HB1108 HD1.DOC

SECTION 1. The purpose of this Act is to ensure the provision of quality health care for all Hawaii residents by requiring coverage of treatment for autism spectrum disorders.

SECTION 2. Chapter 431, Hawaii Revised Statutes, is amended by adding a new section to article 10A to be appropriately designated and to read as follows:

"§431:10A- Autism spectrum disorders benefits and coverage; notice; definitions. (a) Each individual or group accident and health or sickness insurance policy, contract, plan, or agreement issued or renewed in this State after December 31, 2016, shall provide to the policyholder and individuals twenty-one years of age and under covered under the policy, contract, plan, or agreement, coverage for the screening, including well-baby and well-child screening, diagnosis, and evidence-based treatment of autism spectrum disorders, as prescribed or ordered for an individual with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner.

(b) Every insurer shall provide notice to its policyholders regarding the coverage required by this section. The notice shall be prominently positioned in any literature or correspondence sent to policyholders and shall be transmitted to policyholders within calendar year 2016 when annual information is made available to members or in any other mailing to members, but in no case later than December 31, 2016.

(c) Individual coverage for behavioral health treatment provided under this section shall be subject to a maximum benefit of $50,000 per year and a maximum lifetime benefit of $300,000, but shall not be subject to any limits on the number of visits to an autism service provider. After December 31, 2017, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation using the medical care component of the United States Bureau of Labor Consumer Price Index for urban Honolulu; provided that the commissioner shall post notice of and hold a public meeting in the same manner as required by section 91-3(a) before adjusting the maximum benefit. The commissioner shall publish the adjusted maximum benefit annually no later than April 1 of each calendar year, which shall apply during the following calendar year to health insurance policies subject to this section. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, or service other than behavioral health treatment shall not be applied toward any maximum benefit established under this subsection.

(d) Coverage under this section may be subject to

copayment, deductible, and coinsurance provisions of an accident and health or sickness insurance policy, contract, plan, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the policy, contract, plan, or agreement.

(e) This section shall not be construed as limiting benefits that are otherwise available to an individual under an accident and health or sickness insurance policy, contract, plan, or agreement.

(f) Coverage for treatment under this section shall not be denied on the basis that the treatment is habilitative or non-restorative in nature.

(g) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer may request a review of that treatment. The cost of obtaining any review shall be borne by the insurer.

(h) This section shall not be construed as reducing any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.

(i) Nothing in this section shall apply to non-grandfathered plans in the individual and small group markets that are required to include essential health benefits under the Patient Protection and Affordable Care Act, Public Law 111-148, as amended, or to medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies.

(j) Insurers shall include in their network of approved autism service providers only those providers who have cleared criminal background checks as determined by the insurer.

(k) Insurers shall include board certified behavior analysts in their provider network.

(l) If an individual has been diagnosed as having an autism spectrum disorder, then that individual shall not be required to undergo repeat evaluation upon publication of a subsequent edition of the Diagnostic and Statistical Manual of Mental Disorders to remain eligible for coverage under this section.

(m) Coverage for applied behavior analysis shall include the services of the personnel who work under the supervision of the board certified behavior analyst or the licensed psychologist overseeing the program.

(n) As used in this section, unless the context clearly requires otherwise:

"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. The practice of applied behavior analysis expressly excludes psychological testing, diagnosis of a mental or physical disorder, neuropsychology, psychotherapy, cognitive therapy, sex therapy, psychoanalysis, hypnotherapy, and long-term counseling as treatment modalities.

"Autism service provider" means any person, entity, or group that provides treatment for autism spectrum disorders.

"Autism spectrum disorders" means any of the pervasive developmental disorders or autism spectrum disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.

"Behavioral health treatment" means evidence-based counseling and treatment programs, including applied behavior analysis, that are:

(1) Necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual;

(2) Prescribed or ordered for an individual with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner; and

(3) Provided or supervised by a board certified behavior analyst or by a licensed psychologist so long as the services performed are commensurate with the psychologist's formal university training and supervised experience.

