Bill Text: IA SF64 | 2011-2012 | 84th General Assembly | Introduced
Bill Title: A bill for an act requiring certain group health insurance policies, contracts, or plans to provide coverage for autism spectrum disorders for certain persons, requiring certification of behavior specialists, providing for a repeal, and including applicability and effective date provisions.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2012-01-19 - Subcommittee reassigned, Rielly, Beall, and Bertrand. S.J. 96. [SF64 Detail]
Download: Iowa-2011-SF64-Introduced.html
Senate
File
64
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Introduced
SENATE
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BY
BEALL
A
BILL
FOR
An
Act
requiring
certain
group
health
insurance
policies,
1
contracts,
or
plans
to
provide
coverage
for
autism
spectrum
2
disorders
for
certain
persons,
requiring
certification
of
3
behavior
specialists,
providing
for
a
repeal,
and
including
4
applicability
and
effective
date
provisions.
5
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
6
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Section
1.
NEW
SECTION
.
514C.29
Autism
spectrum
disorders
1
coverage.
2
1.
Notwithstanding
the
uniformity
of
treatment
requirements
3
of
section
514C.6,
a
group
policy,
contract,
or
plan
providing
4
for
third-party
payment
or
prepayment
of
health,
medical,
and
5
surgical
coverage
benefits
shall
provide
coverage
benefits
6
to
covered
individuals
under
twenty-one
years
of
age
for
the
7
diagnostic
assessment
of
autism
spectrum
disorders
and
for
the
8
treatment
of
autism
spectrum
disorders
if
the
policy,
contract,
9
or
plan
is
either
of
the
following:
10
a.
A
policy,
contract,
or
plan
issued
by
a
carrier,
as
11
defined
in
section
513B.2,
or
an
organized
delivery
system
12
authorized
under
1993
Iowa
Acts,
chapter
158,
to
an
employer
13
who
on
at
least
fifty
percent
of
the
employer’s
working
days
14
during
the
preceding
calendar
year
employed
more
than
fifty
15
full-time
equivalent
employees.
In
determining
the
number
16
of
full-time
equivalent
employees
of
an
employer,
employers
17
who
are
affiliated
or
who
are
able
to
file
a
consolidated
tax
18
return
for
purposes
of
state
taxation
shall
be
considered
one
19
employer.
20
b.
A
plan
established
pursuant
to
chapter
509A
for
public
21
employees.
22
2.
As
used
in
this
section,
unless
the
context
otherwise
23
requires:
24
a.
“Applied
behavioral
analysis”
means
the
design,
25
implementation,
and
evaluation
of
environmental
modifications,
26
using
behavioral
stimuli
and
consequences,
to
produce
socially
27
significant
improvement
in
human
behavior
or
to
prevent
loss
28
of
attained
skill
or
function,
including
the
use
of
direct
29
observation,
measurement,
and
functional
analysis
of
the
30
relations
between
environment
and
behavior.
31
b.
“Autism
service
provider”
means
a
person,
entity,
32
or
group
providing
treatment
of
autism
spectrum
disorders,
33
pursuant
to
a
treatment
plan.
34
c.
“Autism
spectrum
disorders”
means
any
of
the
pervasive
35
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developmental
disorders
including
autistic
disorder,
Asperger’s
1
disorder,
and
pervasive
developmental
disorders
not
otherwise
2
specified.
The
commissioner,
by
rule,
shall
define
“autism
3
spectrum
disorders”
consistent
with
definitions
provided
in
the
4
most
recent
edition
of
the
American
psychiatric
association’s
5
diagnostic
and
statistical
manual
of
mental
disorders,
as
such
6
definitions
may
be
amended
from
time
to
time.
The
commissioner
7
may
adopt
the
definitions
provided
in
such
manual
by
reference.
8
d.
“Behavior
specialist”
means
an
individual,
certified
9
by
the
commissioner,
who
designs,
implements,
or
evaluates
a
10
behavior
modification
intervention
component
of
a
treatment
11
plan,
including
those
based
on
applied
behavioral
analysis,
to
12
produce
socially
significant
improvements
in
human
behavior
or
13
to
prevent
loss
of
attained
skill
or
function,
through
skill
14
acquisition
and
the
reduction
of
problematic
behavior.
15
e.
“Diagnostic
assessment
of
autism
spectrum
disorders”
means
16
medically
necessary
assessment,
evaluations,
or
tests
performed
17
by
a
licensed
physician,
licensed
physician
assistant,
licensed
18
psychologist,
or
licensed
registered
nurse
practitioner
to
19
diagnose
whether
an
individual
has
an
autism
spectrum
disorder.
