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Senator Geller moved the following Senate amendment to House

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amendment (370293):

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     Senate Amendment (with title amendment)

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     Delete line(s) 5-1537

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and insert:

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     Section 1.  Subsection (26) is added to section 409.906,

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Florida Statutes, to read:

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     409.906  Optional Medicaid services.--Subject to specific

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appropriations, the agency may make payments for services which

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are optional to the state under Title XIX of the Social Security

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Act and are furnished by Medicaid providers to recipients who are

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determined to be eligible on the dates on which the services were

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provided. Any optional service that is provided shall be provided

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only when medically necessary and in accordance with state and

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federal law. Optional services rendered by providers in mobile

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units to Medicaid recipients may be restricted or prohibited by

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the agency. Nothing in this section shall be construed to prevent

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or limit the agency from adjusting fees, reimbursement rates,

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lengths of stay, number of visits, or number of services, or

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making any other adjustments necessary to comply with the

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availability of moneys and any limitations or directions provided

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for in the General Appropriations Act or chapter 216. If

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necessary to safeguard the state's systems of providing services

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to elderly and disabled persons and subject to the notice and

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review provisions of s. 216.177, the Governor may direct the

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Agency for Health Care Administration to amend the Medicaid state

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plan to delete the optional Medicaid service known as

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"Intermediate Care Facilities for the Developmentally Disabled."

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Optional services may include:

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     (26) HOME AND COMMUNITY-BASED SERVICES for AUTISM SPECTRUM

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DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.--The agency is

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authorized to seek federal approval through a Medicaid waiver or

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a state plan amendment for the provision of occupational therapy,

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speech therapy, physical therapy, behavior analysis, and behavior

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assistant services to individuals who are 5 years of age and

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under and have a diagnosed developmental disability as defined in

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s. 393.063, autism spectrum disorder as defined in s. 627.6686,

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or Down syndrome, a genetic disorder caused by the presence of

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extra chromosomal material on chromosome 21. Causes of the

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syndrome may include Trisomy 21, Mosaicism, Robertsonian

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Translocation, and other duplications of a portion of chromosome

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21. Coverage for such services shall be limited to $36,000

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annually and may not exceed $108,000 in total lifetime benefits.

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The agency shall submit an annual report beginning on January 1,

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2009, to the President of the Senate, the Speaker of the House of

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Representatives, and the relevant committees of the Senate and

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the House of Representatives regarding progress on obtaining

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federal approval and recommendations for the implementation of

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these home and community-based services. The agency may not

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implement this subsection without prior legislative approval.

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     Section 2.  Section 624.916, Florida Statutes, is created to

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read:

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     624.916 Developmental disabilities compact.--

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     (1) This section may be cited as the "Window of Opportunity

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Act."

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(2) The Office of Insurance Regulation shall convene a

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workgroup by August 31, 2008, for the purpose of negotiating a

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compact that includes a binding agreement among the participants

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relating to insurance and access to services for persons with

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developmental disabilities. The workgroup shall consist of the

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following:

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     (a) Representatives of all health insurers licensed under

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this chapter.

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     (b) Representatives of all health maintenance organizations

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licensed under part I of chapter 641.

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     (c) Representatives of employers with self-insured health

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benefit plans.

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     (d) Two designees of the Governor, one of whom must be a

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consumer advocate.

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     (e) A designee of the President of the Senate.

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     (f) A designee of the Speaker of the House of

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Representatives.

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     (3) The Office of Insurance Regulation shall convene a

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consumer advisory workgroup for the purpose of providing a forum

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for comment on the compact negotiated in subsection (2). The

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office shall convene the workgroup prior to finalization of the

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compact.

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     (4) The agreement shall include the following components:

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     (a) A requirement that each signatory to the agreement

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increase coverage for behavior analysis and behavior assistant

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services as defined in s. 409.815(2)(r) and speech therapy,

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physical therapy, and occupational therapy when medically

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necessary due to the presence of a developmental disability.

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     (b) Procedures for clear and specific notice to

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policyholders identifying the amount, scope, and conditions under

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which coverage is provided for behavior analysis and behavior

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assistant services as defined in s. 409.815(2)(r) and speech

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therapy, physical therapy, and occupational therapy when

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medically necessary due to the presence of a developmental

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disability.

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     (c) Penalties for documented cases of denial of claims for

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medically necessary services due to the presence of a

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developmental disability.

