THE SENATE

S.B. NO.

2054

TWENTY-SEVENTH LEGISLATURE, 2014

S.D. 3

STATE OF HAWAII

H.D. 2

 

Proposed

 

 

 

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 December 31, 2015, shall provide to the policyholder and individuals under nine 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.

     Nothing in this section shall be construed to require the coverage in a medicaid plan.

     (b)  Every insurer shall provide notice to its policyholders regarding the coverage required by this section.  The notice shall be prominently positioned in any literature or correspondence sent to policyholders and shall be transmitted to policyholders within calendar year 2014 when annual information is made available to members or in any other mailing to members, but in no case later than December 31, 2014.

     (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, 2015, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation using the medical care component of the United States Bureau of Labor Consumer Price Index for urban Honolulu; provided that the commissioner shall post notice of and hold a public meeting in the same manner as required by section 91-3(a) 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 substantially all 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.  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)  Nothing in this section shall apply to non-grandfathered plans in the individual and small group markets that are required to include essential health benefits under the Patient Protection and Affordable Care Act, Public Law 111-148, as amended, or to Medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies.

     (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 board certified behavior analysts in their provider network.

     (l)  If an individual has been diagnosed as having an autism spectrum disorder, 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)  Coverage for applied behavior analysis shall include the services of the personnel who work under the supervision of the board certified behavior analyst or the licensed psychologist overseeing the program.

     (n)  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 relationship between environment and behavior.  The practice of applied behavior analysis expressly excludes psychological testing, diagnosis of a mental or physical disorder, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, and long-term counseling as treatment modalities.

     "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.

     "Board certified behavior analyst" means a behavior analyst credentialed by the Behavior Analyst Certification Board as a board certified analyst.

     "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 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 with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or 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 December 31, 2015, shall provide to the member and individuals under nine 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.

     Nothing in this section shall be construed to require the coverage in a medicaid plan.

     (b)  Every mutual benefit society shall provide written notice to its members regarding the coverage required by this section.  The notice shall be prominently positioned in any literature or correspondence sent to members and shall be transmitted to members within calendar year 2014 when annual information is made available to members or in any other mailing to members, but in no case later than December 31, 2014.

     (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, 2015, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation, using the medical care component of the United States Bureau of Labor Consumer Price Index for urban Honolulu.  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 shall post notice of and hold a public meeting in the same manner as required by section 91-3(a) 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 substantially all 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.  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)  Nothing in this section shall apply to non-grandfathered plans in the individual and small group markets that are required to include essential health benefits under the Patient Protection and Affordable Care Act, Public Law 111-148, as amended, or to Medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies.

     (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 board certified behavior analysts in their provider network.

     (l)  If an individual has been diagnosed as having an autism spectrum disorder, 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)  Coverage for applied behavior analysis shall include the services of the personnel who work under the supervision of the board certified behavior analyst or the licensed psychologist overseeing the program.

     (n)  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 relationship between environment and behavior.  The practice of applied behavior analysis expressly excludes psychological testing, diagnosis of a mental or physical disorder, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, and long-term counseling as treatment modalities.

     "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.

     "Board certified behavior analyst" means a behavior analyst credentialed by the Behavior Analyst Certification Board as a board certified analyst.

     "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 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 with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or 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-116.2, 431:10A‑116.5, 431:10A-116.6, 431:10A-119, 431:10A-120, 431:10A‑121, 431:10A‑122, 431:10A-125, 431:10A-126, [431:10A-122, and 431:10A-116.2] and 431:10A-   , and chapter 431M."

     SECTION 6.  (a)  The legislative reference bureau shall contract for the performance of an actuarial analysis by a licensed actuary who is a member in good standing with the American Academy of Actuaries of the projected costs of providing insurance coverage for screening, diagnosis, and treatment of autism spectrum disorders as required by this Act.

     (b)  The actuarial analysis shall:

(1)  Include a statement by the actuary certifying that the techniques and methods used are generally accepted within the actuarial profession and that the assumptions and cost estimates used are reasonable; and

(2)  Provide a financial analysis of the cost of providing insurance coverage for screening, diagnosis, and treatment of autism spectrum disorders as required by this Act, including an estimate of the cost benefits provided by this Act and the cost impact if this Act is applied to the Hawaii medicaid market.

     (c)  The actuarial analysis shall be completed and submitted to the legislative reference bureau in sufficient time for the legislative reference bureau to submit a report to the legislature, including findings, recommendations, and proposed legislation, if any, based on the results of the actuarial analysis no later than twenty days prior to the convening of the regular session of 2015.

     SECTION 7.  There is appropriated out of the general revenues of the State of Hawaii the sum of $         or so much thereof as may be necessary for fiscal year 2014-2015 for the performance of the actuarial analysis required under this Act.

     The sum appropriated shall be expended by the legislative reference bureau for the purposes of this Act.

     SECTION 8.  Notwithstanding section 432D-23, Hawaii Revised Statutes, the coverage and benefits 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 December 31, 2015.

     SECTION 9.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 10.  This Act shall take effect on July 1, 2050.


 


 

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.  Requires an actuarial analysis to estimate the costs of providing autism spectrum disorder benefits.  Effective July 1, 2050.  (SB2054 HD2 PROPOSED)

 

 

 

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