20
f.
“Pharmacy
care”
means
medications
prescribed
by
a
21
licensed
physician,
licensed
physician
assistant,
or
licensed
22
registered
nurse
practitioner
and
any
assessment,
evaluation,
23
or
test
prescribed
or
ordered
by
a
licensed
physician,
licensed
24
physician
assistant,
or
licensed
registered
nurse
practitioner
25
to
determine
the
need
for
or
effectiveness
of
such
medications.
26
g.
“Psychiatric
care”
means
direct
or
consultative
services
27
provided
by
a
licensed
physician
who
specializes
in
psychiatry.
28
h.
“Psychological
care”
means
direct
or
consultative
29
services
provided
by
a
licensed
psychologist.
30
i.
“Rehabilitative
care”
means
professional
services
and
31
treatment
programs,
including
applied
behavioral
analysis,
32
provided
by
an
autism
service
provider
to
produce
socially
33
significant
improvement
in
human
behavior
or
to
prevent
loss
34
of
attained
skill
or
function.
35
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j.
“Therapeutic
care”
means
services
provided
by
a
licensed
1
speech
pathologist,
licensed
occupational
therapist,
or
2
licensed
physical
therapist.
3
k.
“Treatment
of
autism
spectrum
disorders”
means
treatment
4
that
is
identified
in
a
treatment
plan
and
includes
medically
5
necessary
pharmacy
care,
psychiatric
care,
psychological
care,
6
rehabilitative
care,
and
therapeutic
care
that
is
one
of
the
7
following:
8
(1)
Prescribed,
ordered,
or
provided
by
a
licensed
9
physician,
licensed
physician
assistant,
licensed
psychologist,
10
licensed
social
worker,
or
licensed
registered
nurse
11
practitioner.
12
(2)
Provided
by
an
autism
service
provider.
13
(3)
Provided
by
a
person,
entity,
or
group
that
works
under
14
the
direction
of
an
autism
service
provider.
15
l.
“Treatment
plan”
means
a
plan
for
the
treatment
of
16
autism
spectrum
disorders
developed
by
a
licensed
physician
or
17
licensed
psychologist
pursuant
to
a
comprehensive
evaluation
18
or
reevaluation
performed
in
a
manner
consistent
with
the
most
19
recent
clinical
report
or
recommendations
of
the
American
20
academy
of
pediatrics,
as
determined
by
the
commissioner
by
21
rule.
22
3.
Coverage
is
required
pursuant
to
this
section
in
a
23
maximum
benefit
amount
of
not
less
than
thirty-six
thousand
24
dollars
per
year
but
shall
not
be
subject
to
any
limits
on
the
25
number
of
visits
to
an
autism
service
provider
for
treatment
of
26
autism
spectrum
disorders.
Beginning
in
2015,
the
commissioner
27
shall,
on
or
before
April
1
of
each
calendar
year,
publish
28
an
adjustment
to
the
maximum
benefit
required
equal
to
the
29
percentage
change
in
the
United
States
department
of
labor
30
consumer
price
index
for
all
urban
consumers
in
the
preceding
31
year,
and
the
published
adjusted
maximum
benefit
shall
be
32
applicable
to
group
policies,
contracts,
or
plans
subject
to
33
this
section
that
are
issued
or
renewed
on
or
after
January
1
34
of
the
following
calendar
year.
Payments
made
under
a
group
35
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policy,
contract,
or
plan
subject
to
this
section
on
behalf
1
of
a
covered
individual
for
treatment
of
a
health
condition
2
unrelated
to
or
distinguishable
from
the
individual’s
autism
3
spectrum
disorder
shall
not
be
applied
toward
any
maximum
4
benefit
established
under
this
subsection.
5
4.
Coverage
required
pursuant
to
this
section
shall
be
6
subject
to
copayment,
deductible,
and
coinsurance
provisions,
7
and
any
other
general
exclusions
or
limitations
of
a
group
8
policy,
contract,
or
plan
to
the
same
extent
as
other
medical
9
or
surgical
services
covered
by
the
group
policy,
contract,
or
10
plan.
11
5.
Coverage
required
by
this
section
shall
be
provided
12
in
coordination
with
coverage
required
for
the
treatment
of
13
autistic
disorders
pursuant
to
section
514C.22.
14
6.
This
section
shall
not
be
construed
to
limit
benefits
15
which
are
otherwise
available
to
an
individual
under
a
group
16
policy,
contract,
or
plan.
17
7.
