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HOUSE DOCKET, NO. 984 FILED ON: 1/13/2009 HOUSE . . . . . . . . . . . . . . No. 3809
The Commonwealth of Massachusetts _______________ PRESENTED BY: Barbara A. L'Italien _______________
To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
The undersigned legislators and/or citizens respectfully petition for the passage of the accompanying bill: An Act relative to insurance coverage for autism. _______________ PETITION OF:
The Commonwealth of Massachusetts
_______________ In the Year Two Thousand and Nine _______________
An Act relative to insurance coverage for autism.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
SECTION 1. Chapter 32A of the General Laws is hereby amended by adding the following section:- Section 24. (a) The commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Autism Spectrum Disorder in individuals. (b) Any such policy shall be deemed to be providing such benefits on a nondiscriminatory basis if the policy does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of said Autism Spectrum Disorders which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (c) This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy. (d) Coverage under this section will not be subject to any limits on the number of visits an individual may make to an autism services provider. (e) This section will not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan. (f) Definitions - 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 the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 2. “Autism services provider” means any person, entity, or group that provides treatment of autism spectrum disorders. 3. “Autism spectrum disorders” means any of the Pervasive Developmental Disorders (PDD) as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder, and PDD Not Otherwise Specified. 4. "Board Certified Behavior Analyst" means a behavior analyst credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst. 5. “Diagnosis of autism spectrum disorders” means medically necessary assessments, evaluations, including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has one of the autism spectrum disorders. 6. “Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including applied behavior analysis supervised by a Board Certified Behavior Analyst, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual. 7. “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the policy for other medical conditions. 8. “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. 9. “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. 10. “Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. 11. “Treatment of Autism Spectrum Disorders” will include the following care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: a . habilitative or rehabilitative care; b . pharmacy care; c . psychiatric care; d . psychological care; and e . therapeutic care. SECTION 2. C hapter 175 of the General Laws is hereby amended by inserting the following new section after section 47T:- Section 47U (a) Any individual policy of accident and sickness insurance issued pursuant to section 108, which provides hospital expense and surgical expense insurance, and any group blanket or general policy of accident and sickness insurance issued pursuant to section 110, which provides hospital expense and surgical expense insurance, which is issued or renewed within or without the commonwealth, shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Autism Spectrum Disorder in individuals. (b) Any such policy shall be deemed to be providing such benefits on a nondiscriminatory basis if the policy does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of said Autism Spectrum Disorders which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (c) This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy. (d) Coverage under this section will not be subject to any limits on the number of visits an individual may make to an autism services provider. (e) This section will not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan. (f) Definitions - 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 the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 2. “Autism services provider” means any person, entity, or group that provides treatment of autism spectrum disorders. 3. “Autism spectrum disorders” means any of the Pervasive Developmental Disorders (PDD) as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder, and PDD Not Otherwise Specified. 4. "Board Certified Behavior Analyst" means a behavior analyst credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst. 5. “Diagnosis of autism spectrum disorders” means medically necessary assessments, evaluations, including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has one of the autism spectrum disorders. 6. “Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including applied behavior analysis supervised by a Board Certified Behavior Analyst, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual. 7. “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the policy for other medical conditions. 8. “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. 9. “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. 10. “Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. 11. “Treatment of Autism Spectrum Disorders” will include the following care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: a . habilitative or rehabilitative care; b . pharmacy care; c . psychiatric care; d . psychological care; and e . therapeutic care. SECTION 3. Chapter 176A of the General Laws is hereby amended by inserting after section 8AA, the following section:- Section 8AB. (a) Any contract between a subscriber and the corporation under an individual or group hospital service plan which is issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Autism Spectrum Disorder in individuals. (b) Any such policy shall be deemed to be providing such benefits on a nondiscriminatory basis if the policy does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of said Autism Spectrum Disorders which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (c) This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy. (d) Coverage under this section will not be subject to any limits on the number of visits an individual may make to an autism services provider. (e) This section will not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan. (f) Definitions - 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 the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 2. “Autism services provider” means any person, entity, or group that provides treatment of autism spectrum disorders. 