Section 1. Amend Chapter 33, Title 18, Delaware Code by
inserting therein the following:
Ҥ3361. Autism Spectrum
Disorders Coverage
(a) All individual health benefit plans as
defined in section §3343(a)(2) of
this Title shall provide coverage for the screening and diagnosis of autism
spectrum disorders and the treatment of autism spectrum disorders in
individuals less than 21 years of age. To the extent that the diagnosis of
autism spectrum disorders and the treatment of autism spectrum disorders are
not already covered by a health benefit plan, coverage under this section shall
be included in health benefit plans that are delivered, issued, executed or
renewed in this State pursuant to this Title after this Act takes effect. No
insurer shall terminate coverage or refuse to deliver, execute, issue, amend,
adjust, or renew coverage to an individual solely because the individual or a
family member is diagnosed with one of the autism spectrum disorders or has
received treatment for autism spectrum disorders. Coverage under this section shall not be
denied on the basis that the treatment is habilitative or nonrestorative in
nature.
(b) Coverage for applied behavior analysis
services under this section by an insurer shall be subject to a maximum benefit
of thirty-six thousand dollars ($36,000) per twelve month period, but shall not
be subject to any limits on the number of visits an individual may make to an
autism services provider or that a provider may make to an individual
regardless of the locations in which services are provided. After December 30, 2011, the Insurance Commissioner
shall, on or before April 1 of each calendar year, publish in the Delaware
Register of Regulations an adjustment to the maximum benefit equal to the
change in the United States Department of Labor Consumer Price Index for all
Urban Consumers
(CPI-U) in the preceding year and the published
adjusted maximum benefit shall be applicable to all health insurance policies
issued or renewed thereafter. Payments made by an insurer on behalf of a
covered individual for treatment unrelated to applied behavior analysis shall
not be applied toward any maximum benefit established under this subsection.
(c) The coverage required
under this section shall not be subject to dollar limits, deductibles, or
coinsurance provisions that are less favorable to an insured than the dollar
limits, deductibles, or coinsurance provisions that apply to physical illness
generally under the health benefit plan, except as otherwise provided in
subsection (b) of this section.
(d) This section shall not be construed as
limiting benefits that are otherwise available to an individual or family
member under their health benefit plan.
(e) As
used in this section:
(1) “Applied behavior
analysis” means 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 services provider’
means any person, entity, or group authorized by this section that provides treatment of autism spectrum disorders.
This includes licensed physicians, psychologists, psychiatrists, speech
therapists or their aides, occupational therapists or their aides, physical
therapists or their assistants, practitioners with the national certification
of board-certified behavior analyst or those working under their supervision,
or any person, entity, or group meeting the standards set by the Department of
Health and Social Services as authorized by subsection
(f) of this section.
(3) ‘Autism spectrum
disorders’ means any of the pervasive developmental disorders as defined by the
most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM), including Autistic Disorder, Asperger’s Disorder and Pervasive
Developmental Disorder Not Otherwise Specified, as such may be amended
hereafter from time to time.
(4) ‘Screening and diagnosis
of autism spectrum disorders’ means medically necessary assessments,
evaluations, or tests to diagnose whether an individual has or is at risk for one
of the autism spectrum disorders.
(5) ‘Behavioral health
treatment’ means professional counseling, guidance services or treatment
programs, including applied behavior analysis, that are necessary to develop,
maintain, or restore, to the maximum extent practicable, the functioning of an
individual. This definition also applies to treatment or counseling to improve
social skills and function.
(6) ‘Medically necessary’ means
reasonably expected to do the following:
a. prevent the onset of an
illness, condition, injury, or disability;
b. reduce or ameliorate the
physical, mental, or developmental effects of an illness, condition, injury, or
disability; or
c. assist to achieve or
maintain maximum functional capacity in performing daily activities, taking
into account both the functional capacity of the individual and the functional
capacities that are appropriate for individuals of the same age.
(7) ‘Pharmacy care’ means
medications prescribed by a licensed practitioner and any health-related
services deemed medically necessary to determine the need or effectiveness of
the medications.
(8) ‘Psychiatric care’ means
direct or consultative services provided by a psychiatrist licensed in the
state in which the psychiatrist practices.
(9) ‘Psychological care’
means direct or consultative services provided by a psychologist licensed in
the state in which the psychologist practices.
(10) ‘Therapeutic care’
means services provided by speech, occupational, or physical therapists or an
aide or assistant under their supervision.
