HOUSE OF REPRESENTATIVES

H.B. NO.

2225

TWENTY-SEVENTH LEGISLATURE, 2014

 

STATE OF HAWAII

 

 

 

 

 

 

A BILL FOR AN ACT

 

 

relating to health.

 

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 


     SECTION 1.  The purpose of this Act is to ensure the provision of quality health care for all Hawaii residents by requiring coverage of treatment for autism spectrum disorders.

     SECTION 2.  This Act shall be known and may be cited as "Luke's Law".

     SECTION 3.  Chapter 431, Hawaii Revised Statutes, is amended by adding a new section to article 10A to be appropriately designated and to read as follows:

     "§431:10A-    Autism spectrum disorders benefits and coverage; notice; definitions.  (a)  Each individual or group accident and health or sickness insurance policy, contract, plan, or agreement issued or renewed in this State after January 1,     , shall provide to the policyholder and individuals under twenty-one years of age covered under the policy, contract, plan, or agreement, coverage for the screening, including well-baby and well-child screening, diagnosis, and evidence-based treatment of autism spectrum disorders.

     (b)  Every insurer shall provide written notice to its policyholders regarding the coverage required by this section.  The notice shall be in writing and prominently positioned in any literature or correspondence sent to policyholders and shall be transmitted to policyholders within calendar year 2015 when annual information is made available to members or in any other mailing to members, but in no case later than December 31, 2015.

     (c)  Individual coverage for behavioral health treatment provided under this section shall be subject to a maximum benefit of $50,000 per year and a maximum lifetime benefit of $300,000, but shall not be subject to any limits on the number of visits to an autism service provider.  After December 31, 2016, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation using the medical care component of the United States Department of Labor Consumer Price Index for all urban consumers; provided that the commissioner may post notice of and hold a public meeting pursuant to chapter 92 before adjusting the maximum benefit.  The commissioner shall publish the adjusted maximum benefit annually no later than April 1 of each calendar year, which shall apply during the following calendar year to health insurance policies subject to this section.  Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, or service other than behavioral health treatment shall not be applied toward any maximum benefit established under this subsection.

     (d)  Coverage under this section may be subject to copayment, deductible, and coinsurance provisions of an accident and health or sickness insurance policy, contract, plan, or agreement that are no less favorable than the co-payment, deductible, and coinsurance provisions for other medical services covered by the policy, contract, plan, or agreement.

     (e)  This section shall not be construed as limiting benefits that are otherwise available to an individual under an accident and health or sickness insurance policy, contract, plan, or agreement.

     (f)  Coverage for treatment under this section shall not be denied on the basis that the treatment is habilitative or non-restorative in nature.

     (g)  Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer may request a review of that treatment not more than once every twelve months unless the insurer and licensed physician, psychiatrist, psychologist, clinical social worker, or registered nurse practitioner agree that a more frequent review is necessary.  The cost of obtaining any review shall be borne by the insurer.

     (h)  This section shall not be construed as reducing any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.

     (i)  As of January 1, 2014, to the extent that this section requires benefits that exceed the essential health benefits specified under section 1302(b) of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), the specific benefits that exceed the specified essential health benefits shall not be required of a qualified health plan when the plan is offered in this State through the Hawaii health insurance exchange by a health carrier.  Nothing in this subsection shall nullify the application of this section to plans offered outside the Hawaii health insurance exchange.

     (j)  Insurers shall include in their network of approved autism service providers only those providers who have cleared criminal background checks as determined by the insurer.

     (k)  Insurers shall include at least as many board-certified behavior analysts in their provider network as there are qualified licensed psychologists in their network of approved providers of applied behavior analysis.

     (l)  If an individual has been diagnosed as having a pervasive developmental disorder or autism spectrum disorder meeting the diagnostic criteria described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders available at the time of diagnosis, then that individual shall not be required to undergo repeat evaluation upon publication of a subsequent edition of the Diagnostic and Statistical Manual of Mental Disorders to remain eligible for coverage under this section.

