Bill Text: IA SF2019 | 2015-2016 | 86th General Assembly | Introduced
Bill Title: A bill for an act relating to insurance coverage for the assessment and treatment of eating disorders and including applicability date provisions. (See SF 2204.)
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2016-02-10 - Returned to committee. [SF2019 Detail]
Download: Iowa-2015-SF2019-Introduced.html
Senate File 2019 - Introduced SENATE FILE BY McCOY A BILL FOR 1 An Act relating to insurance coverage for the assessment and 2 treatment of eating disorders and including applicability 3 date provisions. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 5000XS (2) 86 av/rj PAG LIN 1 1 Section 1. NEW SECTION. 514C.31 Eating disorders == 1 2 coverage. 1 3 1. Notwithstanding the uniformity of treatment requirements 1 4 of section 514C.6, a policy, contract, or plan providing for 1 5 third=party payment or prepayment of health or medical expenses 1 6 shall provide coverage benefits for the diagnostic assessment 1 7 and treatment of eating disorders. 1 8 2. As used in this section, unless the context otherwise 1 9 requires: 1 10 a. "Diagnostic assessment of eating disorders" means 1 11 medically necessary assessments, evaluations, or tests 1 12 performed by a physician or psychiatrist licensed pursuant to 1 13 chapter 148, a psychologist licensed pursuant to chapter 154B, 1 14 a social worker licensed pursuant to chapter 154C, or a mental 1 15 health counselor or marital and family therapist licensed 1 16 pursuant to chapter 154D, to diagnose whether an individual has 1 17 an eating disorder. 1 18 b. "Eating disorders" means pica, rumination disorder, 1 19 avoidant or restrictive food intake disorder, anorexia nervosa, 1 20 bulimia nervosa, binge eating disorder, other specified feeding 1 21 or eating disorder, or any other eating disorder not otherwise 1 22 specified. The commissioner, by rule, shall define "eating 1 23 disorders" consistent with definitions provided in the most 1 24 recent edition of the American psychiatric association's 1 25 diagnostic and statistical manual of mental disorders, as such 1 26 definitions may be amended from time to time. The commissioner 1 27 may adopt the definitions provided in such manual by reference. 1 28 c. "Pharmacy care" means medications prescribed by 1 29 a licensed physician or psychiatrist and includes any 1 30 health=related services deemed medically necessary to determine 1 31 the need for or effectiveness of the medications prescribed, 1 32 but only to the extent that coverage of such medications is 1 33 included in the insured's health coverage benefits. 1 34 d. "Psychiatric care" or "psychological care" means 1 35 direct or consultative services provided during inpatient 2 1 hospitalization, partial hospitalization, residential 2 2 care, intensive outpatient treatment, follow=up outpatient 2 3 care, or counseling, provided by a licensed psychiatrist or 2 4 psychologist. 2 5 e. "Therapeutic care" means medical care or behavioral 2 6 interventions provided by a licensed physician, psychiatrist, 2 7 psychologist, social worker, mental health counselor, or 2 8 marital and family therapist. 2 9 f. "Treatment of eating disorders" means treatment that 2 10 is identified in a treatment plan and includes medically 2 11 necessary pharmacy care, psychiatric or psychological care, or 2 12 therapeutic care, that is provided by a licensed physician, 2 13 psychiatrist, psychologist, social worker, mental health 2 14 counselor, or marital and family therapist. 2 15 g. "Treatment plan" means a plan for the treatment of eating 2 16 disorders developed by a licensed physician, psychiatrist, 2 17 psychologist, social worker, mental health counselor, 2 18 or marital and family therapist that includes all of the 2 19 following: 2 20 (1) A diagnosis. 2 21 (2) Proposed treatment by type, frequency, and duration of 2 22 treatment. 2 23 (3) Goals. 2 24 (4) All elements necessary for the third=party payment or 2 25 prepayment of claims. 2 26 3. Coverage required by this section is limited to 2 27 medically necessary diagnostic assessment and treatment of 2 28 eating disorders in accordance with a treatment plan, that is 2 29 provided by a licensed physician, psychiatrist, psychologist, 2 30 social worker, mental health counselor, or marital and family 2 31 therapist acting pursuant to that person's applicable scope of 2 32 practice. 2 33 4. Coverage required pursuant to this section shall be 2 34 subject to copayment, deductible, and coinsurance provisions, 2 35 and any other general exclusions or limitations of a policy, 3 1 contract, or plan to the same extent as other health or medical 3 2 services covered by the policy, contract, or plan. 3 3 5. This section shall not be construed to limit benefits 3 4 which are otherwise available to an individual under a policy, 3 5 contract, or plan. 3 6 6. a. Coverage of the diagnosis and treatment of eating 3 7 disorders may be subject to other general exclusions and 3 8 limitations of the policy, contract, or plan providing for 3 9 third=party payment or prepayment of health or medical expenses 3 10 not in conflict with the provisions of this section, such 3 11 as coordination of benefits, and utilization of health care 3 12 services, which include reviews of medical necessity and care 3 13 management. 3 14 b. Medical necessity determinations and care management 3 15 for the treatment of eating disorders shall do all of the 3 16 following: 3 17 (1) Consider the overall medical and mental health needs of 3 18 the individual diagnosed with an eating disorder. 