2010 -- H 7260

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LC00106

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2010

____________

A N A C T

RELATING TO INSURANCE -- AUTISM SPECTRUM DISORDERS

     Introduced By: Representatives Palumbo, Naughton, Corvese, Jackson, and D Caprio

     Date Introduced: January 28, 2010

     Referred To: House Corporations

It is enacted by the General Assembly as follows:

1-1

     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness

1-2

Insurance Policies" is hereby amended by adding thereto the following section:

1-3

     27-18-71. Mandatory coverage for diagnosis and treatment of autism spectrum

1-4

disorders. – (a) As used in this section:

1-5

     (1) "Applied behavior analysis" means the design, implementation and evaluation of

1-6

environmental modifications, using behavioral stimuli and consequences, to produce socially

1-7

significant improvement in human behavior, including the use of direct observation,

1-8

measurement, and functional analysis of the relationship between environment and behavior.

1-9

     (2) "Autism services provider" means any person, entity, or group that provides treatment

1-10

of autism spectrum disorders.

1-11

     (3) "Autism spectrum disorders" means any of the pervasive developmental disorders as

1-12

defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders

1-13

(DSM), including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Not

1-14

Otherwise Specified.

1-15

     (4) "Diagnosis of autism spectrum disorders" means medically necessary assessment,

1-16

evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.

1-17

     (5) "Habilitative or rehabilitative care" means professional counseling, and guidance

1-18

services and treatment programs, including applied behavioral analysis, that are necessary to

1-19

develop, maintain, and restore, to the maximum extent practicable, the functioning of an

2-1

individual.

2-2

     (6) "Health insurance policy" means any group health policy or contract issued by an

2-3

insurance entity subject to chapters 18, 19, 20 and 41 of title 27 of the general laws.

2-4

     (7) "Medically necessary" means reasonably expected to do the following:

2-5

     (i) Prevent the onset of an illness, condition, injury or disability;

2-6

     (ii) Reduce or ameliorate the physical, mental or developmental effects of an illness,

2-7

condition, injury or disability; or

2-8

     (iii) Assist to achieve or maintain maximum functional capacity in performing daily

2-9

activities, taking into account both the functional capacity of the individual and the functional

2-10

capacities that are appropriate for individuals of the same age.

2-11

     (8) "Pharmacy care" means medications prescribed by a licensed physician and any

2-12

health-related services deemed medically necessary to determine the need or effectiveness of the

2-13

medications.

2-14

     (9) "Psychiatric care" means direct or consultative services provided by a psychiatrist

2-15

licensed in the state in which the psychiatrist practices.

2-16

     (10) "Psychological care" means direct or consultative services provided by a

2-17

psychologist licensed in the state in which the psychologist practices.

2-18

     (11) "Therapeutic care" means services provided by licensed or certified speech

2-19

therapists, occupational therapists, or physical therapists.

2-20

     (12) "Treatment for autism spectrum disorders" will include the following care

2-21

prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum

2-22

disorders by a licensed physician or a licensed psychologist who determines the care to be

2-23

medically necessary:

2-24

     (i) Habilitative or rehabilitative care;

2-25

     (ii) Pharmacy care;

2-26

     (iii) Psychiatric care;

2-27

     (iv) Psychological care; and

2-28

     (v) Therapeutic care.

2-29

     (b)(1) Every individual or group health insurance contract, plan, or policy delivered,

2-30

issued for delivery or renewed in this state shall provide coverage for the diagnosis and treatment

2-31

of autism spectrum disorders. No insurer shall terminate coverage, or refuse to deliver, execute,

2-32

issue, mend, adjust, or renew coverage to an individual solely because the individual is diagnosed

2-33

with one of the autism spectrum disorders or has received treatment for autism spectrum

2-34

disorders.

3-1

     (2) The coverage required under this section shall not be subject to dollar limits,

3-2

deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits,

3-3

deductibles, or coinsurance provisions that apply to physical illness generally under the health

3-4

insurance policy.

