7/21/2011

Autism Speaks Model Autism Insurance Act – Revised Feb. 2009

Autism Speaks Model Autism Insurance Act – Revised Feb. 2009

A. A health insurance policy will provide coverage for the diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders [OPTIONAL: add “in individuals less than X years of age”]. To the extent that the diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders are not already covered by a health insurance policy, coverage under this section will be included in health insurance policies that are delivered, executed, issued, amended, adjusted, or renewed in this state, or outside this state if insuring residents of this state, on or after XX days from the effective date of this section. No insurer can terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with one of the autism spectrum disorders or has received treatment for autism spectrum disorders.

B. Coverage under this section will not be subject to any limits on the number of visits an individual may make to an autism services provider.

C. The coverage required under this section must not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the health insurance policy. [When benefits are capped, add “except as otherwise provided in subsection (D)”.]

D. This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy.

[OPTIONAL: add as an additional paragraph, “Coverage for applied behavior analysis will be subject to a maximum benefit of $XX,XXX per year {benefit limit should be no less than $36,000}. After December 31, 20XX, the insurance commissioner will, on an annual basis, adjust the maximum benefit for inflation by using the Medical Care Component of the United States Department of Labor Consumer Price Index for all urban consumers (CPI-U). The commissioner will submit the adjusted maximum benefit for publication annually no later than Month X of each calendar year, and the published adjusted maximum benefit will be applicable in the following calendar year to health insurance policies subject to this act. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item unrelated to autism spectrum disorders will not be applied towards any maximum benefit established under this section.”]

E. This section will [will not] apply to the following types of policies [specify types of policies].

F. As used in this section:

1. “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

2. “Autism services provider” means any person, entity, or group that provides treatment of autism spectrum disorders.

3. “Autism spectrum disorders” means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.

4. “Diagnosis of autism spectrum disorders” means medically necessary assessment, evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.

[OPTIONAL: in the event that 12.f. below is used, add the following definition: “Evidence-based research” means research that applies rigorous, systematic, and objective procedures to obtain valid knowledge relevant to autism spectrum disorders.]

5. “Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.

6. “Health insurance policy” means any group health policy or contract issued by an insurance entity subject to one of the following: [cite applicable statutes].

7. “Medically necessary” means reasonably expected to do the following:

a. prevent the onset of an illness, condition, injury, or disability;

b. reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or

c. assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age.

8. “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

9. “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

10. “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

11. “Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, or physical therapists.

12. “Treatment for autism spectrum disorders” will include the following care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary:

a. habilitative or rehabilitative care;

b. pharmacy care;

c. psychiatric care;

d. psychological care; and

e. therapeutic care.

[OPTIONAL: f. Any care for individuals with autism spectrum disorders that is determined by the state health department, based upon its review of best practices or evidence-based research, may be medically necessary and that is published in the gazette for rulemaking by state agencies. Any such care, treatment, intervention, service, or item that was not previously covered will be included in any health insurance policy delivered, executed, issued, amended, adjusted, or renewed on or after XX days following the date of its publication in the gazette.]

[OPTIONAL: The state health department will promulgate regulations establishing standards for qualified autism services providers. Once the regulations are promulgated, payment for the treatment of autism spectrum disorders covered under this section will only be made to autism services providers who meet the standards.]

G. Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer will have the right to request a review of that treatment not more than once every XX months unless the insurer and the individual’s licensed physician or licensed psychologist agrees that a more frequent review is necessary. The cost of obtaining any review will be borne by the insurer.

[OPTIONAL: The state health department will establish standards to be utilized by managed care plans for the credentialing of autism service providers. The department may require that a managed care plan grant credentials to any autism services provider whom the department determines meets or exceeds the department’s credentialing standards.]

H. This section will not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.

I. This act will take effect in XX days.

PLEASE CONTACT THE AUTISM SPEAKS GOVERNMENT RELATIONS TEAM FOR ASSISTANCE IN FRAMING STATE-SPECIFIC LEGISLATION.

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