SECOND REGULAR SESSION
HOUSE BILL NO. 1311
95TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES SCHARNHORST (Sponsor), GRISAMORE, WALTON GRAY, FUNDERBURK, COOPER, CASEY, HARRIS, ALLEN, NANCE, WALSH, GRILL, JONES (63), PACE, CARTER, RUCKER, ROORDA, DUSENBERG, McGHEE, FALLERT, NORR, ENGLUND AND SCHUPP (Co-sponsors).
3679L.01I D. ADAM CRUMBLISS, Chief Clerk
To amend chapter 376, RSMo, by adding thereto one new section relating to insurance coverage for diagnosis and treatment of autism spectrum disorders.
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 relationships between environment and behavior;
(2) "Autism service provider":
(a) Any person, entity, or group that provides diagnostic or treatment services for autism spectrum disorders who is licensed or certified by the state of Missouri;
(b) Any person who is certified as a board certified behavior analyst by the behavior analyst certification board; or
(c) Any person, if not licensed or certified, who is supervised by a person who is certified as a board certified behavioral analyst by the Behavioral Analyst Certification Board, whether such board certified behavioral analyst supervises as an individual or as an employee of or in association with an entity or group; provided however, the definition of autism service provider shall specifically exclude parents and siblings of autistic persons to the extent such parents or siblings are providing diagnostic or treatment services to their child or sibling;
(3) "Autism spectrum disorders", a neurobiological disorder, an illness of the nervous system, which includes Autistic Disorder, Asperger's Disorder, Pervasive Developmental Disorder Not Otherwise Specified, Rett's Disorder, and Childhood Disintegrative Disorder, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association;
(4) "Diagnosis of autism spectrum disorders", medically necessary assessments, evaluations, or tests in order to diagnose whether an individual has an autism spectrum disorder;
(5) "Habilitative or rehabilitative care", professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop and restore the functioning of an individual;
(6) "Health benefit plan", shall have the same meaning ascribed to it as in section 376.1350;
(7) "Health carrier", shall have the same meaning ascribed to it as in section 376.1350;
(8) "Pharmacy care", medications or nutritional supplements used to address symptoms of an autism spectrum disorder prescribed by a licensed physician, and any health-related services deemed medically necessary to determine the need or effectiveness of the medications or nutritional supplements;
(9) "Psychiatric care", direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices;
(10) "Psychological care", direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices;
(11) "Therapeutic care", services provided by licensed speech therapists, occupational therapists, or physical therapists;
(12) "Treatment for autism spectrum disorders", care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist, including, without limitation, equipment necessary for such care, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, including, but not limited to:
(a) Psychiatric care;
(b) Psychological care;
(c) Habilitative or rehabilitative care, including applied behavior analysis therapy;
(d) Therapeutic care;
(e) Pharmacy care.
2. All health benefit plans that are delivered, issued for delivery, continued, or renewed on or after August 28, 2010, if written inside the state of Missouri, or written outside the state of Missouri but insuring Missouri residents, shall provide individuals coverage for the diagnosis and treatment of autism spectrum disorders.
3. With regards to a health benefit plan, a health carrier shall not deny or refuse to issue coverage on, refuse to contract with, or refuse to renew or refuse to reissue or otherwise terminate or restrict coverage on an individual or their dependent solely because the individual is diagnosed with autism spectrum disorder or because the individual receives coverage under this section.
4. (1) Coverage provided under this section is limited to treatment that is ordered by the insured's treating licensed physician or licensed psychologist, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, in accordance with a treatment plan. Service exclusions contained in the insurance policy or health maintenance organization contract that are inconsistent with the treatment plan shall be considered invalid as to autism spectrum disorder;
(2) The treatment plan, upon request by the health benefit plan or health carrier, shall include all elements necessary for the health benefit plan or health carrier to review the treatment plan;
(3) Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, a health carrier shall have the right to review the treatment plan not more than once every six months unless the health carrier and the individual's treating physician or psychologist agree that a more frequent review is necessary. The cost of obtaining any review shall be borne by the health benefit plan or health carrier, as applicable.
5. Coverage provided under this section for applied behavior analysis shall be subject to a maximum benefit of seventy-two thousand dollars per calendar year and such coverage shall only be afforded to individuals under the age of twenty-one. Any coverage required under this section, other than the coverage for applied behavior analysis, shall not be subject to the age limitation described in this subsection.
6. Subject to the provisions set forth in subdivision (3) of subsection 4 of this section, coverage provided under this section shall not be subject to any limits on the number of visits an individual may make to an autism service provider.
7. This section shall not be construed as limiting benefits which are otherwise available to an individual under a health benefit plan. Subject to the provisions of subsection 5 of this section, the coverage required by this section shall not be subject to any greater deductible, coinsurance, co-payment, or utilization review of health care services, including review of medical necessity, than other physical health care services provided by a health benefit plan. Coverage for treatment under this section shall not be denied on the basis that it is educational or habilitative in nature.
8. To the extent any payments or reimbursements are being made for applied behavior analysis, such payments or reimbursements shall be made to either:
(1) The autism service provider;
(2) The person who is supervising an autism service provider, who is also certified as a board certified behavior analyst by the Behavior Analyst Certification Board; or
(3) The entity or group for whom such supervising person, who is certified as a board certified behavior analyst by the Behavior Analyst Certification Board, works or is associated.
9. If a request for qualifications is made of a person who is not an autism service provider, such person shall provide documented evidence of education and professional training, if any, of such person.
10. The provisions of this section shall apply to any health care plans issued to employees and their dependents under the Missouri consolidated health care plan established pursuant to chapter 103, that are delivered, issued for delivery, continued, or renewed in this state on or after August 28, 2010. The terms "employees" and "health care plans" shall have the same meaning ascribed to them in section 103.003.
11. The provisions of this section shall also apply to the following types of plans that are established, extended, modified, or renewed on or after August 28, 2010:
(1) All self-insured governmental plans, as that term is defined in 29 U.S.C. Section 1002(32);
(2) All self-insured group arrangements, to the extent not preempted by federal law;
(3) All plans provided through a multiple employer welfare arrangement, or plans provided through another benefit arrangement, to the extent permitted by the Employee Retirement Income Security Act of 1974, or any waiver or exception to that act provided under federal law or regulation; and
(4) All self-insured school district health plans.
12. The provisions of this section shall not automatically apply to an individually underwritten health benefit plan, but shall be offered as an option to any such plan.
13. The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy.
14. Any health carrier or other entity subject to the provisions of this section shall not be required to provide reimbursement to a school district for treatment for autism spectrum disorders provided by the school district. This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education plan, or an individualized service plan.
15. The provisions of sections 376.1350 to 376.1399, 376.383, and 376.384 shall apply to this section.
16. The director of the department of insurance, financial institutions and professional registration shall grant a small employer with a group health plan, as that term is defined in section 379.930, a waiver from the provisions of this section if the small employer demonstrates to the director by actual experience over any consecutive twenty-four month period that compliance with this section has increased the cost of the health insurance policy by an amount that results in a five percent increase over the period of a calendar year, in premium costs to the small employer.
17. The provisions of this section shall not apply to the MO HealthNet program as described in section 208.001, nor shall the provisions of this section apply to any program administered or sponsored by the MO HealthNet division. Nothing in this section shall be construed as providing the coverage described in this section to MO HealthNet participants.