First Substitute S.B. 57

Representative Brad L. Dee proposes the following substitute bill:




Chief Sponsor: Brian E. Shiozawa

House Sponsor: Brad L. Dee

             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:
             28          None
             29      Other Special Clauses:
             30          This bill provides an effective date.
             31      Utah Code Sections Affected:
             32      AMENDS:
             33           63I-1-231 (Effective 07/01/14), as last amended by Laws of Utah 2013, Chapters 261
             34      and 417
             35      ENACTS:
             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;
             75      and
             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
             89      commissioner.
             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
             134      commissioner;
             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
             139      31A30-107(3)(d).
             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,
             152      2014.

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