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     (d) Proposals for new product lines that may be offered in

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conjunction with traditional health insurance and provide a more

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appropriate means of spreading risk, financing costs, and

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accessing favorable prices.

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     (5) Upon completion of the negotiations for the compact,

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the office shall report the results to the Governor, the

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President of the Senate, and the Speaker of the House of

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Representatives.

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     (6) Beginning February 15, 2009, and continuing annually

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thereafter, the Office of Insurance Regulation shall provide a

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report to the Governor, the President of the Senate, and the

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Speaker of the House of Representatives regarding the

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implementation of the agreement negotiated under this section.

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The report shall include:

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     (a) The signatories to the agreement.

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     (b) An analysis of the coverage provided under the

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agreement in comparison to the coverage required under ss.

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627.6686 and 641.31098.

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     (c) An analysis of the compliance with the agreement by the

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signatories, including documented cases of claims denied in

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violation of the agreement.

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     (7) The Office of Insurance Regulation shall continue to

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monitor participation, compliance, and effectiveness of the

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agreement and report its findings at least annually.

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     (8) As used in this section, the term "developmental

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disabilities" includes:

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     (a) The term as defined in s. 393.063;

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     (b) Down syndrome, a genetic disorder caused by the

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presence of extra chromosomal material on chromosome 21. Causes

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of the syndrome may include Trisomy 21, Mosaicism, Robertsonian

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Translocation, and other duplications of a portion of chromosome

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21; and

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     (c) Autism spectrum disorder, as defined in s. 627.6686.

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     Section 3.  Section 627.6686, Florida Statutes, is created

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to read:

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     627.6686 Coverage for individuals with autism spectrum

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disorder required; exception.--

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     (1) This section and section 641.31098, may be cited as the

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"Steven A. Geller Autism Coverage Act."

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(2) As used in this section, the term:

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     (a) "Applied behavior analysis" means the design,

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implementation, and evaluation of environmental modifications,

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using behavioral stimuli and consequences, to produce socially

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significant improvement in human behavior, including, but not

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limited to, the use of direct observation, measurement, and

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functional analysis of the relations between environment and

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behavior.

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     (b) "Autism spectrum disorder" means any of the following

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disorders as defined in the most recent edition of the Diagnostic

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and Statistical Manual of Mental Disorders of the American

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Psychiatric Association:

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     1. Autistic disorder.

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     2. Asperger's syndrome.

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     3. Pervasive developmental disorder not otherwise

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specified.

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     (c) "Eligible individual" means an individual under 18

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years of age or an individual 18 years of age or older who is in

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high school who has been diagnosed as having a developmental

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disability at 8 years of age or younger.

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     (d) "Health insurance plan" means a group health insurance

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policy or group health benefit plan offered by an insurer which

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includes the state group insurance program provided under s.

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110.123. The term does not include any health insurance plan

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offered in the individual market, any health insurance plan that

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is individually underwritten, or any health insurance plan

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provided to a small employer.

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     (e) "Insurer" means an insurer providing health insurance

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coverage, which is licensed to engage in the business of

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insurance in this state and is subject to insurance regulation.

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     (3) A health insurance plan issued or renewed on or after

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April 1, 2009, shall provide coverage to an eligible individual

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for:

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     (a) Well-baby and well-child screening for diagnosing the

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presence of autism spectrum disorder.

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     (b) Treatment of autims spectrum disorder through speech

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therapy, occupational therapy, physical therapy, and applied

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behavior analysis. Applied behavior analysis services shall be

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provided by an individual certified pursuant to s. 393.17 or an

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individual licensed under chapter 490 or chapter 491.

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     (4) The coverage required pursuant to subsection (3) is

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subject to the following requirements:

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     (a) Coverage shall be limited to treatment that is

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prescribed by the insured's treating physician in accordance with

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a treatment plan.

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     (b) Coverage for the services described in subsection (3)

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shall be limited to $36,000 annually and may not exceed $200,000

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in total lifetime benefits.

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     (c) Coverage may not be denied on the basis that provided

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services are habilitative in nature.

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     (d) Coverage may be subject to other general exclusions and

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limitations of the insurer's policy or plan, including, but not

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limited to, coordination of benefits, participating provider

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requirements, restrictions on services provided by family or

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household members, and utilization review of health care

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services, including the review of medical necessity, case

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management, and other managed care provisions.

