Senate File 2349 - Reprinted
SENATE FILE
BY COMMITTEE ON COMMERCE
(SUCCESSOR TO SF 1)
(As Amended and Passed by the Senate February 23, 2010)
A BILL FOR
1 An Act requiring certain group health insurance plans
2 established for employees of the state to provide coverage
3 for autism spectrum disorders for certain persons, requiring
4 certification of behavior specialists, and providing an
5 applicability date.
6 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
SF 2349 (1) 83
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PAG LIN
1 1 Section 1. NEW SECTION. 514C.26 Autism spectrum disorders
1 2 coverage.
1 3 1. Notwithstanding the uniformity of treatment requirements
1 4 of section 514C.6, a group plan established pursuant to chapter
1 5 509A for employees of the state providing for third=party
1 6 payment or prepayment of health, medical, and surgical coverage
1 7 benefits shall provide coverage benefits to covered individuals
1 8 under twenty=one years of age for the diagnostic assessment
1 9 of autism spectrum disorders and for the treatment of autism
1 10 spectrum disorders.
1 11 2. As used in this section, unless the context otherwise
1 12 requires:
1 13 a. "Applied behavioral analysis" means the design,
1 14 implementation, and evaluation of environmental modifications,
1 15 using behavioral stimuli and consequences, to produce socially
1 16 significant improvement in human behavior or to prevent loss
1 17 of attained skill or function, including the use of direct
1 18 observation, measurement, and functional analysis of the
1 19 relations between environment and behavior.
1 20 b. "Autism service provider" means a person, entity,
1 21 or group providing treatment of autism spectrum disorders,
1 22 pursuant to a treatment plan.
1 23 c. "Autism spectrum disorders" means any of the pervasive
1 24 developmental disorders including autistic disorder, Asperger's
1 25 disorder, and pervasive developmental disorders not otherwise
1 26 specified. The commissioner, by rule, shall define "autism
1 27 spectrum disorders" consistent with definitions provided in the
1 28 most recent edition of the American psychiatric association's
1 29 diagnostic and statistical manual of mental disorders, as such
1 30 definitions may be amended from time to time. The commissioner
1 31 may adopt the definitions provided in such manual by reference.
1 32 d. "Behavior specialist" means an individual, certified by
1 33 the board of medicine, who designs, implements, or evaluates
1 34 a behavior modification intervention component of a treatment
1 35 plan, including those based on applied behavioral analysis, to
2 1 produce socially significant improvements in human behavior or
2 2 to prevent loss of attained skill or function, through skill
2 3 acquisition and the reduction of problematic behavior.
2 4 e. "Diagnostic assessment of autism spectrum disorders" means
2 5 medically necessary assessment, evaluations, or tests performed
2 6 by a licensed physician, licensed physician assistant, licensed
2 7 psychologist, or licensed registered nurse practitioner to
2 8 diagnose whether an individual has an autism spectrum disorder.
2 9 f. "Pharmacy care" means medications prescribed by a
2 10 licensed physician, licensed physician assistant, or licensed
2 11 registered nurse practitioner and any assessment, evaluation,
2 12 or test prescribed or ordered by a licensed physician, licensed
2 13 physician assistant, or licensed registered nurse practitioner
2 14 to determine the need for or effectiveness of such medications.
2 15 g. "Psychiatric care" means direct or consultative services
2 16 provided by a licensed physician who specializes in psychiatry.
2 17 h. "Psychological care" means direct or consultative
2 18 services provided by a licensed psychologist.
2 19 i. "Rehabilitative care" means professional services and
2 20 treatment programs, including applied behavioral analysis,
2 21 provided by an autism service provider to produce socially
2 22 significant improvement in human behavior or to prevent loss
2 23 of attained skill or function.
2 24 j. "Therapeutic care" means services provided by a licensed
2 25 speech pathologist, licensed occupational therapist, or
2 26 licensed physical therapist.
2 27 k. "Treatment of autism spectrum disorders" means treatment
2 28 that is identified in a treatment plan and includes medically
2 29 necessary pharmacy care, psychiatric care, psychological care,
2 30 rehabilitative care, and therapeutic care that is one of the
2 31 following:
2 32 (1) Prescribed, ordered, or provided by a licensed
2 33 physician, licensed physician assistant, licensed psychologist,
2 34 licensed social worker, or licensed registered nurse
2 35 practitioner.
3 1 (2) Provided by an autism service provider.
3 2 (3) Provided by a person, entity, or group that works under
3 3 the direction of an autism service provider.
3 4 l. "Treatment plan" means a plan for the treatment of
3 5 autism spectrum disorders developed by a licensed physician or
3 6 licensed psychologist pursuant to a comprehensive evaluation
3 7 or reevaluation performed in a manner consistent with the most
3 8 recent clinical report or recommendations of the American
3 9 academy of pediatrics, as determined by the commissioner by
3 10 rule.
3 11 3. Coverage is required pursuant to this section in a
3 12 maximum benefit amount of not more than thirty=six thousand
3 13 dollars per year but shall not be subject to any limits
3 14 on the number of visits to an autism service provider for
3 15 treatment of autism spectrum disorders. Beginning in 2014,
3 16 the commissioner shall, on or before April 1 of each calendar
3 17 year, publish an adjustment to the maximum benefit required
3 18 equal to the percentage change in the United States department
3 19 of labor consumer price index for all urban consumers in the
3 20 preceding year, and the published adjusted maximum benefit
3 21 shall be applicable to group policies, contracts, or plans
3 22 subject to this section that are issued or renewed on or after
3 23 January 1 of the following calendar year. Payments made under
3 24 a group plan subject to this section on behalf of a covered
3 25 individual for treatment of a health condition unrelated to or
3 26 distinguishable from the individual's autism spectrum disorder
3 27 shall not be applied toward any maximum benefit established
3 28 under this subsection.
