SB-0415, As Passed House, March 29, 2012

 

 

 

 

 

 

 

 

 

 

 

HOUSE SUBSTITUTE FOR

 

SENATE BILL NO. 415

 

 

 

 

 

 

 

 

 

 

 

     A bill to amend 1956 PA 218, entitled

 

"The insurance code of 1956,"

 

(MCL 500.100 to 500.8302) by adding section 3406s.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 3406s. (1) Except as otherwise provided in this section,

 

an expense-incurred hospital, medical, or surgical group or

 

individual policy or certificate delivered, issued for delivery, or

 

renewed in this state and a health maintenance organization group

 

or individual contract shall provide coverage for the diagnosis of

 

autism spectrum disorders and treatment of autism spectrum

 

disorders. An insurer and a health maintenance organization shall

 

not do any of the following:

 

     (a) Terminate coverage or refuse to deliver, execute, issue,

 

amend, adjust, or renew coverage solely because an individual is

 

diagnosed with, or has received treatment for, an autism spectrum

 

disorder.

 

     (b) Limit the number of visits an insured or enrollee may use

 

for treatment of autism spectrum disorders covered under this

 

section.

 

     (c) Deny or limit coverage under this section on the basis

 

that treatment is educational or habilitative in nature.

 

     (d) Except as otherwise provided in this subdivision, subject

 

coverage under this section to dollar limits, copays, deductibles,

 

or coinsurance provisions that do not apply to physical illness

 

generally. Coverage under this section for treatment of autism

 

spectrum disorders may be limited to an insured or enrollee through

 

18 years of age and may be subject to a maximum annual benefit as

 

follows:

 

     (i) For a covered insured or enrollee through 6 years of age,

 

$50,000.00.

 

     (ii) For a covered insured or enrollee from 7 years of age

 

through 12 years of age, $40,000.00.

 

     (iii) For a covered insured or enrollee from 13 years of age

 

through 18 years of age, $30,000.00.

 

     (2) This section does not limit benefits that are otherwise

 

available to an insured or enrollee under a policy, contract, or

 

certificate. An insurer or health maintenance organization shall

 

utilize evidence-based care and managed care cost-containment

 

practices pursuant to the insurer's or health maintenance

 

organization's procedures so long as that care and those practices

 

are consistent with this section. The coverage under this section

 

may be subject to other general exclusions and limitations of the

 

policy, contract, or certificate, including, but not limited to,

 

coordination of benefits, participating provider requirements,

 

restrictions on services provided by family or household members,

 

utilization review of health care services including review of

 

medical necessity, case management, and other managed care

 

provisions.

 

     (3) If an insured or enrollee is receiving treatment for an

 

autism spectrum disorder, an insurer or health maintenance

 

organization may, as a condition to providing the coverage under

 

this section, do all of the following:

 

     (a) Require a review of that treatment consistent with current

 

protocols and may require a treatment plan. If requested by the

 

insurer or health maintenance organization, the cost of treatment

 

review shall be borne by the insurer or health maintenance

 

organization.

 

     (b) Request the results of the autism diagnostic observation

 

schedule that has been used in the diagnosis of an autism spectrum

 

disorder for that insured or enrollee.

 

     (c) Request that the autism diagnostic observation schedule be

 

performed on that insured or enrollee not more frequently than once

 

every 3 years.

 

     (d) Request that an annual development evaluation be conducted

 

and the results of that annual development evaluation be submitted

 

to the insurer or health maintenance organization.

 

     (4) Beginning January 1, 2014, a qualified health plan offered

 

through an American health benefit exchange established in this

 

state pursuant to the federal act is not required to provide

 

coverage under this section to the extent that it exceeds coverage

 

that is included in the essential health benefits as required

 

pursuant to the federal act. As used in this subsection, "federal

 

act" means the federal patient protection and affordable care act,

 

Public Law 111-148, as amended by the federal health care and

 

education reconciliation act of 2010, Public Law 111-152, and any

 

regulations promulgated under those acts.

 

     (5) This section does not apply to a short-term or 1-time

 

limited duration policy or certificate of no longer than 6 months

 

as described in section 2213b.

 

     (6) This section does not require the coverage of prescription

 

drugs and related services unless the insured or enrollee is

 

covered by a prescription drug plan. This section does not require

 

an insurer or health maintenance organization to provide coverage

 

for autism spectrum disorders to an insured or enrollee under more

 

than 1 of its policies, certificates, or contracts. If an insured

 

or enrollee has more than 1 policy, certificate, or contract that

 

covers autism spectrum disorders, the benefits provided are subject

 

to the limits of this section when coordinating benefits.

