SB-0415, As Passed Senate, March 13, 2012


























     A bill to amend 1956 PA 218, entitled


"The insurance code of 1956,"


(MCL 500.100 to 500.8302) by adding section 3406s.




     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 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 it 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 applied behavior


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


per covered insured or enrollee and may be limited to an insured or


enrollee up to age 18.


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


available to an insured or enrollee under a policy or certificate.


     (3) If an insured or enrollee is receiving treatment for an


autism spectrum disorder, an insurer or health maintenance


organization 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 insurer or


health maintenance organization. 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.


     (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) 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) "Behavioral health treatment" means evidence-based,


counseling and treatment programs, including applied behavior


analysis, that meets 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


Senate Bill No. 415 as amended March 13, 2012


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


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. 414.


     (b) Senate Bill No. 981.