Senate Bill 2175

AN ACT TO REQUIRE ALL HEALTH INSURANCE POLICIES TO PROVIDE COVERAGE FOR THE DIAGNOSIS AND TREATMENT OF AUTISM SPECTRUM DISORDERS IN INDIVIDUALS LESS THAN 21 YEARS OF AGE; TO PROVIDE THAT COVERAGE SHALL BE SUBJECT TO A CERTAIN MAXIMUM BENEFIT PER YEAR; TO REQUIRE THE DEPARTMENT OF MENTAL HEALTH TO ESTABLISH STANDARDS TO BE UTILIZED BY MANAGED CARE PLANS FOR THE CREDENTIALING OF AUTISM SERVICE PROVIDERS; AND FOR RELATED PURPOSES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1. (1) 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 socially 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 any person, entity or group that provides treatment of autism spectrum disorders.

(c) "Autism spectrum disorders" means any of the pervasive development disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperager's Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

(d) "Diagnosis of autism spectrum disorders" means medically necessary assessment, evaluations or tests to diagnose whether an individual has one (1) of the autism spectrum disorders.

(e) "Evidence-based research" means research that applies rigorous, systemic and objective procedures to obtain valid knowledge relevant to autism spectrum disorders.

(f) "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.

(g) "Health insurance policy" means any group health policy or contract issued by an insurance entity.

(h) "Medically necessary" means any care, treatment, intervention, service or item that is prescribed, provided or ordered by a licensed physician or a licensed psychologist in accordance with accepted standards of practice and that will, or is reasonably expected to, do any of the following:

(i) Prevent the onset of an illness, condition, injury or disability;

(ii) Reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability; or

(iii) Assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age.

(i) "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.

(j) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

(k) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

(l) "Therapeutic care" means services provided by licensed or certified speech therapists, occupational therapists or physical therapists.

(m) "Treatment for autism spectrum disorders" shall 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:

(i) Habilitative or rehabilitative care;

(ii) Pharmacy care;

(iii) Psychiatric care;

(iv) Psychological care;

(v) Therapeutic care; and

(vi) Any care for individuals with autism spectrum disorders that is determined by the Department of Mental Health, based upon its review of best practices or evidence-based research that is medically necessary and that is properly promulgated under regulations establishing standards for qualified autism services providers. Once the regulations are promulgated, payment for the treatment of autism spectrum disorders covered under this section shall only be made to autism services providers who meet the standards.

(2) All health insurance policies shall provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals less than twenty-one (21) years of age. To the extent that the diagnosis treatment of autism spectrum disorders are not already covered by a health insurance policy, coverage under this section shall be included in health insurance policies that are delivered, executed, issued, amended, adjusted or renewed on or after July 1, 2010. No insurer can terminate coverage, or refuse to deliver, execute, issue, amend, adjust or renew coverage to an individual solely because the individual is diagnosed with one of the autism spectrum disorders or has received treatment for autism spectrum disorders.

(3) Coverage under this act will not be subject to any limits on the number of visits an individual may make to an autism services provider.

(4) Coverage under this act may be subject to copayment, deductible and coinsurance provisions of a health insurance policy to the extent that other medical services covered by the health insurance policy are subject to these provisions.

(5) This act will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy.

(6) Coverage under this act for "applied behavior analysis" will be subject to a maximum benefit of Fifty Thousand Dollars ($50,000.00) per year. After January 1, 2012, the Commissioner of Insurance shall, on an annual basis, adjust the maximum benefit for inflation by using the Medical Care Component of the United States Department of Labor Consumer Price Index for All Urban Consumers (CPI-U). The commissioner shall submit the adjusted maximum benefit for publication annually no later than July 1 of each calendar year, and the published adjusted maximum benefit shall be applicable in the following calendar year to health insurance policies subject to this act. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service or item unrelated to autism spectrum disorders shall not be applied towards any maximum benefit established under this section.

(7) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer shall have the right to request a review of that treatment not more than once every six (6) months unless the insurer and the individual's licensed physician or licensed psychologist agrees that a more frequent review is necessary. The cost of obtaining any review shall be borne by the insurer.

(8) To be eligible for benefits and coverage under this section, an individual must be diagnosed with one (1) of the autism spectrum disorders at age ten (10) or younger.

(9) The Department of Mental Health shall establish standards to be utilized by managed care plans for the credentialing of autism service providers. The department may require that a managed care plan grant credentials to any autism services provider whom the department determines meets or exceeds the department's credentialing standards.

SECTION 2. This act shall take effect and be in force from and after July 1, 2010.