SB-0414, As Passed Senate, March 13, 2012

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 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 it 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 applied behavior

analysis may be subject to a maximum annual benefit of $50,000.00

per covered member and may be limited to a member up to age 18.

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

available to a member under a certificate.

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

disorder, a health care corporation may request a review of that

treatment consistent with current protocols and may require a

treatment plan. The cost of obtaining a treatment review shall be

borne by the health care corporation. 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.

(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) 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 spectrum disorders" means any of the following

pervasive developmental disorders as defined by the "Diagnostic and

Statistical Manual of Mental Disorders" of the American psychiatric

association:

(i) Autistic disorder.

(ii) Asperger's disorder.

(iii) Pervasive developmental disorder not otherwise specified.

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.

(d) "Diagnosis of autism spectrum disorders" means

assessments, evaluations, or tests performed by a licensed

physician or a licensed psychologist to diagnose whether an

individual has 1 of the autism spectrum disorders.

(e) "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.

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

consultative services provided by a psychiatrist licensed in the

state in which the psychiatrist practices.

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

consultative services provided by a psychologist licensed in the

state in which the psychologist practices.

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

by a licensed or certified speech therapist, occupational

therapist, physical therapist, or social worker.

(i) "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.

(j) "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

Senate Bill No. 414 as amended March 13, 2012

treatment of an autism spectrum disorder is first prescribed or

ordered by a licensed physician or licensed psychologist as

described in subdivision (i).

<<Enacting section 1. This amendatory act takes effect October 1, 2012.>>

Enacting section <<2>>. This amendatory act does not take effect

unless all of the following bills of the 96th Legislature are

enacted into law:

(a) Senate Bill No. 415.

(b) Senate Bill No. 981.