HOUSE SUBSTITUTE FOR
SENATE BILL NO. 414
A bill to amend 1980 PA 350, entitled
"The nonprofit health care corporation reform act,"
(MCL 550.1101 to 550.1704) by adding section 416e.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 416e. (1) Except as otherwise provided in this section, a
health care corporation group or nongroup certificate shall provide
coverage for the diagnosis of autism spectrum disorders and
treatment of autism spectrum disorders. A health care corporation
shall not do any of the following:
(a) Limit the number of visits a member may use for treatment
of autism spectrum disorders covered under this section.
(b) Deny or limit coverage under this section on the basis
that treatment is educational or habilitative in nature.
(c) 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 a member through 18 years of
age and may be subject to a maximum annual benefit as follows:
(i) For a covered member through 6 years of age, $50,000.00.
(ii) For a covered member from 7 years of age through 12 years
of age, $40,000.00.
(iii) For a covered member 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 a member under a certificate. A health care
corporation shall utilize evidence-based care and managed care
cost-containment practices pursuant to the health care
corporation'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
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 provisions.
(3) If a member is receiving treatment for an autism spectrum
disorder, a health care corporation 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
health care corporation, the cost of treatment review shall be
borne by the health care corporation.
(b) Request the results of the autism diagnostic observation
schedule that has been used in the diagnosis of an autism spectrum
disorder for that member.
(c) Request that the autism diagnostic observation schedule be
performed on that member not more frequently than once every 3
(d) Request that an annual development evaluation be conducted
and the results of that annual development evaluation be submitted
to the health care corporation.
(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 require the coverage of prescription
drugs and related services unless the member is covered by a
prescription drug plan. This section does not require a health care
corporation to provide coverage for autism spectrum disorders to a
member under more than 1 of its certificates. If a member 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.
(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 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
certificates delivered, executed, issued, amended, adjusted, or
renewed in 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. 415.
(b) Senate Bill No. 981.