SB-0415, As Passed Senate, March 13, 2012
SENATE BILL NO. 415
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
(MCL 500.100 to 500.8302) by adding section 3406s.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
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.