3 19 (2) Not be based solely on the weight of the individual 3 20 diagnosed with an eating disorder. 3 21 (3) Take into consideration the most recent practice 3 22 guideline for the treatment of patients with eating disorders 3 23 adopted by the American psychiatric association in addition to 3 24 current standards based upon the medical literature generally 3 25 recognized as authoritative in the medical community. 3 26 7. The commissioner shall adopt rules pursuant to chapter 3 27 17A to implement and administer this section. 3 28 8. This section shall not apply to accident=only, 3 29 specified disease, short=term hospital or medical, hospital 3 30 confinement indemnity, credit, dental, vision, Medicare 3 31 supplement, long=term care, basic hospital and medical=surgical 3 32 expense coverage as defined by the commissioner, disability 3 33 income insurance coverage, coverage issued as a supplement 3 34 to liability insurance, workers' compensation or similar 3 35 insurance, or automobile medical payment insurance, or 4 1 individual accident and sickness policies issued to individuals 4 2 or to individual members of a member association. 4 3 9. This section applies to the following classes of 4 4 third=party payment provider policies, contracts, or plans 4 5 delivered, issued for delivery, continued, or renewed in this 4 6 state on or after January 1, 2017: 4 7 a. Individual or group accident and sickness insurance 4 8 providing coverage on an expense=incurred basis. 4 9 b. An individual or group hospital or medical service 4 10 contract issued pursuant to chapter 509, 514, or 514A. 4 11 c. An individual or group health maintenance organization 4 12 contract regulated under chapter 514B. 4 13 d. Any other entity engaged in the business of insurance, 4 14 risk transfer, or risk retention, which is subject to the 4 15 jurisdiction of the commissioner. 4 16 e. A plan established pursuant to chapter 509A for public 4 17 employees. 4 18 f. An organized delivery system licensed by the director of 4 19 public health. 4 20 EXPLANATION 4 21 The inclusion of this explanation does not constitute agreement with 4 22 the explanation's substance by the members of the general assembly. 4 23 This bill provides that a policy, contract, or plan 4 24 providing for third=party payment or prepayment of health 4 25 or medical expenses shall provide coverage benefits for the 4 26 diagnostic assessment and treatment of eating disorders. 4 27 "Eating disorders" is defined to mean pica, rumination 4 28 disorder, avoidant or restrictive food intake disorder, 4 29 anorexia nervosa, bulimia nervosa, binge eating disorder, 4 30 other specified feeding or eating disorder, or any other 4 31 eating disorder not otherwise specified. The commissioner, by 4 32 rule, is required to define "eating disorders" consistent with 4 33 definitions provided in the most recent edition of the American 4 34 psychiatric association's diagnostic and statistical manual of 4 35 mental disorders. 5 1 Coverage required by the bill is limited to medically 5 2 necessary diagnostic assessment and treatment of eating 5 3 disorders in accordance with a treatment plan, that is 5 4 provided by a licensed physician, psychiatrist, psychologist, 5 5 social worker, mental health counselor, or marital and 5 6 family therapist acting pursuant to that person's applicable 5 7 scope of practice. The treatment plan must include a 5 8 diagnosis; proposed treatment by type, frequency, and duration 5 9 of treatment; goals; and all elements necessary for the 5 10 third=party payment or prepayment of claims. "Treatment of 5 11 eating disorders" includes medically necessary pharmacy care, 5 12 psychiatric or psychological care, or therapeutic care. 5 13 Coverage required is subject to copayment, deductible, and 5 14 coinsurance provisions, and any other general exclusions or 5 15 limitations of a policy, contract, or plan to the same extent 5 16 as other health or medical services that are covered. The 5 17 required coverage shall not be construed to limit benefits 5 18 which are otherwise available to an individual under a policy, 5 19 contract, or plan. 5 20 The required coverage may be subject to other general 5 21 exclusions and limitations of the contract, policy, or plan 5 22 that are not in conflict with the provisions of the bill, 5 23 such as coordination of benefits, and utilization of health 5 24 care services, which include reviews of medical necessity 5 25 and care management. Medical necessity determinations and 5 26 care management for the treatment of eating disorders must 5 27 consider the overall medical and mental health needs of the 5 28 individual diagnosed with the disorder; not be based solely 5 29 on the weight of the individual diagnosed with the disorder; 5 30 and take into consideration the most recent practice guideline 5 31 for the treatment of patients with eating disorders adopted 5 32 by the American psychiatric association in addition to 5 33 current standards based upon the medical literature generally 5 34 recognized as authoritative in the medical community. 5 35 The commissioner is directed to adopt rules pursuant to Code 6 1 chapter 17A to implement and administer the provisions of the 6 2 bill. 6 3 The bill applies to specified individual and group policies, 6 4 contracts, and plans that are delivered, issued for delivery, 6 5 continued, or renewed in this state on or after January 1, 6 6 2017. LSB 5000XS (2) 86 av/rj
