Florida Senate - 2015                                     SB 146
       
       
        
       By Senator Ring
       
       
       
       
       
       29-00046-15                                            2015146__
    1                        A bill to be entitled                      
    2         An act relating to autism; creating s. 381.988, F.S.;
    3         requiring a physician, to whom a parent or legal
    4         guardian reports observing symptoms of autism
    5         exhibited by a minor child, to refer the minor to an
    6         appropriate specialist for screening for autism
    7         spectrum disorder under certain circumstances;
    8         authorizing the parent or legal guardian to have
    9         direct access to screening for, or evaluation or
   10         diagnosis of, autism spectrum disorder for the minor
   11         child from the Early Steps program or another
   12         appropriate specialist in autism under certain
   13         circumstances; defining the term “appropriate
   14         specialist”; amending ss. 627.6686 and 641.31098,
   15         F.S.; defining the term “direct patient access”;
   16         requiring that certain insurers and health maintenance
   17         organizations provide direct patient access for a
   18         minimum number of visits to an appropriate specialist
   19         for screening for, or evaluation or diagnosis of,
   20         autism spectrum disorder; providing an effective date.
   21          
   22  Be It Enacted by the Legislature of the State of Florida:
   23  
   24         Section 1. Section 381.988, Florida Statutes, is created to
   25  read:
   26         381.988Screening for autism spectrum disorder.—
   27         (1) If the parent or legal guardian of a minor believes
   28  that the minor exhibits symptoms of autism spectrum disorder and
   29  reports his or her observation to a physician licensed under
   30  chapter 458 or chapter 459, the physician shall screen in
   31  accordance with the guidelines of the American Academy of
   32  Pediatrics. If the physician determines that referral to a
   33  specialist is medically necessary, the physician shall refer the
   34  minor to an appropriate specialist to determine whether the
   35  minor meets diagnostic criteria for autism spectrum disorder. If
   36  the physician determines that referral to a specialist is not
   37  medically necessary, the physician shall inform the parent or
   38  legal guardian that the parent or legal guardian may have direct
   39  access to screening for, or evaluation or diagnosis of, autism
   40  spectrum disorder for the minor from the Early Steps program or
   41  another appropriate specialist in autism without a referral for
   42  at least three visits per policy year. This section does not
   43  apply to a physician providing care under s. 395.1041.
   44         (2) As used in this section, the term “appropriate
   45  specialist” means a qualified professional licensed in this
   46  state who is experienced in the evaluation of autism spectrum
   47  disorder and has training in validated diagnostic tools. The
   48  term includes, but is not limited to:
   49         (a) A psychologist;
   50         (b) A psychiatrist;
   51         (c) A neurologist; or
   52         (d) A developmental or behavioral pediatrician.
   53         Section 2. Section 627.6686, Florida Statutes, is amended
   54  to read:
   55         627.6686 Coverage for individuals with autism spectrum
   56  disorder required; exception.—
   57         (1) This section and s. 641.31098 may be cited as the
   58  “Steven A. Geller Autism Coverage Act.”
   59         (2) As used in this section, the term:
   60         (a) “Applied behavior analysis” means the design,
   61  implementation, and evaluation of environmental modifications,
   62  using behavioral stimuli and consequences, to produce socially
   63  significant improvement in human behavior, including, but not
   64  limited to, the use of direct observation, measurement, and
   65  functional analysis of the relations between environment and
   66  behavior.
   67         (b) “Autism spectrum disorder” means any of the following
   68  disorders as defined in the most recent edition of the
   69  Diagnostic and Statistical Manual of Mental Disorders of the
   70  American Psychiatric Association:
   71         1. Autistic disorder.
   72         2. Asperger’s syndrome.
   73         3. Pervasive developmental disorder not otherwise
   74  specified.
   75         (c)“Direct patient access” means the ability of an insured
   76  to obtain services from a contracted provider without a referral
   77  or other authorization before receiving services.
   78         (d)(c) “Eligible individual” means an individual under 18
   79  years of age or an individual 18 years of age or older who is in
   80  high school who has been diagnosed as having a developmental
