research", research that applies rigorous, systematic, and objective procedures to obtain valid knowledge relevant to autism spectrum disorders;

            (7) "Habilitative or rehabilitative care", professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual;

            (8) "Medically necessary", any care, treatment, intervention, service, or item that is prescribed, provided, or ordered by a licensed physician or a licensed psychologist in accordance with accepted standards of practice and that will, or is reasonably expected to, do any of 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 to achieve or maintain maximum functional capacity in performing 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) "Neurobiological disorder", an illness of the nervous system caused by genetic, metabolic or other biological factors;

            (10) "Pharmacy care", medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications;

            (11) "Small employer", shall have the meaning ascribed to such term in subsection 2 of section 379.930, RSMo;

            (12) "Therapeutic care", services provided by licensed or certified speech therapists, occupational therapists, or physical therapists;

            (13) "Treatment for autism spectrum disorders", shall include the following care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician, licensed psychologist, or certified registered nurse practitioner if the care is determined to be medically necessary:

            (a) Psychiatric care;

            (b) Psychological care;

            (c) Habilitative or rehabilitative care;

            (d) Therapeutic care;

            (e) Pharmacy care;

            (f) Nutritional supplements;

            (g) Applied behavior analysis therapy;

            (h) Any care, treatment, intervention, service or item for individuals with an autism spectrum disorder which is determined by the department of health and senior services, based upon its review of best practices or evidence-based research, to be medically necessary.

            2. Each carrier or health benefit plan that offers or issues health benefit plans which are amended, delivered, issued, or renewed after January 1, 2009, shall provide individuals under twenty-one years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders to the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by the policy of accident and health insurance or managed care plan.

            3. With regards to a health benefit plan, a carrier shall not deny or refuse to issue coverage on, refuse to contract with, refuse to renew, or refuse to reissue or otherwise terminate or restrict coverage on an individual solely because the individual is diagnosed with an autism spectrum disorder.

            4. Coverage provided under this section for applied behavior analysis shall be subject to a maximum benefit of fifty thousand dollars per year, but shall not be subject to any limits on the number of visits to an autism service provider. After December 30, 2008, the director of the department of insurance, financial and professional registration shall, on an annual basis, adjust the maximum benefit for inflation using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition unrelated to the covered individual's autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.

            5. Coverage under this section shall be subject to co-payment, deductible, and coinsurance provisions of a health benefit plan to the extent that other medical services covered by the policy of health benefit plan are subject to these provisions.

            6. This section shall not be construed as limiting benefits which are otherwise available to an individual under a health benefit plan. The health care services required by this section shall not be subject to any greater deductible or co-payment than other health care services provided by a health benefit plan.

            7. The department of health and senior services shall establish standards to be utilized by health benefit plans for the credentialing of autism service providers. The department of health and senior services may require that health benefit plans grant credentials to any autism services provider whom the department of health and senior services determines meets or exceeds the department of health and senior services' credentialing standards.

            8. Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, a health benefit plan will have the right to request a review of that treatment not more than once every six months unless the health benefit plan and the individual's licensed physician or licensed psychologist agrees that a more frequent review is necessary. The cost of obtaining any review will be borne by the carrier.

            9. This section shall not apply to health benefit plans offered solely to an individual or through a small employer.