BILL REQ. #:  S-0393.1 

Read first time 01/16/09.   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; and adding a new section to chapter 48.43 RCW.

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

NEW SECTION.  Sec. 1   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 a person, entity, or group providing treatment for autism spectrum disorders pursuant to a treatment plan.
     (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) "Medically necessary" means any care, treatment, intervention, service, or item that is prescribed, provided, or ordered by a licensed physician or a licensed psychologist that will, or is 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.
     (f) "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.     
     (g) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
     (h) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
     (i) "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.
     (j) "Treatment of autism spectrum disorders" includes the following care prescribed, ordered, or provided by a licensed physician or licensed psychologist who determines the care to be medically necessary:          
     (i) Applied behavior analysis and other structured behavior programs;
     (ii) Pharmacy care;
     (iii) Psychiatric care;
     (iv) Psychological care;
     (v) Therapeutic care;
     (vi) Any care for individuals with autism spectrum disorders that is determined by the state health department, based upon its review of best practices or evidence-based research, may be medically necessary and that is published in the Washington State Register. Any such care, treatment, intervention, service, or item that was not previously covered will be included in any health insurance policy delivered, executed, issued, amended, adjusted, or renewed on or after sixty days following the date of its publication in the Washington State Register.
     (k) "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 in individuals less than twenty-one years of age. 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 will 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 will not be subject to any limits on the number of visits an individual may make to an autism services provider.
     (4) 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.
     (5) This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy, including benefits available under RCW 48.44.341, 48.21.241, and 48.46.291.
     (6) Coverage under this section will be subject to a maximum benefit of fifty thousand dollars per year. After July 31, 2010, the insurance commissioner will, on an annual basis, adjust the maximum benefit for inflation by using the medical care component of the United States department of labor consumer price index for all urban consumers. The commissioner will submit the adjusted maximum benefit for publication annually no later than October of each calendar year, and the published adjusted maximum benefit will be applicable in the following calendar year to health insurance policies subject to this section. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item unrelated to autism spectrum disorders will not be applied towards any maximum benefit established under this section.
     (7) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer will have the right to request a review of that treatment not more than once every six months unless the insurer and the individual's licensed physician or licensed psychologist agrees that a more frequent review is necessary. The cost of obtaining any review will be borne by the insurer.
     (8) The department of health will adopt rules establishing standards for qualified autism services providers. Once the rules are adopted, payment for the treatment of autism spectrum disorders covered under this section will be made only to autism service providers who meet the standards.

NEW SECTION.  Sec. 2   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 a person, entity, or group providing treatment for autism spectrum disorders pursuant to a treatment plan.
     (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) "Medically necessary" means any care, treatment, intervention, service, or item that is prescribed, provided, or ordered by a licensed physician or a licensed psychologist that will, or is 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.
     (f) "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.     
     (g) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
     (h) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
     (i) "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.
     (j) "Treatment of autism spectrum disorders" includes the following care prescribed, ordered, or provided by a licensed physician or licensed psychologist who determines the care to be medically necessary:          
     (i) Applied behavior analysis and other structured behavior programs;
     (ii) Pharmacy care;
     (iii) Psychiatric care;
     (iv) Psychological care;
     (v) Therapeutic care;
     (vi) Any care for individuals with autism spectrum disorders that is determined by the state health department, based upon its review of best practices or evidence-based research, may be medically necessary and that is published in the Washington State Register. Any such care, treatment, intervention, service, or item that was not previously covered will be included in any health insurance policy delivered, executed, issued, amended, adjusted, or renewed on or after sixty days following the date of its publication in the Washington State Register.
     (k) "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 in individuals less than twenty-one years of age. 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 will 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 will not be subject to any limits on the number of visits an individual may make to an autism services provider.
     (4) 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.
     (5) This section will not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy, including benefits available under RCW 48.44.341, 48.21.241, and 48.46.291.
     (6) Coverage under this section will be subject to a maximum benefit of fifty thousand dollars per year. After July 31, 2010, the insurance commissioner will, on an annual basis, adjust the maximum benefit for inflation by using the medical care component of the United States department of labor consumer price index for all urban consumers. The commissioner will submit the adjusted maximum benefit for publication annually no later than October of each calendar year, and the published adjusted maximum benefit will be applicable in the following calendar year to health insurance policies subject to this section. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item unrelated to autism spectrum disorders will not be applied towards any maximum benefit established under this section.
     (7) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer will have the right to request a review of that treatment not more than once every six months unless the insurer and the individual's licensed physician or licensed psychologist agrees that a more frequent review is necessary. The cost of obtaining any review will be borne by the insurer.
     (8) The department of health will adopt rules establishing standards for qualified autism services providers. Once the rules are adopted, payment for the treatment of autism spectrum disorders covered under this section will be made only to autism service providers who meet the standards.