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Committee Substitute Favorable 5/14/13

Committee Substitute #2 Favorable 5/15/13
Fourth Edition Engrossed 5/15/13


Short Title:        Autism Health Insurance Coverage.




Referred to:


April 3, 2013




The General Assembly of North Carolina enacts:

SECTION 1.  Article 3 of Chapter 58 of the General Statutes is amended by adding a new section to read as follows:

" 58-3-192.  Coverage for autism spectrum disorders.

(a)        As used in this section, the following definitions apply:

(1)        Applied behavior analysis. - The design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

(2)        Autism spectrum disorder. - Any of the pervasive developmental disorders or autism spectrum disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the most recent edition of the International Statistical Classification of Diseases and Related Health Problems.

(3)        Behavioral health treatment. - Counseling and treatment programs, including applied behavior analysis, that are both of the following:

a.         Necessary to (i) increase appropriate or adaptive behaviors, (ii) decrease maladaptive behaviors, or (iii) develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.

b.         Provided or supervised by (i) a Board Certified Behavior Analyst or (ii) a licensed psychologist or licensed psychological associate, so long as the services performed are commensurate with the psychologist's training and experience.

(4)        Diagnosis of autism spectrum disorder. - Any medically necessary assessments, evaluations, or tests to diagnose whether an individual has autism spectrum disorder.

(5)        Health benefit plan. - As defined in G.S. 58-3-167, and including the State Health Plan for Teachers and State Employees established under Article 3B of Chapter 135 of the General Statutes.

(6)        Pharmacy care. - Medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need for or effectiveness of the medications.

(7)        Psychiatric care. - Direct or consultative services provided by a licensed psychiatrist.

(8)        Psychological care. - Direct or consultative services provided by a licensed psychologist or licensed psychological associate.

(9)        Therapeutic care. - Direct or consultative services provided by a licensed or certified speech therapist, occupational therapist, physical therapist, or licensed clinical social worker.

(10)      Treatment for autism spectrum disorders. - Any of the following care or related equipment ordered for an individual diagnosed with autism spectrum disorder by a licensed physician, or a licensed psychologist who determines the care to be medically necessary:

a.         Behavioral health treatment.

b.         Pharmacy care.

c.         Psychiatric care.

d.         Psychological care.

e.         Therapeutic care.

(b)        Every health benefit plan shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder for individuals 23 years of age or younger. No insurer shall terminate coverage or refuse to issue, amend, or renew coverage to an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spectrum disorder. Individuals must have received a diagnosis of autism spectrum disorder prior to the age of eight to qualify for required coverage under this section.

(c)        Coverage under this section may not be subject to any limits on the number of visits an individual may have for treatment of autism spectrum disorder.

(d)        Coverage under this section may not be denied on the basis that the treatments are habilitative or educational in nature.

(e)        Coverage under this section may be subject to co-payment, deductible, and coinsurance provisions of a health benefit plan that are not less favorable than the co-payment, deductible, and coinsurance provisions that apply to substantially all other medical services covered by the health benefit plan.

(f)         This section shall not be construed as limiting benefits that are otherwise available to an individual under a health benefit plan.

(g)        Coverage for behavioral health treatment under this section may be subject to a maximum benefit of up to thirty-six thousand dollars ($36,000) per year.

(h)        Except for inpatient services, if an individual is receiving treatment for autism spectrum disorder, an insurer shall have the right to request a review of that treatment not more than once annually, unless the insurer and the individual's licensed physician or the individual's licensed psychologist agree that a more frequent review is necessary. Any such agreement regarding the right to review a treatment plan more frequently shall apply only to a particular insured being treated for an autism spectrum disorder and shall not apply to all individuals being treated for an autism spectrum disorder by a physician or psychologist. The cost of obtaining any review shall be borne by the insurer.

