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H. B. No. 376 As IntroducedAs Introduced
129th General Assembly | Regular Session | 2011-2012 |
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Representatives Celeste, Garland
Cosponsors:
Representatives Antonio, Ashford, Barnes, Boyd, Carney, Clyde, DeGeeter, Driehaus, Fedor, Fende, Foley, Gentile, Gerberry, Goyal, Hagan, R., Heard, Letson, Lundy, Mallory, Milkovich, Murray, O'Brien, Okey, Patmon, Phillips, Pillich, Ramos, Reece, Slesnick, Stinziano, Sykes, Szollosi, Weddington, Winburn, Yuko
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,
3923.24, 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 developmental disabilities pursuant to division (I)(4)
of section 3923.84 of the Revised Code.
(B) Coverage provided under this section shall be delineated
in a treatment plan developed by the attending psychologist or
physician and shall not be subject to any limits on the number or
duration of visits an individual may make to any autism services
provider, except as delineated in the treatment plan, 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. Coverage provided under this section may be
subject to a yearly maximum limitation of thirty-six thousand
dollars on claims paid for services related to coverage provided
under this section.
(D)(1) Not more than once every six months, a health insuring
corporation may request a review of any treatment provided under
this section 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 division (D)(1) of this section.
(2) If requested by the health insuring corporation, the
provider shall provide the health insuring corporation with an
annual treatment plan.
(3) Inpatient services are not subject to the six-month
review limitations under division (D)(1) of this section.
(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 opining that the increase in costs described in
division (G)(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 makes both of the following
determinations from the documentation and opinion submitted
pursuant to divisions (G)(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 division
(G)(3) of this section is subject to Chapter 119. of the Revised
Code.
(H) The services covered under this section shall not be
considered supplemental health care services under division (B)(1)
of section 1751.01 of the Revised Code.
(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 whose
professional scope of practice allows treatment of autism spectrum
disorders, whose services are delineated in the treatment plan
under division (B) of this section, and of whom one of the
following is true:
(a) The person is licensed, certified, or registered by an
appropriate agency of this state to perform the services assigned
to the person in the treatment plan.
(b) The person is directly supervised by an individual who is
licensed, certified, or registered by an appropriate agency of
this state to perform the services assigned to the person in the
treatment plan.
(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 disorder 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 or plan provides coverage for
other prescription drug services;
(7) Any additional treatments or therapies adopted by the
director of developmental disabilities pursuant to division (I)(4)
of this section.
(B) Coverage provided under this section shall be delineated
in a treatment plan developed by the attending psychologist or
physician and shall not be subject to any limits on the number or
duration of visits an individual may make to any autism services
provider, except as delineated in the treatment plan, 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. Coverage
provided under this section may be subject to a yearly maximum
limitation of thirty-six thousand dollars on claims paid for
services related to coverage provided under this section.
(D)(1) Not more than once every six months, an insurer or
public employee benefit plan may request a review of any treatment
provided under this section unless the insured's licensed
physician or licensed psychologist agrees that more frequent
review is necessary. The insurer or public employee benefit plan
shall pay for any review requested under division (D)(1) of this
section.
(2) If requested by the insurer or public employee benefit
plan, the provider shall provide the insurer or public employee
benefit plan with an annual treatment plan.
(3) Inpatient services are not subject to the six-month
review limitations under division (D)(1) of this section.
(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 opining that the increase in
costs described in division (H)(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 makes both of the following
determinations from the documentation and opinion submitted
pursuant to divisions (H)(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 division
(H)(3) of this section is subject to Chapter 119. of the Revised
Code.
(I)(1) The director of 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 and the qualifications of the providers of those
treatments or therapies.
(2) The committee shall consist of nine members appointed by
the director of developmental disabilities including the director
of developmental disabilities, the director of health, and 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 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, whose services are delineated in the treatment plan
under division (B) of this section, and of whom one of the
following is true:
(a) The person is licensed, certified, or registered by an
appropriate agency of this state to perform the services assigned
to the person in the treatment plan.
(b) The person is directly supervised by an individual who is
licensed, certified, or registered by an appropriate agency of
this state to perform the services assigned to the person in the
treatment plan.
(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 disorder 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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