2011 -- S 0107 SUBSTITUTE A

=======

LC00114/SUB A

=======

STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2011

____________

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

     Referred To: Senate Health & Human Services

It is enacted by the General Assembly as follows:

1-1

     SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended

1-2

by adding thereto the following chapter:

1-3

     CHAPTER 20.11

1-4

AUTISM SPECTRUM DISORDERS

1-5

     27-20.11-1. Mandatory coverage for Autism spectrum disorders. – (a) Every group

1-6

health insurance contract, or every group hospital or medical expense insurance policy, plan, or

1-7

group policy delivered, issued for delivery, or renewed in this state, by any health insurance

1-8

carrier, on or after January 1, 2012, shall provide coverage for autism spectrum disorders;

1-9

provided, however, the provisions of this chapter shall not apply to contracts, plans or group

1-10

policies subject to the Small Employer Health Insurance Availability Act, chapter 50 of this title,

1-11

or subject to the Individual Health Insurance Coverage Act, chapter 18.5 of this title.

1-12

     27-20.11-2. Definitions. – As used in this chapter:

1-13

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

1-14

environmental modifications using behavioral stimuli and consequences to produce socially

1-15

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

1-16

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

1-17

     (2) “Autism spectrum disorders” means any of the pervasive developmental disorders as

1-18

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

1-19

(DSM) published by the American Psychiatric Association.

2-1

     (3)"Health insurance carrier" or "carrier" means any entity subject to the insurance laws

2-2

and regulations of this state, that contracts or offers to contract to provide, deliver, arrange for,

2-3

pay for, or reimburse any of the costs of health care services, including, without limitation, an

2-4

insurance company offering accident and sickness insurance, a health maintenance organization,

2-5

a nonprofit hospital, medical service corporation, or any other entity subject to chapter 18, 19, 20

2-6

or 41 of this title, providing a plan of health insurance, health benefits, or health services.

2-7

     27-20.11-3. Scope of coverage. – (a) Benefits under this section shall include coverage

2-8

for applied behavior analysis, physical therapy, speech therapy and occupational therapy services

2-9

for the treatment of Autism spectrum disorders, as defined in the most recent edition of the DSM.

2-10

Provided, however: (1) Coverage for physical therapy, speech therapy and occupational therapy

2-11

services shall be to the extent such services are a covered benefit for other diseases and conditions

2-12

under such policy; and (2) Applied behavior analysis shall be limited to thirty-two thousand

2-13

dollars ($32,000) per person per year.

2-14

     (b) Benefits under this section shall continue until the covered individual reaches age

2-15

fifteen (15).

2-16

     (c) The health care benefits outlined in this chapter apply only to services delivered

2-17

within the State of Rhode Island; provided, that all health insurance carriers shall be required to

2-18

provide coverage for those benefits mandated by this chapter outside of the State of Rhode Island

2-19

where it can be established through a pre-authorization process that the required services are not

2-20

available in the State of Rhode Island from a provider in the health insurance carrier’s network.

2-21

     27-20.11-4. Medical necessity and appropriateness of treatment. – (a) Upon request of

2-22

the reimbursing health insurance carrier, all providers shall furnish medical records or other

2-23

necessary data which substantiates that initial or continued treatment is at all times medically

2-24

necessary and appropriate.

2-25

     (b) Medical necessity criteria may be based in part on evidence of continued

2-26

improvement as a result of treatment. When the provider cannot establish the medical necessity

2-27

and/or appropriateness of the treatment modality being provided, neither the health insurer nor the

2-28

patient shall be obligated to reimburse for that period or type of care that was not established. The

2-29

exception to the preceding can only be made if the patient has been informed of the provisions of

2-30

this subsection and has agreed in writing to continue to receive treatment at his or her own

2-31

expense.

2-32

     (c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter

2-33

may appeal a denial in accordance with the rules and regulations promulgated by the department

2-34

of health pursuant to chapter 17.12 of title 23.

3-1

     (d) A health insurance carrier may require submission of a treatment plan, including the

3-2

frequency and duration of treatment, signed by a child psychiatrist, a behavioral developmental

3-3

pediatrician, a child neurologist or a licensed psychologist with training in child psychology, that

3-4

the treatment is medically necessary for the patient and is consistent with nationally recognized

3-5

treatment standards for the condition such as those set forth by the American Academy of

3-6

Pediatrics. An insurer may require an updated treatment plan no more frequently than on a

3-7

quarterly basis.

3-8

     27-20.11-5. Limits on cost sharing. – Benefits for services under this chapter shall be

3-9

reimbursed in accordance with the respective principles and mechanisms of reimbursement for

3-10

each health insurance carrier. Except as otherwise provided in this section, any policy, contract or

3-11

certificate that provides coverage for services under this section may contain provisions for

3-12

maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the

3-13

extent that these provisions are no more extensive than coverage provided for other conditions or

3-14

illnesses. Coverage for autism spectrum disorders is otherwise subject to the same terms and

3-15

conditions of the policy as any other condition or illness.

3-16

     27-20.11-6. Educational and other services provided to children diagnosed with

3-17

Autism spectrum disorders. – Nothing in this section shall be construed to alter any obligation

3-18

of a school district or the State of Rhode Island to provide services to an individual under an

3-19

individualized family service plan or an individualized education program, as required under the

3-20

federal Individuals with Disabilities Education Act, or the provision of services to an individual

3-21

under any other federal or state law. A health insurance carrier assessed for services provided

3-22

under section 42-12-29, children’s health account, shall not be required to provide duplicative

3-23

coverage for the same beneficiary for the same or similar services mandated under this section.

3-24

     27-20.11-7. Credentialing and contracting practices. – (a) Any individual providing

3-25

applied behavior analysis treatment under this section shall be:

3-26

     (1) Individually licensed by the department of health as a healthcare provider/clinician

3-27

pursuant to chapter 42-35 or 42-35-1 et al. and nationally certified as a Board Certified Behavior

3-28

Analyst (BCBA); and credentialed by the insurer; or

3-29

     (2) Individually nationally certified as a Board Certified Assistant Behavior Analyst

3-30

(BCaBA) supervised by a Board Certified Behavior Analyst who is licensed by the department of

3-31

health as a psychologist, social worker or therapist; and credentialed by the insurer.

3-32

     (b) Nothing in this chapter shall be construed to require a change in the credentialing or

3-33

contracting practices of health insurers for mental health or substance abuse providers.

4-1

     27-20.11-8. Exclusions. -- This chapter shall not apply to insurance coverage providing

4-2

benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4)

4-3

Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease

4-4

indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other limited

4-5

benefit policies.

4-6

     SECTION 2. This act shall take effect upon passage.

=======

LC00114/SUB A

========

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO INSURANCE -- AUTISM SPECTRUM DISORDERS

***

5-1

     This act would require that most every group health insurance contract, or every group

5-2

hospital or medical expense insurance policies, plans, or group policies effective on or after

5-3

January 1, 2012, provide coverage for autism spectrum disorders. This act would not apply to

5-4

contracts, plans or group policies subject to the Small Employer Health Insurance Availability

5-5

Act and those subject to the Individual Health Insurance Coverage Act.

5-6

     This act would take effect upon passage.

=======

LC00114/SUB A

=======