Florida Senate - 2016                                     SB 144
       
       
        
       By Senator Ring
       
       
       
       
       
       29-00062-16                                            2016144__
    1                        A bill to be entitled                      
    2         An act relating to autism; creating s. 381.988, F.S.;
    3         requiring a physician, to whom the parent or legal
    4         guardian of a minor reports observing symptoms of
    5         autism exhibited by the minor, to refer the minor to
    6         an 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 a minor
   11         from the Early Steps program or another appropriate
   12         specialist in autism under certain circumstances;
   13         defining the term “appropriate specialist”; amending
   14         ss. 627.6686 and 641.31098, F.S.; defining the term
   15         “direct patient access”; requiring that certain
   16         insurers and health maintenance organizations provide
   17         direct patient access for a minimum number of visits
   18         to an appropriate specialist for screening for, or
   19         evaluation or diagnosis of, autism spectrum disorder;
   20         providing effective dates.
   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 the minor
   31  in 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. Effective January 1, 2017, section 627.6686,
   54  Florida Statutes, is amended 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 younger
   79  than under 18 years of age or an individual 18 years of age or
   80  older who is in high school who has been diagnosed as having a
   81  developmental 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, 2017, 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 is
  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  is 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 under pursuant to subsection (3)
  126  may 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 for an individual because the
  133  individual is diagnosed as having a developmental disability,
  134  and may not refuse to contract with such an individual, or
  135  refuse to renew or reissue or otherwise terminate or restrict
  136  coverage for such an individual because the individual is
  137  diagnosed as having a developmental disability.
  138         (7) The treatment plan required pursuant to subsection (4)
  139  must shall include all elements necessary for the health
  140  insurance plan to appropriately pay claims. These elements
  141  include, but are not limited to, a diagnosis, the proposed
  142  treatment by type, the frequency and duration of treatment, the
  143  anticipated outcomes stated as goals, the frequency with which
  144  the treatment plan will be updated, and the signature of the
  145  treating physician.
  146         (8) The maximum benefit under paragraph (4)(b) shall be
  147  adjusted annually on January 1 of each calendar year to reflect
  148  any change from the previous year in the medical component of
  149  the then current Consumer Price Index for All Urban Consumers,
  150  published by the Bureau of Labor Statistics of the United States
  151  Department of Labor.
  152         (9) This section does may not limit be construed as
  153  limiting benefits and coverage otherwise available to an insured
  154  under a health insurance plan.
  155         Section 3. Effective January 1, 2017, section 641.31098,
  156  Florida Statutes, is amended to read:
  157         641.31098 Coverage for individuals with developmental
  158  disabilities.—
  159         (1) This section and s. 627.6686 may be cited as the
  160  “Steven A. Geller Autism Coverage Act.”
  161         (2) As used in this section, the term:
  162         (a) “Applied behavior analysis” means the design,
  163  implementation, and evaluation of environmental modifications,
  164  using behavioral stimuli and consequences, to produce socially
  165  significant improvement in human behavior, including, but not
  166  limited to, the use of direct observation, measurement, and
  167  functional analysis of the relations between environment and
  168  behavior.
  169         (b) “Autism spectrum disorder” means any of the following
  170  disorders as defined in the most recent edition of the
  171  Diagnostic and Statistical Manual of Mental Disorders of the
  172  American Psychiatric Association:
  173         1. Autistic disorder.
  174         2. Asperger’s syndrome.
  175         3. Pervasive developmental disorder not otherwise
  176  specified.
  177         (c)“Direct patient access” means the ability of an insured
  178  to obtain services from an in-network provider without a
  179  referral or other authorization before receiving services.
  180         (d)(c) “Eligible individual” means an individual younger
  181  than under 18 years of age or an individual 18 years of age or
  182  older who is in high school who has been diagnosed as having a
  183  developmental disability at 8 years of age or younger.
  184         (e)(d) “Health maintenance contract” means a group health
  185  maintenance contract offered by a health maintenance
  186  organization. This term does not include a health maintenance
  187  contract offered in the individual market, a health maintenance
  188  contract that is individually underwritten, or a health
  189  maintenance contract provided to a small employer.
  190         (3) A health maintenance contract issued or renewed on or
  191  after January 1, 2017, must April 1, 2009, shall provide
  192  coverage to an eligible individual for:
  193         (a) Direct patient access to an appropriate specialist, as
  194  defined in s. 381.988, for a minimum of three visits per policy
  195  year for screening for, or evaluation or diagnosis of, autism
  196  spectrum disorder.
  197         (b)(a) Well-baby and well-child screening for diagnosing
  198  the presence of autism spectrum disorder.
  199         (c)(b) Treatment of autism spectrum disorder through speech
  200  therapy, occupational therapy, physical therapy, and applied
  201  behavior analysis services. Applied behavior analysis services
  202  must shall be provided by an individual certified pursuant to s.
  203  393.17 or an individual licensed under chapter 490 or chapter
  204  491.
  205         (4) The coverage required pursuant to subsection (3) is
  206  subject to the following requirements:
  207         (a) Except as provided in paragraph (3)(a), coverage is
  208  shall be limited to treatment that is prescribed by the
  209  subscriber’s treating physician in accordance with a treatment
  210  plan.
  211         (b) Coverage for the services described in subsection (3)
  212  is shall be limited to $36,000 annually and may not exceed
  213  $200,000 in total benefits.
  214         (c) Coverage may not be denied on the basis that provided
  215  services are habilitative in nature.
  216         (d) Coverage may be subject to general exclusions and
  217  limitations of the subscriber’s contract, including, but not
  218  limited to, coordination of benefits, participating provider
  219  requirements, and utilization review of health care services,
  220  including the review of medical necessity, case management, and
  221  other managed care provisions.
  222         (5) The coverage required pursuant to subsection (3) may
  223  not be subject to dollar limits, deductibles, or coinsurance
  224  provisions that are less favorable to a subscriber than the
  225  dollar limits, deductibles, or coinsurance provisions that apply
  226  to physical illnesses that are generally covered under the
  227  subscriber’s contract, except as otherwise provided in
  228  subsection (3).
  229         (6) A health maintenance organization may not deny or
  230  refuse to issue coverage for medically necessary services for an
  231  individual solely because the individual is diagnosed as having
  232  a developmental disability, and may not refuse to contract with
  233  such an individual, or refuse to renew or reissue or otherwise
  234  terminate or restrict coverage for such an individual solely
  235  because the individual is diagnosed as having a developmental
  236  disability.
  237         (7) The treatment plan required pursuant to subsection (4)
  238  must shall include, but need is not be limited to, a diagnosis,
  239  the proposed treatment by type, the frequency and duration of
  240  treatment, the anticipated outcomes stated as goals, the
  241  frequency with which the treatment plan will be updated, and the
  242  signature of the treating physician.
  243         (8) The maximum benefit under paragraph (4)(b) shall be
  244  adjusted annually on January 1 of each calendar year to reflect
  245  any change from the previous year in the medical component of
  246  the then current Consumer Price Index for All Urban Consumers,
  247  published by the Bureau of Labor Statistics of the United States
  248  Department of Labor.
  249         Section 4. Except as otherwise expressly provided in this
  250  act, this act shall take effect July 1, 2016.