FIRST REGULAR SESSION
95TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES SCHARNHORST (Sponsor), SCHOEMEHL, NIEVES, BIVINS, VIEBROCK, DOUGHERTY, PRATT, JONES (89), SANDER AND SMITH (14) (Co-sponsors).
1030L.01I D. ADAM CRUMBLISS, Chief Clerk
AN ACT
To amend chapter 376, RSMo, by adding thereto one new section relating to insurance coverage for the diagnosis and treatment of autism spectrum disorders.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be known as section 376.1224, to read as follows:
376.1224. 1. For purposes of this section, the following terms shall mean:
(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 relationships between environment and behavior;
(2) "Autism service provider":
(a) Any person, entity, or group that provides diagnostic or treatment services for autism spectrum disorders who is licensed or certified by the state of Missouri;
(b) Any person who is certified as a board certified behavior analyst by the behavior analyst certification board;
(c) Any person, if not licensed or certified, who shall provide, if requested, documented evidence of equivalent education, professional training, and supervised experience in applied behavior analysis when the treatment provided by the autism service provider is applied behavior analysis; or
(d) A direct implementer;
(3) "Autism spectrum disorders", a neurobiological disorder, an illness of the nervous system, which includes Autistic Disorder, Asperger's Disorder, Pervasive Developmental Disorder Not Otherwise Specified, Rett's Disorder, and Childhood Disintegrative Disorder, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association;
(4) "Diagnosis of autism spectrum disorders", medically necessary assessments, evaluations, or tests in order to diagnose whether an individual has an autism spectrum disorder;
(5) "Direct implementer", any person who provides diagnostic or treatment services for autism spectrum disorders who is not licensed or certified, as described in paragraphs (a) and (b) of subdivision (2) of this subsection, and is supervised by a person who is certified as a Board Certified Behavior Analyst by the Behavior Analyst Certification Board, whether such Board Certified Behavior Analyst supervises as an individual or as an employee of or in association with an entity or group;
(6) "Habilitative or rehabilitative care", professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore the functioning of an individual;
(7) "Health benefit plan", shall have the same meaning ascribed to it as in section 376.1350;
(8) "Health carrier", shall have the same meaning ascribed to it as in section 376.1350;
(9) "Medically necessary", any care, treatment, intervention, service or item that is prescribed, provided, or ordered by a licensed physician or a licensed psychologist, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, that will, or is reasonably expected to, do any of the following:
(a) Prevent the onset of an illness, condition, injury, or disability;
(b) Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or
(c) Assist to achieve or maintain functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age;
(10) "Pharmacy care", medications or nutritional supplements used to address symptoms of an autism spectrum disorder prescribed by a licensed physician, and any health-related services deemed medically necessary to determine the need or effectiveness of the medications or nutritional supplements;
(11) "Psychiatric care", direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices;
(12) "Psychological care", direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices;
(13) "Therapeutic care", services provided by licensed speech therapists, occupational therapists, or physical therapists;
(14) "Treatment for autism spectrum disorders", care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, if the care is determined to be medically necessary, including, but not limited to:
(a) Psychiatric care;
(b) Psychological care;
(c) Habilitative or rehabilitative care, including applied behavior analysis therapy;
(d) Therapeutic care;
(e) Pharmacy care.
2. A health benefit plan shall provide individuals less than twenty-one years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders. To the extent that the diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders are not already covered by a health benefit plan, the coverage required under this section shall be included in health benefit plans that are delivered, executed, issued, amended, adjusted, or renewed on or after August 28, 2009.
3. With regards to a health benefit plan, a health carrier shall 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 or their dependent solely because the individual is diagnosed with autism spectrum disorder.
4. (1) Coverage provided under this section is limited to treatment that is ordered by the insured's treating licensed physician or licensed psychologist, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, in accordance with a treatment plan.
(2) The treatment plan upon request by the health benefit plan or health carrier shall include all elements necessary for the health benefit plan or health carrier to appropriately pay claims. Such elements include, but are not limited to, a diagnosis, proposed treatment by type, frequency and duration of treatment and goals.
(3) Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, a health benefit plan or health carrier shall have the right to request a review of that treatment not more than once every six months unless the health benefit plan or health carrier and the individual's treating physician or psychologist agrees that a more frequent review is necessary. The cost of obtaining any review will be borne by the health benefit plan or health carrier, as applicable.
5. Coverage provided under this section for applied behavior analysis shall be subject to a maximum benefit of seventy-two thousand dollars per year, but shall not be subject to any limits on the number of visits by an individual to an autism service provider for applied behavior analysis. Coverage provided under this section for services other than applied behavior analysis shall not be subject to any limits on the number of visits an individual may make to an autism service provider. After December 31, 2010, the director of the department of insurance, financial and professional registration shall, on an annual basis, adjust the maximum benefit (for applied behavioral analysis) for inflation using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers. Payments made by a health carrier on behalf of a covered individual for any care, treatment, intervention, service or item, the provision of which was for the treatment of a health condition unrelated to the covered individual's autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.
6. This section shall not be construed as limiting benefits which are otherwise available to an individual under a health benefit plan. The health care services required by this section shall not be subject to any greater deductible, coinsurance or co-payment than other physical health care services provided by a health benefit plan.
7. To the extent any payments or reimbursements are being made for services rendered by a direct implementer for applied behavior analysis, such payments or reimbursements shall be made to either:
(1) The person who is supervising the direct implementer, who is certified as a board certified behavior analyst by the Behavior Analyst Certification Board; or
(2) The entity or group for whom such supervising person works or is associated.
8. This section shall not apply to health benefit plans offered solely to an individual.
9. The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy.
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