3-5

     (3) Coverage under this section shall not be subject to any limits on the number of visits

3-6

an individual may make to an autism services provider.

3-7

     (4) This section shall not be construed as limiting benefits that are otherwise available to

3-8

an individual under a health insurance policy.

3-9

     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

3-10

Corporations" is hereby amended by adding thereto the following section:

3-11

     27-19-62. Mandatory coverage for diagnosis and treatment of autism spectrum

3-12

disorders. – (a) As used in this section:

3-13

     (1) "Applied behavior analysis" means the design, implementation and evaluation of

3-14

environmental modifications, using behavioral stimuli and consequences, to produce socially

3-15

significant improvement in human behavior, including the use of direct observation,

3-16

measurement, and functional analysis of the relationship between environment and behavior.

3-17

     (2) "Autism services provider" means any person, entity, or group that provides treatment

3-18

of autism spectrum disorders.

3-19

     (3) "Autism spectrum disorders" means any of the pervasive developmental disorders as

3-20

defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders

3-21

(DSM), including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Not

3-22

Otherwise Specified.

3-23

     (4) "Diagnosis of autism spectrum disorders" means medically necessary assessment,

3-24

evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.

3-25

     (5) "Habilitative or rehabilitative care" means professional counseling, and guidance

3-26

services and treatment programs, including applied behavioral analysis, that are necessary to

3-27

develop, maintain, and restore, to the maximum extent practicable, the functioning of an

3-28

individual.

3-29

     (6) "Health insurance policy" means any group health policy or contract issued by an

3-30

insurance entity subject to chapters 18, 19, 20 and 41 of title 27 of the general laws.

3-31

     (7) "Medically necessary" means reasonably expected to do the following:

3-32

     (i) Prevent the onset of an illness, condition, injury or disability;

3-33

     (ii) Reduce or ameliorate the physical, mental or developmental effects of an illness,

3-34

condition, injury or disability; or

4-1

     (iii) Assist to achieve or maintain maximum functional capacity in performing daily

4-2

activities, taking into account both the functional capacity of the individual and the functional

4-3

capacities that are appropriate for individuals of the same age.

4-4

     (8) "Pharmacy care" means medications prescribed by a licensed physician and any

4-5

health-related services deemed medically necessary to determine the need or effectiveness of the

4-6

medications.

4-7

     (9) "Psychiatric care" means direct or consultative services provided by a psychiatrist

4-8

licensed in the state in which the psychiatrist practices.

4-9

     (10) "Psychological care" means direct or consultative services provided by a

4-10

psychologist licensed in the state in which the psychologist practices.

4-11

     (11) "Therapeutic care" means services provided by licensed or certified speech

4-12

therapists, occupational therapists, or physical therapists.

4-13

     (12) "Treatment for autism spectrum disorders" will include the following care

4-14

prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum

4-15

disorders by a licensed physician or a licensed psychologist who determines the care to be

4-16

medically necessary:

4-17

     (i) Habilitative or rehabilitative care;

4-18

     (ii) Pharmacy care;

4-19

     (iii) Psychiatric care;

4-20

     (iv) Psychological care; and

4-21

     (v) Therapeutic care.

4-22

     (b)(1) Every individual or group health insurance contract, plan, or policy, including any

4-23

nonprofit hospital service contract plan or policy delivered, issued for delivery or renewed in this

4-24

state shall provide coverage for the diagnosis and treatment of autism spectrum disorders. No

4-25

insurer shall terminate coverage, or refuse to deliver, execute, issue, mend, adjust, or renew

4-26

coverage to an individual solely because the individual is diagnosed with one of the autism

4-27

spectrum disorders or has received treatment for autism spectrum disorders.

4-28

     (2) The coverage required under this section shall not be subject to dollar limits,

4-29

deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits,

4-30

deductibles, or coinsurance provisions that apply to physical illness generally under the health

4-31

insurance policy.

4-32

     (3) Coverage under this section shall not be subject to any limits on the number of visits

4-33

an individual may make to an autism services provider.