(11) ‘Treatment for autism
spectrum disorders’ shall include the following care prescribed or ordered for
an individual diagnosed with one of the autism spectrum disorders by a licensed
physician or 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;
f. items and equipment
necessary to provide, receive, or advance in the above listed services,
including those necessary for applied behavioral analysis; and
g. any care for individuals
with autism spectrum disorders that is determined by the Secretary of the
Department of Health and Social Services, based upon their review of best
practices and/or evidence-based research, to be medically necessary. The
Secretary shall inform the Insurance Commissioner of such determination, and
upon receiving notice the Insurance Commissioner shall issue a bulletin stating
that any such care, treatment, intervention, service, or item that was not
previously covered shall be included in any health benefit plan delivered,
executed, issued, amended, adjusted, or renewed on or after 120 days following
the date of such bulletin.
(f) The Department of Health
and Social Services shall promulgate regulations establishing standards for
certifying qualified autism services providers within 6 months after enactment
of this Act. If an autism services provider meets recognized national
certification as a Board Certified Behavior Analyst, such autism services
provider shall be deemed to have met the standards to be established under this
section, as will those working under the supervision of such providers to
provide applied behavioral analysis services. Once the regulations are
promulgated, payment for the treatment of autism spectrum disorders covered
under this section shall only be required to be made to autism services
providers who meet the standards.
(g) Except for inpatient
services, if an individual is receiving treatment for autism spectrum
disorders, an insurer will have the right to request a review of that treatment
not more than once every twelve (12) months unless the insurer and the licensed
physician or licensed psychologist agree that a more frequent review is
necessary. The cost of obtaining any review shall be borne by the insurer.
(h) This section shall not
be construed as affecting any obligation to provide services to an individual
under an individualized family service plan (IFSP); an individualized education
program (IEP); an individual plan for employment (IPE); or an individualized
service plan, including an essential lifestyle plan (ELP).
(i) The Insurance Commissioner
may promulgate rules and regulations as may be necessary or appropriate to
implement and administer this section, except for subsection (f) of this
section.”.
Section 2. Amend §3343 of Title 18 by adding a new
subsection (g) to read as follows:
“(g) Nothing in
this section shall be construed to limit or reduce any benefit, entitlement, or
coverage conferred by §3361 of this Title including, but not limited
to, provider and service eligibility.”.
Section 3. Amend Subchapter III, Chapter 35, Title 18,
Delaware Code by inserting therein the following:
Ҥ3570A. Autism Spectrum
Disorders Coverage
(a) All group and blanket health benefit plans as
defined in §3578(a)(2) of this Title
shall provide coverage for the screening and diagnosis of autism spectrum
disorders and the treatment of autism spectrum disorders in individuals less
than 21 years of age. To the extent that the diagnosis of autism spectrum
disorders and the treatment of autism spectrum disorders are not already
covered by a health benefit plan, coverage under this section shall be included
in health benefit plans that are
delivered, issued, executed or renewed in this State pursuant to this
Title after this Act takes effect. No insurer shall terminate coverage or
refuse to deliver, execute, issue, amend, adjust, or renew coverage to a group
solely because an individual in that group
or a family member of an individual in that group is diagnosed with one
of the autism spectrum disorders or has received treatment for autism spectrum
disorders. Coverage under this section
shall not be denied on the basis that the treatment is habilitative or
nonrestorative in nature.
(b) Coverage for applied behavior analysis
services under this section by an insurer shall be subject to a maximum benefit
of thirty-six thousand dollars ($36,000) per twelve month period, but shall not
be subject to any limits on the number of visits an individual may make to an
autism services provider, or that a provider may make to an individual,
regardless of the locations in which services are provided. After December 30, 2011, the Insurance
Commissioner shall, on or before April 1 of each calendar year, publish in the
Delaware Register of Regulations an adjustment to the maximum benefit equal to
the change in the United States Department of Labor Consumer Price Index for
all Urban Consumers
(CPI-U) in the preceding year and the published
adjusted maximum benefit shall be applicable to all health insurance policies
issued or renewed thereafter. Payments made by an insurer on behalf of a
covered individual for treatment unrelated to applied behavior analysis shall
not be applied toward any maximum benefit established under this subsection.
(c) The coverage required
under this section shall not be subject to dollar limits, deductibles, or
coinsurance provisions that are less favorable to an insured than the dollar
limits, deductibles, or coinsurance provisions that apply to physical illness
generally under the health benefit plan, except as otherwise provided in
subsection (b) of this section.
(d) This section shall not be construed as
limiting benefits that are otherwise available to an individual or family
member under their health benefit plan.