This
section
shall
not
be
construed
to
require
coverage
18
by
a
group
policy,
contract,
or
plan
of
any
service
solely
19
based
on
inclusion
of
the
service
in
an
individualized
20
education
program.
Consistent
with
federal
or
state
law
and
21
upon
consent
of
the
parent
or
guardian
of
a
covered
individual,
22
the
treatment
of
autism
spectrum
disorders
may
be
coordinated
23
with
any
services
included
in
an
individualized
education
24
program.
However,
coverage
for
the
treatment
of
autism
25
spectrum
disorders
shall
not
be
contingent
upon
coordination
of
26
services
with
an
individualized
education
program.
27
8.
This
section
shall
not
apply
to
accident-only,
28
specified
disease,
short-term
hospital
or
medical,
hospital
29
confinement
indemnity,
credit,
dental,
vision,
Medicare
30
supplement,
long-term
care,
basic
hospital
and
medical-surgical
31
expense
coverage
as
defined
by
the
commissioner,
disability
32
income
insurance
coverage,
coverage
issued
as
a
supplement
33
to
liability
insurance,
workers’
compensation
or
similar
34
insurance,
or
automobile
medical
payment
insurance,
or
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individual
accident
and
sickness
policies
issued
to
individuals
1
or
to
individual
members
of
a
member
association.
2
9.
A
carrier,
organized
delivery
system,
or
plan
3
established
pursuant
to
chapter
509A
may
manage
the
benefits
4
provided
through
common
methods
including
but
not
limited
to
5
providing
payment
of
benefits
or
providing
care
and
treatment
6
under
a
capitated
payment
system,
prospective
reimbursement
7
rate
system,
utilization
control
system,
incentive
system
8
for
the
use
of
least
restrictive
and
costly
levels
of
care,
9
a
preferred
provider
contract
limiting
choice
of
specific
10
providers,
or
any
other
system,
method,
or
organization
11
designed
to
assure
services
are
medically
necessary
and
12
clinically
appropriate.
13
10.
An
insurer
may
review
a
treatment
plan
for
treatment
14
of
autism
spectrum
disorders
once
every
six
months,
subject
to
15
its
utilization
review
requirements,
including
case
management,
16
concurrent
review,
and
other
managed
care
provisions.
A
more
17
or
less
frequent
review
may
be
agreed
upon
by
the
insured
and
18
the
licensed
physician
or
licensed
psychologist
developing
the
19
treatment
plan.
20
11.
For
the
purposes
of
this
section,
the
results
of
a
21
diagnostic
assessment
of
autism
spectrum
disorder
shall
be
22
valid
for
a
period
of
not
less
than
twelve
months,
unless
a
23
licensed
physician
or
licensed
psychologist
determines
that
a
24
more
frequent
assessment
is
necessary.
25
12.
The
commissioner,
in
consultation
with
the
board
of
26
medicine,
shall
adopt
rules
providing
for
the
certification
of
27
behavior
specialists.
28
a.
An
applicant
for
a
certificate
as
a
behavior
specialist
29
shall
submit
a
written
application
on
forms
provided
by
the
30
commissioner
evidencing
and
insuring
that
the
applicant
meets
31
all
of
the
following
requirements:
32
(1)
Is
of
good
moral
character.
33
(2)
Has
received
a
master’s
or
higher
degree
from
a
34
board-approved,
accredited
college
or
university,
including
35
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a
major
course
of
study
in
school,
clinical,
or
counseling
1
psychology,
special
education,
social
work,
speech
therapy,
2
occupational
therapy,
or
another
related
field.
3
(3)
Has
at
least
one
year
of
experience
involving
4
functional
behavior
assessments,
including
the
development
and
5
implementation
of
behavioral
supports
or
treatment
plans.
6
(4)
Has
completed
at
least
one
thousand
hours
in
direct
7
clinical
experience
with
individuals
with
behavioral
challenges
8
or
at
least
one
thousand
hours
of
experience
in
a
related
field
9
with
individuals
with
autism
spectrum
disorders.
10
(5)
Has
completed
relevant
training
programs,
including
11
professional
ethics,
autism-specific
training,
assessments
12
training,
instructional
strategies
and
best
practices,
13
crisis
intervention,
comorbidity
and
medications,
family
14
collaboration,
and
addressing
specific
skill
deficits
training.
15
b.
The
commissioner
shall
not
issue
a
certificate
to
an
16
applicant
who
has
been
convicted
of
a
felony,
of
a
controlled
17
substance-related
offense
under
chapter
124
or
of
the
laws
of
18
another
jurisdiction
unless
all
of
the
following
requirements
19
have
been
met:
20
(1)
At
least
ten
years
have
elapsed
from
the
date
of
21
conviction
of
such
an
offense.
