Sub. H. B. No. 8 As Reported by the House Healthcare Access and Affordability Committee

Cosponsors: Representatives Okey, Harris, Dyer, Foley, Lundy, Harwood, Koziura, Stebelton, Hagan, Skindell, Stewart, Heard, Mallory, DeBose, Patten, Pryor, Yuko, Pillich, Newcomb, Murray, Phillips, Winburn, Letson, Bolon, Luckie, Williams, B., Slesnick, Moran

Sec. 1739.05. (A) A multiple employer welfare arrangement	9
that is created pursuant to sections 1739.01 to 1739.22 of the	10
Revised Code and that operates a group self-insurance program may	11
be established only if any of the following applies:	12

(1) The arrangement has and maintains a minimum enrollment of	13
three hundred employees of two or more employers.	14

(2) The arrangement has and maintains a minimum enrollment of	15
three hundred self-employed individuals.	16

(3) The arrangement has and maintains a minimum enrollment of	17
three hundred employees or self-employed individuals in any	18
combination of divisions (A)(1) and (2) of this section.	19

(B) A multiple employer welfare arrangement that is created	20
pursuant to sections 1739.01 to 1739.22 of the Revised Code and	21
that operates a group self-insurance program shall comply with all	22
laws applicable to self-funded programs in this state, including	23
sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381	24
to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14,	25
3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, 3923.80,	26
3923.84, 3924.031, 3924.032, and 3924.27 of the Revised Code.	27

Section 1. That section 1739.05 be amended and sections	6
1751.68 and 3923.84 of the Revised Code be enacted to read as	7
follows:	8

(C) A multiple employer welfare arrangement created pursuant	28
to sections 1739.01 to 1739.22 of the Revised Code shall solicit	29
enrollments only through agents or solicitors licensed pursuant to	30
Chapter 3905. of the Revised Code to sell or solicit sickness and	31
accident insurance.	32

(D) A multiple employer welfare arrangement created pursuant	33
to sections 1739.01 to 1739.22 of the Revised Code shall provide	34
benefits only to individuals who are members, employees of	35
members, or the dependents of members or employees, or are	36
eligible for continuation of coverage under section 1751.53 or	37
3923.38 of the Revised Code or under Title X of the "Consolidated	38
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29	39
U.S.C.A. 1161, as amended.	40

Sec. 1751.68. (A) Notwithstanding section 3901.71 of the	41
Revised Code, no health insuring corporation policy, contract, or	42
agreement that provides basic health care services that is	43
delivered, issued for delivery, or renewed in this state shall	44
exclude coverage for the screening and diagnosis of autism	45
spectrum disorders or for any of the following services when	46
those services are medically necessary and are prescribed,	47
provided, or ordered for an individual diagnosed with an autism	48
spectrum disorder by a health care professional licensed or	49
certified under the laws of this state to prescribe, provide, or	50
order such services:	51

(2) Pharmacy care if the policy, contract, or agreement	53
provides coverage for other prescription drug services;	54

(7) Any additional treatments or therapies adopted by the	59
director of mental retardation and developmental disabilities	60
pursuant to division (I)(4) of section 3923.84 of the Revised	61
Code.	62

(B) Coverage provided under this section shall not be subject	63
to any limits on the number or duration of visits an individual	64
may make to any autism service provider if the services are	65
medically necessary.	66

(C) Coverage provided under this section may be subject to	67
any copayment, deductible, and coinsurance provisions of the	68
policy, contract, or agreement to the extent that other medical	69
services covered by the policy, contract, or agreement are	70
subject to those provisions.	71

(D) Not more than once every twelve months, a health insuring	72
corporation may request a review of any treatment provided under	73
this section except inpatient services unless the insured's	74
licensed physician or licensed psychologist agrees that more	75
frequent review is necessary. The health insuring corporation	76
shall pay for any review requested under this division.	77

(E) This section shall not be construed as limiting benefits	78
otherwise available under an individual's policy, contract, or	79
agreement.	80

(F) This section shall not be construed as affecting any	81
obligation to provide services to an individual under an	82
individualized family service plan developed under 20 U.S.C. 1436	83
or individualized service plan developed under section 5126.31 of	84
the Revised Code, or affecting the duty of a public school to	85
provide a child with a disability with a free appropriate public	86
education under the "Individuals with Disabilities Education	87
Improvement Act of 2004," 20 U.S.C. 1400 et seq., as amended, and	88
Chapter 3323. of the Revised Code.	89

(1) The health insuring corporation submits documentation	95
certified by an independent member of the American academy of	96
actuaries to the superintendent of insurance showing that incurred	97
claims for the coverage required under division (A) of this	98
section for a period of at least six months independently caused	99
the health insuring corporation's costs for claims and	100
administrative expenses for the coverage of all covered services	101
to increase by more than one per cent per year.	102

