SB224 By Senator Allen RFD Banking and Insurance Rd 1 11-FEB-16

SYNOPSIS: Under existing law, a health benefit plan is required to offer coverage for the treatment of Autism Spectrum Disorder for a child age nine or under for certain defined group insurance plans and contracts.

This bill would require health benefit plans to cover the treatment of Autism Spectrum Disorder for a child age nine or under for certain insurance plans and contracts.

A BILL TO BE ENTITLED AN ACT

Relating to health benefit plans; to amend Sections 10A-20-6.16, 27-21A-23, and 27-54A-2, Code of Alabama 1975, to require health benefit plans to cover the treatment of Autism Spectrum Disorder for certain children in certain health insurance plans and contracts.

BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:Section 1. Sections 10A-20-6.16, 27-21A-23, and 27-54A-2, Code of Alabama 1975, are amended to read as follows:

§10A-20-6.16.

"(a) No statute of this state applying to insurance companies shall be applicable to any corporation organized under this article and amendments thereto or to any contract made by the corporation; except the corporation shall be subject to all of the following:

"(1) The provisions regarding annual premium tax to be paid by insurers on insurance premiums.

"(2) Chapter 55 of Title 27, regarding the prohibition of unfair discriminatory acts by insurers on the basis of an applicant's or insured's abuse status.

"(3) The Medicare Supplement Minimum Standards set forth in Article 2 of Chapter 19 of Title 27, and Long-Term Care Insurance Policy Minimum Standards set forth in Article 3 of Chapter 19 of Title 27.

"(4) Section 27-1-17, requiring insurers and health plans to pay health care providers in a timely manner.

"(5) Chapter 56 of Title 27, regarding the Access to Eye Care Act.

"(6) Rules promulgated by the Commissioner of Insurance pursuant to Sections 27-7-43 and 27-7-44.

"(7) Chapter 54 of Title 27.

"(8) Chapter 57 of Title 27, requiring coverage to be offered for the payment of colorectal cancer examinations for covered persons who are 50 years of age or older, or for covered persons who are less than 50 years of age and at high risk for colorectal cancer according to current American Cancer Society colorectal cancer screening guidelines.

"(9) Chapter 58 of Title 27, requiring that policies and contracts including coverage for prostate cancer early detection be offered, together with identification of associated costs.

"(10) Chapter 59 of Title 27, requiring that policies and contracts including coverage for chiropractic be offered, together with identification of associated costs.

"(11) Chapter 54A of Title 27, requiring that policies and contracts to offer coverage for cover certain treatment for Autism Spectrum Disorder under certain conditions.

"(12) Chapter 12A of Title 27.

"(13) Chapter 2B of Title 27.

"(b) The provisions in subsection (a) that require specific types of coverage to be offered or provided shall not apply when the corporation is administering a self-funded benefit plan or similar plan, fund, or program that it does not insure.

§27-21A-23.

"(a) Except as otherwise provided in this chapter, provisions of the insurance law and provisions of health care service plan laws shall not be applicable to any health maintenance organization granted a certificate of authority under this chapter. This provision shall not apply to an insurer or health care service plan licensed and regulated pursuant to the insurance law or the health care service plan laws of this state except with respect to its health maintenance organization activities authorized and regulated pursuant to this chapter.

"(b) Solicitation of enrollees by a health maintenance organization granted a certificate of authority shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.

"(c) Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and shall be exempt from the provisions of Section 34-24-310, et seq., relating to the practice of medicine.

"(d) No person participating in the arrangements of a health maintenance organization other than the actual provider of health care services or supplies directly to enrollees and their families shall be liable for negligence, misfeasance, nonfeasance, or malpractice in connection with the furnishing of such services and supplies.

"(e) Nothing in this chapter shall be construed in any way to repeal or conflict with any provision of the certificate of need law.

"(f) Notwithstanding the provisions of subsection (a), a health maintenance organization shall be subject to all of the following:

"(1) Section 27-1-17.

"(2) Chapter 56, regarding the Access to Eye Care Act.

"(3) Chapter 54.

"(4) Chapter 57, requiring coverage to be offered for the payment of colorectal cancer examinations for covered persons who are 50 years of age or older, or for covered persons who are less than 50 years of age and at high risk for colorectal cancer according to current American Cancer Society colorectal cancer screening guidelines.

"(5) Chapter 58, requiring that policies and contracts including coverage for prostate cancer early detection be offered, together with identification of associated costs.

"(6) Chapter 59, requiring that policies and contracts including coverage for chiropractic be offered, together with identification of associated costs.

"(7) Rules promulgated by the Commissioner of Insurance pursuant to Sections 27-7-43 and 27-7-44.

"(8) Chapter 12A.

"(9) Chapter 54A, requiring policies and contracts to offer coverage for cover certain treatment for Autism Spectrum Disorder under certain conditions.

"(10) Chapter 2B, regarding risk-based capital.

§27-54A-2.

"(a) As used in this section, the following words have the following meanings:

"(1) APPLIED BEHAVIOR ANALYSIS. The design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

"(2) AUTISM SPECTRUM DISORDER. Any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.