(i)         This section shall not apply to plans that are certified as qualified health plans, as defined in 45 C.F.R. 155.20, if the requirements of this section are determined by the federal government to require the State to make payments for a state-required benefit that is in excess of the essential health benefits, pursuant to 45 C.F.R. 155.170(a)(3). Nothing in this subsection shall nullify the application of this section to plans that are not certified as qualified health plans.

(j)         This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.

(k)        The Commissioner of Insurance shall grant a health benefit plan issuer a waiver from the provisions of this section for a health benefit plan if the issuer demonstrates to the Commissioner, by actual claims experience over any consecutive 12-month period, that compliance with this section has increased the cost of the health benefit plan by an amount of one percent (1%) or greater in the premium rate charged under the health benefit plan over the most recent calendar year."

SECTION 2.  G.S. 90-270.4 is amended by adding a new subsection to read as follows:

"(f1)     Nothing in this Article shall be construed to prevent a Board Certified Behavior Analyst (BCBA) or a Board Certified Assistant Behavior Analyst (BCaBA) from offering services within the scope of practice authorized by the Behavior Analyst Certification Board, including behavior analysis and therapy, in accordance with professional standards of the BCBA or BCaBA's certification, if both of the following are true:

(1)        The BCBA or BCaBA is properly certified and in good standing with the Behavior Analyst Certification Board.

(2)        The BCBA or BCaBA does not hold himself or herself out to the public by any title or description stating or implying that the BCBA or BCaBA is a psychologist or is licensed, certified, or registered to practice psychology in this State."

SECTION 3.(a)  G.S. 135-48.51 reads as rewritten:

" 135-48.51.  Coverage and operational mandates related to Chapter 58 of the General Statutes.

The following provisions of Chapter 58 of the General Statutes apply to the State Health Plan:

(1)        G.S. 58-3-191, Managed care reporting and disclosure requirements.

(2)        G.S. 58-3-192, Coverage for autism spectrum disorders.

(2)(3)   G.S. 58-3-221, Access to nonformulary and restricted access prescription drugs.

(3)(4)   G.S. 58-3-223, Managed care access to specialist care.

(4)(5)   G.S. 58-3-225, Prompt claim payments under health benefit plans.

(5)(6)   G.S. 58-3-235, Selection of specialist as primary care provider.

(6)(7)   G.S. 58-3-240, Direct access to pediatrician for minors.

(7)(8)   G.S. 58-3-245, Provider directories.

(8)(9)   G.S. 58-3-250, Payment obligations for covered services.

(9)(10) G.S. 58-3-265, Payment obligations for covered services.

(10)(11)     G.S. 58-3-280, Coverage for the diagnosis and treatment of lymphedema.

(11)(12)     G.S. 58-3-285, Coverage for hearing aids.

(12)(13)     G.S. 58-50-30, Right to choose services of optometrist, podiatrist, licensed clinical social worker, certified substance abuse professional, licensed professional counselor, dentist, physical therapist, chiropractor, psychologist, pharmacist, certified fee-based practicing pastoral counselor, advanced practice nurse, licensed marriage and family therapist, or physician assistant.

(13)(14)     G.S. 58-67-88, Continuity of care."

SECTION 3.(b)  No later than March 1, 2015, and every March 1st thereafter, the Department of the State Treasurer shall submit a report to the General Assembly regarding the implementation of coverage under the State Health Plan for Teachers and State Employees required under this section. The report shall include the following information:

(1)        The total number of insureds diagnosed with autism spectrum disorder.

(2)        The total costs of all claims paid out in the prior fiscal year for coverage required by this section.

(3)        The cost of coverage required under this section per insured per month.

(4)        The average cost per insured for coverage of any treatment involving applied behavior analysis.

SECTION 4.  Section 1 of this act becomes effective October 1, 2013, and applies to insurance contracts issued, renewed, or amended on or after that date. Section 3 of this act becomes effective January 1, 2014. The remainder of this act is effective when it becomes law.