Missouri Senate

Senate Committee Substitute

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 solely 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 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 appropriately pay claims. 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 benefit plan shall provide coverage for treatment 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.

The act applies different annual maximum benefit levels for behavior analysis based upon the age of the child. The annual maximum benefit levels for behavior analysis are as follows:

(1) $72,000 per year for children under 6 years of age;

(2) $36,000 per year for children who are at least 6 years of age but less than 14 years of age; and

(3) $18,000 per year for children who are at least 14 years of age but less than 21 years of age.

The annual maximum benefits for applied behavior analysis shall not be subject to any limits on the number of visits by an individual to an autism service provider for applied behavior analysis.

Coverage under the act for services other than applied behavior analysis shall not be subject to any limits on the number of visits an individual may make to an autism service provider.

After December 31, 2010, the director of the Department of Insurance, Financial and Professional Registration shall, on an annual basis, adjust the maximum benefit (for applied behavioral analysis) for inflation using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers.

Payments made by a health carrier on behalf of a covered individual for any care, treatment, intervention, service or item, the provision of which was for the treatment of a health condition unrelated to the covered individual's autism spectrum disorder, shall not be applied toward any maximum benefit established under the act.

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.

To the extent any payments or reimbursements are being made for applied behavior analysis, such payments or reimbursements shall be made to either:

(1) Any autism provider;

(2) The person who is supervising an autism service provider, who is certified as a board certified behavior analyst by the Behavior Analyst Certification Board; or

(3) The entity or group for whom such supervising person works or is associated.

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, 2010:

(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 also apply to limited mandate health insurance policies issued under section 376.995.

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, 2010.

The provisions of this act are similar to provisions contained in HB 2351 (2008), SB 1229 (2008), and SB 1122 (2008).

STEPHEN WITTE