SB-0414, As Passed House, March 29, 2012                                                 Amendment No. 1

                                                                                                                                                      

 The Committee on Families, Children, and Seniors offered the following substitute (H-3):

 

 

 

 

 

 

 

 

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

 

years.

 

     (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

 

statistical manual:

 

     (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.