CCS/SCS/HCS/HBs 1311 & 1341 - This act requires health carriers to provide insurance coverage for the diagnosis and treatment of autism spectrum disorders and provides for the licensure of applied behavior analysts. This act creates the Behavior Analyst Advisory Board under the State Committee of Psychologists within the Department of Insurance, Financial Institutions and Professional Registration to establish licensure and registration requirements for behavior analysts and assistant behavior analysts who provide applied behavior analysis therapies for children with autism spectrum disorders (Sections 337.300 to 337.345).
The board shall be comprised of 7 members appointed by the Governor and confirmed by the Senate. The board shall meet quarterly. Members of the board shall receive compensation in the amount established by the division not to exceed $50 per day.
The act sets forth the various powers of the board. The board's primary powers involve reviewing applications for licensure and establishing criteria for the practice of behavior analysis.
The act established procedures for obtaining temporary licenses for behavior analysts and assistant behavior analysts. The act also establishes procedures for obtaining provisional licenses.
The act sets forth a procedure for renewing a behavior analyst or assistant behavior analyst license.
Under the act, the State Committee of Psychologists is authorized to discipline licensees by filing a complaint with the administrative hearing commission. The act sets forth various causes for which a behavior analyst license or assistant behavior analyst license may be revoked or suspended.
Persons who violate the licensing standards established by the act shall be guilty of class A misdemeanor.
Under this act, health carriers that issue or renew group health benefit plans on or after January 1, 2011, must provide coverage for the diagnosis and treatment of autism spectrum disorders to the extent that such diagnosis and treatment is not already covered by the health benefit plan.
The act prohibits health carriers from denying or refusing to issue coverage on, refuse to contract with, or refuse to renew or refuse to reissue or otherwise terminating or restricting coverage on an individual or their dependent because the individual is diagnosed with an autism spectrum disorder.
The act sets forth the coverage limits for autism spectrum disorders. Coverage under the act is limited to medically necessary treatment that is ordered by the insured's treating licensed physician or licensed psychologist, in accordance with a treatment plan.
The treatment plan shall include all elements necessary for the health benefit plan or health carrier to review the treatment plan. Such elements include, but are not limited to, a diagnosis, proposed treatment by type, frequency and duration of treatment and goals.
Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, a health carrier shall have the right to review the treatment plan not more than once every 6 months unless the health carrier and the individual's treating physician or psychologist agree that a more frequent review is necessary. Any agreement between a health carrier and a provider that provides for more frequent review of a treatment plan shall only apply to a particular individual being treated for an autism spectrum disorder and shall not apply to all individuals being treated for autism spectrum disorders by a physician or psychologist.
Coverage provided by the act for applied behavior analysis is subject to a maximum benefit of $40,000 per calendar year for individuals through 18 years of age. The $40,000 ABA limit may be exceeded, upon prior approval by the health benefit plan, if the provision of applied behavior analysis services beyond the maximum limit is medically necessary. The act provides the maximum benefit limitation for applied behavior analysis shall be adjusted by the health carrier at least triennially for inflation.
Coverage under the act shall not be subject to any limits on the number of visits an individual may make to an autism service provider except that the maximum total benefit for applied behavior analysis shall apply.
The health care services required by the act shall not be subject to any greater deductible, coinsurance or co-payment than other physical health care services provided by a health benefit plan. Coverage of services may be subject to other general exclusions and limitations of the contract or benefit plan, not in conflict with the provisions of this section, such as coordination of benefits, exclusions for services provided by family or household members, and utilization review of health care services, including review of medical necessity and care management; however, coverage for treatment under this section shall not be denied on the basis that it is educational or habilitative in nature.
To the extent any payments or reimbursements are being made for applied behavior analysis, such payments or reimbursements shall be made to either:
(1) The autism provider; or
(2) The entity or group for whom such supervising person works or is associated.
Such payments or reimbursements to an autism service provider or a board certified behavior analyst shall include payments or reimbursements for services provided by a line therapist under the supervision of such provider or behavior analyst if such services provided by the line therapist are included in the treatment plan and are deemed medically necessary.
The provisions of act shall not automatically apply to health benefit plan individually underwritten, but shall be offered as an option to any such plan.
The act provides the provisions of the autism mandate shall also apply to the following types of plans that are established, extended, modified or renewed on or after January 1, 2011:
(1) All self-insured governmental plans, as that term is defined in 29 U.S.C. Section 1002(32);
(2) All self-insured group arrangements, to the extent not preempted by federal law;
(3) All plans provided through a multiple employer welfare arrangement, or plans provided through another benefit arrangement, to the extent permitted by the Employee Retirement Income Security Act of 1974, or any waiver or exception to that act provided under federal law or regulation; and
(4) All self-insured school district health plans.
The provisions of the act do not apply to various forms of supplemental insurance policies such as specified disease policies or Medicare supplement policies.
The autism mandate shall apply to any health care plans issued to employees and their dependents under the Missouri Consolidated Health Care Plan on or after January 1, 2011.
Under this act, health carriers are not be required to provide reimbursement to a school district for treatment for autism spectrum disorders provided by the school district. This act shall not be construed as affecting any obligation to provide service to an individual under an individualized family service plan, an individualized education plan, or an individualized service plan.
Under the act, the director of the Department of Insurance must grant a small employer with a group health plan a waiver from the autism insurance mandate if the small employer demonstrates to the director by actual experience over any consecutive 12 month period that compliance with the autism mandate has increased the cost of the health insurance policy by an amount that results in a 2.5% or greater over the period of a calendar year, in premium costs to the small employer.
The provisions of this act do not apply to the MO HealthNet program.
The act requires the Department of Insurance to submit an annual report to the General Assembly regarding the implementation of the autism insurance mandate. The report shall include:
(1) The total number of insureds diagnosed with autism spectrium disorder;
(2) The total cost of all claims paid out in the immediately preceding calendar year for ASD;
(3) The cost of such coverage per insured per month; and
(4) The average cost per insured for coverage of applied behavior analysis.
The provisions of this act are similar to provisions contained in SB 167 (2009), HB 2351 (2008), SB 1229 (2008), and SB 1122 (2008).
STEPHEN WITTE