SB-0414, As Passed Senate, March 13, 2012

 

 

 

 

 

 

 

 

 

 

 

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 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 it 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 applied behavior

 

analysis may be subject to a maximum annual benefit of $50,000.00

 

per covered member and may be limited to a member up to age 18.

 

     (2) This section does not limit benefits that are otherwise

 

available to a member under a certificate.

 

     (3) If a member is receiving treatment for an autism spectrum

 

disorder, a health care corporation may request a review of that

 

treatment consistent with current protocols and may require a

 

treatment plan. The cost of obtaining a treatment review shall be

 

borne by the health care corporation. 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.

 

     (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) 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 spectrum disorders" means any of the following

 

pervasive developmental disorders as defined by the "Diagnostic and

 

Statistical Manual of Mental Disorders" of the American psychiatric

 

association:

 

     (i) Autistic disorder.

 

     (ii) Asperger's disorder.

 

     (iii) Pervasive developmental disorder not otherwise specified.

 

     (c) "Behavior 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.

 

     (d) "Diagnosis of autism spectrum disorders" means

 

assessments, evaluations, or tests performed by a licensed

 

physician or a licensed psychologist to diagnose whether an

 

individual has 1 of the autism spectrum disorders.

 

     (e) "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.

 

     (f) "Psychiatric care" means evidence-based direct or

 

consultative services provided by a psychiatrist licensed in the

 

state in which the psychiatrist practices.

 

     (g) "Psychological care" means evidence-based direct or

 

consultative services provided by a psychologist licensed in the

 

state in which the psychologist practices.

 

     (h) "Therapeutic care" means evidence-based services provided

 

by a licensed or certified speech therapist, occupational

 

therapist, physical therapist, or social worker.

 

     (i) "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.

 

     (j) "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

 


Senate Bill No. 414 as amended March 13, 2012

 

treatment of an autism spectrum disorder is first prescribed or

 

ordered by a licensed physician or licensed psychologist as

 

described in subdivision (i).

<<Enacting section 1. This amendatory act takes effect October 1, 2012.>>

     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.