4-34

     (4) This section shall not be construed as limiting benefits that are otherwise available to

5-1

an individual under a health insurance policy.

5-2

     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

5-3

Corporations" is hereby amended by adding thereto the following sections:

5-4

     27-20-57. Mandatory coverage for diagnosis and treatment of autism spectrum

5-5

disorders. – (a) As used in this section:

5-6

     (1) "Applied behavior analysis" means the design, implementation and evaluation of

5-7

environmental modifications, using behavioral stimuli and consequences, to produce socially

5-8

significant improvement in human behavior, including the use of direct observation,

5-9

measurement, and functional analysis of the relationship between environment and behavior.

5-10

     (2) "Autism services provider" means any person, entity, or group that provides treatment

5-11

of autism spectrum disorders.

5-12

     (3) "Autism spectrum disorders" means any of the pervasive developmental disorders as

5-13

defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders

5-14

(DSM), including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Not

5-15

Otherwise Specified.

5-16

     (4) "Diagnosis of autism spectrum disorders" means medically necessary assessment,

5-17

evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.

5-18

     (5) "Habilitative or rehabilitative care" means professional counseling, and guidance

5-19

services and treatment programs, including applied behavioral analysis, that are necessary to

5-20

develop, maintain, and restore, to the maximum extent practicable, the functioning of an

5-21

individual.

5-22

     (6) "Health insurance policy" means any group health policy or contract issued by an

5-23

insurance entity subject to chapters 18, 19, 20 and 41 of title 27 of the general laws.

5-24

     (7) "Medically necessary" means reasonably expected to do the following:

5-25

     (i) Prevent the onset of an illness, condition, injury or disability;

5-26

     (ii) Reduce or ameliorate the physical, mental or developmental effects of an illness,

5-27

condition, injury or disability; or

5-28

     (iii) Assist to achieve or maintain maximum functional capacity in performing daily

5-29

activities, taking into account both the functional capacity of the individual and the functional

5-30

capacities that are appropriate for individuals of the same age.

5-31

     (8) "Pharmacy care" means medications prescribed by a licensed physician and any

5-32

health-related services deemed medically necessary to determine the need or effectiveness of the

5-33

medications.

5-34

     (9) "Psychiatric care" means direct or consultative services provided by a psychiatrist

6-1

licensed in the state in which the psychiatrist practices.

6-2

     (10) "Psychological care" means direct or consultative services provided by a

6-3

psychologist licensed in the state in which the psychologist practices.

6-4

     (11) "Therapeutic care" means services provided by licensed or certified speech

6-5

therapists, occupational therapists, or physical therapists.

6-6

     (12) "Treatment for autism spectrum disorders" will include the following care

6-7

prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum

6-8

disorders by a licensed physician or a licensed psychologist who determines the care to be

6-9

medically necessary:

6-10

     (i) Habilitative or rehabilitative care;

6-11

     (ii) Pharmacy care;

6-12

     (iii) Psychiatric care;

6-13

     (iv) Psychological care; and

6-14

     (v) Therapeutic care.

6-15

     (b)(1) Any nonprofit medical service contract, plan, or policy delivered, issued for

6-16

delivery or renewed in this state shall provide coverage for the diagnosis and treatment of autism

6-17

spectrum disorders. No insurer shall terminate coverage, or refuse to deliver, execute, issue,

6-18

mend, adjust, or renew coverage to an individual solely because the individual is diagnosed with

6-19

one of the autism spectrum disorders or has received treatment for autism spectrum disorders.

6-20

     (2) The coverage required under this section shall not be subject to dollar limits,

6-21

deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits,

6-22

deductibles, or coinsurance provisions that apply to physical illness generally under the health

6-23

insurance policy.

6-24

     (3) Coverage under this section shall not be subject to any limits on the number of visits

6-25

an individual may make to an autism services provider.

6-26

     (4) This section shall not be construed as limiting benefits that are otherwise available to

6-27

an individual under a health insurance policy.

