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H. B. No. 8 As IntroducedAs Introduced
128th General Assembly | Regular Session | 2009-2010 |
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Representatives Celeste, Garland
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
A BILL
To amend section 1739.05 and to enact
sections
1751.68 and 3923.84 of the Revised Code to
prohibit
health insurers from excluding coverage
for
specified services for individuals diagnosed
with
an autism spectrum disorder.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
Section 1. That section 1739.05 be amended and
sections
1751.68 and 3923.84 of the Revised Code be enacted to read as
follows:
Sec. 1739.05. (A) A multiple employer welfare arrangement
that is created pursuant to sections 1739.01 to 1739.22 of the
Revised Code and that operates a group self-insurance program may
be established only if any of the following applies:
(1) The arrangement has and maintains a minimum enrollment
of
three hundred employees of two or more employers.
(2) The arrangement has and maintains a minimum enrollment
of
three hundred self-employed individuals.
(3) The arrangement has and maintains a minimum enrollment
of
three hundred employees or self-employed individuals in any
combination of divisions (A)(1) and (2) of this section.
(B) A multiple employer welfare arrangement that is
created
pursuant to sections 1739.01 to 1739.22 of the Revised
Code and
that operates a group self-insurance program shall
comply with all
laws applicable to self-funded programs in this
state, including
sections 3901.04, 3901.041, 3901.19 to 3901.26,
3901.38, 3901.381
to
3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to
3902.14,
3923.282,
3923.30,
3923.301, 3923.38,
3923.581, 3923.63, 3923.80,
3923.84,
3924.031,
3924.032,
and
3924.27
of the Revised Code.
(C) A multiple employer welfare arrangement created
pursuant
to sections 1739.01 to 1739.22 of the Revised Code shall
solicit
enrollments only through agents or solicitors licensed
pursuant to
Chapter 3905. of the Revised Code to sell or solicit
sickness and
accident insurance.
(D) A multiple employer welfare arrangement created
pursuant
to sections 1739.01 to 1739.22 of the Revised Code shall
provide
benefits only to individuals who are members, employees
of
members, or the dependents of members or employees, or are
eligible for continuation of coverage under section 1751.53 or
3923.38 of the Revised Code or under Title X of the "Consolidated
Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29
U.S.C.A. 1161, as amended.
Sec. 1751.68. (A) Notwithstanding section 3901.71 of the
Revised Code, no health insuring corporation policy, contract, or
agreement that provides basic health care services that is
delivered, issued for delivery, or renewed in this state shall
exclude coverage for any of the following services when
those
services are medically necessary and are prescribed, provided, or
ordered for an
individual
diagnosed with an autism spectrum
disorder by a
health care professional licensed or certified
under the laws of this state to prescribe, provide, or order such
services:
(1) Habilitative or rehabilitative care;
(7) Any additional treatments or therapies adopted by the
director of health pursuant to division (H)(4) of section 3923.84
of the Revised Code.
(B) Coverage provided under this section shall not be subject
to any limits on the number or duration of visits an individual
may make to any autism service provider.
(C) Coverage provided under this section may be subject to
any copayment, deductible, and coinsurance provisions of the
policy, contract, or agreement to the extent that other medical
services
covered by the health benefit plan are subject to those
provisions.
(D) Not more than once every twelve months, a health insuring
corporation may
request a review of any treatment provided under
this section
except inpatient services unless the insured's
licensed physician
or licensed psychologist agrees that more
frequent review is
necessary. The health insuring corporation
shall pay for any review requested under
this division.
(E) This section shall not be construed as limiting benefits
otherwise available under an individual's policy, contract, or
agreement.
(F) This section shall not be construed as affecting any
obligation to provide services to an individual under an
individualized family service plan developed under 20 U.S.C. 1436
or individualized service plan developed under section 5126.31 of
the Revised Code, or affecting the duty of a public school to
provide a child with a disability with a free appropriate public
education under the "Individuals with Disabilities Education
Improvement Act of 2004," 20 U.S.C. 1400 et seq., as amended, and
Chapter 3323. of the Revised Code.
(G) As used in this section:
(1) "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, but not
limited to, the use of direct observation, measurement, and
functional analysis of the relationship between environment and
behavior.
(2) "Autism services provider" means any person that provides
treatment of autism spectrum disorders.
(3) "Autism spectrum disorder" means any of the pervasive
developmental disorders as defined by the most recent edition of
the diagnostic and statistical manual of mental disorders,
published by the American psychiatric association, or if that
manual is no longer published, a similar diagnostic manual. Autism
spectrum disorders includes, but is not limited to, autistic
disorder, Asperger's disorder, Rett's disorder, childhood
disintegrative disorder, and pervasive developmental disorder.
(4) "Diagnosis of autism spectrum disorders" means medically
necessary assessments, evaluations, or tests, including but not
limited to genetic and psychological tests to determine whether an
individual has an autism spectrum disorder.
(5) "Habilitative or rehabilitative care" means professional,
counseling, and guidance services and treatment programs,
including applied behavior analysis, that are necessary to
develop, maintain, or restore the functioning of an individual to
the maximum extent practicable.
(6) "Medically necessary" means the service is based upon
evidence; is
prescribed, provided, or ordered by a health care
professional licensed or certified under the laws of this state to
prescribe, provide, or order autism-related services in accordance
with accepted standards of
practice; and will or is reasonably
expected to do any of the
following:
(a) Prevent the onset of an illness, condition, injury, or
disability;
(b) Reduce or ameliorate the physical, mental or
developmental effects of an illness, condition, injury, or
disability;
(c) Assist in achieving or maintaining maximum functional
capacity for performing daily activities, taking into account both
the functional capacity of the individual and the appropriate
functional capacities of individuals of the same age.
