HOUSE DOCKET, NO. 881        FILED ON: 1/15/2019

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 999

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

Natalie M. Higgins

_________________

To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:

The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:

An Act providing insurance coverage for Alfi’s syndrome.

_______________

PETITION OF:

HOUSE DOCKET, NO. 881        FILED ON: 1/15/2019

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 999

[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE HOUSE, NO. 3969 OF 2017-2018.]

The Commonwealth of Massachusetts

_______________

In the One Hundred and Ninety-First General Court
(2019-2020)

_______________

An Act providing insurance coverage for Alfi’s syndrome.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

SECTION 1. Chapter 32A of the General Laws is hereby amended by adding the following section:-

Section 28. (a) For purposes of this section, the following terms shall have the following meanings, unless the context clearly requires otherwise:

“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.

“Alfi’s syndrome services provider”, a person, entity or group that provides treatment of Alfi’s syndrome.

“Alfi’s syndrome”,  a genetic condition also known as 9p deletion syndrome or monosomy 9p.

“Board certified behavior analyst”, a behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst.

“Diagnosis of Alfi’s syndrome”, medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has Alfi’'s syndrome.

“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 Alfi’s syndrome”, includes the following care prescribed, provided or ordered for an individual diagnosed with Alfi’s syndrome 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 Alfi’s syndrome 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 Alfi’s syndrome 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 Alfi’s syndrome 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 Alfi’s syndrome 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, 2019, 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, 2019, 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.

SECTION 2. Chapter 175 of the General Laws is hereby amended by inserting after section 47II the following section:-

Section 47JJ. (a) For purposes of this section, the following terms shall have the following meanings, unless the context clearly requires otherwise:

“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.

“Alfi’s syndrome services provider”, a person, entity or group that provides treatment of Alfi’s syndrome.

“Alfi’s syndrome”, a genetic condition also known as 9p deletion syndrome or monosomy 9p.

“Board certified behavior analyst”, a behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst.

“Diagnosis of Alfi’s syndrome”, medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has Alfi’'s syndrome.

“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 Alfi’s syndrome”, includes the following care prescribed, provided or ordered for an individual diagnosed with Alfi’s syndrome 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) An individual policy of accident and sickness insurance issued under section 108 that provides hospital expense and surgical expense insurance and any group blanket or general policy of accident and sickness insurance issued under section 110 that provides hospital expense and surgical expense insurance, which is issued or renewed within or without the commonwealth, shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Alfi’s syndrome in individuals.

(c) Such policy shall be in compliance with subsection (b) if the policy does not contain annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of Alfi’s syndrome 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 Alfi’s syndrome 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 Alfi’s syndrome 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, 2019, 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, 2019, 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.

SECTION 3. Chapter 176A of the General Laws is hereby amended by inserting after section 8KK the following section:-

Section 8LL. (a) For purposes of this section, the following terms shall have the following meanings, unless the context clearly requires otherwise:

“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.

“Alfi’s syndrome services provider”, a person, entity or group that provides treatment of Alfi’s syndrome.

“Alfi’s syndrome”, a genetic condition also known as 9p deletion syndrome or monosomy 9p.

“Board certified behavior analyst”, a behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst.

“Diagnosis of Alfi’s syndrome”, medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has Alfi’'s syndrome.

“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 Alfi’s syndrome”, includes the following care prescribed, provided or ordered for an individual diagnosed with Alfi’s syndrome 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) A contract between a subscriber and the corporation under an individual or group hospital service plan which is issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Alfi’s syndrome in individuals.

(c) Such contract shall be in compliance with subsection (b) if the contract does not contain annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of Alfi’s syndrome 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 Alfi’s syndrome 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 Alfi’s syndrome 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, 2019, 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, 2019, 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.

SECTION 4. Chapter 176B of the General Laws is hereby amended by inserting after section 4KK the following section:-

Section 4LL. (a) For purposes of this section, the following terms shall have the following meanings, unless the context clearly requires otherwise:

“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.

“Alfi’s syndrome services provider”, a person, entity or group that provides treatment of Alfi’s syndrome.

“Alfi’s syndrome”, a genetic condition also known as 9p deletion syndrome or monosomy 9p.

“Board certified behavior analyst”, a behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst.

“Diagnosis of Alfi’s syndrome”, medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has Alfi’'s syndrome.

“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 Alfi’s syndrome”, includes the following care prescribed, provided or ordered for an individual diagnosed with Alfi’s syndrome 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) A subscription certificate under an individual or group medical service agreement which is issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Alfi’s syndrome in individuals.

(c) Such certificate shall be in compliance with subsection (b) if the certificate does not contain annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of Alfi’s syndrome 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 Alfi’s syndrome 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 Alfi’s syndrome 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, 2019, 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, 2019, 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.

SECTION 5. Chapter 176G of the General Laws is hereby amended by inserting after section 4CC the following section:-

Section 4DD. (a) For purposes of this section, the following terms shall have the following meanings, unless the context clearly requires otherwise:

“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.

“Alfi’s syndrome services provider”, a person, entity or group that provides treatment of Alfi’s syndrome.

“Alfi’s syndrome”, a genetic condition also known as 9p deletion syndrome or monosomy 9p.

“Board certified behavior analyst”, a behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst.

“Diagnosis of Alfi’s syndrome”, medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has Alfi’'s syndrome.

“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 Alfi’s syndrome”, includes the following care prescribed, provided or ordered for an individual diagnosed with Alfi’s syndrome 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) A health maintenance contract issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of Alfi’s syndrome in individuals.

(c) Such health maintenance contract shall be in compliance with subsection (b) if the contract does not contain annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of Alfi’s syndrome 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 Alfi’s syndrome 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 Alfi’s syndrome 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, 2019, 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, 2019, 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.

SECTION 6. All policies, contracts and certificates of health insurance subject to section 28 of chapter 32A, section 47JJ of chapter 175, section 8LL of chapter 176A, section 4LL of chapter 176B, and section 4DD of chapter 176G of the General Laws which are delivered, issued or renewed on or after January 1, 2018 shall conform with the provisions of this act. Form filings implementing this act shall be subject to the approval of the commissioner of insurance.

SECTION 7. This act shall take effect on January 1, 2020.