     (m)  As used in this section, unless the context clearly requires otherwise:

     "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.

     "Autism service provider" means any person, entity, or group that provides treatment for autism spectrum disorders.

     "Autism spectrum disorders" means any of the pervasive developmental disorders or autism spectrum disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.

     "Behavioral health treatment" means evidence based counseling and treatment programs, including applied behavior analysis, that are:

     (1)  Necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual; and

     (2)  Provided or supervised by a board-certified behavior analyst or by a licensed psychologist so long as the services performed are commensurate with the psychologist's formal university training and supervised experience.

     "Diagnosis of autism spectrum disorders" means medically necessary assessments, evaluations, or tests conducted to diagnose whether an individual has an autism spectrum disorder.

     "Pharmacy care" means medications prescribed by a licensed physician or registered nurse practitioner and any health-related services that are deemed medically necessary to determine the need or effectiveness of the medications.

     "Psychiatric care" means direct or consultative services provided by a licensed psychiatrist.

     "Psychological care" means direct or consultative services provided by a licensed psychologist.

     "Therapeutic care" means services provided by licensed speech pathologists, registered occupational therapists, licensed social workers, licensed clinical social workers, or licensed physical therapists.

     "Treatment for autism spectrum disorders" includes the following care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or registered nurse practitioner if the care is determined to be medically necessary:

     (1)  Behavioral health treatment;

     (2)  Pharmacy care;

     (3)  Psychiatric care;

     (4)  Psychological care; and

     (5)  Therapeutic care."

     SECTION 4.  Chapter 432, Hawaii Revised Statutes, is amended by adding a new section to article 1 to be appropriately designated and to read as follows:

     "§432:1-    Autism spectrum disorders benefits and coverage; notice; definitions.  (a)  Each individual or group hospital or medical service plan, policy, contract, or agreement issued or renewed in this State after January 1,     , shall provide to the member and individuals under twenty-one years of age covered under the service plan, policy, contract, or agreement, coverage for the screening, including well-baby and well-child screening, diagnosis, and evidence-based treatment of autism spectrum disorders.

     (b)  Every mutual benefit society shall provide written notice to its members regarding the coverage required by this section.  The notice shall be in writing and prominently positioned in any literature or correspondence sent to members and shall be transmitted to members within calendar year 2015 when annual information is made available to members or in any other mailing to members, but in no case later than December 31, 2015.

     (c)  Individual coverage for behavioral health treatment provided under this section shall be subject to a maximum benefit of $50,000 per year and a maximum lifetime benefit of $300,000, but shall not be subject to any limits on the number of visits to an autism service provider.  After December 31, 2016, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation, using the medical care component of the United States Department of Labor Consumer Price Index for all urban consumers.  The commissioner shall publish the adjusted maximum benefit annually no later than April 1 of each calendar year, which shall apply during the following calendar year to health insurance policies subject to this section; provided that the commissioner may post notice of and hold a public meeting pursuant to chapter 92 before adjusting the maximum benefit.  Payments made by a mutual benefit society on behalf of a covered individual for any care, treatment, intervention, or service other than behavioral health treatment, shall not be applied toward any maximum benefit established under this subsection.

     (d)  Coverage under this section may be subject to copayment, deductible, and coinsurance provisions of an individual or group hospital or medical service plan, policy, contract, or agreement that are no less favorable than the co-payment, deductible, and coinsurance provisions for other medical services covered by the plan, policy, contract, or agreement.

     (e)  This section shall not be construed as limiting benefits that are otherwise available to an individual under an individual or group hospital or medical service plan, policy, contract, or agreement.

     (f)  Coverage for treatment under this section shall not be denied on the basis that the treatment is habilitative or non-restorative in nature.

     (g)  Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer may request a review of that treatment not more than once every twelve months unless the insurer and licensed physician, psychiatrist, psychologist, clinical social worker, or registered nurse practitioner agree that a more frequent review is necessary.  The cost of obtaining any review shall be borne by the insurer.

