HCS HB 1311 & 1341 -- INSURANCE COVERAGE FOR PERVASIVE
DEVELOPMENTAL DISORDERS

SPONSOR:  Wilson, 130 (Scharnhorst)

COMMITTEE ACTION:  Voted "do pass" by the Special Committee on
Health Insurance by a vote of 14 to 0.

This substitute establishes provisions regarding the diagnosis
and treatment of pervasive developmental disorders (PDD).  In its
main provisions, the substitute:

(1)  Establishes the Behavior Analyst Advisory Board under the
State Committee of Psychologists within the Department of
Insurance, Financial Institutions and Professional Registration
to establish licensure and registration requirements for behavior
analysts, assistance behavior analysts, and line therapists who
provide applied behavior analysis therapies for children with
PDD;

(2)  Requires all health benefit plans that are delivered,
issued, continued, or renewed on or after January 1, 2011, to
provide coverage for the diagnosis and treatment of PDD for
children through 21 years of age;

(3)  Requires the department director to grant an employer with
25 to 50 employees who offers a group health plan a waiver from
offering PDD coverage if the employer demonstrates by actual
experience over any consecutive 24-month period that the cost of
providing the coverage has resulted in a 5% increase in the
health plan premiums over a calendar year.  Employers with less
than 25 employees with a group health plan are not required to
provide PDD coverage, but insurers are required to offer PDD
coverage to these employers;

(4)  Prohibits carriers from denying or refusing to issue
insurance coverage on; refusing to contract with; or refusing to
renew or reissue, terminate, or restrict coverage on an
individual or his or her dependent solely because of being
diagnosed with a PDD or because he or she receives coverage;

(5)  Limits the coverage provided by an insurance carrier for PDD
to the treatment ordered by the insured individual's licensed
treating physician or psychologist in accordance with a treatment
plan.  Service exclusions contained in an insurance policy or
health maintenance organization contract that are inconsistent
with a PDD treatment plan will be considered invalid as to PDD.
A PDD treatment plan must include all elements necessary for a
health carrier to review the plan when requested and to
appropriately pay the claim.  Except for inpatient services, the
health benefit plan or carrier can request, at its expense, a
review of the treatment plan not more than once every six months
unless the individual's treating physician or psychologist agrees
that a more frequent review is necessary;

(6)  Specifies that coverage for individuals younger than 10
years of age for the applied behavior analysis (ABA) services
will have a maximum benefit of $36,000 per year and for
individuals 10 to 21 years of age will have a maximum benefit of
$20,000 per year, with no limit on the number of visits to a PDD
service provider.  Coverage cannot be denied on the basis that it
is educational or habilitative in nature.  Beginning December 31,
2010, the maximum benefit limits will be adjusted annually for
inflation by the department director;

(7)  Prohibits PDD services from being subject to any greater
deductible, co-insurance, co-payment, or utilization review than
other physical health care services provided by the health
benefit plan.  Payments and reimbursements for ABA services can
only be made to a PDD service provider;

(8)  Requires health benefit plans established, extended,
modified, or renewed on or after January 1, 2011, under the
Missouri Consolidated Health Care Plan, self-insured governmental
plans, self-insured group arrangements, multiple employer welfare
arrangements, and self-insured school district health plans to
offer individual PDD coverage;

(9)  Exempts the MO HealthNet Program and supplemental insurance
policies from the provisions of the bill;

(10)  Specifies that health carriers and benefit plans are not
required to reimburse a school district for PDD services that it
provided;

(11)  Specifies that health carriers and benefits plans will be
the payor of last resort for PDD services in areas where the
First Steps Program is available;

(12)  Specifies that the provisions regarding providing insurance
coverage for PDD are subject to the utilization review laws for
health insurers and the department; and

(13)  Requires, beginning February 1, 2012, the department to
submit an annual report to the General Assembly regarding the
implementation of the coverage and cost analysis data for PDD
service claims from health insurers.