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     (5) The coverage required pursuant to subsection (3) may

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not be subject to dollar limits, deductibles, or coinsurance

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provisions that are less favorable to an insured than the dollar

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limits, deductibles, or coinsurance provisions that apply to

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physical illnesses that are generally covered under the health

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insurance plan, except as otherwise provided in subsection (4).

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     (6) An insurer may not deny or refuse to issue coverage for

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medically necessary services, refuse to contract with, or refuse

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to renew or reissue or otherwise terminate or restrict coverage

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for an individual because the individual is diagnosed as having a

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developmental disability.

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     (7) The treatment plan required pursuant to subsection (4)

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shall include all elements necessary for the health insurance

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plan to appropriately pay claims. These elements include, but are

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not limited to, a diagnosis, the proposed treatment by type, the

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frequency and duration of treatment, the anticipated outcomes

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stated as goals, the frequency with which the treatment plan will

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be updated, and the signature of the treating physician.

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     (7) Beginning January 1, 2011, the maximum benefit under

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paragraph (4)(b) shall be adjusted annually on January 1 of each

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calendar year to reflect any change from the previous year in the

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medical component of the then current Consumer Price Index for

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all urban consumers, published by the Bureau of Labor Statistics

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of the United States Department of Labor.

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     (7) This section may not be construed as limiting benefits

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and coverage otherwise available to an insured under a health

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insurance plan.

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     (8) The Office of Insurance Regulation may not enforce this

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section against an insurer that is a signatory no later than

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April 1, 2009, to the developmental disabilities compact

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established under s. 624.916. The Office of Insurance Regulation

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shall enforce this section against an insurer that is a signatory

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to the compact established under s. 624.916 if the insurer has

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not complied with the terms of the compact for all health

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insurance plans by April 1, 2010.

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     Section 4.  Section 641.31098, Florida Statutes, is created

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to read:

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     641.31098 Coverage for individuals with developmental

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disabilities.--

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     (1) This section and section 627.6686, may be cited as the

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"Steven A. Geller Autism Coverage Act."

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(2) As used in this section, the term:

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     (a) "Applied behavior analysis" means the design,

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implementation, and evaluation of environmental modifications,

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using behavioral stimuli and consequences, to produce socially

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significant improvement in human behavior, including, but not

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limited to, the use of direct observation, measurement, and

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functional analysis of the relations between environment and

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behavior.

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     (b) "Autism spectrum disorder" means any of the following

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disorders as defined in the most recent edition of the Diagnostic

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and Statistical Manual of Mental Disorders of the American

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Psychiatric Association:

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     1. Autistic disorder.

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     2. Asperger's syndrome.

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     3. Pervasive developmental disorder not otherwise

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specified.

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     (b) "Eligible individual" means an individual under 18

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years of age or an individual 18 years of age or older who is in

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high school who has been diagnosed as having a developmental

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disability at 8 years of age or younger.

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     (c) "Health maintenance contract" means a group health

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maintenance contract offered by a health maintenance

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organization. This term does not include a health maintenance

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contract offered in the individual market, a health maintenance

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contract that is individually underwritten, or a health

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maintenance contract provided to a small employer.

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     (3) A health maintenance contract issued or renewed on or

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after April 1, 2009, shall provide coverage to an eligible

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individual for:

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     (a) Well-baby and well-child screening for diagnosing the

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presence of autism spectrum disorder.

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     (b) Treatment of autism spectrum disorder through speech

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therapy, occupational therapy, physical therapy, and applied

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behavior analysis services. Applied behavior analysis services

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shall be provided by an individual certified pursuant to s.

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393.17 or an individual licensed under chapter 490 or chapter

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491.

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     (4) The coverage required pursuant to subsection (3) is

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subject to the following requirements:

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     (a) Coverage shall be limited to treatment that is

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prescribed by the subscriber's treating physician in accordance

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with a treatment plan.

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     (b) Coverage for the services described in subsection (3)

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shall be limited to $36,000 annually and may not exceed $200,000

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in total benefits.

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     (c) Coverage may not be denied on the basis that provided

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services are habilitative in nature.

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     (d) Coverage may be subject to general exclusions and

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limitations of the subscriber's contract, including, but not

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limited to, coordination of benefits, participating provider

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requirements, and utilization review of health care services,

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including the review of medical necessity, case management, and

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other managed care provisions.