22
(2)
The
applicant
satisfactorily
demonstrates
to
the
23
commissioner
that
the
applicant
has
made
significant
progress
24
in
personal
rehabilitation
since
the
conviction
such
that
25
certification
of
the
applicant
would
not
be
expected
to
create
26
a
substantial
risk
of
harm
to
the
health
and
safety
of
patients
27
or
the
public,
or
a
substantial
risk
of
further
criminal
28
violations.
29
(3)
The
applicant
otherwise
satisfies
the
requirements
of
30
this
subsection.
31
13.
The
commissioner
shall
adopt
rules
pursuant
to
chapter
32
17A
to
implement
and
administer
this
section.
33
14.
This
section
applies
to
third-party
payment
provider
34
policies,
contracts,
or
plans,
and
to
plans
established
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pursuant
to
chapter
509A
that
are
delivered,
issued
for
1
delivery,
continued,
or
renewed
in
this
state
on
or
after
2
January
1,
2012.
3
Sec.
2.
REPEAL.
Section
514C.28,
Code
2011,
is
repealed.
4
Sec.
3.
EFFECTIVE
DATE.
The
following
provision
of
this
Act
5
takes
effect
January
1,
2012:
6
1.
The
section
of
this
Act
repealing
section
514C.28.
7
EXPLANATION
8
This
bill
creates
new
Code
section
514C.24
which
requires
9
certain
group
health
insurance
policies,
contracts,
or
plans
to
10
provide
coverage
benefits
for
the
diagnosis
and
treatment
of
11
autism
spectrum
disorders.
The
new
provision
is
applicable
to
12
group
health
policies,
contracts,
or
plans
issued
to
employers
13
with
more
than
50
employees
and
to
health
plans
established
14
under
Code
chapter
509A
for
public
employees.
Coverage
15
benefits
are
required
for
covered
individuals
under
21
years
16
of
age.
17
“Autism
spectrum
disorders”
includes
autistic
disorder,
18
Asperger’s
disorder,
and
pervasive
developmental
disorders
19
not
otherwise
specified,
as
defined
by
the
commissioner
of
20
insurance
by
rule
consistent
with
definitions
provided
in
the
21
most
recent
edition
of
the
American
psychiatric
association’s
22
diagnostic
and
statistical
manual
of
mental
disorders.
23
Required
coverage
for
the
diagnosis
and
treatment
of
autism
24
spectrum
disorders
must
be
not
less
than
$36,000
per
year
and
25
without
limits
on
the
number
of
visits
to
an
autism
service
26
provider.
Beginning
in
2015,
the
commissioner
is
required
to
27
make
annual
adjustments
to
the
maximum
benefit
required
equal
28
to
the
change
in
the
United
States
department
of
labor
consumer
29
price
index.
Payments
made
on
behalf
of
a
covered
individual
30
that
are
unrelated
to
or
distinguishable
from
the
individual’s
31
autism
spectrum
disorder
cannot
be
applied
toward
this
maximum
32
benefit.
33
Coverage
of
autism
spectrum
disorders
under
the
new
Code
34
section
is
to
be
provided
in
coordination
with
coverage
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required
for
the
treatment
of
autistic
disorders
pursuant
to
1
Code
section
514C.22.
The
Code
section
shall
not
be
construed
2
to
limit
benefits
otherwise
available
to
an
individual
under
a
3
group
health
policy,
contract,
or
plan.
4
The
commissioner,
in
consultation
with
the
board
of
5
medicine,
is
required
to
adopt
rules
for
the
certification
6
of
behavior
specialists
who
design,
implement,
or
evaluate
7
behavior
modification
intervention
components
of
treatment
8
plans
for
autism
spectrum
disorders
that
are
developed
by
a
9
licensed
physician
or
licensed
psychologist.
10
The
new
Code
section
applies
to
third-party
payment
provider
11
policies,
contracts,
or
plans,
and
to
plans
established
12
pursuant
to
Code
chapter
509A
that
are
delivered,
issued
for
13
delivery,
continued,
or
renewed
in
this
state
on
or
after
14
January
1,
2012.
15
Code
section
514C.28,
which
currently
mandates
coverage
16
for
autism
spectrum
disorders
only
in
group
plans
established
17
pursuant
to
Code
chapter
509A
for
state
employees,
is
repealed
18
effective
January
1,
2012.
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