SB 894 Requires state employee health care plan to offer actuarially equivalent benefit products to Medicare eligible participants and enacts various provisions relating to the diagnosis and treatment of autism spectrum disorders
Sponsor: Dempsey Co-Sponsor(s)
LR Number: 4894L.03C Fiscal Note: 4894-03N.ORG
Committee: Small Business, Insurance and Industry
Last Action: 5/14/2010 - H Calendar S Bills for Third Reading Journal Page:
Title: HCS SB 894 Calendar Position:
Effective Date: August 28, 2010
House Handler: Wilson

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Current Bill Summary


HCS/SB 894 - This act modifies various provisions relating to insurance coverage for Medicare participants in the state employee health insurance program and for the diagnosis and treatment of autism spectrum disorders.

MCHCP PARTICIPANTS - Under this act, Missouri Consolidated Health Care Plan participants who are eligible for Medicare benefits and who are not eligible for their state employee health care coverage to be their primary plan of coverage shall be offered actuarially equivalent benefit products provided participants who are not eligible for Medicare benefits. Under current law, a participant in the state employee health care plan who is eligible for Medicare, and whose state employee coverage is not primary, must be provided the same benefits provided to participants who are not eligible for Medicare benefits (section 103.089). This provision may also be found in SS/SCS/HB 2205 (2010).

LICENSING OF BEHAVIOR ANALYSTS, ASSISTANT BEHAVIOR ANALYSTS AND LINE THERAPISTS - The act establishes 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, assistance behavior analysts, and line therapists who provide applied behavior analysis therapies for children with autism spectrum disorders. The board shall consist of the following 7 members:

1) 3 licensed behavior analysts;

2) 1 licensed behavior analyst holding a doctoral degree;

3) 1 licensed assistant behavior analyst;

4) 1 professional member of the committee; and

5) 1 public member.

The board must meet quarterly. Each member of the board shall receive compensation for their duties not to exceed $50 a day.

The board is authorized to review licensure applications for behavior analysts, assistant behavior analysts, and line therapists. The board is authorized to review all complaints made relating to the practice of behavior analysis and make recommendations to the committee regarding any investigation of the complaint, referral for discipline, or other resolution of the complaint. The board may make recommendations to the committee rules pertaining to licensure, establishment of fees, grievance procedures, investigation procedures, and any other policies or procedures necessary to implement the licensure of behavior analysts. The committee shall make all final decisions regarding the board's recommendations on licensing, registration, complaint resolution, and other rules.

The act establishes standards for an applied behavior analysis intervention. An applied behavior analysis intervention shall produce socially significant improvements in human behavior through skill acquisition, increase or decrease in behaviors under specific environmental conditions and the reduction of problematic behavior. An applied behavior analysis intervention shall:

(1) Be based on empirical research and the identification of functional relations between behavior and environment, contextual factors, antecedent stimuli and reinforcement operations through the direct observation and measurement of behavior, arrangement of events and observation of effects on behavior, as well as other information gathering methods such as record review and interviews; and

(2) Utilize changes and arrangements of contextual factors, antecedent stimuli, positive reinforcement, and other consequences to produce behavior change.

The act sets forth the requirements for persons desiring to practice as licensed behavior analysts (application form, fees, fingerprinting, examination requirements. The act sets forth similar requirements for persons wishing to practice as licensed assistant behavior analysts and line therapists.

The act authorizes the committee to issue temporary licenses to applicants for a behavior analyst licenses or assistant behavior analyst licenses upon receipt of complete applications for behavior analysts or assistant behavior analysts or a showing of valid licensure as behavior analysts in other states, only if such applicants have submitted fingerprints and no disqualifying criminal history appears on the family care safety registry. Temporary licenses shall expire upon issuance of a license or denial of the application but no later than 90 days from issuance of the temporary license.

The act establishes various grounds for which the committee may refuse to issue or renew a license (controlled substance abuse, fraud, etc.). The act establishes the administrative hearing procedures for disciplining a person licensed under the act.

The act establishes procedures for obtaining provisional licenses for behavioral analysts, assistant behavioral analysts, and line therapists (sections 337.300 to 337.345). The licensing provisions are similar to those contained in the perfected version of HB 1311 and 1341 and HCS/SS/SB 618 (2010).

HEALTH INSURANCE COVERAGE FOR AUTISM - 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 treatment is not already covered by the health benefit plan. The act painstakingly demarcates what constitutes an autism spectrum disorder and that which does not.

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 (subsection 4).

The act sets forth the coverage limits for autism spectrum disorders. Coverage is limited to medically necessary treatment ordered by the insured's treating licensed physician or licensed psychologist, in accordance with a treatment plan (subsection 5).

The treatment plan shall include all elements necessary for the health benefit plan or health carrier to 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 carrier shall have the right to review the treatment plan not more than once every 3 months unless the health carrier and the individual's treating physician or psychologist agree that a more frequent review is necessary.

Coverage provided by the act for applied behavior analysis is subject to a maximum benefit of $36,000 per year for individuals through 18 years of age (no coverage for applied behavior analysis is required for individuals older than 18 years of age).

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.

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, such as coordination of benefits, 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 the autism service providers except for line therapists; the person who is supervising an autism service provider who is also certified as a board certified behavior analyst and licensed by the state of Missouri; or any entity or group for whom such supervising person, who is certified as a board certified behavior analyst by the Behavior Analyst Certification Board, works or is associated (subsection 9).

If a request for qualifications is made by a health carrier of a person who is not licensed as an autism service provider, such person shall provide documented evidence of education and professional training, if any, in applied behavior analysis.

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 (subsection 16).

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 (subsection 12).

The provisions of the act do not apply to various forms of supplemental insurance policies such as specified disease policies or Medicare supplement policies (subsection 13).

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 (subsection 11).

Under this act, health carriers are not be required to provide reimbursement for the services delivered by any school-based service (subsection 14).

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% over the period of a calendar year, in premium costs to the small employer (subsection 3).

The provisions of this act do not apply to the MO HealthNet program (subsection 13).

The act requires the department of insurance to submit a n 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 spectrum disorder;

(2) The total cost of all claims paid out in the immediately preceding calendar year for PDD;

(3) The cost of such coverage per insured per month; and

(4) The average cost per insured for coverage of applied behavior analysis.

The autism insurance mandate provisions of the act are similar to provisions contained in HB 1311 & 1341 (2010), HCS/SS/SB 618 (2010), SB 167 (2009), HB 2351 (2008), SB 1229 (2008), and SB 1122 (2008).

STEPHEN WITTE