First Substitute S.B. 57
7 LONG TITLE
8 General Description:
9 This bill amends the Insurance Code to provide health benefit plan coverage for the
10 treatment of autism spectrum disorder.
11 Highlighted Provisions:
12 This bill:
13 . defines terms;
14 . requires a health benefit plan offered or renewed in the individual market or large
15 group market, on or after January 1, 2016, to provide coverage for the treatment of
16 autism spectrum disorder for children 2 to 9 years of age;
17 . describes minimum coverage limits for autism coverage;
18 . requires an assessment of treatment plan every six months;
19 . permits the commissioner to waive coverage under this section if the attorney
20 general issues a legal opinion that the limits on autism coverage are unenforceable
21 under federal law;
22 . clarifies that all other terms of the insurance plan related to deductibles, provider
23 networks, and cost sharing apply to the autism coverage;
24 . provides a waiver for an insurer if premium costs increase by more than a certain
25 percentage; and
26 . sunsets the autism coverage on January 1, 2019.
27 Money Appropriated in this Bill:
29 Other Special Clauses:
30 This bill provides an effective date.
31 Utah Code Sections Affected:
33 63I-1-231 (Effective 07/01/14), as last amended by Laws of Utah 2013, Chapters 261
34 and 417
36 31A-22-642 , Utah Code Annotated 1953
38 Be it enacted by the Legislature of the state of Utah:
39 Section 1. Section 31A-22-642 is enacted to read:
40 31A-22-642. Insurance coverage for autism spectrum disorder.
41 (1) As used in this section:
42 (a) "Applied behavior analysis" means the design, implementation, and evaluation of
43 environmental modifications, using behavioral stimuli and consequences, to produce socially
44 significant improvement in human behavior, including the use of direct observation,
45 measurement, and functional analysis of the relationship between environment and behavior.
46 (b) "Autism spectrum disorder" means pervasive developmental disorders as defined
47 by most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
48 (c) "Behavioral health treatment" means counseling and treatment programs, including
49 applied behavior analysis, that are:
50 (i) necessary to develop, maintain, or restore, to the maximum extent practicable, the
51 functioning of an individual; and
52 (ii) provided or supervised by a:
53 (A) board certified behavior analyst; or
54 (B) person licensed under Title 58, Chapter 1, Division of Occupational and
55 Professional Licensing Act, whose scope of practice includes mental health services.
56 (d) "Diagnosis of autism spectrum disorder" means medically necessary assessments,
57 evaluations, or tests:
58 (i) performed by a licensed physician who is board certified in neurology, psychiatry,
59 or pediatrics and has experience diagnosing autism spectrum disorder, or a licensed
60 psychologist with experience diagnosing autism spectrum disorder; and
61 (ii) necessary to diagnose whether an individual has an autism spectrum disorder.
62 (e) "Pharmacy care" means medications prescribed by a licensed physician and any
63 health-related services considered medically necessary to determine the need or effectiveness
64 of the medications.
65 (f) "Psychiatric care" means direct or consultative services provided by a psychiatrist
66 licensed in the state in which the psychiatrist practices.
67 (g) "Psychological care" means direct or consultative services provided by a
68 psychologist licensed in the state in which the psychologist practices.
69 (h) "Therapeutic care" means services provided by licensed or certified speech
70 therapists, occupational therapists, or physical therapists.
71 (i) "Treatment for autism spectrum disorder":
72 (i) means evidence-based care and related equipment prescribed or ordered for an
73 individual diagnosed with an autism spectrum disorder by a physician or a licensed
74 psychologist described in Subsection (1)(d) who determines the care to be medically necessary;
76 (ii) includes:
77 (A) behavioral health treatment, provided or supervised by a person described in
78 Subsection (1)(c)(ii);
79 (B) pharmacy care;
80 (C) psychiatric care;
81 (D) psychological care; and
82 (E) therapeutic care.
83 (2) Notwithstanding the provisions of Section 31A-22-618.5 , a health benefit plan
84 offered in the individual market or the large group market and entered into or renewed on or
85 after January 1, 2016, shall provide coverage for the diagnosis and treatment of autism
86 spectrum disorder:
87 (a) for a child who is at least two years old, but younger than 10 years old; and
88 (b) in accordance with the requirements of this section and rules made by the
90 (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah
91 Administrative Rulemaking Act, to set the minimum standards of coverage for the treatment of
92 autism spectrum disorder.
