HCS HB 1311 & 1341 -- HEALTH INSURANCE COVERAGE FOR AUTISM
SPECTRUM DISORDER (Scharnhorst)

COMMITTEE OF ORIGIN:  Special Committee on Health Insurance

This substitute establishes provisions regarding the diagnosis
and treatment of autism spectrum disorders (ASD).  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, assistant behavior analysts, and line therapists who
provide applied behavior analysis therapies to children with ASD;

(2)  Requires all group health benefit plans that are delivered,
issued, continued, or renewed on or after January 1, 2011,
written inside or outside the state, to provide coverage for the
diagnosis and treatment of ASD;

(3)  Requires the department director to grant a small employer
who offers a group health plan a waiver from offering ASD
coverage if the employer demonstrates by actual experience over
any consecutive 12-month period that the cost of providing the
coverage has resulted in at least a 2.5% increase in health plan
premium costs to the employer over a calendar year;

(4)  Prohibits carriers from denying or refusing to issue
insurance coverage on, refusing to contract with, refusing to
renew or reissue coverage on, or terminating or restricting
coverage on an individual or his or her dependent because the
individual is diagnosed with ASD;

(5)  Limits the coverage provided by an insurance carrier for ASD
to medically necessary treatment that is ordered by the insured
individual's licensed treating physician or psychologist in
accordance with a treatment plan.  An ASD treatment plan must
include all elements necessary for a health benefit plan or
carrier to pay the claim.  Except for inpatient services, the
health benefit plan or carrier can review, at its expense, the
treatment plan not more than once every three 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 19
years of age for the applied behavior analysis (ABA) services
will have a maximum benefit of $36,000 per year with no limit on
the number of visits to an ASD service provider.  No coverage
will be required for individuals older than 18 years of age.
Coverage of services may be subject to general exclusions and
limitations of the contract or benefit plan including
coordination of benefits, services provided by family members,
and utilization review of health care services but cannot be
denied on the basis that it is educational or habilitative in
nature;

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

(8)  Requires these provisions to apply to any healthcare plan
issued to employees and their dependents under the Missouri
Consolidated Health Care Plan that is delivered, issued,
continued, or renewed on or after January 1, 2011.  These
provisions also apply to plans that are established, extended,
modified, or renewed on or after January 1, 2011, by self-insured
governmental plans, self-insured group arrangements, multiple
employer welfare arrangements, and self-insured school district
health plans;

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

(10)  Specifies that a health carrier or other entity that is
subject to these provisions is not required to reimburse for ASD
services provided by any school-based service;

(11)  Requires individual health benefit plans to offer ASD
coverage as an option but will not automatically be applied to an
individually underwritten health benefit plan; and

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

FISCAL NOTE:  Estimated Cost on General Revenue Fund of $354,504
in FY 2011, $709,008 in FY 2012, and $709,008 in FY 2013.
Estimated Cost on Other State Funds of Unknown exceeding $183,732
in FY 2011, Unknown exceeding $318,322 in FY 2012, and Unknown
exceeding $354,689 in FY 2013.

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