BILL REQ. #:  S-0069.5 

Read first time 01/12/11.   Referred to Committee on Health & Long-Term Care.

     AN ACT Relating to insurance coverage for autism spectrum disorders; adding a new section to chapter 41.05 RCW; adding a new section to chapter 48.43 RCW; and creating a new section.

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

NEW SECTION.  Sec. 1   This act may be known and cited as Shayan's law, an act extending coverage for autism spectrum disorders.

NEW SECTION.  Sec. 2   A new section is added to chapter 41.05 RCW to read as follows:
     (1) 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 socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.
     (b) "Autism services provider" means any licensed or certified person, entity, or group providing treatment for autism spectrum disorders.
     (c) "Autism spectrum disorders" means 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 disorder not otherwise specified.
     (d) "Diagnosis of autism spectrum disorders" means medically necessary assessments, evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.
     (e) "Habilitative or rehabilitative care" means professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.
     (f) "Medically necessary" means reasonably expected to do any of the following:
     (i) Prevent the onset of an illness, condition, injury, or disability;
     (ii) Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or
     (iii) Assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age.
     (g) "Pharmacy care" means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.     
     (h) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
     (i) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
     (j) "Therapeutic care" means direct or consultative services provided by a speech therapist, occupational therapist, or physical therapist licensed or certified in the state in which the therapist practices.
     (k) "Treatment of autism spectrum disorders" means care and equipment prescribed or ordered by a licensed physician or licensed psychologist who determines the care to be medically necessary, including, but not limited to:
     (i) Behavioral health treatment;
     (ii) Pharmacy care;
     (iii) Psychiatric care;
     (iv) Psychological care;
     (v) Therapeutic care;
     (vi) Any care for individuals with autism spectrum disorders that is demonstrated, based upon best practices or evidence-based research, to be medically necessary.
     (l) "Treatment plan" means a plan for the treatment of autism spectrum disorders developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendations of the American academy of pediatrics.
     (2) Each health plan offered to public employees and their covered dependents under this chapter which is not subject to the provisions of Title 48 RCW must include coverage for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders. To the extent that the diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders are not already covered by a health insurance policy, coverage under this section must be included in health insurance policies that are delivered, executed, issued, amended, adjusted, or renewed on or after the effective date of this section. No insurer can terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with one of the autism spectrum disorders or has received treatment for autism spectrum disorders.
     (3) Coverage under this section is not subject to any limits on the number of visits an individual may make to an autism services provider.
     (4) Coverage under this section may not be denied on the basis that the treatment is nonrestorative, educational, or custodial in nature.
     (5) Coverage under this section may be subject to copayment, deductible, and coinsurance provisions of a health insurance policy to the extent that other medical services covered by the health insurance policy are subject to these provisions.
     (6) This section may not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy, including benefits available under RCW 48.21.241, 48.44.341, and 48.46.291.
     (7) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer has the right to request a review of that treatment not more than once every twelve months unless the insurer and the individual's licensed physician or licensed psychologist agree, on an individual basis, that a more frequent review is necessary. The cost of obtaining any review must be borne by the insurer.

NEW SECTION.  Sec. 3   A new section is added to chapter 48.43 RCW to read as follows:
     (1) 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 socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.
     (b) "Autism services provider" means any licensed or certified person, entity, or group providing treatment for autism spectrum disorders.
     (c) "Autism spectrum disorders" means 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 disorder not otherwise specified.
     (d) "Diagnosis of autism spectrum disorders" means medically necessary assessments, evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.
     (e) "Habilitative or rehabilitative care" means professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.
     (f) "Medically necessary" means reasonably expected to do any of the following:
     (i) Prevent the onset of an illness, condition, injury, or disability;
     (ii) Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or
     (iii) Assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age.
     (g) "Pharmacy care" means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.     
     (h) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
     (i) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
     (j) "Therapeutic care" means direct or consultative services provided by a speech therapist, occupational therapist, or physical therapist licensed or certified in the state in which the therapist practices.
     (k) "Treatment of autism spectrum disorders" means care and equipment prescribed or ordered by a licensed physician or licensed psychologist who determines the care to be medically necessary, including, but not limited to:
     (i) Behavioral health treatment;
     (ii) Pharmacy care;
     (iii) Psychiatric care;
     (iv) Psychological care;
     (v) Therapeutic care;
     (vi) Any care for individuals with autism spectrum disorders that is demonstrated, based upon best practices or evidence-based research, to be medically necessary.
     (l) "Treatment plan" means a plan for the treatment of autism spectrum disorders developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendations of the American academy of pediatrics.
     (2) Each health plan offered to the public under chapter 48.21, 48.44, or 48.46 RCW must include coverage for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders. To the extent that the diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders are not already covered by a health insurance policy, coverage under this section must be included in health insurance policies that are delivered, executed, issued, amended, adjusted, or renewed on or after the effective date of this section. No insurer can terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with one of the autism spectrum disorders or has received treatment for autism spectrum disorders.
     (3) Coverage under this section is not subject to any limits on the number of visits an individual may make to an autism services provider.
     (4) Coverage under this section may not be denied on the basis that the treatment is nonrestorative, educational, or custodial in nature.
     (5) Coverage under this section may be subject to copayment, deductible, and coinsurance provisions of a health insurance policy to the extent that other medical services covered by the health insurance policy are subject to these provisions.
     (6) This section may not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy, including benefits available under RCW 48.21.241, 48.44.341, and 48.46.291.
     (7) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer has the right to request a review of that treatment not more than once every twelve months unless the insurer and the individual's licensed physician or licensed psychologist agree, on an individual basis, that a more frequent review is necessary. The cost of obtaining any review must be borne by the insurer.