(e) As used in this section:
(1) “Applied behavior
analysis” means 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 services
provider’ means any person, entity, or group authorized by this section that provides treatment of
autism spectrum disorders. This includes licensed physicians, psychologists,
psychiatrists, speech therapists or their aides, occupational therapists or
their aides, physical therapists or their assistants, practitioners with the
national certification of board-certified behavior analyst or those working
under their supervision, or any person, entity, or group meeting the standards
set by the Department of Health and Social Services as authorized by subsection (f) of this section.
(3) ‘Autism spectrum
disorders’ means any of the pervasive developmental disorders as defined by the
most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM), including Autistic Disorder, Asperger’s Disorder and Pervasive
Developmental Disorder Not Otherwise Specified, as such may be amended
hereafter from time to time.
(4) ‘Screening and diagnosis
of autism spectrum disorders’ means medically necessary assessments,
evaluations, or tests to diagnose whether an individual has or is at risk for one
of the autism spectrum disorders.
(5)
‘Behavioral health treatment’ means professional counseling, guidance services or
treatment programs, including applied behavior analysis, that are necessary to
develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. This definition also applies to treatment or
counseling to improve social skills and function.
(6) ‘Medically necessary’ means reasonably
expected to do the following:
a. prevent the onset of an
illness, condition, injury, or disability;
b. reduce or ameliorate the
physical, mental, or developmental effects of an illness, condition, injury, or
disability; or
c. assist to achieve or
maintain maximum functional capacity in performing daily activities, taking
into account both the functional capacity of the individual and the functional
capacities that are appropriate for individuals of the same age.
(7) ‘Pharmacy care’ means
medications prescribed by a licensed practitioner and any health-related
services deemed medically necessary to determine the need or effectiveness of
the medications.
(8) ‘Psychiatric care’ means
direct or consultative services provided by a psychiatrist licensed in the
state in which the psychiatrist practices.
(9) ‘Psychological care’
means direct or consultative services provided by a psychologist licensed in
the state in which the psychologist practices.
(10) ‘Therapeutic care’
means services provided by speech, occupational, or physical therapists or an
aide or assistant under their supervision.
(11) ‘Treatment for autism
spectrum disorders’ shall include the following care prescribed or ordered for
an individual diagnosed with one of the autism spectrum disorders by a licensed
physician or 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;
f. items and equipment
necessary to provide, receive, or advance in the above listed services,
including those necessary for applied behavioral analysis; and
g. any care for individuals
with autism spectrum disorders that is determined by the Secretary of the
Department of Health and Social Services, based upon their review of best
practices and/or evidence-based research, to be medically necessary. The
Secretary shall inform the Insurance Commissioner of such determination, and
upon receiving notice the Insurance Commissioner shall issue a bulletin stating
that any such care, treatment, intervention, service, or item that was not
previously covered shall be included in any health benefit plan delivered,
executed, issued, amended, adjusted, or renewed on or after 120 days following
the date of such bulletin.
(f) The Department of Health
and Social Services shall promulgate regulations establishing standards for
certifying qualified autism services providers within 6 months of the enactment
of this Act. If an autism services provider meets recognized national
certification as a Board Certified Behavior Analyst, such autism services
provider shall be deemed to have met the standards to be established under this
section, as will those working under the supervision of such providers to
provide applied behavioral analysis services. Once the regulations are
promulgated, payment for the treatment of autism spectrum disorders covered
under this section shall only be required to be made to autism services
providers who meet the standards.
(g) Except for inpatient
services, if an individual is receiving treatment for autism spectrum
disorders, an insurer will have the right to request a review of that treatment
not more than once every twelve (12) months unless the insurer and the licensed
physician or licensed psychologist agree that a more frequent review is
necessary. The cost of obtaining any review shall be borne by the insurer.
(h) This section shall not be construed as
affecting any obligation to provide services to an individual under an
individualized family service plan (IFSP); an individualized education program
(IEP); an individual plan for employment (IPE); or an individualized service plan,
including an essential lifestyle plan (ELP).
(i) The Insurance
Commissioner may promulgate rules and regulations as may be necessary or
appropriate to implement and administer this section, except for subsection (f)
of this section.”.
Section 4. Amend §3578 of Title 18 by adding a new
subsection (g) to read as follows:
“(g) Nothing in
this section shall be construed to limit or reduce any benefit, entitlement, or
coverage conferred by §3570A of this Title including,
but not limited to, provider and service eligibility.”.
Section 5. This act shall
take effect 120 days after its enactment.
