Missouri Senate

Senate 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 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. Service exclusions contained in the insurance policy or health maintenance organization contract that are inconsistent with the treatment plan shall be considered invalid as to autism spectrum disorder.

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 $55,000 per calendar year for individuals under the age of 21 (no coverage for applied behavior analysis is afforded to those 21 years of age or older).

The act adjusts the maximum benefit limitation for applied behavior analysis to reflect any change from the previous year in the medical component of the Consumer Price Index. The current value of the maximum benefit limitation for applied behavior analysis coverage shall be calculated by the director of the Department of Insurance.

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.

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;

(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 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 August 28, 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 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 August 28, 2010.

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% 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 autism insurance mandate provisions of the act are similar to provisions contained in SB 167 (2009), HB 2351 (2008), SB 1229 (2008), and SB 1122 (2008).

HEALTH INSURANCE ACROSS STATE LINES - The act also allows Missouri residents to purchase health insurance from foreign insurers that are licensed by the state of Illinois, Arkansas, Kansas, Nebraska, Kentucky, Oklahoma, Tennessee, or Iowa to sell health insurance in those states. A Missouri resident shall have the right to purchase health insurance from a foreign insurer, regardless of whether the foreign insurer is licensed or in compliance with the laws this state. Under the terms of the act, a foreign insurer domiciled in the state of Illinois, Arkansas, Kansas, Nebraska, Kentucky, Oklahoma, Tennessee, or Iowa is exempt from holding a license or certificate of authority, if it meets the following criteria:

(1) It offers, sells, or renews a health benefit plan in Missouri that complies with all of the requirements of the domiciliary state applicable to the plan;

(2) It is authorized to issue the plan in the state where it is domiciled and to transact business there; and

(3) It maintains a process to resolve disputes between it and a Missouri resident pertaining to the health insurance policy or health benefit plan.

If a Missouri resident purchases or enrolls in a health insurance policy or health benefit plan that is lawfully sold, offered, or issued in the state of Illinois, Arkansas, Kansas, Nebraska, Kentucky, Oklahoma, Tennessee, or Iowa , the policy or plan shall not be subject to the requirements of Missouri's insurance laws. A foreign health insurer, however, shall be subject to regulation by the director with regard to enforcement of the contractual benefits under the policy or health benefit plan (section 376.685).

STEPHEN WITTE