(2) The health insuring corporation submits a signed letter	103
from an independent member of the American academy of actuaries to	104
the superintendent of insurance opining that the increase in costs	105
described in division (D)(1) of this section could reasonably	106
justify an increase of more than one per cent in the annual	107
premiums or rates charged by the health insuring corporation for	108
the coverage of basic health care services.	109

(3) The superintendent of insurance makes the following	110
determinations from the documentation and opinion submitted	111
pursuant to divisions (D)(1) and (2) of this section:	112

(G) A health insuring corporation that offers coverage for	90
basic health care services is not required to offer the coverage	91
required under division (A) of this section in combination with	92
the offer of coverage for basic health care services if all of	93
the following apply:	94

(a) Incurred claims for the coverage required under division	113
(A) of this section for a period of at least six months	114
independently caused the health insuring corporation's costs for	115
claims and administrative expenses for the coverage of all covered	116
services to increase by more than one per cent per year.	117

(b) The increase in costs reasonably justifies an increase of	118
more than one per cent in the annual premiums or rates charged by	119
the health insuring corporation for the coverage of basic health	120
care services.	121

Any determination made by the superintendent under this	122
division is subject to Chapter 119. of the Revised Code.	123

(1) "Applied behavior analysis" means the design,	125
implementation, and evaluation of environmental modifications	126
using behavioral stimuli and consequences to produce socially	127
significant improvement in human behavior, including, but not	128
limited to, the use of direct observation, measurement, and	129
functional analysis of the relationship between environment and	130
behavior.	131

(2) "Autism services provider" means any person whose	132
professional scope of practice allows treatment of autism spectrum	133
disorders.	134

(3) "Autism spectrum disorder" means any of the pervasive	135
developmental disorders as defined by the most recent edition of	136
the diagnostic and statistical manual of mental disorders,	137
published by the American psychiatric association, or if that	138
manual is no longer published, a similar diagnostic manual. Autism	139
spectrum disorders includes, but is not limited to, autistic	140
disorder, Asperger's disorder, Rett's disorder, childhood	141
disintegrative disorder, and pervasive developmental disorder.	142

(4) "Diagnosis of autism spectrum disorders" means medically	143
necessary assessments, evaluations, or tests, including but not	144
limited to genetic and psychological tests to determine whether an	145
individual has an autism spectrum disorder.	146

(5) "Habilitative or rehabilitative care" means professional,	147
counseling, and guidance services and treatment programs,	148
including applied behavior analysis, that are necessary to	149
develop, maintain, or restore the functioning of an individual to	150
the maximum extent practicable.	151

(6) "Medically necessary" means the service is based upon	152
evidence; is prescribed, provided, or ordered by a health care	153
professional licensed or certified under the laws of this state to	154
prescribe, provide, or order autism-related services in accordance	155
with accepted standards of practice; and will or is reasonably	156
expected to do any of the following:	157

(a) Prevent the onset of an illness, condition, injury, or	158
disability;	159

(b) Reduce or ameliorate the physical, mental or	160
developmental effects of an illness, condition, injury, or	161
disability;	162

(c) Assist in achieving or maintaining maximum functional	163
capacity for performing daily activities, taking into account both	164
the functional capacity of the individual and the appropriate	165
functional capacities of individuals of the same age.	166

(7) "Pharmacy care" means prescribed medications and any	167
medically necessary health-related services used to determine the	168
need or effectiveness of the medications.	169

(8) "Psychiatric care" means direct or consultative services	170
provided by a psychiatrist licensed in the state in which the	171
psychiatrist practices psychiatry.	172

(9) "Psychological care" means direct or consultative	173
services provided by a psychologist licensed in the state in which	174
the psychologist practices psychology.	175

(10) "Therapeutic care" means services, communication	176
devices, or other adaptive devices or equipment provided by a	177
licensed speech-language pathologist, licensed occupational	178
therapist, or licensed physical therapist.	179

Sec. 3923.84. (A) Notwithstanding section 3901.71 of the	180
Revised Code, no individual or group policy of sickness and	181
accident insurance that is delivered, issued for delivery, or	182
renewed in this state or public employee benefit plan established	183
or modified in this state shall exclude coverage for the screening	184
and diagnosis of autism spectrum disorders or for any of the	185
following services when those services are medically necessary	186
and are prescribed, provided, or ordered for an individual	187
diagnosed with an autism spectrum disorder by a health care	188
professional licensed or certified under the laws of this state to	189
prescribe, provide, or order such services:	190

(7) Any additional treatments or therapies adopted by the	198
director of mental retardation and developmental disabilities	199
pursuant to division (I)(4) of this section.	200

(B) Coverage provided under this section shall not be subject	201
to any limits on the number or duration of visits an individual	202
may make to any autism services provider if the services are	203
medically necessary.	204