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Sub. H. B. No. 8 As Reported by the House Healthcare Access and Affordability CommitteeAs Reported by the House Healthcare Access and Affordability Committee
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, Moran
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 the screening and diagnosis of autism
spectrum disorders or 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;
(2) Pharmacy care if the policy, contract, or
agreement
provides coverage for other prescription drug services;
(7) Any additional treatments or therapies adopted by the
director of mental retardation
and developmental disabilities
pursuant to division (I)(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 if the services are
medically necessary.
(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 policy, contract, or agreement 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) A health insuring corporation
that offers coverage for
basic health care services is not
required to offer the coverage
required under division (A) of
this section
in combination with
the offer of coverage for
basic
health care
services if all of
the following apply:
(1) The health insuring corporation submits documentation
certified by an independent member of the American academy of
actuaries to the superintendent of insurance showing that incurred
claims for the coverage required under division (A) of this
section for a period of at least six months
independently caused
the health insuring corporation's costs for
claims and
administrative expenses for the coverage of all covered services
to increase by more than one per cent per
year.
(2) The health insuring corporation submits a signed letter
from an independent member of the American academy of actuaries to
the superintendent of insurance opining that the increase in costs
described in division (D)(1) of this section could reasonably
justify an increase of more than one per cent in the annual
premiums or rates charged by the health insuring corporation for
the coverage of basic health care services.
(3) The superintendent of insurance makes the following
determinations from the documentation and opinion submitted
pursuant to divisions (D)(1) and (2) of this section:
(a) Incurred claims for the coverage required under division
(A) of this section for a period of at least six months
independently caused the health insuring corporation's costs for
claims and administrative expenses for the coverage of all covered
services to increase by more than one per cent per
year.
(b) The increase in costs reasonably justifies an increase of
more than one per cent in the annual premiums or rates charged by
the health insuring corporation for the coverage of basic health
care services.
Any determination made by the superintendent under this
division is subject to Chapter 119. of the Revised Code.
(H) 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 whose
professional scope of practice allows 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, communication
devices, or other adaptive
devices or equipment 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 the screening
and diagnosis
of autism spectrum disorders or 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;
(2) Pharmacy care if the policy, contract, or
agreement
provides coverage for other prescription drug services;
(7) Any additional treatments or therapies adopted by the
director of mental retardation
and developmental disabilities
pursuant to division (I)(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 services provider if the services are
medically necessary.
(C) Coverage provided under this section may be subject to
any copayment, deductible, and coinsurance provisions of the
policy or 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 policy or 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) A public employee benefit
plan or insurer that offers a
policy of sickness and accident
insurance is not required to
offer
the coverage required under
division (A) of this section
if all
of the following apply:
(1) The insurer or public employee benefit plan submits
documentation
certified by an independent member of the American
academy of
actuaries to the superintendent of insurance showing
that incurred
claims for the coverage required under division (A)
of this section for a period of at least six months
independently
caused the costs for
claims and administrative
expenses for the
coverage of all covered services to
increase by more than one per
cent per
year.
(2) The insurer or public employee benefit plan submits a
signed letter
from an independent member of the American academy
of actuaries to
the superintendent of insurance opining that the
increase in costs
described in division (D)(1) of this section
could reasonably
justify an increase of more than one per cent in
the annual
premiums or rates charged by the insurer or public
employee benefit plan for
the coverage of all covered
services.
(3) The superintendent of insurance makes the following
determinations from the documentation and opinion submitted
pursuant to divisions (D)(1) and (2) of this section:
(a) Incurred claims for the coverage required under division
(A) of this section for a period of at least six months
independently caused the costs for
claims and administrative
expenses for the coverage of all covered services to
increase by
more than one per cent per
year.
(b) The increase in costs reasonably justifies an increase of
more than one per cent in the annual premiums or rates charged by
the insurer or public employee benefit plan for the coverage of
all covered services.
Any determination made by the superintendent under this
division is subject to Chapter 119. of the Revised Code.
(I)(1) The director of mental
retardation and developmental
disabilities shall convene a
committee on the coverage of autism
spectrum disorders to investigate and recommend treatments or
therapies for
autism spectrum disorders that the committee
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 committee shall consist of nine members appointed by
the director of mental retardation and developmental disabilities
including the
director of mental retardation and developmental
disabilities, the
director of health, at least one licensed
physician,
licensed psychologist, and parent of an individual
diagnosed with
an autism spectrum disorder.
(3) The committee shall serve at the pleasure of the
director.
(4) The committee shall submit its recommendations to the
director of mental retardation and developmental disabilities. The
director may
adopt rules in accordance with Chapter 119. of the
Revised Code 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.
(J) 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 whose
professional scope of practice allows
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, communication
devices, or other adaptive devices or equipment 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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