 

     (7) As used in this section:

 

     (a) "Applied behavior analysis" means the design,

 

implementation, and evaluation of environmental modifications,

 

using behavioral stimuli and consequences, to produce significant

 

improvement in human behavior, including the use of direct

 

observation, measurement, and functional analysis of the

 

relationship between environment and behavior.

 

     (b) "Autism diagnostic observation schedule" means the

 

protocol available through western psychological services for

 

diagnosing and assessing autism spectrum disorders or any other

 

standardized diagnostic measure for autism spectrum disorders that

 

is approved by the commissioner, if the commissioner determines

 

that the diagnostic measure is recognized by the health care

 

industry and is an evidence-based diagnostic tool.

 

     (c) "Autism spectrum disorders" means any of the following

 

pervasive developmental disorders as defined by the diagnostic and

 

statistical manual:

 

     (i) Autistic disorder.

 

     (ii) Asperger's disorder.

 

     (iii) Pervasive developmental disorder not otherwise specified.

 

     (d) "Behavioral health treatment" means evidence-based

 

counseling and treatment programs, including applied behavior

 

analysis, that meet both of the following requirements:

 

     (i) Are necessary to develop, maintain, or restore, to the

 

maximum extent practicable, the functioning of an individual.

 

     (ii) Are provided or supervised by a board certified behavior

 

analyst or a licensed psychologist so long as the services

 

performed are commensurate with the psychologist's formal

 

university training and supervised experience.

 

     (e) "Diagnosis of autism spectrum disorders" means

 

assessments, evaluations, or tests, including the autism diagnostic

 

observation schedule, performed by a licensed physician or a

 

licensed psychologist to diagnose whether an individual has 1 of

 

the autism spectrum disorders.

 

     (f) "Diagnostic and statistical manual" or "DSM" means the

 

diagnostic and statistical manual of mental disorders published by

 

the American psychiatric association or other manual that contains

 

common language and standard criteria for the classification of

 

mental disorders and that is approved by the commissioner, if the

 

commissioner determines that the manual is recognized by the health

 

care industry and the classification of mental disorders is at

 

least as comprehensive as the manual published by the American

 

psychiatric association on the effective date of this section.

 

     (g) "Pharmacy care" means medications prescribed by a licensed

 

physician and related services performed by a licensed pharmacist

 

and any health-related services considered medically necessary to

 

determine the need or effectiveness of the medications.

 

     (h) "Psychiatric care" means evidence-based direct or

 

consultative services provided by a psychiatrist licensed in the

 

state in which the psychiatrist practices.

 

     (i) "Psychological care" means evidence-based direct or

 

consultative services provided by a psychologist licensed in the

 

state in which the psychologist practices.

 

     (j) "Therapeutic care" means evidence-based services provided

 

by a licensed or certified speech therapist, occupational

 

therapist, physical therapist, or social worker.

 

     (k) "Treatment of autism spectrum disorders" means evidence-

 

based treatment that includes the following care prescribed or

 

ordered for an individual diagnosed with 1 of the autism spectrum

 

disorders by a licensed physician or a licensed psychologist who

 

determines the care to be medically necessary:

 

     (i) Behavioral health treatment.

 

     (ii) Pharmacy care.

 

     (iii) Psychiatric care.

 

     (iv) Psychological care.

 

     (v) Therapeutic care.

 

     (l) "Treatment plan" means a written, comprehensive, and

 

individualized intervention plan that incorporates specific

 

treatment goals and objectives and that is developed by a board

 

certified or licensed provider who has the appropriate credentials

 

and who is operating within his or her scope of practice, when the

 

treatment of an autism spectrum disorder is first prescribed or

 

ordered by a licensed physician or licensed psychologist as

 

described in subdivision (k).

 

     Enacting section 1. This amendatory act applies to policies,

 

certificates, and contracts delivered, executed, issued, amended,

 

adjusted, or renewed in this state, or outside of this state if

 

covering residents of this state, beginning 180 days after the date

 

this amendatory act is enacted into law.

 

     Enacting section 2. This amendatory act does not take effect

 

unless all of the following bills of the 96th Legislature are

 

enacted into law:

 

     (a) Senate Bill No. 414.

 

     (b) Senate Bill No. 981.