"(3) BEHAVIORAL HEALTH TREATMENT. Counseling and treatment programs, including applied behavior analysis that are both of the following:

"a. Necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.

"b. Provided or supervised by a Board Certified Behavior Analyst, licensed in the State of Alabama, or a psychologist, licensed in the State of Alabama, so long as the services performed are commensurate with the psychologist's formal university training and supervised experience.

"c. Behavioral health treatment does not include psychological testing, neuropsychology, psychotherapy, intellectual assessment, cognitive therapy, sex therapy, psychoanalysis, hypotherapy, and long-term counseling as treatment modalities.

"(4) DIAGNOSIS OF AUTISM SPECTRUM DISORDER. Medically necessary assessment, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

"(5) HEALTH BENEFIT PLAN. Any group insurance plan, policy, or contract for health care services that covers hospital, medical, or surgical expenses, health maintenance organizations, preferred provider organizations, medical service organizations, physician-hospital organizations, or any other person, firm, corporation, joint venture, or other similar business entity that pays for, purchases, or furnishes group health care services to patients, insureds, or beneficiaries in this state. For the purposes of this section, a health benefit plan located or domiciled outside of the State of Alabama is deemed to be subject to this section if the plan, policy, or contract is issued or delivered in the State of Alabama. The term includes, but is not limited to, entities created pursuant to Article 6, Chapter 20, Title 10A. The term does not include the Alabama Health Insurance Plan or the Alabama Small Employer Allocation Program provided in Chapter 52 of this title. The term does not include accident-only, specified disease, individual hospital indemnity, credit, dental-only, Medicare-supplement, long-term care, or disability income insurance, other limited benefit health insurance policies, coverage issued as a supplemental to liability insurance, workers' compensation or similar insurance, or automobile medical-payment insurance.

"(6) PHARMACY CARE. Medications prescribed by a licensed physician and any health related services deemed medically necessary to determine the need or effectiveness of the medications.

"(7) PSYCHIATRIC CARE. Direct or consultative services provided by a psychiatrist licensed in the State of Alabama.

"(8) PSYCHOLOGICAL CARE. Direct or consultative services provided by a psychologist licensed in the State of Alabama.

"(9) THERAPEUTIC CARE. Services provided by licensed and certified speech therapists, occupational therapists, or physical therapists.

"(10) TREATMENT FOR AUTISM SPECTRUM DISORDER. Evidence-based care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary, including, but not limited to, all of the following:

"a. Behavioral health treatment.

"b. Pharmacy care.

"c. Psychiatric care.

"d. Psychological care.

"e. Therapeutic care.

"(b)(1) A health benefit plan shall offer coverage for cover the screening, diagnosis, and treatment of Autism Spectrum Disorder for an insured nine years of age or under in policies and contracts issued or delivered in the State of Alabama to employers with at least 51 employees for at least 50 percent of its working days during the preceding calendar year. Coverage provided under this section is limited to treatment that is prescribed by the insured's treating licensed physician or licensed psychologist in accordance with a treatment plan.

"(2) To the extent that the screening, diagnosis, and treatment of autism spectrum disorder are not already covered by a health insurance policy, coverage under this section shall be offered for inclusion included in health insurance policies that are delivered, executed, issued, amended, adjusted, or renewed in the State of Alabama at the date of the annual renewal for coverage.

"(3) A health benefit plan may not deny or refuse to issue coverage on, refuse to contract with, or refuse to renew or refuse to reissue or otherwise terminate or restrict coverage on an individual solely because the individual is diagnosed with Autism Spectrum Disorder.

"(c)(1) The coverage required pursuant to this section may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the health insurance plan, except as otherwise provided for in subsection (e).

"(2) The coverage required pursuant to subsection (b) may be subject to other general exclusions and limitations of the health benefit plan, 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.

"(d) The treatment plan required pursuant to subsection (b) shall include all elements necessary for the health insurance plan to appropriately pay claims. These elements include, but are not limited to, a diagnosis, proposed treatment by type, frequency, and duration of treatment, the anticipated outcomes stated as goals, the frequency by which the treatment plan will be updated, and the treating licensed physician's or licensed psychologist's signature. The health insurance plan may only request an updated treatment plan only once every six months from the treating licensed physician or licensed psychologist to review medical necessity, unless the health insurance plan and the treating licensed physician or licensed psychologist agree that a more frequent review is necessary for a particular patient.

"(e) The benefits and coverage provided pursuant to this section shall be provided to any eligible person nine years of age or under. Coverage for behavioral therapy is subject to a thirty-six thousand dollars ($36,000) maximum benefit per year. Beginning October 1, 2013, this maximum benefit shall be adjusted annually on January 1 of each calendar year to reflect any change from the previous year in the current Consumer Price Index, All Urban Consumers, as published by the United States Department of Labor's Bureau of Labor Statistics."

Section 2. This act shall become effective October 1, 2016.

Health

Health Benefit Plans

Autism

Insurance

Health Maintenance Organizations

Code Amended