93 (4) Subject to Subsection (5), the rules described in Subsection (3) shall establish
94 durational limits, amount limits, deductibles, copayments, and coinsurance for the treatment of
95 autism spectrum disorder that are similar to, or identical to, the coverage provided for other
96 illnesses or diseases.
97 (5) (a) Coverage for behavioral health treatment for a person with an autism spectrum
98 disorder shall cover at least 600 hours a year. Other terms and conditions in the health benefit
99 plan that apply to other benefits covered by the health benefit plan apply to coverage required
100 by this section.
101 (b) Notwithstanding Subsection 31A-22-617 (6), a health benefit plan providing
102 treatment under Subsection (5)(a) shall include in the plan's provider network both board
103 certified behavior analysts and mental health providers qualified under Subsection (1)(c)(ii).
104 (6) A health care provider shall submit a treatment plan for autism spectrum disorder to
105 the insurer within 14 business days of starting treatment for an individual. If an individual is
106 receiving treatment for an autism spectrum disorder, an insurer shall have the right to request a
107 review of that treatment not more than once every six months. A review of treatment under
108 this Subsection (6) may include a review of treatment goals and progress toward the treatment
109 goals. If an insurer makes a determination to stop treatment as a result of the review of the
110 treatment plan under this subsection, the determination of the insurer may be reviewed under
111 Section 31A-22-629 .
112 (7) (a) In accordance with Subsection (7)(b), the commissioner shall waive the
113 requirements of this section for all insurers in the individual market or the large group market,
114 if an insurer demonstrates to the commissioner that the insurer's entire pool of business in the
115 individual market or the large group market has incurred claims for the autism coverage
116 required by this section in a 12 consecutive month period that will cause a premium increase
117 for the insurer's entire pool of business in the individual market or the large group market in
118 excess of 1% over the insurer's premiums in the previous 12 consecutive month period.
119 (b) The commissioner shall waive the requirements of this section if:
120 (i) after a public hearing in accordance with Title 63G, Chapter 4, Administrative
121 Procedures Act, the commissioner finds that the insurer has demonstrated to the commissioner
122 based on generally accepted actuarial principles and methodologies that the insurer's entire pool
123 of business in the individual market or the large group market will experience a premium
124 increase of 1% or greater as a result of the claims for autism services as described in this
125 section; or
126 (ii) the attorney general issues a legal opinion that the limits under Subsection (5)(a)
127 cannot be implemented by an insurer in a manner that complies with federal law.
128 (8) If a waiver is granted under Subsection (7), the insurer may:
129 (a) continue to offer autism coverage under the existing plan until the next renewal
130 period for the plan, at which time the insurer:
131 (i) may delete the autism coverage from the plan without having to re-apply for the
132 waiver under Subsection (7); and
133 (ii) file the plan with the commissioner in accordance with guidelines issued by the
135 (b) discontinue offering plans subject to Subsection (2), no earlier than the next
136 calendar quarter following the date the waiver is granted, subject to filing guidelines issued by
137 the commissioner; or
138 (c) nonrenew existing plans that are subject to Subsection (2), in compliance with
140 (9) This section sunsets in accordance with Section 63I-1-231 .
141 Section 2. Section 63I-1-231 (Effective 07/01/14) is amended to read:
142 63I-1-231 (Effective 07/01/14). Repeal dates, Title 31A.
143 (1) Section 31A-2-208.5 , Comparison tables, is repealed July 1, 2015.
144 (2) Section 31A-2-217 , Coordination with other states, is repealed July 1, 2023.
145 (3) Section 31A-22-619.6 , Coordination of benefits with workers' compensation
146 claim--Health insurer's duty to pay, is repealed on July 1, 2018.
147 (4) Section 31A-22-642 , Insurance coverage for autism spectrum disorder, is repealed
148 on January 1, 2019.
149 Section 3. Effective date.
150 (1) Except as provided in Subsection (2), this bill takes effect on May 13, 2014.
151 (2) The amendments to Section 63I-1-231 (Effective 07/01/14) take effect on July 1,
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