BILL REQ. #:  H-1910.1 

READ FIRST TIME 02/17/09.   

     AN ACT Relating to health benefit plan coverage of neurodevelopmental therapies; adding a new section to chapter 41.05 RCW; adding a new section to chapter 48.43 RCW; creating new sections; repealing RCW 41.05.170, 48.21.310, 48.44.450, and 48.46.520; and providing an effective date.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   The legislature finds that:
     (1) Access to appropriate early intervention services significantly improves function in children with developmental delays and developmental disabilities. Health care services, including neurodevelopmental therapies, are an essential component of early intervention services.
     (2) The provision of early intervention services is a shared responsibility of federal and state government, private health insurance, state purchased health care programs, and schools.
     (3) The existing neurodevelopmental therapy benefit is unreasonably limited, in light of the nature of the diagnoses that neurodevelopmental services are used to treat. Children with medical disorders that result in developmental delays or developmental disabilities have an ongoing need for appropriate neurodevelopmental services that are designed to improve and maintain their ability to function and to prevent deterioration in functioning. The provision of appropriate health care interventions, such as neurodevelopmental therapies, to treat these disorders significantly and positively affects a child's ability to function in an age-appropriate manner. Research demonstrates that the timing of the provision of these interventions is critical to a child's ability to function and the failure to intervene at a meaningful point in a child's development can result in a lost opportunity that cannot be fully compensated for later.

NEW SECTION.  Sec. 2   A new section is added to chapter 41.05 RCW to read as follows:
     (1) Each health plan offered to public employees and their covered dependents under this chapter that is established or renewed on or after January 1, 2011, must include coverage for neurodevelopmental therapies for covered individuals under eighteen years of age.
     (2) As used in this section:
     (a) "Neurodevelopmental therapies" means occupational therapy, speech therapy, physical therapy, applied behavior analysis, and other therapies for the treatment of developmental delays, developmental disabilities, or developmental disorders that are consistent with generally accepted standards of practice, as defined in subsection (5) of this section.
     (b) "Applied behavior analysis" means the design, implementation, and evaluation of therapeutic programs, 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 social or learning environment and behavior.
     (3) Neurodevelopmental therapy benefits are payable when the services have been delivered or supervised by a health professional regulated under Title 18 RCW, pursuant to an individualized written treatment plan developed by a health care provider licensed under chapter 18.71 or 18.57 RCW, or when covered services have been rendered by such licensee. The treatment plan must be developed based upon the results of a comprehensive evaluation or periodic reevaluation of the child. A carrier may require that the treatment plan be reviewed periodically. A carrier may require that neurodevelopmental therapy services be delivered by a health care provider who participates in the carrier's provider network, unless no participating provider is available to deliver covered services. Nothing in this section prohibits a carrier from negotiating rates with qualified providers.
     (4) The treatment plan should complement and not duplicate any other neurodevelopmental services that a child is receiving through publicly funded programs, including special education. Services that are being provided by a school district to a child through an individual education plan under the federal individuals with disabilities education act do not have to be provided to the child under this section. However, consistent with part C of the federal individuals with disabilities education act, for early intervention services provided to children birth to three years of age, a child's health insurance coverage must be considered the primary payer.
     (5) Benefits are payable for services to improve age-appropriate functioning, and for maintenance of function in cases where significant deterioration in the child's condition would result without the service. Deductibles, copayments, or coinsurance for neurodevelopmental services may be no more than the deductible, copayment, or coinsurance for other medical services otherwise provided under the health plan. Neurodevelopmental therapy coverage under this section is subject to a maximum benefit of fifty thousand dollars per year. Coverage under this section also may be subject to health benefit plan provisions establishing cumulative annual or lifetime benefit limits for all services provided under the health benefit plan.
     (6) In determining whether services are medically necessary, the health plan may use reasonable criteria that are in accordance with generally accepted standards of practice, and are clinically appropriate, giving strong consideration to the diagnoses for which neurodevelopmental therapies are prescribed for children, the ongoing nature of such diagnoses, and the use of neurodevelopmental therapy services to improve and prevent deterioration in functioning. As used in this subsection, "generally accepted standards of practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, evidence-based clinical guidelines developed by relevant physician or health care practitioner specialty societies, or other clinical guidelines that are supported by multiple site random controlled trials or other credible research demonstrating that the therapy is effective.

