Chief Sponsor: Curtis S. Bramble

House Sponsor: Steve Eliason


8     General Description:
9          This bill requires the Department of Health to request a state plan amendment for the
10     Medicaid program to provide coverage for autism treatment services.
11     Highlighted Provisions:
12          This bill:
13          ▸     defines terms; and
14          ▸     requires the Department of Health to request a state plan amendment for the
15     Medicaid program to provide coverage for autism treatment services.
16     Money Appropriated in this Bill:
17          None
18     Other Special Clauses:
19          None
20     Utah Code Sections Affected:
21     ENACTS:
22          26-18-28, Utah Code Annotated 1953

24     Be it enacted by the Legislature of the state of Utah:
25          Section 1. Section 26-18-28 is enacted to read:
26          26-18-28. Coverage for autism spectrum disorder.
27          (1) As used in this section:

28          (a) (i) "Applied behavior analysis" means the design, implementation, and evaluation
29     of environmental modifications, using behavioral stimuli and consequences, to produce
30     socially significant improvement in human behavior.
31          (ii) "Applied behavior analysis" includes the use of direct observation, measurement,
32     and functional analysis of the relationship between environment and behavior.
33          (b) "Autism spectrum disorder" means pervasive developmental disorders as defined
34     by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.
35          (c) "Behavioral health treatment" means counseling and treatment programs, including
36     applied behavior analysis, that are:
37          (i) necessary to develop, maintain, or restore, to the maximum extent practicable, the
38     functioning of an individual; and
39          (ii) provided or supervised by:
40          (A) a board certified behavior analyst; or
41          (B) an individual licensed under Title 58, Occupations and Professions, whose scope of
42     practice includes mental health services.
43          (d) "Diagnosis of autism spectrum disorder" means medically necessary assessments,
44     evaluations, or tests:
45          (i) performed by:
46          (A) a licensed physician who is board certified in neurology, psychiatry, or pediatrics
47     and has experience diagnosing autism spectrum disorder; or
48          (B) a licensed psychologist with experience diagnosing autism spectrum disorder; and
49          (ii) necessary to diagnose whether an individual has an autism spectrum disorder.
50          (e) "Pharmacy care" means medications prescribed by a licensed physician and any
51     health-related services considered medically necessary to determine the need or effectiveness
52     of the medications.
53          (f) "Psychiatric care" means direct or consultative services provided by a psychiatrist
54     licensed in the state in which the psychiatrist practices.
55          (g) "Psychological care" means direct or consultative services provided by a
56     psychologist licensed in the state in which the psychologist practices.
57          (h) "Therapeutic care" means services provided by a licensed or certified speech
58     therapist, occupational therapist, or physical therapist.

59          (i) (i) "Treatment for autism spectrum disorder" means evidence-based care and related
60     equipment prescribed or ordered for an enrollee diagnosed with an autism spectrum disorder by
61     a physician or a licensed psychologist described in Subsection (1)(d) who determines the care
62     to be medically necessary.
63          (ii) "Treatment for autism spectrum disorder" includes:
64          (A) behavioral health treatment, provided or supervised by a person described in
65     Subsection (1)(c)(ii);
66          (B) pharmacy care;
67          (C) psychiatric care;
68          (D) psychological care; and
69          (E) therapeutic care.
70          (2) The department shall request a state plan amendment with CMS to provide
71     treatment for autism spectrum disorder for an enrollee diagnosed with autism spectrum
72     disorder.