     (h)  This section shall not be construed to reduce any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.

     (i)  As of January 1, 2014, to the extent that this section requires benefits that exceed the essential health benefits specified under section 1302(b) of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), the specific benefits that exceed the specified essential health benefits shall not be required of a qualified health plan when the plan is offered in this State through the Hawaii health insurance exchange by a health carrier.  Nothing in this subsection shall nullify the application of this section to plans offered outside the Hawaii health insurance exchange.

     (j)  Insurers shall include in their network of approved autism service providers only those providers who have cleared criminal background checks as determined by the insurer.

     (k)  Insurers shall include at least as many board-certified behavior analysts in their provider network as there are qualified licensed psychologists in their network of approved providers of applied behavior analysis.

     (l)  If an individual has been diagnosed as having a pervasive developmental disorder or autism spectrum disorder meeting the diagnostic criteria described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders available at the time of diagnosis, then that individual shall not be required to undergo a repeat evaluation upon publication of a subsequent edition of the Diagnostic and Statistical Manual of Mental Disorders to remain eligible for coverage under this section.

     (m)  As used in this section, unless the context clearly requires otherwise:

     "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.

     "Autism service provider" means any person, entity, or group that provides treatment for autism spectrum disorders.

     "Autism spectrum disorders" means any of the pervasive developmental disorders or autism spectrum disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.

     "Behavioral health treatment" means evidence-based counseling and treatment programs, including applied behavior analysis, that are:

     (1)  Necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual; and

     (2)  Provided or supervised by a board-certified behavior analyst or by a licensed psychologist so long as the services performed are commensurate with the psychologist's formal university training and supervised experience.

     "Diagnosis of autism spectrum disorders" means medically necessary assessments, evaluations, or tests conducted to diagnose whether an individual has an autism spectrum disorder.

     "Pharmacy care" means medications prescribed by a licensed physician or registered nurse practitioner and any health-related services that are deemed medically necessary to determine the need or effectiveness of the medications.

     "Psychiatric care" means direct or consultative services provided by a licensed psychiatrist.

     "Psychological care" means direct or consultative services provided by a licensed psychologist.

     "Therapeutic care" means services provided by licensed speech pathologists, registered occupational therapists, licensed social workers, licensed clinical social workers, or licensed physical therapists.

     "Treatment for autism spectrum disorders" includes the following care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or registered nurse practitioner if the care is determined to be medically necessary:

     (1)  Behavioral health treatment;

     (2)  Pharmacy care;

     (3)  Psychiatric care;

     (4)  Psychological care; and

     (5)  Therapeutic care."

     SECTION 5.  Section 432D-23, Hawaii Revised Statutes, is amended to read as follows:

     "§432D-23  Required provisions and benefits.  Notwithstanding any provision of law to the contrary, each policy, contract, plan, or agreement issued in the State after January 1, 1995, by health maintenance organizations pursuant to this chapter, shall include benefits provided in sections 431:10-212, 431:10A-115, 431:10A-115.5, 431:10A-116, 431:10A‑116.5, 431:10A-116.6, 431:10A-119, 431:10A-120, 431:10A‑121, 431:10A-125, 431:10A-126, 431:10A-122, [and] 431:10A-116.2, and 431:10A-   , and chapter 431M."

     SECTION 6.  Notwithstanding section 432D-23, Hawaii Revised Statutes, the coverage and benefit for autism spectrum disorders to be provided by a health maintenance organization under section 5 of this Act shall apply to all policies, contracts, plans, or agreements issued or renewed in this State by a health maintenance organization after January 1,     .

     SECTION 7.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 8.  This Act shall take effect upon its approval.

 

INTRODUCED BY:

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Report Title:

Health; Insurance; Mandatory Health Coverage; Autism Spectrum Disorders

 

Description:

Requires health insurers, mutual benefit societies, and health maintenance organizations to provide coverage for autism spectrum disorder treatments.

 

 

 

The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.