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     (5) The coverage required pursuant to subsection (3) may

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not be subject to dollar limits, deductibles, or coinsurance

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provisions that are less favorable to a subscriber than the

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dollar limits, deductibles, or coinsurance provisions that apply

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to physical illnesses that are generally covered under the

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subscriber's contract, except as otherwise provided in subsection

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(3).

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     (6) A health maintenance organization may not deny or

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refuse to issue coverage for medically necessary services, refuse

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to contract with, or refuse to renew or reissue or otherwise

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terminate or restrict coverage for an individual solely because

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the individual is diagnosed as having a developmental disability.

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     (7) The treatment plan required pursuant to subsection (4)

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shall include, but is not limited to, a diagnosis, the proposed

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treatment by type, the frequency and duration of treatment, the

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anticipated outcomes stated as goals, the frequency with which

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the treatment plan will be updated, and the signature of the

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treating physician.

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     (8) Beginning January 1, 2011, the maximum benefit under

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paragraph (4)(b) shall be adjusted annually on January 1 of each

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calendar year to reflect any change from the previous year in the

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medical component of the then current Consumer Price Index for

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all urban consumers, published by the Bureau of Labor Statistics

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of the United States Department of Labor.

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     (9) The Office of Insurance Regulation may not enforce this

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section against a health maintenance organization that is a

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signatory no later than April 1, 2009, to the developmental

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disabilities compact established under s. 624.916. The Office of

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Insurance Regulation shall enforce this section against a health

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maintenance organization that is a signatory to the compact

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established under s. 624.916 if the health maintenance

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organization has not complied with the terms of the compact for

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all health maintenance contracts by April 1, 2010.

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     Section 5.  This act shall take effect July 1, 2008.

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================ T I T L E  A M E N D M E N T ================

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And the title is amended as follows:

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     Delete line(s) 1545-1719

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and insert:

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An act relating to children with disabilities;

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amending s. 409.906, F.S.; creating the "Window of

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Opportunity Act"; authorizing the Agency for Health Care

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Administration to seek federal approval through a state

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plan amendment to provide home and community-based

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services for autism spectrum disorder and other

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development disabilities; specifying eligibility criteria;

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specifying limitations on provision of benefits; requiring

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reports to the Legislature; requiring legislative approval

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for implementation of certain provisions; creating s.

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624.916, F.S.; creating the Steven A. Geller Autism

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Coverage Act"; directing the Office of Insurance

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Regulation to establish a workgroup to develop and execute

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a compact relating to coverage for insured persons with

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development disabilities; providing for membership of the

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workgroup; requiring the workgroup to convene within a

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specified period of time; directing the office to

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establish a consumer advisory workgroup and providing

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purpose thereof; requiring the compact to contain

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specified components; requiring reports to the Governor

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and the Legislature; creating s. 627.6686, F.S.; providing

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health insurance coverage for individuals with autims

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spectrum disorder; providing definitions; providing

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coverage for certain screening to diagnose and treat

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autims spectrum disorder; providing limitations on

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coverage; providing for eligibility standards for benefits

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and coverage; prohibiting insurers from denying coverage

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under certain circumstances; specifying required elements

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of a treatment plan; providing, beginning January 1, 2011,

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that the maximum benefit shall be adjusted annually;

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clarifying that the section may not be construed as

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limiting benefits and coverage otherwise available to an

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insured under a health insurance plan; prohibiting the

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Office of Insurance Regulation from enforcing certain

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provisions against insurers that are signatories to the

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developmental disabilities compact by a specified date;

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creating s. 641.31098, F.S.; providing coverage under a

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health maintenance contract for individuals with autism

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spectrum disorder; providing definitions; providing

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coverage for certain screening to diagnose and treat

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autism spectrum disorder; providing limitations on

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coverage; providing for eligibility standards for benefits

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and coverage; prohibiting health maintenance organizations

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from denying coverage under certain circumstances;

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specifying required elements of a treatment plan;

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providing, beginning January 1, 2011, that the maximum

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benefit shall be adjusted annually; prohibiting the Office

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of Insurance Regulation from enforcing certain provisions

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against health maintenance organizations that are

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signatories to the developmental disabilities compact by a

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specified date; providing an effective date.

5/2/2008  10:39:00 AM     31-09550-08