First Substitute S.B. 55

Senator Brian E. Shiozawa proposes the following substitute bill:

1 INSURANCE COVERAGE FOR AUTISM SPECTRUM
2 DISORDER
3 2013 GENERAL SESSION
4 STATE OF UTAH
5 Chief Sponsor: Brian E. Shiozawa
6 House Sponsor: ____________
7
8 LONG TITLE
9 General Description:
10 This bill amends the Insurance Code to provide health benefit plan coverage for the
11 treatment of autism spectrum disorder.
12 Highlighted Provisions:
13 This bill:
14 . defines terms;
15 . requires a health benefit plan to provide coverage for the treatment of autism
16 spectrum disorder;
17 . grants rulemaking authority to the insurance commissioner;
18 . describes minimum coverage amounts and limits for the insurance coverage;
19 . provides for the annual adjustment of the coverage amounts based on the Consumer
20 Price Index; and
21 . provides an exemption for small employers if premium costs increase by more than
22 a certain percentage.
23 Money Appropriated in this Bill:
24 None
25 Other Special Clauses:

26 None
27 Utah Code Sections Affected:
28 ENACTS:
29 31A-22-641, Utah Code Annotated 1953
30
31 Be it enacted by the Legislature of the state of Utah:
32 Section 1. Section 31A-22-641 is enacted to read:
33 31A-22-641. Insurance coverage for autism spectrum disorders.
34 (1) As used in this section:
35 (a) "Applied behavior analysis" means the design, implementation, and evaluation of
36 environmental modifications, using behavioral stimuli and consequences, to produce socially
37 significant improvement in human behavior, including the use of direct observation,
38 measurement, and functional analysis of the relationship between environment and behavior.
39 (b) "Autism spectrum disorder" means any of the pervasive developmental disorders or
40 autism spectrum disorders as defined by the most recent edition of the Diagnostic and
41 Statistical Manual of Mental Disorders (DSM).
42 (c) "Behavioral health treatment" means counseling and treatment programs, including
43 applied behavior analysis, that are:
44 (i) necessary to develop, maintain, or restore, to the maximum extent practicable, the
45 functioning of an individual; and
46 (ii) provided or supervised by a:
47 (A) person licensed under Title 58, Division of Occupational and Professional
48 Licensing, whose scope of practice includes mental health services; or
49 (B) Board Certified Behavior Analyst.
50 (d) "Diagnosis of autism spectrum disorder" means medically necessary assessment,
51 evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.
52 (e) "Pharmacy care" means medications prescribed by a licensed physician and any
53 health-related services deemed medically necessary to determine the need or effectiveness of
54 the medications.
55 (f) "Psychiatric care" means direct or consultative services provided by a psychiatrist
56 licensed in the state in which the psychiatrist practices.

57 (g) "Psychological care" means direct or consultative services provided by a person
58 licensed in the state to provide mental health services.
59 (h) "Therapeutic care" means services provided by licensed or certified speech
60 therapists, occupational therapists, or physical therapists.
61 (i) "Treatment for autism spectrum disorder":
62 (i) means evidence-based care and related equipment prescribed or ordered for an
63 individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed
64 psychologist who determines the care to be medically necessary; and
65 (ii) includes:
66 (A) behavioral health treatment, provided or supervised by a person described in
67 Subsection (1)(c)(ii);
68 (B) pharmacy care;
69 (C) psychiatric care;
70 (D) psychological care; and
71 (E) therapeutic care.
72 (2) Notwithstanding the provisions of Section 31A-22-618.5 , a health benefit plan
73 entered into or renewed on or after July 1, 2013, shall provide coverage for the treatment for
74 autism spectrum disorder in accordance with the requirements of this section and the rules
75 made by the commissioner under this section.
76 (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah
77 Administrative Rulemaking Act, to set the minimum standards of coverage for the treatment
78 for autism spectrum disorder.
79 (4) Subject to Subsection (5), the rules described in Subsection (3) shall establish
80 durational limits, amount limits, deductibles, copayments, and coinsurance for the treatment for
81 autism spectrum disorder that are similar to, or identical to, the coverage provided for other
82 illnesses or diseases.
83 (5) Subject to Subsection (6), coverage for behavioral health treatment for a person
84 with an autism spectrum disorder is subject to a maximum benefit of:
85 (a) $50,000 annually for a child who is younger than nine years old; and
86 (b) $25,000 annually for a child who is at least nine years old, but younger than 18
87 years old.

88 (6) Beginning on July 1, 2015, the commissioner has authority to annually adjust the
89 amounts described in Subsection (5) by a percentage equal to the percentage difference
90 between the Consumer Price Index for the current calendar year and the Consumer Price Index
91 for the preceding calendar year.
92 (7) The commissioner shall grant a small employer with a group health benefit plan a
93 waiver from the provisions of this section if the small employer demonstrates to the
94 commissioner by actual claims experience over any consecutive 12-month period that
95 compliance with this section has increased the cost of the health benefit plan by an amount of
96 2-1/2% or greater over the period of a calendar year in premium costs to the small employer.

[Bill Documents]