Senator Curtis S. Bramble proposes the following substitute bill:


1     
AUTISM AMENDMENTS

2     
2019 GENERAL SESSION

3     
STATE OF UTAH

4     
Chief Sponsor: Curtis S. Bramble

5     
House Sponsor: Tim Quinn

6     

7     LONG TITLE
8     General Description:
9          This bill amends provisions related to insurance coverage for autism spectrum disorder.
10     Highlighted Provisions:
11          This bill:
12          ▸     requires certain health benefit plans to provide coverage for behavioral health
13     treatment for individuals with an autism spectrum disorder;
14          ▸     prohibits certain health benefit plans from limiting hours of treatment for autism
15     spectrum disorder; and
16          ▸     removes a provision that allows the commissioner to waive the requirement that a
17     health benefit plan cover the diagnosis and treatment of autism spectrum disorder.
18     Money Appropriated in this Bill:
19          None
20     Other Special Clauses:
21          None
22     Utah Code Sections Affected:
23     AMENDS:
24          31A-22-642, as last amended by Laws of Utah 2018, Chapter 183
25     

26     Be it enacted by the Legislature of the state of Utah:
27          Section 1. Section 31A-22-642 is amended to read:
28          31A-22-642. Insurance coverage for autism spectrum disorder.
29          (1) As used in this section:
30          (a) "Applied behavior analysis" means the design, implementation, and evaluation of
31     environmental modifications, using behavioral stimuli and consequences, to produce socially
32     significant improvement in human behavior, including the use of direct observation,
33     measurement, and functional analysis of the relationship between environment and behavior.
34          (b) "Autism spectrum disorder" means pervasive developmental disorders as defined
35     by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
36     (DSM).
37          (c) "Behavioral health treatment" means counseling and treatment programs, including
38     applied behavior analysis, that are:
39          (i) necessary to develop, maintain, or restore, to the maximum extent practicable, the
40     functioning of an individual; and
41          (ii) provided or supervised by a:
42          (A) board certified behavior analyst; or
43          (B) person licensed under Title 58, Chapter 1, Division of Occupational and
44     Professional Licensing Act, whose scope of practice includes mental health services.
45          (d) "Diagnosis of autism spectrum disorder" means medically necessary assessments,
46     evaluations, or tests:
47          (i) performed by a licensed physician who is board certified in neurology, psychiatry,
48     or pediatrics and has experience diagnosing autism spectrum disorder, or a licensed
49     psychologist with experience diagnosing autism spectrum disorder; and
50          (ii) necessary to diagnose whether an individual has an autism spectrum disorder.
51          (e) "Pharmacy care" means medications prescribed by a licensed physician and any
52     health-related services considered medically necessary to determine the need or effectiveness
53     of the medications.
54          (f) "Psychiatric care" means direct or consultative services provided by a psychiatrist
55     licensed in the state in which the psychiatrist practices.
56          (g) "Psychological care" means direct or consultative services provided by a
57     psychologist licensed in the state in which the psychologist practices.
58          (h) "Therapeutic care" means services provided by licensed or certified speech
59     therapists, occupational therapists, or physical therapists.
60          (i) "Treatment for autism spectrum disorder":
61          (i) means evidence-based care and related equipment prescribed or ordered for an
62     individual diagnosed with an autism spectrum disorder by a physician or a licensed
63     psychologist described in Subsection (1)(d) who determines the care to be medically necessary;
64     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) (a) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan
73     offered in the individual market or the large group market and entered into or renewed on or
74     after January 1, 2016, and before January 1, 2020, shall provide coverage for the diagnosis and
75     treatment of autism spectrum disorder:
76          [(a)] (i) for a child who is at least two years old, but younger than 10 years old; and
77          [(b)] (ii) in accordance with the requirements of this section and rules made by the
78     commissioner.
79          (b) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan
80     offered in the individual market or the large group market and entered into or renewed on or
81     after January 1, 2020, shall provide coverage for the diagnosis and treatment of autism
