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
(b) Limit the number of visits an insured or enrollee may use
for treatment of autism spectrum disorders covered under this
(c) Deny or limit coverage under this section on the basis
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
(i) For a covered insured or enrollee through 6 years of age,
(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
(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
(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.
(c) Request that the autism diagnostic observation schedule be
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.
(c) "Autism spectrum disorders" means any of the following
pervasive developmental disorders as defined by the diagnostic and
(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.