(7) "Pharmacy care" means prescribed medications and any
medically necessary health-related services used to determine the
need or effectiveness of the medications.
(8) "Psychiatric care" means direct or consultative services
provided by a psychiatrist licensed in the state in which the
psychiatrist practices psychiatry.
(9) "Psychological care" means direct or consultative
services provided by a psychologist licensed in the state in which
the psychologist practices psychology.
(10) "Therapeutic care" means services or communication
devices provided by a licensed speech-language pathologist,
licensed occupational therapist, or licensed physical therapist.
Sec. 3923.84. (A) Notwithstanding section 3901.71 of the
Revised Code, no individual or group policy of sickness and
accident insurance that is delivered, issued for delivery, or
renewed in this state or public employee benefit
plan established
or modified in this state shall exclude coverage for any of the
following services when
those services are medically necessary
and are prescribed, provided,
or ordered for an
individual
diagnosed with an autism spectrum
disorder by a
health care
professional licensed or certified under the laws of this state to
prescribe, provide, or order such services:
(1) Habilitative or rehabilitative care;
(7) Any additional treatments or therapies adopted by the
director of health pursuant to division (G)(4) of this section.
(B) Coverage provided under this section shall not be subject
to any limits on the number or duration of visits an individual
may make to any autism service provider.
(C) Coverage provided under this section may be subject to
any copayment, deductible, and coinsurance provisions of the
health benefit plan to the extent that other medical services
covered by the policy or plan are subject to those
provisions.
(D) Not more than once every twelve months, an insurer may
request a review of any treatment provided under this section
except inpatient services unless the insured's licensed physician
or licensed psychologist agrees that more frequent review is
necessary. The insurer shall pay for any review requested under
this division.
(E) This section shall not be construed as limiting benefits
otherwise available under an individual's health benefit plan.
(F) This section shall not be construed as affecting any
obligation to provide services to an individual under an
individualized family service plan developed under 20 U.S.C. 1436
or individualized service plan developed under section 5126.31 of
the Revised Code, or affecting the duty of a public school to
provide a child with a disability with a free appropriate public
education under the "Individuals with Disabilities Education
Improvement Act of 2004," 20 U.S.C. 1400 et seq., as amended, and
Chapter 3323. of the Revised Code.
(G) This section does not apply to the offer or renewal of
any individual or group policy of sickness and accident insurance
that provides coverage for specific diseases or accidents only, or
to any hospital indemnity, medicare supplement, medicare, tricare,
long-term care, disability income, one-time limited duration
policy of not longer than six months, or other policy that offers
only supplemental benefits.
(H)(1) The commission on autism spectrum disorders is hereby
established as an independent commission in the department of
health to investigate and recommend treatments or therapies for
autism spectrum disorders that the commission believes should be
included in the services that health benefit plans and public
employee benefit plans are required to cover under division (A) of
this section.
(2) The commission shall consist of 10 members appointed by
the director of health including at least one licensed physician,
licensed psychologist, and parent of an individual diagnosed with
an autism spectrum disorder.
(3) The commission shall serve at the pleasure of the
director.
(4) At the recommendation of the commission, the director may
adopt rules to include additional treatments or therapies for
autism spectrum disorders in the services that health benefit
plans and public employee benefit plans are required to cover
under division (A) of this section.
(I) As used in this section:
(1) "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, but not
limited to, the use of direct observation, measurement, and
functional analysis of the relationship between environment and
behavior.
(2) "Autism services provider" means any person that provides
treatment of autism spectrum disorders.
(3) "Autism spectrum disorder" means any of the pervasive
developmental disorders as defined by the most recent edition of
the diagnostic and statistical manual of mental disorders,
published by the American psychiatric association, or if that
manual is no longer published, a similar diagnostic manual. Autism
spectrum disorders includes, but is not limited to, autistic
disorder, Asperger's disorder, Rett's disorder, childhood
disintegrative disorder, and pervasive developmental disorder.
(4) "Diagnosis of autism spectrum disorders" means medically
necessary assessments, evaluations, or tests, including but not
limited to genetic and psychological tests to determine whether an
individual has an autism spectrum disorder.
(5) "Habilitative or rehabilitative care" means professional,
counseling, and guidance services and treatment programs,
including applied behavior analysis, that are necessary to
develop, maintain, or restore the functioning of an individual to
the maximum extent practicable.
(6) "Health benefit plan" has the same meaning as in section
3924.01 of the Revised Code.
(7) "Medically necessary" means the service is based upon
evidence; is
prescribed, provided, or ordered by a health care
professional licensed or certified under the laws of this state to
prescribe, provide, or order autism-related services in accordance
with accepted standards of
practice; and will or is reasonably
expected to do any of the
following:
(a) Prevent the onset of an illness, condition, injury, or
disability;
(b) Reduce or ameliorate the physical, mental or
developmental effects of an illness, condition, injury, or
disability;
(c) Assist in achieving or maintaining maximum functional
capacity for performing daily activities, taking into account both
the functional capacity of the individual and the appropriate
functional capacities of individuals of the same age.
(8) "Pharmacy care" means prescribed medications and any
medically necessary health-related services used to determine the
need or effectiveness of the medications.
(9) "Psychiatric care" means direct or consultative services
provided by a psychiatrist licensed in the state in which the
psychiatrist practices psychiatry.
(10) "Psychological care" means direct or consultative
services provided by a psychologist licensed in the state in which
the psychologist practices psychology.
(11) "Therapeutic care" means services or communication
devices provided by a licensed speech-language pathologist,
licensed occupational therapist, or licensed physical therapist.
Section 2. That existing section 1739.05 of the
Revised
Code is hereby repealed.
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