   81  disability at 8 years of age or younger.
   82         (e)(d) “Health insurance plan” means a group health
   83  insurance policy or group health benefit plan offered by an
   84  insurer which includes the state group insurance program
   85  provided under s. 110.123. The term does not include any health
   86  insurance plan offered in the individual market, any health
   87  insurance plan that is individually underwritten, or any health
   88  insurance plan provided to a small employer.
   89         (f)(e) “Insurer” means an insurer providing health
   90  insurance coverage, which is licensed to engage in the business
   91  of insurance in this state and is subject to insurance
   92  regulation.
   93         (3) A health insurance plan issued or renewed on or after
   94  January 1, 2016, must April 1, 2009, shall provide coverage to
   95  an eligible individual for:
   96         (a) Direct patient access to an appropriate specialist, as
   97  defined in s. 381.988, for a minimum of three visits per policy
   98  year for screening for, or evaluation or diagnosis of, autism
   99  spectrum disorder.
  100         (b)(a) Well-baby and well-child screening for diagnosing
  101  the presence of autism spectrum disorder.
  102         (c)(b) Treatment of autism spectrum disorder through speech
  103  therapy, occupational therapy, physical therapy, and applied
  104  behavior analysis. Applied behavior analysis services must shall
  105  be provided by an individual certified pursuant to s. 393.17 or
  106  an individual licensed under chapter 490 or chapter 491.
  107         (4) The coverage required pursuant to subsection (3) is
  108  subject to the following requirements:
  109         (a) Except as provided in paragraph (3)(a), coverage must
  110  shall be limited to treatment that is prescribed by the
  111  insured’s treating physician in accordance with a treatment
  112  plan.
  113         (b) Coverage for the services described in subsection (3)
  114  must shall be limited to $36,000 annually and may not exceed
  115  $200,000 in total lifetime benefits.
  116         (c) Coverage may not be denied on the basis that provided
  117  services are habilitative in nature.
  118         (d) Coverage may be subject to other general exclusions and
  119  limitations of the insurer’s policy or plan, including, but not
  120  limited to, coordination of benefits, participating provider
  121  requirements, restrictions on services provided by family or
  122  household members, and utilization review of health care
  123  services, including the review of medical necessity, case
  124  management, and other managed care provisions.
  125         (5) The coverage required pursuant to subsection (3) may
  126  not be subject to dollar limits, deductibles, or coinsurance
  127  provisions that are less favorable to an insured than the dollar
  128  limits, deductibles, or coinsurance provisions that apply to
  129  physical illnesses that are generally covered under the health
  130  insurance plan, except as otherwise provided in subsection (4).
  131         (6) An insurer may not deny or refuse to issue coverage for
  132  medically necessary services, refuse to contract with, or refuse
  133  to renew or reissue or otherwise terminate or restrict coverage
  134  for an individual because the individual is diagnosed as having
  135  a developmental disability.
  136         (7) The treatment plan required pursuant to subsection (4)
  137  must shall include all elements necessary for the health
  138  insurance plan to appropriately pay claims. These elements
  139  include, but are not limited to, a diagnosis, the proposed
  140  treatment by type, the frequency and duration of treatment, the
  141  anticipated outcomes stated as goals, the frequency with which
  142  the treatment plan will be updated, and the signature of the
  143  treating physician.
  144         (8) The maximum benefit under paragraph (4)(b) shall be
  145  adjusted annually on January 1 of each calendar year to reflect
  146  any change from the previous year in the medical component of
  147  the then current Consumer Price Index for All Urban Consumers,
  148  published by the Bureau of Labor Statistics of the United States
  149  Department of Labor.
  150         (9) This section does may not limit be construed as
  151  limiting benefits and coverage otherwise available to an insured
  152  under a health insurance plan.
  153         Section 3. Section 641.31098, Florida Statutes, is amended
  154  to read:
  155         641.31098 Coverage for individuals with developmental
  156  disabilities.—
  157         (1) This section and s. 627.6686 may be cited as the
  158  “Steven A. Geller Autism Coverage Act.”
  159         (2) As used in this section, the term:
  160         (a) “Applied behavior analysis” means the design,
  161  implementation, and evaluation of environmental modifications,
  162  using behavioral stimuli and consequences, to produce socially
