Section 25: Insurance coverage for diagnosis and treatment of autism spectrum disorder
Section 25. (a) As used in this section the following words shall, unless the context clearly requires otherwise, have the following meanings:—
''Actuary'', a person who is a member of American Academy of Actuaries and meets the academy's professional qualification standards for rendering an actuarial opinion related to health insurance rate making.
''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.
''Autism services provider'', a person, entity or group that provides treatment of autism spectrum disorders.
''Autism spectrum disorders'', any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger's disorder and pervasive developmental disorders not otherwise specified.
''Board certified behavior analyst'', a behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst.
''Diagnosis of autism spectrum disorders'', medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has 1 of the autism spectrum disorders.
''Habilitative or rehabilitative care'', professional, counseling and guidance services and treatment programs, including, but not limited to, applied behavior analysis supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual.
''Pharmacy care'', medications prescribed by a licensed physician and health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the insurance policy for other medical conditions.
''Psychiatric care'', direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
''Psychological care'', direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
''Therapeutic care'', services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers.
''Treatment of autism spectrum disorders'', includes the following care prescribed, provided 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: habilitative or rehabilitative care; pharmacy care; psychiatric care; psychological care; and therapeutic care.
(b) The commission shall provide to an active or retired employee of the commonwealth who is insured under the group insurance commission benefits on a nondiscriminatory basis for the diagnosis and treatment of autism spectrum disorder in individuals.
(c) A health plan provided by the commission shall be in compliance with subsection (b) if the plan does not contain an annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of autism spectrum disorders which is less than an annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions.
(d) This section shall not limit benefits that are otherwise available to an individual under a health insurance policy.
(e) Coverage under this section shall not be subject to a limit on the number of visits an individual may make to an autism services provider.
(f) This section shall not affect an obligation to provide services to an individual under an individualized family service plan, an individualized education program or an individualized service plan. Services related to autism spectrum disorder provided by school personnel under an individualized education program are not subject to reimbursement under this section.
(g) An insurer, corporation or health maintenance organization shall be exempt for a period of 3 years from the requirement to provide coverage for habilitative or rehabilitative care required under this section and not covered by the insurer, corporation or health maintenance organization as of December 31, 2010, if:
(1) an actuary, affiliated with the insurer, corporation or health maintenance organization certifies in writing to the commissioner of insurance that:
(i) based on an analysis to be completed not more than once annually by each insurer, corporation or health maintenance organization for the most recent experience period of at least 1 year's duration, the annual costs associated with coverage of habilitative or rehabilitative care required under this section and not covered as of December 31, 2010, exceeded 1 per cent of the premiums charged over the experience period by the insurer, corporation or health maintenance organization;
(ii) those costs solely would lead to an increase in average premiums charged of more than 1 per cent for all insurance policies, subscription contracts or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer, corporation or health maintenance organization employs; and
(iii) the commissioner of insurance approves the certification of the actuary.
(2) An exemption allowed under paragraph (1) shall apply for a 3 year coverage period following inception or next renewal date of all insurance policies, subscription contracts or health care plans issued or renewed during the 1–year period following the date of the exemption, after which the insurer, corporation or health maintenance organization shall again provide coverage for habilitative or rehabilitative care required under this section.
(3) Notwithstanding the exemption allowed under paragraph (1), an insurer, corporation or health maintenance organization may elect to continue to provide coverage for habilitative or rehabilitative care required under this section.