3. “Autism spectrum disorders” means any of the Pervasive Developmental Disorders (PDD) as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder, and PDD Not Otherwise Specified. 4. "Board Certified Behavior Analyst" means a behavior analyst credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst. 5. “Diagnosis of autism spectrum disorders” means medically necessary assessments, evaluations, including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has one of the autism spectrum disorders. 6. “Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including applied behavior analysis supervised by a Board Certified Behavior Analyst, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual. 7. “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the policy for other medical conditions. 8. “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. 9. “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. 10. “Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. 11. “Treatment of Autism Spectrum Disorders” will include the following care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: a . habilitative or rehabilitative care; b . pharmacy care; c . psychiatric care; d . psychological care; and e . therapeutic care. SECTION 4. Chapter 176B of the General Laws is hereby amended by inserting after section 4R, the following section:- Section 4S. (a) Any subscription certificate under an individual or group medical service agreement which is issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Autism Spectrum Disorder in individuals. (b) Any such policy shall be deemed to be providing such benefits on a nondiscriminatory basis if the policy does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of said Autism Spectrum Disorders which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (c) This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy. (d) Coverage under this section will not be subject to any limits on the number of visits an individual may make to an autism services provider. (e) This section will not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan. (f) Definitions - 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 the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 2. “Autism services provider” means any person, entity, or group that provides treatment of autism spectrum disorders. 3. “Autism spectrum disorders” means any of the Pervasive Developmental Disorders (PDD) as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder, and PDD Not Otherwise Specified. 4. "Board Certified Behavior Analyst" means a behavior analyst credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst. 5. “Diagnosis of autism spectrum disorders” means medically necessary assessments, evaluations, including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has one of the autism spectrum disorders. 6. “Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including applied behavior analysis supervised by a Board Certified Behavior Analyst, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual. 7. “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the policy for other medical conditions. 8. “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. 9. “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. 10. “Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. 11. “Treatment of Autism Spectrum Disorders” will include the following care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: a . habilitative or rehabilitative care; b . pharmacy care; c . psychiatric care; d . psychological care; and e . therapeutic care. SECTION 5. Said chapter 176G is hereby amended by inserting after section 4Q, as so appearing, the following section:- Section 4R. (a) A health maintenance contract issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Autism Spectrum Disorder in individuals. (b) Any such policy shall be deemed to be providing such benefits on a nondiscriminatory basis if the policy does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of said Autism Spectrum Disorders which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (c) This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy. (d) Coverage under this section will not be subject to any limits on the number of visits an individual may make to an autism services provider. (e) This section will not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan. (f) Definitions - 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 the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 2. “Autism services provider” means any person, entity, or group that provides treatment of autism spectrum disorders. 3. “Autism spectrum disorders” means any of the Pervasive Developmental Disorders (PDD) as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder, and PDD Not Otherwise Specified. 4. "Board Certified Behavior Analyst" means a behavior analyst credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst. 5. “Diagnosis of autism spectrum disorders” means medically necessary assessments, evaluations, including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has one of the autism spectrum disorders. 6. “Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including applied behavior analysis supervised by a Board Certified Behavior Analyst, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual. 7. “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the policy for other medical conditions. 8. “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. 9. “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. 10. “Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. 11. “Treatment of Autism Spectrum Disorders” will include the following care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: a . habilitative or rehabilitative care; b . pharmacy care; c . psychiatric care; d . psychological care; and e . therapeutic care. SECTION 6. All policies, contracts and certificates of health insurance subject to the provisions of section 24 of chapter 32A, section 47U of chapter 175, section 8AB of chapter 176A, section 4S of chapter 176B, and section 4R of chapter 176G of the General Laws which are delivered, issued, or renewed on or after January 1, 2010 shall conform with the provisions of this act. Form filings implementing this act shall be subject to the approval of the commissioner of insurance. SECTION 7. This act shall take effect on January 1, 2010. |