Report Title:

Mandatory Health Coverage; Autism Spectrum Disorders

 

Description:

Requires all health insurers, mutual benefit societies, and health maintenance organizations to provide mandatory coverage for all policyholders, member, subscribers, and individuals under age 21 for the diagnosis and treatment of autism spectrum disorders beginning 1/1/2009.

 


HOUSE OF REPRESENTATIVES

H.B. NO.

2727

TWENTY-FOURTH LEGISLATURE, 2008

 

STATE OF HAWAII

 

 

 

 

 

 

A BILL FOR AN ACT


 

 

relating to health insurance.

 

 

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 procedures for all Hawaii residents by requiring coverage of and treatment for autism spectrum disorders.

     SECTION 2.  Chapter 431, article 10A, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

     "§431:10A-     Autism spectrum disorders benefits and coverage; notice; definitions.  (a)  Any other law to the contrary notwithstanding, each employer group health policy, contract, plan, or agreement issued or renewed in this State after December 31, 2008, shall provide to the policyholder and individuals under twenty-one years of age covered under the policy, contract, plan, or agreement, coverage for the diagnosis and treatment of autism spectrum disorders.

     (b)  Every insurer shall provide 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 2008 when annual information is made available to policyholders, or in any other mailing to policyholders, but in no case later than December 31, 2008.

     (c)  Coverage provided under this section shall be subject to a maximum benefit of $75,000 per year but shall not be subject to any limits on the number of visits to an autism service provider.  After December 31, 2010, 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 (CPI-U).  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, service, or item, the provision of which was for the treatment of a health condition unrelated to the covered individual's autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.

     (d)  Coverage under this section shall be subject to co-payment, deductible, and coinsurance provisions of a health insurance policy to the extent that other medical services covered by the policy are subject to these provisions.

     (e)  This section shall not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy.

     (f)  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 of autism spectrum disorders.

     "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger’s disorder, pervasive developmental disorder not otherwise specified, Rett’s disorder, and childhood disintegrative disorder.

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

     "Health insurance policy" means any group health, sickness, or accident policy or subscriber contract or certificate issued by an insurance entity subject to this section.

     "Medically necessary" means any care, treatment, intervention, service, or item that is prescribed, provided, or ordered by a physician, psychologist, or registered nurse practitioner licensed to practice in this State in accordance with accepted standards or practice and that is reasonably expected to accomplish any of the following:

     (1)  Prevent the onset of an illness, condition, injury, or disability;

     (2)  Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or

     (3)  Assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate to recipients of care of the same age.

     "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.

     "Rehabilitative and habilitative care" means professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.

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

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

     (1)  Psychiatric care;

     (2)  Psychological care;

     (3)  Rehabilitative and habilitative care;

     (4)  Therapeutic care; and

     (5)  Pharmacy care."

     SECTION 3.  Chapter 432, article 1, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

     "§432:1‑     Autism spectrum disorders benefits and coverage; notice; definitions.  (a)  Any other law to the contrary notwithstanding, each individual and group hospital or medical service plan, policy, contract, or agreement issued or renewed in this State after December 31, 2008, 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 diagnosis and treatment of autism spectrum disorders.

     (b)  Every mutual benefit society shall provide 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 2008 when annual information is made available to members, or in any other mailing to members, but in no case later than December 31, 2008.

     (c)  Coverage provided under this section shall be subject to a maximum benefit of $75,000 per year but shall not be subject to any limits on the number of visits to an autism service provider.  After December 31, 2010, 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 (CPI-U).  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 a mutual benefit society on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition unrelated to the covered individual's autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection.

     (d)  Coverage under this section shall be subject to co-payment, deductible, and coinsurance provisions of a health insurance policy to the extent that other medical services covered by the policy are subject to these provisions.

     (e)  This section shall not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy.

     (f)  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 of autism spectrum disorders.

     "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger’s disorder, pervasive developmental disorder not otherwise specified, Rett’s disorder, and childhood disintegrative disorder.

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

     "Health insurance policy" means any group health, sickness, or accident policy or subscriber contract or certificate issued by a mutual benefit society subject to this section.

     "Medically necessary" means any care, treatment, intervention, service or item that is prescribed, provided, or ordered by a physician, psychologist, or registered nurse practitioner licensed to practice in this State in accordance with accepted standards or practice and that is reasonably expected to accomplish any of the following:

     (1)  Prevent the onset of an illness, condition, injury, or disability;

     (2)  Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or

     (3)  Assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate to recipients of care of the same age.

     "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.

     "Rehabilitative care" means professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.

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

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

     (1)  Psychiatric care;

     (2)  Psychological care;

     (3)  Rehabilitative care;

     (4)  Therapeutic care; and

     (5)  Pharmacy care."

     SECTION 4.  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, [and] 431:10A‑121, and 431:10A‑   , and chapter 431M."

     SECTION 5.  The benefit to be provided by health maintenance organizations corresponding to the benefit provided under section 431:10A‑   , Hawaii Revised Statutes, as contained in the amendment to section 432D‑23, Hawaii Revised Statutes, in section 4 of this Act, shall take effect for all policies, contracts, plans, or agreements issued in the State after December 31, 2008.

     SECTION 6.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 7.  This Act shall take effect upon its approval.

 

INTRODUCED BY:

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