NEW SECTION.  Sec. 3   A new section is added to chapter 48.43 RCW to read as follows:
     (1) All group health benefit plans entered into, or renewed, on or after January 1, 2011, must include coverage for neurodevelopmental therapies for covered individuals under eighteen years of age.
     (2) As used in this section:
     (a) "Neurodevelopmental therapies" means occupational therapy, speech therapy, physical therapy, applied behavior analysis, and other therapies for the treatment of developmental delays, developmental disabilities, or developmental disorders that are consistent with generally accepted standards of practice, as defined in subsection (5) of this section.
     (b) "Applied behavior analysis" means the design, implementation, and evaluation of therapeutic programs, 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 the social or learning environment and behavior.
     (3) Neurodevelopmental therapy benefits are payable when the services have been delivered or supervised by a health professional regulated under Title 18 RCW, pursuant to an individualized written treatment plan developed by a health care provider licensed under chapter 18.71 or 18.57 RCW, or when covered services have been rendered by such licensee. The treatment plan must be developed based upon the results of a comprehensive evaluation or periodic reevaluation of the child. A carrier may require that the treatment plan be reviewed periodically. A carrier may require that neurodevelopmental therapy services be delivered by a health care provider who participates in the carrier's provider network, unless no participating provider is available to deliver covered services. Nothing in this section prohibits a carrier from negotiating rates with qualified providers.
     (4) The treatment plan should complement and not duplicate any other neurodevelopmental services that a child is receiving through publicly funded programs, including special education. Services that are being provided by a school district to a child through an individual education plan under the federal individuals with disabilities education act do not have to be provided to the child under this section. However, consistent with part C of the federal individuals with disabilities education act, for early intervention services provided to children birth to three years of age, a child's health insurance coverage must be considered the primary payer.
     (5) Benefits shall be payable for services to restore and improve age-appropriate functioning and for maintenance of function in cases where significant deterioration in the child's condition would result without the service. Deductibles, copayments, or coinsurance for neurodevelopmental services may be no more than the deductible, copayment, or coinsurance for other medical services otherwise provided under the health benefit plan. Neurodevelopmental therapy coverage under this section is subject to a maximum benefit of fifty thousand dollars per year. Coverage under this section also may be subject to health benefit plan provisions establishing cumulative annual or lifetime benefit limits for all services provided under the health benefit plan.
     (6) In determining whether services are medically necessary, the carrier may use reasonable criteria that are in accordance with generally accepted standards of practice, and are clinically appropriate, giving strong consideration to the diagnoses for which neurodevelopmental therapies are prescribed for children, the ongoing nature of such diagnoses, and the use of neurodevelopmental therapy services to improve and prevent deterioration in functioning. As used in this subsection, "generally accepted standards of practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, evidence-based clinical guidelines developed by relevant physician or health care practitioner specialty societies, or other clinical guidelines that are supported by multiple site random controlled trials or other credible research demonstrating that the therapy is effective.

NEW SECTION.  Sec. 4   The department of health shall conduct a review under chapter 18.120 RCW to determine the most appropriate means to regulate persons who utilize applied behavior analysis for the treatment of persons with an autism spectrum disorder. The review should address, at a minimum, whether applied behavior analysis providers should be regulated through establishment of a new health profession or through establishment of a new classification within an existing health profession, and appropriate education and experience requirements. In determining appropriate education and experience requirements, the department shall give great weight to the certification criteria established by the institute for applied behavior analysis. In developing its recommendations, the department shall consult with interested organizations. The department must submit its recommendations to the governor and the legislature on or before November 15, 2009.

NEW SECTION.  Sec. 5   The department of health shall establish a process to periodically review credible sources of scientific evidence related to effective therapies for treatment of individuals under eighteen years of age with autism spectrum disorder. The results of the review will identify treatment modalities that should be considered to be in accordance with generally accepted standards of practice, as that term is defined in section 2(6) and section 3(6) of this act. The review shall be conducted with substantial involvement of individuals with medical expertise in this field, and with consultation from health care providers, autism researchers, family members of persons with autism spectrum disorders, carriers, the department of social and health services, the health care authority, educators, and other interested persons. The department must report its findings to the governor and the legislature by November 15, 2009, and on a biannual basis thereafter.

NEW SECTION.  Sec. 6   The following acts or parts of acts are each repealed:
     (1) RCW 41.05.170 (Neurodevelopmental therapies -- Employer-sponsored group contracts) and 1989 c 345 s 4;
     (2) RCW 48.21.310 (Neurodevelopmental therapies -- Employer-sponsored group contracts) and 1989 c 345 s 2;
     (3) RCW 48.44.450 (Neurodevelopmental therapies -- Employer-sponsored group contracts) and 1989 c 345 s 1; and
     (4) RCW 48.46.520 (Neurodevelopmental therapies -- Employer-sponsored group contracts) and 1989 c 345 s 3.

NEW SECTION.  Sec. 7   Section 6 of this act takes effect January 1, 2011.