  163  significant improvement in human behavior, including, but not
  164  limited to, the use of direct observation, measurement, and
  165  functional analysis of the relations between environment and
  166  behavior.
  167         (b) “Autism spectrum disorder” means any of the following
  168  disorders as defined in the most recent edition of the
  169  Diagnostic and Statistical Manual of Mental Disorders of the
  170  American Psychiatric Association:
  171         1. Autistic disorder.
  172         2. Asperger’s syndrome.
  173         3. Pervasive developmental disorder not otherwise
  174  specified.
  175         (c)“Direct patient access” means the ability of an insured
  176  to obtain services from an in-network provider without a
  177  referral or other authorization before receiving services.
  178         (d)(c) “Eligible individual” means an individual under 18
  179  years of age or an individual 18 years of age or older who is in
  180  high school who has been diagnosed as having a developmental
  181  disability at 8 years of age or younger.
  182         (e)(d) “Health maintenance contract” means a group health
  183  maintenance contract offered by a health maintenance
  184  organization. This term does not include a health maintenance
  185  contract offered in the individual market, a health maintenance
  186  contract that is individually underwritten, or a health
  187  maintenance contract provided to a small employer.
  188         (3) A health maintenance contract issued or renewed on or
  189  after January 1, 2016, must April 1, 2009, shall provide
  190  coverage to an eligible individual for:
  191         (a) Direct patient access to an appropriate specialist, as
  192  defined in s. 381.988, for a minimum of three visits per policy
  193  year for screening for, or evaluation or diagnosis of, autism
  194  spectrum disorder.
  195         (b)(a) Well-baby and well-child screening for diagnosing
  196  the presence of autism spectrum disorder.
  197         (c)(b) Treatment of autism spectrum disorder through speech
  198  therapy, occupational therapy, physical therapy, and applied
  199  behavior analysis services. Applied behavior analysis services
  200  must shall be provided by an individual certified pursuant to s.
  201  393.17 or an individual licensed under chapter 490 or chapter
  202  491.
  203         (4) The coverage required pursuant to subsection (3) is
  204  subject to the following requirements:
  205         (a) Except as provided in paragraph (3)(a), coverage must
  206  shall be limited to treatment that is prescribed by the
  207  subscriber’s treating physician in accordance with a treatment
  208  plan.
  209         (b) Coverage for the services described in subsection (3)
  210  must shall be limited to $36,000 annually and may not exceed
  211  $200,000 in total benefits.
  212         (c) Coverage may not be denied on the basis that provided
  213  services are habilitative in nature.
  214         (d) Coverage may be subject to general exclusions and
  215  limitations of the subscriber’s contract, including, but not
  216  limited to, coordination of benefits, participating provider
  217  requirements, and utilization review of health care services,
  218  including the review of medical necessity, case management, and
  219  other managed care provisions.
  220         (5) The coverage required pursuant to subsection (3) may
  221  not be subject to dollar limits, deductibles, or coinsurance
  222  provisions that are less favorable to a subscriber than the
  223  dollar limits, deductibles, or coinsurance provisions that apply
  224  to physical illnesses that are generally covered under the
  225  subscriber’s contract, except as otherwise provided in
  226  subsection (3).
  227         (6) A health maintenance organization may not deny or
  228  refuse to issue coverage for medically necessary services,
  229  refuse to contract with, or refuse to renew or reissue or
  230  otherwise terminate or restrict coverage for an individual
  231  solely because the individual is diagnosed as having a
  232  developmental disability.
  233         (7) The treatment plan required pursuant to subsection (4)
  234  must shall include, but need is not be limited to, a diagnosis,
  235  the proposed treatment by type, the frequency and duration of
  236  treatment, the anticipated outcomes stated as goals, the
  237  frequency with which the treatment plan will be updated, and the
  238  signature of the treating physician.
  239         (8) The maximum benefit under paragraph (4)(b) shall be
  240  adjusted annually on January 1 of each calendar year to reflect
  241  any change from the previous year in the medical component of
  242  the then current Consumer Price Index for All Urban Consumers,
  243  published by the Bureau of Labor Statistics of the United States
  244  Department of Labor.
  245         Section 4. This act shall take effect July 1, 2015.