OLR Bill Analysis
AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR AUTISM SPECTRUM DISORDERS.
This bill broadens what a group health insurance policy must cover regarding autism spectrum disorders. It requires a policy to cover the diagnosis and treatment of autism spectrum disorders, including behavioral therapy for a child age 12 or younger and certain prescription drugs and psychiatric and psychological services.
By law, a group health insurance policy must cover physical, speech, and occupational therapy services provided to treat autism to the same extent that it covers them for other diseases and conditions. The bill removes that limitation, but specifies different conditions for coverage of the therapy and other services. It permits a policy to set a certain annual dollar maximum for behavioral therapy coverage.
The bill prohibits (1) policy cancellation because a covered person has been diagnosed with, or received treatment for, autism and (2) specified coverage limitations or restrictions. It authorizes an insurer, HMO, hospital or medical service corporation, or fraternal benefit society to review an autism treatment plan's outpatient services in accordance with its utilization review requirements, but not more often than once every six months, unless the insured's licensed physician, psychologist, or clinical social worker agrees a more frequent review is necessary. The entity requesting the review must pay the cost of it.
The bill also specifies that it is not to be interpreted as limiting or affecting (1) other covered benefits under the policy, the state mental and nervous condition insurance law, and the state birth-to three program or (2) a board of education's obligation to provide services to an autistic student under an individualized education program in accordance with law.
The law defines “autism spectrum disorder” as set forth in the American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders (see BACKGROUND).
EFFECTIVE DATE: January 1, 2010
The bill defines “diagnosis” as the medically necessary assessment, evaluation, or testing a licensed physician, psychologist, or clinical social worker performs to determine if a person has an autism spectrum disorder. It specifies that a diagnosis is valid for at least 12 months, unless a licensed physician, psychologist, or clinical social worker decides a shorter period is appropriate.
COVERAGE AND CONDITIONS
The bill requires a group health insurance policy to cover:
1. behavioral therapy;
2. medications a licensed physician prescribes;
3. psychiatric and psychological services, direct and consultative, a licensed psychiatrist or psychologist provides; and
4. physical, speech, and occupational therapy services a licensed or certified medical professional provides.
Under the bill, in order for the policy to cover these, they must be (1) medically necessary and (2) ordered or prescribed by a licensed physician, psychologist, or clinical social worker for an insured person diagnosed with autism based on a treatment plan. A licensed physician, psychologist, or clinical social worker must have developed the treatment plan in accordance with the American Academy of Pediatrics', American Academy of Child and Adolescent Psychiatry's, or American Psychological Association's most recent report or recommendations.
The bill defines “behavioral therapy” as interactive therapies derived from evidence-based research, including applied behavioral analysis, a Behavior Analyst Certification Board-certified behavioral therapist supervises or provides for a child under age 13. It permits a policy to limit coverage of behavioral therapy to $ 50,000 annually for a child under age nine and $ 35,000 annually for a child who is at least age 9 but under age 13.
The bill defines “applied behavioral analysis” as environmental modification design, implementation, and evaluation using behavioral stimuli and consequences, including direct observation, measurement, and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in behavior.
The bill prohibits a group health insurance policy from:
1. being cancelled or not issued, delivered, renewed, amended, or continued solely because a person is diagnosed with, or receiving treatment for, an autism spectrum disorder;
2. imposing a limit on the number of medically necessary visits to an “autism services provider” (a person, entity, or group that provides treatment for autism spectrum disorders); or
3. imposing a coinsurance, copayment, deductible, or other out-of-pocket expense that is more restrictive than that imposed on substantially all other policy benefits.
It specifies that the deductible limit does not apply to a high-deductible health plan designed to be compatible with federally qualified health savings accounts.
The bill specifically says that a policy cannot be cancelled or not issued, delivered, renewed, amended, or continued “to an individual solely because such individual” is diagnosed with, or receiving treatment for, an autism spectrum disorder. However, the bill applies to group health insurance policies, under which a policy is entered into with a policyholder (e. g. , an employer or association) for the benefit of its employees or members. Perhaps the bill means to prohibit adverse action if a person covered under the group policy is diagnosed with, or receiving treatment for, autism.
APPLICABILITY OF BILL
The bill applies to group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including coverage under an HMO plan.
Due to federal law (ERISA), state insurance benefit mandates do not apply to self-insured benefit plans.
Autism Spectrum Disorder
The American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR (fourth edition, text revision), refers to autism as a pervasive developmental disorder, more often referred to today as autism spectrum disorder (ASD).
ASD ranges from a severe form, called autistic disorder, to a milder form, Asperger syndrome. If a child has symptoms of either but does not meet the specific diagnostic criteria, the diagnosis is called pervasive developmental disorder not otherwise specified. Other rare, severe disorders that ASD includes are Rett syndrome and childhood disintegrative disorder.
The law defines “medically necessary” as health care services that a physician, exercising prudent clinical judgment, would provide to a patient to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms, and that are:
1. in accordance with generally accepted standards of medical practice;
2. clinically appropriate, in terms of type, frequency, extent, site, and duration and considered effective for the patient's illness, injury, or disease;
3. not primarily for the convenience of the patient, physician, or other health care provider; and
4. and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.
“Generally accepted standards of medical practice” means standards that are (1) based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or (2) otherwise consistent with the standards set forth in policy issues involving clinical judgment.
Mental or Nervous Conditions. Under Connecticut law, insurance must cover the diagnosis and treatment of mental or nervous conditions. It defines “mental or nervous conditions” as mental disorders, as it is used in the DSM-IV-TR. It specifically excludes coverage for (1) mental retardation; (2) learning, motor skills, communication, and caffeine-related disorders; (3) relational problems; and (4) additional conditions not otherwise defined as mental disorders in the DSM-IV-TR (CGS §§ 38a-488a and 38a-514).
Birth-to-Three. Insurance must cover medically necessary early intervention services for a child from birth until age three that are part of an individualized family service plan. Coverage is limited to $ 3,200 per child per year, up to $ 9,600 for the three years (CGS §§ 38a-490a and 38a-516a).
The Insurance and Real Estate Committee favorably reported sHB 6240, which includes many of this bill's provisions, except coverage for behavioral therapy.
Insurance and Real Estate Committee