3 29 4. Coverage required pursuant to this section shall be
3 30 subject to copayment, deductible, and coinsurance provisions,
3 31 and any other general exclusions or limitations of a group
3 32 plan to the same extent as other medical or surgical services
3 33 covered by the group plan.
3 34 5. Coverage required by this section shall be provided
3 35 in coordination with coverage required for the treatment of
4 1 autistic disorders pursuant to section 514C.22.
4 2 6. This section shall not be construed to limit benefits
4 3 which are otherwise available to an individual under a group
4 4 plan.
4 5 7. This section shall not be construed to require coverage
4 6 by a group plan of any service solely based on inclusion of the
4 7 service in an individualized education program. Consistent
4 8 with federal or state law and upon consent of the parent or
4 9 guardian of a covered individual, the treatment of autism
4 10 spectrum disorders may be coordinated with any services
4 11 included in an individualized education program. However,
4 12 coverage for the treatment of autism spectrum disorders
4 13 shall not be contingent upon coordination of services with an
4 14 individualized education program.
4 15 8. This section shall not apply to accident=only,
4 16 specified disease, short=term hospital or medical, hospital
4 17 confinement indemnity, credit, dental, vision, Medicare
4 18 supplement, long=term care, basic hospital and medical=surgical
4 19 expense coverage as defined by the commissioner, disability
4 20 income insurance coverage, coverage issued as a supplement
4 21 to liability insurance, workers' compensation or similar
4 22 insurance, or automobile medical payment insurance, or
4 23 individual accident and sickness policies issued to individuals
4 24 or to individual members of a member association.
4 25 9. A plan established pursuant to chapter 509A for employees
4 26 of the state may manage the benefits provided through common
4 27 methods including but not limited to providing payment of
4 28 benefits or providing care and treatment under a capitated
4 29 payment system, prospective reimbursement rate system,
4 30 utilization control system, incentive system for the use of
4 31 least restrictive and costly levels of care, a preferred
4 32 provider contract limiting choice of specific providers, or
4 33 any other system, method, or organization designed to assure
4 34 services are medically necessary and clinically appropriate.
4 35 10. An insurer may review a treatment plan for treatment
5 1 of autism spectrum disorders once every six months, subject to
5 2 its utilization review requirements, including case management,
5 3 concurrent review, and other managed care provisions. A more
5 4 or less frequent review may be agreed upon by the insured and
5 5 the licensed physician or licensed psychologist developing the
5 6 treatment plan.
5 7 11. For the purposes of this section, the results of a
5 8 diagnostic assessment of autism spectrum disorder shall be
5 9 valid for a period of not less than twelve months, unless a
5 10 licensed physician or licensed psychologist determines that a
5 11 more frequent assessment is necessary.
5 12 12. The board of medicine shall adopt rules providing for
5 13 the certification of behavior specialists.
5 14 a. An applicant for a certificate as a behavior specialist
5 15 shall submit a written application on forms provided by the
5 16 board of medicine evidencing and insuring that the applicant
5 17 meets all of the following requirements:
5 18 (1) Is of good moral character.
5 19 (2) Has received a master's or higher degree from a
5 20 board=approved, accredited college or university, including
5 21 a major course of study in school, clinical, or counseling
5 22 psychology, special education, social work, speech therapy,
5 23 occupational therapy, or another related field.
5 24 (3) Has at least one year of experience involving
5 25 functional behavior assessments, including the development and
5 26 implementation of behavioral supports or treatment plans.
5 27 (4) Has completed at least one thousand hours in direct
5 28 clinical experience with individuals with behavioral challenges
5 29 or at least one thousand hours experience in a related field
5 30 with individuals with autism spectrum disorders.
5 31 (5) Has completed relevant training programs, including
5 32 professional ethics, autism=specific training, assessments
5 33 training, instructional strategies and best practices,
5 34 crisis intervention, comorbidity and medications, family
5 35 collaboration, and addressing specific skill deficits training.
6 1 b. The board of medicine shall not issue a certificate to an
6 2 applicant who has been convicted of a felony, of a controlled
6 3 substance=related offense under chapter 124 or of the laws of
6 4 another jurisdiction unless all of the following requirements
6 5 have been met:
6 6 (1) At least ten years have elapsed from the date of
6 7 conviction of such an offense.
6 8 (2) The applicant satisfactorily demonstrates to the board
6 9 of medicine that the applicant has made significant progress
6 10 in personal rehabilitation since the conviction such that
6 11 certification of the applicant would not be expected to create
6 12 a substantial risk of harm to the health and safety of patients
6 13 or the public, or a substantial risk of further criminal
6 14 violations.
6 15 (3) The applicant otherwise satisfies the requirements of
6 16 this subsection.
6 17 13. The commissioner shall adopt rules pursuant to chapter
6 18 17A to implement and administer this section.
6 19 14. This section applies to plans established pursuant to
6 20 chapter 509A for employees of the state that are delivered,
6 21 issued for delivery, continued, or renewed in this state on or
6 22 after January 1, 2011.
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