Act No. 158 (S.223). Health; insurance; early childhood developmental disorders

An act relating to health insurance coverage for early childhood developmental disorders, including autism spectrum disorders

This act requires health insurance plans, including public assistance plans, to provide coverage for the evidence-based diagnosis and treatment of early childhood developmental disorders for individuals beginning at birth and until 21 years of age. Any benefits required by this act that exceed the essential health benefits specified under the Patient Protection and Affordable Care Act shall not be required in health insurance plans offered in individual, small group, and large group markets on or after January 1, 2014.

This act requires that health insurance plans provide coverage for applied behavior analysis (ABA) provided or supervised by a licensed provider who is either working within the scope of licensure or is a nationally board-certified behavior analyst. Treatment in the natural environment, meaning the individual's home or child care setting, shall be covered when provided or supervised by a licensed provider working within the scope of licensure. ABA treatment in the natural environment shall also be covered if provided or supervised by a licensed provider who is a nationally board-certified behavior analyst.

This act specifies that the amount, frequency, and duration of treatment shall be based on medical necessity and may be subject to prior authorization. Except for inpatient services, when an individual is receiving treatment for an early developmental delay, the health insurance plan may require treatment plan reviews based on individual needs, so long as the review is consistent with reviews for other diagnostic areas and with the department of financial regulation's rules. For children under age eight, a health insurance plan may review the treatment plan no more frequently than once every six months.

The general assembly intends that the department of financial regulation facilitate and encourage health insurance plans to bundle co-payments for services received under this act.

This act requires the agency of human services to submit a report, in consultation with Autism Speaks and health insurers, to the house committee on health care and the senate committee on health and welfare by January 15, 2014 regarding the implementation of this act, including an assessment of whether eligible individuals are receiving evidence-based services, how services may be improved, and the fiscal impact of services.

Multiple effective dates, beginning July 1, 2012

Also see: Commerce and Trade; Act No. 78 (H.512); An act relating to banking, insurance, securities, and health care administration

Also see: Health; Act No. 96 (S.209); An act relating to naturopathic physicians

Also see: Health; Act No. 107 (H.37); An act relating to telemedicine

Also see: Health; Act No. 150 (S.200); An act relating to pharmacy audits, reimbursement for ambulance services, and the reporting requirements of health insurers

Also see: Health; Act No. 171 (H.559); An act relating to health care reform implementation