"Board certified behavior analyst" means a person with a master's degree or higher, who has at least one thousand five hundred supervised hours of applied behavior analysis work experience and who is credentialed by the Behavior Analyst Certification Board as a board certified behavior analyst.

"Diagnosis of autism spectrum disorders" means medically necessary assessments, evaluations, or tests conducted to diagnose whether an individual has an autism spectrum disorder.

"Pharmacy care" means medications prescribed by a licensed physician or nurse practitioner and any health-related services that are deemed medically necessary to determine the need or effectiveness of the medications.

"Psychiatric care" means direct or consultative services provided by a licensed psychiatrist.

"Psychological care" means direct or consultative services provided by a licensed psychologist.

"Therapeutic care" means services provided by licensed speech pathologists, registered occupational therapists, licensed social workers, licensed clinical social workers, or licensed physical therapists.

"Treatment for autism spectrum disorders" includes the following care prescribed or ordered for an individual with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner if the care is determined to be medically necessary:

(1) Behavioral health treatment;

(2) Pharmacy care;

(3) Psychiatric care;

(4) Psychological care; and

(5) Therapeutic care."

SECTION 3. Chapter 432, Hawaii Revised Statutes, is amended by adding a new section to article 1 to be appropriately designated and to read as follows:

"§432:1- Autism spectrum disorders benefits and coverage; notice; definitions. (a) Each individual or group hospital or medical service plan, policy, contract, or agreement issued or renewed in this State after December 31, 2016, shall provide to the member and individuals twenty-one years of age and under covered under the service plan, policy, contract, or agreement, coverage for the screening, including well-baby and well-child screening, diagnosis, and evidence-based treatment of autism spectrum disorders, as prescribed or ordered for an individual with an autism spectrum disorder by a licensed physician, psychiatrist, psychologist, licensed clinical social worker, or nurse practitioner.

(b) Every mutual benefit society shall provide notice to its members regarding the coverage required by this section. The notice shall be prominently positioned in any literature or correspondence sent to members and shall be transmitted to members within calendar year 2016 when annual information is made available to members or in any other mailing to members, but in no case later than December 31, 2016.

(c) Individual coverage for behavioral health treatment provided under this section shall be subject to a maximum benefit of $50,000 per year and a maximum lifetime benefit of $300,000, but shall not be subject to any limits on the number of visits to an autism service provider. After December 31, 2017, the insurance commissioner, on an annual basis, shall adjust the maximum benefit for inflation, using the medical care component of the United States Bureau of Labor Consumer Price Index for urban Honolulu; provided that the commissioner shall post notice of and hold a public meeting in the same manner as required by section 91-3(a) before adjusting the maximum benefit. The commissioner shall publish the adjusted maximum benefit annually no later than April 1 of each calendar year, which shall apply during the following calendar year to health insurance policies subject to this section. Payments made by a mutual benefit society on behalf of a covered individual for any care, treatment, intervention, or service other than behavioral health treatment shall not be applied toward any maximum benefit established under this subsection.

(d) Coverage under this section may be subject to

copayment, deductible, and coinsurance provisions of an individual or group hospital or medical service plan, policy, contract, or agreement that are no less favorable than the copayment, deductible, and coinsurance provisions for substantially all other medical services covered by the service plan, policy, contract, or agreement.

(e) This section shall not be construed as limiting benefits that are otherwise available to an individual under an individual or group hospital or medical service plan, policy, contract, or agreement.

(f) Coverage for treatment under this section shall not be denied on the basis that the treatment is habilitative or non-restorative in nature.

(g) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, a mutual benefit society may request a review of that treatment. The cost of obtaining any review shall be borne by the mutual benefit society.

(j) Mutual benefit societies shall include in their network of approved autism service providers only those providers who have cleared criminal background checks as determined by the mutual benefit society.

(k) Mutual benefit societies shall include board certified behavior analysts in their provider network.