82     spectrum disorder in accordance with the requirements of this section and rules made by the
83     commissioner.
84          (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah
85     Administrative Rulemaking Act, to set the minimum standards of coverage for the treatment of
86     autism spectrum disorder.
87          (4) Subject to Subsection (5), the rules described in Subsection (3) shall establish
88     durational limits, amount limits, deductibles, copayments, and coinsurance for the treatment of
89     autism spectrum disorder that are similar to, or identical to, the coverage provided for other
90     illnesses or diseases.
91          (5) (a) Coverage for behavioral health treatment for a person with an autism spectrum
92     disorder shall cover at least 600 hours a year.
93          (b) Notwithstanding Subsection (5)(a), for a health benefit plan offered in the
94     individual market or the large group market and entered into or renewed on or after January 1,
95     2020, coverage for behavioral health treatment for a person with an autism spectrum disorder
96     may not have a limit on the number of hours covered.
97          (c) Other terms and conditions in the health benefit plan that apply to other benefits
98     covered by the health benefit plan apply to coverage required by this section.
99          [(b)] (d) Notwithstanding Section 31A-45-303, a health benefit plan providing
100     treatment under [Subsection (5)(a)] Subsections (5)(a) and (b) shall include in the plan's
101     provider network both board certified behavior analysts and mental health providers qualified
102     under Subsection (1)(c)(ii).
103          (6) A health care provider shall submit a treatment plan for autism spectrum disorder to
104     the insurer within 14 business days of starting treatment for an individual. If an individual is
105     receiving treatment for an autism spectrum disorder, an insurer shall have the right to request a
106     review of that treatment not more than once every [six] three months. A review of treatment
107     under this Subsection (6) may include a review of treatment goals and progress toward the
108     treatment goals. If an insurer makes a determination to stop treatment as a result of the review
109     of the treatment plan under this subsection, the determination of the insurer may be reviewed
110     under Section 31A-22-629.
111          [(7) (a) In accordance with Subsection (7)(b), the commissioner shall waive the
112     requirements of this section for all insurers in the individual market or the large group market,
113     if an insurer demonstrates to the commissioner that the insurer's entire pool of business in the
114     individual market or the large group market has incurred claims for the autism coverage
115     required by this section in a 12 consecutive month period that will cause a premium increase
116     for the insurer's entire pool of business in the individual market or the large group market in
117     excess of 1% over the insurer's premiums in the previous 12 consecutive month period.]
118          [(b) The commissioner shall waive the requirements of this section if:]
119          [(i) after a public hearing in accordance with Title 63G, Chapter 4, Administrative
120     Procedures Act, the commissioner finds that the insurer has demonstrated to the commissioner
121     based on generally accepted actuarial principles and methodologies that the insurer's entire pool
122     of business in the individual market or the large group market will experience a premium
123     increase of 1% or greater as a result of the claims for autism services as described in this
124     section; or]
125          [(ii) the attorney general issues a legal opinion that the limits under Subsection (5)(a)
126     cannot be implemented by an insurer in a manner that complies with federal law.]
127          [(8) If a waiver is granted under Subsection (7), the insurer may:]
128          [(a) continue to offer autism coverage under the existing plan until the next renewal
129     period for the plan, at which time the insurer:]
130          [(i) may delete the autism coverage from the plan without having to re-apply for the
131     waiver under Subsection (7); and]
132          [(ii) file the plan with the commissioner in accordance with guidelines issued by the
133     commissioner;]
134          [(b) discontinue offering plans subject to Subsection (2), no earlier than the next
135     calendar quarter following the date the waiver is granted, subject to filing guidelines issued by
136     the commissioner; or]
137          [(c) nonrenew existing plans that are subject to Subsection (2), in compliance with
138     Subsection 31A-22-618.6(5) or Subsection 31A-22-618.7(3).]