Chapter 175
2011 -- S 0107 SUBSTITUTE A
Enacted 06/30/11
A N A C T
RELATING TO
INSURANCE -- AUTISM SPECTRUM DISORDERS
Introduced By: Senators E O`Neill, Gallo, Metts, Perry, and Paiva Weed
Date Introduced: January 27, 2011
It is enacted by the
General Assembly as follows:
SECTION 1. Title 27 of the General Laws entitled
"INSURANCE" is hereby amended
by adding thereto the following chapter:
CHAPTER
20.11
AUTISM
SPECTRUM DISORDERS
27-20.11-1.
Mandatory coverage for Autism spectrum disorders. –
(a) Every group
health insurance contract, or every group hospital or
medical expense insurance policy, plan, or
group policy delivered, issued for delivery, or renewed in
this state, by any health insurance
carrier, on or after January 1, 2012, shall provide coverage
for autism spectrum disorders;
provided, however, the provisions of this chapter shall not
apply to contracts, plans or group
policies subject to the Small Employer Health Insurance
Availability Act, chapter 50 of this title,
or subject to the Individual Health Insurance Coverage
Act, chapter 18.5 of this title.
27-20.11-2.
Definitions. – As used in this chapter:
(1) “Applied behavior
analysis” means the design, implementation and evaluation of
environmental modifications using behavioral stimuli and
consequences to produce socially
significant improvements in human behavior, including the use of
direct observation,
measurement and functional analysis of the relationship between
environment and behavior.
(2) “Autism spectrum
disorders” means any of the pervasive developmental disorders as
defined by the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders
(DSM) published by the American Psychiatric
Association.
(3)"Health
insurance carrier" or "carrier" means any entity subject to the
insurance laws
and regulations of this state, that contracts or offers
to contract to provide, deliver, arrange for,
pay for, or reimburse any of the costs of health care
services, including, without limitation, an
insurance company offering accident and sickness insurance, a
health maintenance organization,
a nonprofit hospital, medical service corporation, or
any other entity subject to chapter 18, 19, 20
or 41 of this title, providing a plan of health
insurance, health benefits, or health services.
27-20.11-3.
Scope of coverage. – (a) Benefits under this
section shall include coverage
for applied behavior analysis, physical therapy, speech
therapy and occupational therapy services
for the treatment of Autism spectrum disorders, as
defined in the most recent edition of the DSM.
Provided, however: (1) Coverage for physical therapy,
speech therapy and occupational therapy
services shall be to the extent such services are a covered
benefit for other diseases and conditions
under such policy; and (2) Applied behavior analysis shall
be limited to thirty-two thousand
dollars ($32,000) per person per year.
(b) Benefits under
this section shall continue until the covered individual reaches age
fifteen (15).
(c) The health care
benefits outlined in this chapter apply only to services delivered
within the State of
provide coverage for those benefits mandated by this chapter
outside of the State of
where it can be established through a pre-authorization
process that the required services are not
available in the State of
27-20.11-4.
Medical necessity and appropriateness of treatment. –
(a) Upon request of
the reimbursing health insurance carrier, all providers
shall furnish medical records or other
necessary data which substantiates that initial or continued
treatment is at all times medically
necessary and appropriate.
(b) Medical necessity
criteria may be based in part on evidence of continued
improvement as a result of treatment. When the provider cannot establish
the medical necessity
and/or appropriateness of the treatment modality being
provided, neither the health insurer nor the
patient shall be obligated to reimburse for that period or
type of care that was not established. The
exception to the preceding can only be made if the patient has
been informed of the provisions of
this subsection and has agreed in writing to continue to
receive treatment at his or her own
expense.
(c) Any subscriber
who is aggrieved by a denial of benefits provided under this chapter
may appeal a denial in accordance with the rules and
regulations promulgated by the department
of health pursuant to chapter 17.12 of title 23.
(d) A health
insurance carrier may require submission of a treatment plan, including the
frequency and duration of treatment, signed by a child
psychiatrist, a behavioral developmental
pediatrician, a child neurologist or a licensed psychologist with
training in child psychology, that
the treatment is medically necessary for the patient and
is consistent with nationally recognized
treatment standards for the condition such as those set forth
by the
Pediatrics. An insurer may require an updated treatment plan no
more frequently than on a
quarterly basis.
27-20.11-5. Limits
on cost sharing. – Benefits for services under this chapter shall be
reimbursed in accordance with the respective principles and
mechanisms of reimbursement for
each health insurance carrier. Except as otherwise
provided in this section, any policy, contract or
certificate that provides coverage for services under this
section may contain provisions for
maximum benefits and coinsurance and reasonable limitations,
deductibles and exclusions to the
extent that these provisions are no more extensive than
coverage provided for other conditions or
illnesses. Coverage for autism spectrum disorders is otherwise
subject to the same terms and
conditions of the policy as any other condition or illness.
27-20.11-6.
Educational and other services provided to children diagnosed with
Autism spectrum disorders. – Nothing
in this section shall be construed to alter any obligation
of a school district or the State of
individualized family service plan or an individualized education
program, as required under the
federal Individuals with Disabilities Education Act, or the
provision of services to an individual
under any other federal or state law. A health insurance
carrier assessed for services provided
under section 42-12-29, children’s health account, shall
not be required to provide duplicative
coverage for the same beneficiary for the same or similar
services mandated under this section.
27-20.11-7.
Credentialing and contracting practices. – (a) Any individual providing
applied behavior analysis treatment under this section shall
be:
(1) Individually
licensed by the department of health as a healthcare provider/clinician
pursuant to chapter 42-35 or 42-35-1 et al. and nationally
certified as a Board Certified Behavior
Analyst (BCBA); and credentialed by the insurer; or
(2) Individually
nationally certified as a Board Certified Assistant Behavior Analyst
(BCaBA) supervised by a
Board Certified Behavior Analyst who is licensed by the department of
health as a psychologist, social worker or therapist; and
credentialed by the insurer.
(b) Nothing in this
chapter shall be construed to require a change in the credentialing or
contracting practices of health insurers for mental health or
substance abuse providers.
27-20.11-8.
Exclusions. -- This chapter shall not apply to
insurance coverage providing
benefits for: (1) Hospital confinement indemnity; (2)
Disability income; (3) Accident only; (4)
Long-term care; (5) Medicare supplement; (6) Limited
benefit health; (7) Specified disease
indemnity; (8) Sickness or bodily injury or death by accident
or both; and (9) Other limited
benefit policies.
SECTION 2. This act shall take effect upon passage.
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LC00114/SUB A
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