FISCAL NOTE:  Estimated Cost on General Revenue Fund of $339,785
in FY 2011, $679,571 in FY 2012, and $679,571 in FY 2013.
Estimated Cost on Other State Funds of Unknown exceeding $180,756
in FY 2011, Unknown exceeding $312,371 in FY 2012, and Unknown
exceeding $348,738 in FY 2013.

PROPONENTS:  Supporters say that the bills address the need for
health insurance coverage for the diagnosis and treatment of
pervasive developmental disorders, most common of which is
autism.  Thousands of parents who have a child with autism are
demanding that health insurance carriers offer health benefit
plans that include full coverage for all PDDs.  There are
multiple actuarial studies stating that the increase to health
insurance premiums will be less than 1%.  Providing insurance
coverage to diagnose and treat PDD at an early age will save
costs in the long run because if no intervention is provided, as
the child grows older there often are more needs for medical and
social care.  Early intervention coverage for services is
necessary because the brain can only make adaptations to learning
early in life.  PDDs are a medical condition that can only be
diagnosed and treated by a medical doctor.  There is no cure, but
social and medical obstacles can be overcome to provide a better
quality of life for children with a PDD.  Applied behavior
analysis (ABA) therapy is the best treatment for children with
PDDs and is not an experimental treatment.  ABA treatments help
children with PDD assimilate into school.  ABA treatment claims
average $30,000 per year but can cost up to $75,000 per year, and
not very many families can afford this treatment.  ABA therapy is
necessary because drug therapies are not yet available.  Fourteen
states have passed similar legislation, and 21 have pending
legislation.  There is a need for partnerships between insurance
carriers, health care providers, parents, and educators to best
serve children with PDD.

Testifying for the bill were Representatives Scharnhorst and
Grill; Lorri Unumb, Autism Speaks; John Mantovani; Representative
Dennis O'Brien, Pennsylvania House of Representatives; Stuart
Jackson; Stephen Schad; Michele Kilo; Colin Peeler, Behavioral
Solutions, Incorporated; Ronald Ekstrand, Jr., Touch Point Autism
Services; John Guercio, Missouri Association for Behavior
Analysis; Missouri National Education Association; Wayne Lee;
Department of Mental Health; and Eileen Dillon.

OPPONENTS:  Those who oppose the bill say that the insurance
industry is not opposed to providing care for children; however,
they do have a logical objection because the real problem is to
identify the reason that the diagnosis of ASD has seen such a
dramatic increase in recent years.  The cost of adding a mandate
of coverage for autism spectrum disorders (ASD) will be carried
onto consumers and small businesses which will only serve about
30% of Missourians.  If an investment in early intervention is
made to help children with ASD, the cost of care for their later
years should be less expensive, but should not include both the
early and the later expenses.  The spectrum of disorders that
fall under ASD causes several dilemmas.  Some treatments work for
some, but not all. Early intervention is good for all, but not
all respond.  ABA therapy is not applicable to everyone and is
not proven to be highly successful after a child reaches seven
years of age.  The science of evaluating the needs of children
with ASD requires ongoing research and reporting.  Credentialing
all ABA providers is vital.  Mandates memorialize a certain
standard of care beginning on the effective date which can become
harmful for providing good care in the future.  Coverage should
be tiered so that coverage is scaled back as a child grows older.

Testifying against the bill were Anthem Blue Cross Blue Shield;
Blue Cross Blue Shield of Kansas City; America's Health Insurance
Plans; United Healthcare Services, Incorporated; Associated
Industries of Missouri; Group Health Plans; and Coventry Health
Care.

OTHERS:  Others testifying on the bills say that they should be
mindful of the impact on small businesses.

Testifying on the bill were National Federation of Independent
Business; Division of Professional Registration, Department of
Insurance, Financial Institutions and Professional Registration;
Missouri Insurance Coalition; Blue Cross Blue Shield of Kansas
City; and Blake Williamson.

Missouri House of Representatives
95th General Assembly, 2nd Regular Session
Last Updated September 14, 2010 at 3:10 pm