HB-4183, As Passed House, June 24, 2009

SUBSTITUTE FOR

HOUSE BILL NO. 4183

(As amended June 24, 2009)

     A bill to amend 1956 PA 218, entitled

"The insurance code of 1956,"

(MCL 500.100 to 500.8302) by adding section 3406s.

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

Sec. 3406s. (1) An expense-incurred hospital, medical, or

surgical [group    ] certificate delivered, issued for delivery, or

renewed in this state and a health maintenance organization [group]

contract shall provide coverage for the diagnosis and treatment of

autism spectrum disorders. An insurer and a health maintenance

organization shall not terminate coverage or refuse to deliver,

execute, issue, amend, adjust, or renew coverage solely because an

individual is diagnosed with, or has received treatment for, an

autism spectrum disorder.

     (2) Coverage under this section is not subject to limits on

House Bill No. 4183 (H-3) as amended June 24, 2009

the number of visits an insured or enrollee may make to an autism

services provider.

     (3) Except as provided in subsection (4), coverage under this

section shall not be subject to dollar limits, copays, deductibles,

or coinsurance provisions that do not apply to physical illness

generally.

     (4) Coverage under this section for applied behavior analysis

may be subject to a maximum annual benefit of $50,000.00. [

]

     (5) This section shall not be construed as limiting benefits

that are otherwise available to an insured or enrollee under a

certificate.

     (6) If an insured or enrollee is receiving treatment for

autism spectrum disorder, an insurer or health maintenance

organization may request a review of that treatment consistent with

current protocols and may require a treatment plan. The cost of

obtaining a treatment review shall be borne by the insurer or

health maintenance organization. [An insurer or health maintenance

 organization shall utilize evidence-based care and managed care cost-containment practices in accordance with the insurer's or health maintenance organization's procedures.]

     (7) This section does not apply to a short-term or 1-time

limited duration policy or certificate of no longer than 6 months

as defined in section 2213b.

     (8) As used in this section:

     (a) "Applied behavior analysis" means the design,

House Bill No. 4183 (H-3) as amended June 24, 2009

implementation, and evaluation of environmental modifications,

using behavioral stimuli and consequences, to produce significant

improvement in human behavior, including the use of direct

observation, measurement, and functional analysis of the relations

between environment and behavior.

     (b) "Autism services provider" means a licensed physician, a

licensed psychologist, or a behavior analyst certified by the

behavior analyst certification board, or an individual supervised

by the physician, psychologist, or behavior analyst, who provides

treatment of autism spectrum disorders.

     (c) "Autism spectrum disorder" means any of the following

pervasive developmental disorders:

     (i) Autistic disorder.

     (ii) Asperger's disorder.

     (iii) Pervasive developmental disorder not otherwise specified.

     (d) "Diagnosis of autism spectrum disorders" means

assessments, evaluations, or tests performed by a licensed

physician or a licensed psychologist to diagnose whether an

individual has 1 of the autism spectrum disorders.

     (e) "Habilitative or rehabilitative care" means professional,

counseling, and guidance services and treatment programs, including

applied behavior analysis, that are necessary to develop, maintain,

and restore, to the maximum extent practicable, the functioning of

an individual.

[

House Bill No. 4183 (H-3) as amended June 24, 2009

(f)] "Pharmacy care" means medications prescribed by a licensed

physician and related services performed by a licensed pharmacist

and any health-related services considered medically necessary to

determine the need or effectiveness of the medications.

[(G)] "Psychiatric care" means direct or consultative services

provided by a psychiatrist licensed in the state in which the

psychiatrist practices.

[(h)] "Psychological care" means direct or consultative services

provided by a psychologist licensed in the state in which the

psychologist practices.

[(i)] "Therapeutic care" means services provided by a licensed

or certified speech therapist, occupational therapist, physical

therapist, or social worker.

[(j)] "Treatment for autism spectrum disorders" means evidence-

based treatment that includes the following care prescribed,

provided, or ordered for an individual diagnosed with 1 of the

autism spectrum disorders by a licensed physician or a licensed

psychologist who determines the care to be medically necessary:

     (i) Habilitative or rehabilitative care.

     (ii) Pharmacy care.

     (iii) Psychiatric care.

     (iv) Psychological care.

     (v) Therapeutic care.

[(k)] "Treatment plan" means a written comprehensive evaluation

by a multidisciplinary team, individualized for each patient and

developed by a licensed physician or licensed psychologist.

     Enacting section 1. This amendatory act applies to policies,

certificates, and contracts delivered, executed, issued, amended,

adjusted, or renewed in this state, or outside this state if

covering residents of this state, 180 days after the date this

amendatory act is enacted into law.