CS/HB 107

1	A bill to be entitled
2	An act relating to autism; creating s. 381.986, F.S.;
3	requiring that a physician refer a minor to an appropriate
4	specialist for screening for autism spectrum disorder
5	under certain circumstances; defining the term
6	"appropriate specialist"; amending ss. 627.6686 and
7	641.31098, F.S.; defining the terms "developmental
8	disability" and "direct patient access"; providing health
9	insurance coverage for individuals with certain
10	developmental disabilities; requiring certain insurers and
11	health maintenance organizations to provide direct patient
12	access to an appropriate specialist for screening,
13	evaluation, or diagnosis for autism spectrum disorder or
14	other developmental disabilities; requiring the insurer's
15	policy or the health maintenance organization's contract
16	to provide for a minimum number of visits per year for the
17	screening, evaluation, or diagnosis for autism spectrum
18	disorder or other developmental disabilities; providing an
19	effective date.
20
21	Be It Enacted by the Legislature of the State of Florida:
22
23	Section 1.  Section 381.986, Florida Statutes, is created
24	to read:
25	381.986  Screening for autism spectrum disorder.-
26	(1)  If the parent or legal guardian of a minor believes
27	that the minor exhibits symptoms of autism spectrum disorder,
28	the parent or legal guardian may report his or her observation
29	to a physician licensed in this state. The physician shall
30	perform screening in accordance with American Academy of
31	Pediatrics' guidelines. If the physician determines that
32	referral to a specialist is medically necessary, he or she shall
33	refer the minor to an appropriate specialist to determine
34	whether the minor meets diagnostic criteria for autism spectrum
35	disorder. If the physician determines that referral to a
36	specialist is not medically necessary, the physician shall
37	inform the parent or legal guardian that the parent or legal
38	guardian may self-refer to the Early Steps program or another
39	appropriate specialist in autism. This section does not apply to
40	a physician providing care under s. 395.1041.
41	(2)  As used in this section, the term "appropriate
42	specialist" means a qualified professional who is experienced in
43	the evaluation of autism spectrum disorder, is licensed in this
44	state, and has training in validated diagnostic tools. The term
45	includes, but is not limited to:
46	(a)  A psychologist;
47	(b)  A psychiatrist;
48	(c)  A neurologist;
49	(d)  A developmental or behavioral pediatrician; or
50	(e)  A professional whose licensure is deemed appropriate
51	by the Children's Medical Services Early Steps program within
52	the Department of Health.
53	Section 2.  Section 627.6686, Florida Statutes, is amended
54	to read:
55	627.6686  Coverage for individuals with developmental
56	disabilities autism spectrum 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)  "Developmental disability" means a disorder or
76	syndrome attributable to cerebral palsy or Down syndrome which
77	manifests before the age of 18 years and constitutes a
78	substantial handicap that can reasonably be expected to continue
79	indefinitely. As used in this section, the term:
80	1.  "Cerebral palsy" has the same meaning as in s. 393.063.
81	2.  "Down syndrome" means a disorder caused by the presence
82	of an extra chromosome 21.
83	(d)  "Direct patient access" means the ability of an
84	insured to obtain services from an in-network provider without a
85	referral or other authorization before receiving services.
86	(e)(c)  "Eligible individual" means an individual under 18
87	years of age or an individual 18 years of age or older who is in
88	high school and who has been diagnosed as having a developmental
89	disability at 8 years of age or younger.
90	(f)(d)  "Health insurance plan" means a group health
91	insurance policy or group health benefit plan offered by an
92	insurer which includes the state group insurance program
93	provided under s. 110.123. The term does not include a any
94	health insurance plan offered in the individual market, a any
95	health insurance plan that is individually underwritten, or a
96	any health insurance plan provided to a small employer.
97	(g)(e)  "Insurer" means an insurer providing health
98	insurance coverage, which is licensed to engage in the business
99	of insurance in this state and is subject to insurance
100	regulation.
101	(3)  A health insurance plan issued or renewed on or after
102	April 1, 2009, shall provide coverage to an eligible individual
103	for:
104	(a)  Direct patient access to an appropriate specialist, as
105	defined in s. 381.986, for a minimum of three visits per policy
106	year for the screening for, evaluation of, or diagnosis of
107	autism spectrum disorder or other developmental disability.
108	(b)(a)  Well-baby and well-child screening for diagnosing
109	the presence of autism spectrum disorder.
110	(c)(b)  Treatment of autism spectrum disorder or other
111	developmental disability through speech therapy, occupational
112	therapy, physical therapy, and applied behavior analysis.
113	Applied behavior analysis services shall be provided by an
114	individual certified pursuant to s. 393.17 or an individual
115	licensed under chapter 490 or chapter 491.
116	(4)  The coverage required pursuant to subsection (3) is
117	subject to the following requirements:
118	(a)  Coverage shall be limited to treatment that is
119	prescribed by the insured's treating physician in accordance
120	with a treatment plan.
121	(b)  Coverage for the services described in subsection (3)
122	shall be limited to $36,000 annually and may not exceed $200,000
123	in total lifetime benefits.
