SB-0415, As Passed Senate, March 29, 2012

HOUSE SUBSTITUTE FOR

SENATE BILL NO. 415

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) Except as otherwise provided in this section,

an expense-incurred hospital, medical, or surgical group or

individual policy or certificate delivered, issued for delivery, or

renewed in this state and a health maintenance organization group

or individual contract shall provide coverage for the diagnosis of

autism spectrum disorders and treatment of autism spectrum

disorders. An insurer and a health maintenance organization shall

not do any of the following:

(a) 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.

(b) Limit the number of visits an insured or enrollee may use

for treatment of autism spectrum disorders covered under this

section.

that treatment is educational or habilitative in nature.

(d) Except as otherwise provided in this subdivision, subject

coverage under this section to dollar limits, copays, deductibles,

or coinsurance provisions that do not apply to physical illness

generally. Coverage under this section for treatment of autism

spectrum disorders may be limited to an insured or enrollee through

18 years of age and may be subject to a maximum annual benefit as

follows:

(i) For a covered insured or enrollee through 6 years of age,

$50,000.00.

(ii) For a covered insured or enrollee from 7 years of age

through 12 years of age, $40,000.00.

(iii) For a covered insured or enrollee from 13 years of age

through 18 years of age, $30,000.00.

(2) This section does not limit benefits that are otherwise

available to an insured or enrollee under a policy, contract, or

certificate. An insurer or health maintenance organization shall

utilize evidence-based care and managed care cost-containment

practices pursuant to the insurer's or health maintenance

organization's procedures so long as that care and those practices

are consistent with this section. The coverage under this section

may be subject to other general exclusions and limitations of the

policy, contract, or certificate, including, but not limited to,

coordination of benefits, participating provider requirements,

restrictions on services provided by family or household members,

utilization review of health care services including review of

medical necessity, case management, and other managed care

provisions.

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

autism spectrum disorder, an insurer or health maintenance

organization may, as a condition to providing the coverage under

this section, do all of the following:

(a) Require a review of that treatment consistent with current

protocols and may require a treatment plan. If requested by the

insurer or health maintenance organization, the cost of treatment

review shall be borne by the insurer or health maintenance

organization.

(b) Request the results of the autism diagnostic observation

schedule that has been used in the diagnosis of an autism spectrum

disorder for that insured or enrollee.

performed on that insured or enrollee not more frequently than once

every 3 years.

(d) Request that an annual development evaluation be conducted

and the results of that annual development evaluation be submitted

to the insurer or health maintenance organization.

(4) Beginning January 1, 2014, a qualified health plan offered

through an American health benefit exchange established in this

state pursuant to the federal act is not required to provide

coverage under this section to the extent that it exceeds coverage

that is included in the essential health benefits as required

pursuant to the federal act. As used in this subsection, "federal

act" means the federal patient protection and affordable care act,

Public Law 111-148, as amended by the federal health care and

education reconciliation act of 2010, Public Law 111-152, and any

regulations promulgated under those acts.

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

limited duration policy or certificate of no longer than 6 months

as described in section 2213b.

(6) This section does not require the coverage of prescription

drugs and related services unless the insured or enrollee is

covered by a prescription drug plan. This section does not require

an insurer or health maintenance organization to provide coverage

for autism spectrum disorders to an insured or enrollee under more

than 1 of its policies, certificates, or contracts. If an insured

or enrollee has more than 1 policy, certificate, or contract that

covers autism spectrum disorders, the benefits provided are subject

to the limits of this section when coordinating benefits.

(7) As used in this section:

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

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

relationship between environment and behavior.

(b) "Autism diagnostic observation schedule" means the

protocol available through western psychological services for

diagnosing and assessing autism spectrum disorders or any other

standardized diagnostic measure for autism spectrum disorders that

is approved by the commissioner, if the commissioner determines

that the diagnostic measure is recognized by the health care

industry and is an evidence-based diagnostic tool.

pervasive developmental disorders as defined by the diagnostic and

statistical manual:

(i) Autistic disorder.

(ii) Asperger's disorder.

(iii) Pervasive developmental disorder not otherwise specified.

(d) "Behavioral health treatment" means evidence-based

counseling and treatment programs, including applied behavior

analysis, that meet both of the following requirements:

(i) Are necessary to develop, maintain, or restore, to the

maximum extent practicable, the functioning of an individual.

(ii) Are provided or supervised by a board certified behavior

analyst or a licensed psychologist so long as the services

performed are commensurate with the psychologist's formal

university training and supervised experience.

(e) "Diagnosis of autism spectrum disorders" means

assessments, evaluations, or tests, including the autism diagnostic

observation schedule, performed by a licensed physician or a

licensed psychologist to diagnose whether an individual has 1 of

the autism spectrum disorders.

(f) "Diagnostic and statistical manual" or "DSM" means the

diagnostic and statistical manual of mental disorders published by

the American psychiatric association or other manual that contains

common language and standard criteria for the classification of

mental disorders and that is approved by the commissioner, if the

commissioner determines that the manual is recognized by the health

care industry and the classification of mental disorders is at

least as comprehensive as the manual published by the American

psychiatric association on the effective date of this section.

(g) "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.

(h) "Psychiatric care" means evidence-based direct or

consultative services provided by a psychiatrist licensed in the

state in which the psychiatrist practices.

(i) "Psychological care" means evidence-based direct or

consultative services provided by a psychologist licensed in the

state in which the psychologist practices.

(j) "Therapeutic care" means evidence-based services provided

by a licensed or certified speech therapist, occupational

therapist, physical therapist, or social worker.

(k) "Treatment of autism spectrum disorders" means evidence-

based treatment that includes the following care prescribed 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) Behavioral health treatment.

(ii) Pharmacy care.

(iii) Psychiatric care.

(iv) Psychological care.

(v) Therapeutic care.

(l) "Treatment plan" means a written, comprehensive, and

individualized intervention plan that incorporates specific

treatment goals and objectives and that is developed by a board

certified or licensed provider who has the appropriate credentials

and who is operating within his or her scope of practice, when the

treatment of an autism spectrum disorder is first prescribed or

ordered by a licensed physician or licensed psychologist as

described in subdivision (k).

Enacting section 1. This amendatory act applies to policies,

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

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

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

this amendatory act is enacted into law.

Enacting section 2. This amendatory act does not take effect

unless all of the following bills of the 96th Legislature are

enacted into law:

(a) Senate Bill No. 414.

(b) Senate Bill No. 981.