SB-0414, As Passed House, March 29, 2012 Amendment No. 1

The Committee on Families, Children, and Seniors offered the following substitute (H-3):

HOUSE SUBSTITUTE FOR

SENATE BILL NO. 414

A bill to amend 1980 PA 350, entitled

"The nonprofit health care corporation reform act,"

(MCL 550.1101 to 550.1704) by adding section 416e.

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

Sec. 416e. (1) Except as otherwise provided in this section, a

health care corporation group or nongroup certificate shall provide

coverage for the diagnosis of autism spectrum disorders and

treatment of autism spectrum disorders. A health care corporation

shall not do any of the following:

(a) Limit the number of visits a member may use for treatment

of autism spectrum disorders covered under this section.

(b) Deny or limit coverage under this section on the basis

that treatment is educational or habilitative in nature.

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 treatment of autism

spectrum disorders may be limited to a member through 18 years of

age and may be subject to a maximum annual benefit as follows:

(i) For a covered member through 6 years of age, $50,000.00.

(ii) For a covered member from 7 years of age through 12 years

of age, $40,000.00.

(iii) For a covered member from 13 years of age through 18 years

of age, $30,000.00.

(2) This section does not limit benefits that are otherwise

available to a member under a certificate. A health care

corporation shall utilize evidence-based care and managed care

cost-containment practices pursuant to the health care

corporation's procedures so long as that care and those practices

are consistent with this section. The coverage under this section

may be subject to other general exclusions and limitations of the

certificate, including, but not limited to, coordination of

benefits, participating provider requirements, restrictions on

services provided by family or household members, utilization

review of health care services including review of medical

necessity, case management, and other managed care provisions.

(3) If a member is receiving treatment for an autism spectrum

disorder, a health care corporation may, as a condition to

providing the coverage under this section, do all of the following:

(a) Require a review of that treatment consistent with current

protocols and may require a treatment plan. If requested by the

health care corporation, the cost of treatment review shall be

borne by the health care corporation.

(b) Request the results of the autism diagnostic observation

schedule that has been used in the diagnosis of an autism spectrum

disorder for that member.

performed on that member not more frequently than once every 3

years.

(d) Request that an annual development evaluation be conducted

and the results of that annual development evaluation be submitted

to the health care corporation.

(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 require the coverage of prescription

drugs and related services unless the member is covered by a

prescription drug plan. This section does not require a health care

corporation to provide coverage for autism spectrum disorders to a

member under more than 1 of its certificates. If a member has more

than 1 policy, certificate, or contract that covers autism spectrum

disorders, the benefits provided are subject to the limits of this

section when coordinating benefits.

(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 diagnostic observation schedule" means the

protocol available through western psychological services for

diagnosing and assessing autism spectrum disorders or any other

standardized diagnostic measure for autism spectrum disorders that

is approved by the commissioner, if the commissioner determines

that the diagnostic measure is recognized by the health care

industry and is an evidence-based diagnostic tool.

pervasive developmental disorders as defined by the diagnostic and

statistical manual:

(i) Autistic disorder.

(ii) Asperger's disorder.

(iii) Pervasive developmental disorder not otherwise specified.

(d) "Behavioral health treatment" means evidence-based

counseling and treatment programs, including applied behavior

analysis, that meet 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.

(e) "Diagnosis of autism spectrum disorders" means

assessments, evaluations, or tests, including the autism diagnostic

observation schedule, performed by a licensed physician or a

licensed psychologist to diagnose whether an individual has 1 of

the autism spectrum disorders.

(f) "Diagnostic and statistical manual" or "DSM" means the

diagnostic and statistical manual of mental disorders published by

the American psychiatric association or other manual that contains

common language and standard criteria for the classification of

mental disorders and that is approved by the commissioner, if the

commissioner determines that the manual is recognized by the health

care industry and the classification of mental disorders is at

least as comprehensive as the manual published by the American

psychiatric association on the effective date of this section.

(g) "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.

(h) "Psychiatric care" means evidence-based direct or

consultative services provided by a psychiatrist licensed in the

state in which the psychiatrist practices.

(i) "Psychological care" means evidence-based direct or

consultative services provided by a psychologist licensed in the

state in which the psychologist practices.

(j) "Therapeutic care" means evidence-based services provided

by a licensed or certified speech therapist, occupational

therapist, physical therapist, or social worker.

(k) "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

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.

(l) "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 (k).

Enacting section 1. This amendatory act applies to

certificates delivered, executed, issued, amended, adjusted, or

renewed in this state beginning 180 days after the date this

amendatory act is enacted into law.

Enacting section 2. This amendatory act does not take effect