124	(c)  Coverage may not be denied on the basis that provided
125	services are habilitative in nature.
126	(d)  Coverage may be subject to other general exclusions
127	and limitations of the insurer's policy or plan, including, but
128	not limited to, coordination of benefits, participating provider
129	requirements, restrictions on services provided by family or
130	household members, and utilization review of health care
131	services, including the review of medical necessity, case
132	management, and other managed care provisions.
133	(5)  The coverage required pursuant to subsection (3) may
134	not be subject to dollar limits, deductibles, or coinsurance
135	provisions that are less favorable to an insured than the dollar
136	limits, deductibles, or coinsurance provisions that apply to
137	physical illnesses that are generally covered under the health
138	insurance plan, except as otherwise provided in subsection (4).
139	(6)  An insurer may not deny or refuse to issue coverage
140	for medically necessary services, refuse to contract with, or
141	refuse to renew or reissue or otherwise terminate or restrict
142	coverage for an individual because the individual is diagnosed
143	as having a developmental disability.
144	(7)  The treatment plan required pursuant to subsection (4)
145	shall include all elements necessary for the health insurance
146	plan to appropriately pay claims. These elements include, but
147	are not limited to, a diagnosis, the proposed treatment by type,
148	the frequency and duration of treatment, the anticipated
149	outcomes stated as goals, the frequency with which the treatment
150	plan will be updated, and the signature of the treating
151	physician.
152	(8)  Beginning January 1, 2011, the maximum benefit under
153	paragraph (4)(b) shall be adjusted annually on January 1 of each
154	calendar year to reflect any change from the previous year in
155	the medical component of the then current Consumer Price Index
156	for all urban consumers, published by the Bureau of Labor
157	Statistics of the United States Department of Labor.
158	(9)  This section may not be construed as limiting benefits
159	and coverage otherwise available to an insured under a health
160	insurance plan.
161	(10)  The Office of Insurance Regulation may not enforce
162	this section against an insurer that is a signatory no later
163	than April 1, 2009, to the developmental disabilities compact
164	established under s. 624.916. The Office of Insurance Regulation
165	shall enforce this section against an insurer that is a
166	signatory to the compact established under s. 624.916 if the
167	insurer has not complied with the terms of the compact for all
168	health insurance plans by April 1, 2010.
169	Section 3.  Subsections (2) and (3) of section 641.31098,
170	Florida Statutes, are amended to read:
171	641.31098  Coverage for individuals with developmental
172	disabilities.-
173	(2)  As used in this section, the term:
174	(a)  "Applied behavior analysis" means the design,
175	implementation, and evaluation of environmental modifications,
176	using behavioral stimuli and consequences, to produce socially
177	significant improvement in human behavior, including, but not
178	limited to, the use of direct observation, measurement, and
179	functional analysis of the relations between environment and
180	behavior.
181	(b)  "Autism spectrum disorder" means any of the following
182	disorders as defined in the most recent edition of the
183	Diagnostic and Statistical Manual of Mental Disorders of the
184	American Psychiatric Association:
185	1.  Autistic disorder.
186	2.  Asperger's syndrome.
187	3.  Pervasive developmental disorder not otherwise
188	specified.
189	(c)  "Developmental disability" means a disorder or
190	syndrome attributable to cerebral palsy or Down syndrome which
191	manifests before the age of 18 years and constitutes a
192	substantial handicap that can reasonably be expected to continue
193	indefinitely. As used in this section, the term:
194	1.  "Cerebral palsy" has the same meaning as in s. 393.063.
195	2.  "Down syndrome" means a disorder caused by the presence
196	of an extra chromosome 21.
197	(d)  "Direct patient access" means the ability of an
198	insured to obtain services from an in-network provider without a
199	referral or other authorization before receiving services.
200	(e)(c)  "Eligible individual" means an individual under 18
201	years of age or an individual 18 years of age or older who is in
202	high school and who has been diagnosed as having a developmental
203	disability at 8 years of age or younger.
204	(f)(d)  "Health maintenance contract" means a group health
205	maintenance contract offered by a health maintenance
206	organization. The This term does not include a health
207	maintenance contract offered in the individual market, a health
208	maintenance contract that is individually underwritten, or a
209	health maintenance contract provided to a small employer.
210	(3)  A health maintenance contract issued or renewed on or
211	after April 1, 2009, shall provide coverage to an eligible
212	individual for:
213	(a)  Direct patient access to an appropriate specialist, as
214	defined in s. 381.986, for a minimum of three visits per policy
215	year for the screening for, evaluation of, or diagnosis of
216	autism spectrum disorder or other developmental disability.
217	(b)(a)  Well-baby and well-child screening for diagnosing
218	the presence of autism spectrum disorder.
219	(c)(b)  Treatment of autism spectrum disorder or other
220	developmental disability through speech therapy, occupational
221	therapy, physical therapy, and applied behavior analysis
222	services. Applied behavior analysis services shall be provided
223	by an individual certified pursuant to s. 393.17 or an
224	individual licensed under chapter 490 or chapter 491.
225	Section 4.  This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.