CCS SCS HCS HB 1311 & 1341 -- HEALTH INSURANCE COVERAGE FOR
AUTISM SPECTRUM DISORDERS

This bill establishes provisions regarding health insurance
coverage for individuals diagnosed with autism spectrum disorders
(ASD).

MANDATED INSURANCE COVERAGE

Beginning January 1, 2011, all group health benefit plans
delivered, issued, continued, or renewed that are written inside
the state or written outside the state but insuring a Missouri
resident must provide coverage for the diagnosis and treatment of
ASD.  A health carrier cannot deny or refuse to issue coverage
on, refuse to contract with, refuse to renew or reissue, or
otherwise terminate or restrict coverage on an individual or his
or her dependent because the individual is diagnosed with ASD.
These provisions apply to any health care 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, and 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.  The bill specifies that these provisions
will not automatically apply to an individually underwritten
health plan but must be offered as an option to any individual
plan.  Certain supplemental insurance policies and the MO
HealthNet Program are exempt from providing this coverage.

LIMITS ON COVERAGE

A health carrier can limit coverage for ASD services to the
medically necessary treatment 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 carrier must have the right to
review, at its expense, 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.

Health benefit plan coverage for ASD services cannot be subject
to any greater deductible, co-insurance, or co-payment than other
physical health care services provided by the health benefit
plan.  Coverage of services may be subject to general exclusions
and limitations of the contract or health benefit plan including
coordination of benefits, exclusion for 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.

BEHAVIOR ANALYST ADVISORY BOARD AND APPLIED BEHAVIOR ANALYSIS
SERVICES

The Behavior Analyst Advisory Board is established under the
State Committee of Psychologists within the Department of
Insurance, Financial Institutions and Professional Registration
to establish licensure requirements for behavior analysts and
assistant behavior analysts who provide applied behavior analysis
(ABA) therapies to children with ASD.  ABA services must be
included in the coverage for ASD up to a maximum benefit of
$40,000 per year for an individual younger than 19 years of age.
However, the maximum limit may be exceeded upon prior approval by
the health benefit plan if additional services are medically
necessary.  Beginning January 1, 2012, a health carrier must
adjust the maximum cost benefit at least every three years based
on the increase in the federal Consumer Price Index as calculated
annually by the department.  The payment for the treatment of a
condition unrelated to ASD cannot be applied to the ABA maximum
benefit.  ABA services will not be subject to a limit on the
number of visits an individual utilizes within the maximum
benefit.

Payments and reimbursements for ABA services can only be made to
the ASD service provider or the entity or group for whom the
supervising, board-certified behavior analyst works or is
associated.  ABA services provided by a line therapist under the
supervision of a state-licensed ASD provider must be reimbursed
to the provider if the services are included in the treatment
plan and are deemed medically necessary.  A carrier will not be
liable for the actions of a line therapist in the performance of
his or her duties.

A carrier is not required to reimburse for ABA services provided
by any Part C Early Intervention Program, commonly known as First
Steps, or by any school district to an individual diagnosed with
ASD.

WAIVERS

The department director must grant a small employer that offers a
group health plan a waiver from offering health insurance
coverage for ASD if the employer experiences at least a 2.5%
increase in the health benefit plan premiums over a calendar year
as a result of providing the ASD coverage to its employees.

REPORTING REQUIREMENTS

Beginning February 1, 2012, the department is required 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.

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