SB-0415, As Passed Senate, March 13, 2012

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 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 it 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 applied behavior

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

per covered insured or enrollee and may be limited to an insured or

enrollee up to age 18.

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

available to an insured or enrollee under a policy or certificate.

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

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 pursuant to the insurer's or health

maintenance organization's procedures so long as that care and

those practices are consistent with this section.

(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) 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 spectrum disorders" means any of the following

pervasive developmental disorders as defined by the "Diagnostic and

Statistical Manual of Mental Disorders" of the American psychiatric

association:

(i) Autistic disorder.

(ii) Asperger's disorder.

(iii) Pervasive developmental disorder not otherwise specified.

counseling and treatment programs, including applied behavior

analysis, that meets 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.

(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) "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.

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

consultative services provided by a psychiatrist licensed in the

state in which the psychiatrist practices.

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

consultative services provided by a psychologist licensed in the

state in which the psychologist practices.

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

by a licensed or certified speech therapist, occupational

therapist, physical therapist, or social worker.

(i) "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

Senate Bill No. 415 as amended March 13, 2012

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.

(j) "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 (i).

<<Enacting section 1. This amendatory act takes effect October 1, 2012.>>

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.