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


























     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.




     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




     (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




     (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




     (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.