6-28

     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance

6-29

Organizations" is hereby amended by adding thereto the following section:

6-30

     27-41-75. Mandatory coverage for diagnosis and treatment of autism spectrum

6-31

disorders. – (a) As used in this section:

6-32

     (1) "Applied behavior analysis" means the design, implementation and evaluation of

6-33

environmental modifications, using behavioral stimuli and consequences, to produce socially

6-34

significant improvement in human behavior, including the use of direct observation,

7-1

measurement, and functional analysis of the relationship between environment and behavior.

7-2

     (2) "Autism services provider" means any person, entity, or group that provides treatment

7-3

of autism spectrum disorders.

7-4

     (3) "Autism spectrum disorders" means any of the pervasive developmental disorders as

7-5

defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders

7-6

(DSM), including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Not

7-7

Otherwise Specified.

7-8

     (4) "Diagnosis of autism spectrum disorders" means medically necessary assessment,

7-9

evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.

7-10

     (5) "Habilitative or rehabilitative care" means professional counseling, and guidance

7-11

services and treatment programs, including applied behavioral analysis, that are necessary to

7-12

develop, maintain, and restore, to the maximum extent practicable, the functioning of an

7-13

individual.

7-14

     (6) "Health insurance policy" means any group health policy or contract issued by an

7-15

insurance entity subject to chapters 18, 19, 20 and 41 of title 27 of the general laws.

7-16

     (7) "Medically necessary" means reasonably expected to do the following:

7-17

     (i) Prevent the onset of an illness, condition, injury or disability;

7-18

     (ii) Reduce or ameliorate the physical, mental or developmental effects of an illness,

7-19

condition, injury or disability; or

7-20

     (iii) Assist to achieve or maintain maximum functional capacity in performing daily

7-21

activities, taking into account both the functional capacity of the individual and the functional

7-22

capacities that are appropriate for individuals of the same age.

7-23

     (8) "Pharmacy care" means medications prescribed by a licensed physician and any

7-24

health-related services deemed medically necessary to determine the need or effectiveness of the

7-25

medications.

7-26

     (9) "Psychiatric care" means direct or consultative services provided by a psychiatrist

7-27

licensed in the state in which the psychiatrist practices.

7-28

     (10) "Psychological care" means direct or consultative services provided by a

7-29

psychologist licensed in the state in which the psychologist practices.

7-30

     (11) "Therapeutic care" means services provided by licensed or certified speech

7-31

therapists, occupational therapists, or physical therapists.

7-32

     (12) "Treatment for autism spectrum disorders" will include the following care

7-33

prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum

7-34

disorders by a licensed physician or a licensed psychologist who determines the care to be

8-1

medically necessary:

8-2

     (i) Habilitative or rehabilitative care;

8-3

     (ii) Pharmacy care;

8-4

     (iii) Psychiatric care;

8-5

     (iv) Psychological care; and

8-6

     (v) Therapeutic care.

8-7

     (b)(1) Every health maintenance organization contract, plan, or policy delivered, issued

8-8

for delivery or renewed in this state shall provide coverage for the diagnosis and treatment of

8-9

autism spectrum disorders. No insurer shall terminate coverage, or refuse to deliver, execute,

8-10

issue, mend, adjust, or renew coverage to an individual solely because the individual is diagnosed

8-11

with one of the autism spectrum disorders or has received treatment for autism spectrum

8-12

disorders.

8-13

     (2) The coverage required under this section shall not be subject to dollar limits,

8-14

deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits,

8-15

deductibles, or coinsurance provisions that apply to physical illness generally under the health

8-16

insurance policy.

8-17

     (3) Coverage under this section shall not be subject to any limits on the number of visits

8-18

an individual may make to an autism services provider.

8-19

     (4) This section shall not be construed as limiting benefits that are otherwise available to

8-20

an individual under a health insurance policy.

8-21

     SECTION 5. This act shall take effect upon passage.

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LC00106

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO INSURANCE -- AUTISM SPECTRUM DISORDERS

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9-1

     This act would require coverage for the diagnosis and treatment of autism spectrum

9-2

disorders.

9-3

     This act would take effect upon passage.

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LC00106

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