sb161_Committee_sub_LC_33_3069S

sb161_Committee_sub_LC_33_3069S_4.html

09 LC 33 3069S

The Senate Insurance and Labor Committee offered the following substitute to SB 161:

A BILL TO BE ENTITLED
AN ACT

To amend Code Section 33-24-59.10 of the Official Code of Georgia Annotated, relating to insurance coverage for autism, so as to require certain insurance coverage of autism spectrum disorders; to provide a short title; to provide for definitions; to provide for related matters; to repeal conflicting laws; and for other purposes.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:

SECTION 1.

This Act shall be known and may be cited as "Ava's Law."

SECTION 2.

Code Section 33-24-59.10 of the Official Code of Georgia Annotated, relating to insurance coverage for autism, is amended by revising said Code section as follows:

"33-24-59.10.

(a) As used in this Code section, the term:

(1) 'Accident and sickness contract, policy, or benefit plan' shall have the same meaning as found in Code Section 33-24-59.1. Accident and sickness contract, policy, or benefit plan shall also not include without limitation any health benefit plan established pursuant to Article 1 of Chapter 18 of Title 45. Accident and sickness contract, policy, or benefit plan shall not include limited benefit insurance policies designed, advertised, and marketed to supplement major medical insurance such as accident only, CHAMPUS supplement, dental, disability income, fixed indemnity, long-term care, medicare supplement, specified disease, vision, and any other type of accident and sickness insurance other than basic hospital expense, basic medical-surgical expense, or major medical insurance. Accident and sickness contract, policy, or benefit plan shall not include medical assistance or health care benefits provided pursuant to Article 7 of Chapter 4 of Title 49 or Article 13 of Chapter 5 of Title 49.

(2) '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.

(2)(3) 'Autism spectrum disorder' means a developmental neurological neurobiological disorder, usually appearing in the first three years of life, which affects normal brain functions and is manifested by compulsive, ritualistic behavior and severely impaired social interaction and communication skills qualitative impairment in social interaction, qualitative impairment in communication, and restricted repetitive and stereotyped patterns of behavior, interests, and activities. Autism spectrum disorder includes autistic disorder, Asperger's disorder, Rett's disorder, childhood disintegrative disorder, and 'pervasive developmental disorder not otherwise specified' as defined in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.

(4) 'Generally accepted standards of medical practice' means standards that are based on:

(A) Credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;

(B) Physician and health care provider specialty society recommendations;

(D) Any other relevant factors.

(5) 'Habilitative and rehabilitative care' means behavioral intervention and management services, including counseling, guidance services, and treatment programs including applied behavior analysis and other structured behavioral programs provided by a licensed psychiatrist, licensed psychologist, licensed clinical social worker, licensed behavioral therapist, certified behavioral analyst, or other qualified professional as prescribed by a licensed physician, licensed physician's assistant, or certified nurse practitioner.

(6) 'Medical care' means services provided by a licensed physician, licensed physician's assistant, or certified nurse practitioner, including evaluating, testing, diagnosing, and treating autism spectrum disorders based on generally accepted standards of medical practice.

(7) 'Medically necessary' means health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms that are:

(A) In accordance with generally accepted standards of medical practice;

(B) Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease; and

(C) Not primarily for the convenience of the patient, physician, or other health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease.

(8) 'Pharmacy care' means medications and nutritional supplements prescribed by a licensed physician, licensed physician's assistant, or certified nurse practitioner.

(9) 'Therapeutic care' means services provided by a licensed or certified speech therapist, occupational therapist, or physical therapist as prescribed by a licensed physician, licensed physician's assistant, or certified nurse practitioner.

(10) 'Treatment plan' means medical, therapeutic, habilitative and rehabilitative, pharmacological, or other general care deemed medically necessary and prescribed by a licensed physician, licensed physician's assistant, or certified nurse practitioner.

(b) An insurer that provides benefits for neurological disorders, whether under a group or individual accident and sickness contract, policy, or benefit plan, shall not deny providing benefits in accordance with the conditions, schedule of benefits, limitations as to type and scope of treatment authorized for neurological disorders, exclusions, cost-sharing arrangements, or copayment requirements which exist in such contract, policy, or benefit plan for neurological disorders because of a diagnosis of autism. The provisions of this subsection shall not expand the type or scope of treatment beyond that authorized for any other diagnosed neurological disorder. An insurer shall not deny or refuse to issue coverage on, contract with, renew, or reissue or otherwise terminate or restrict coverage under an accident and sickness contract, policy, or benefit plan on an individual solely because the individual is diagnosed with autism spectrum disorder, nor shall an insurer exclude or deny coverage due to the use of medically necessary therapeutic care, habilitative and rehabilitative care, and pharmacy care or other general care services for an autism spectrum disorder. No service required under this subsection shall be denied on the basis that it is habilitative in nature. Coverage required under this subsection shall not be subject to dollar limits, deductibles, coinsurance provisions, or coverage periods that are less favorable to an insured than the dollar limits, deductibles, coinsurance provisions, or coverage periods that apply to physical illness generally under the health insurance plan, except as provided in subsection (d) of this Code section.

(c) Medical care, therapeutic care, habilitative and rehabilitative care, and pharmacy care for an autism spectrum disorder shall be fully covered under an accident and sickness contract, policy, or benefit plan except as provided in subsection (d) of this Code section. Treatment plans prescribing these care services shall include all elements necessary for claims payments and include, but not be limited to, a diagnosis proposed treatment by type, frequency, and duration of treatment, the anticipated outcomes stated as goals, the frequency by which treatment plans will be updated, and the treatment providers' signatures. An insurer shall have the right to request updated treatment plans once every six months to review medical necessity unless the insurer and the treatment provider agree that a more frequent review is necessary due to emerging clinical circumstances. The cost of obtaining any review shall be borne by the insurer.

(d) Applied behavior analysis under this Code section may be subject to a maximum benefit of $50,000.00 per year and a maximum lifetime benefit of $250,000.00 but shall not be subject to any limits on the number of visits or hours per visit.

(e) This Code section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.

(f) This Code section shall not be construed as limiting benefits that are otherwise available to an individual under an accident and sickness contract, policy, or benefit plan.

(g) Beginning January 1, 2010, the Commissioner shall, on an annual basis, adjust the maximum benefit as provided in subsection (d) of this Code section for inflation, which may be based on the Medical Care Component of the Consumer Price Index for All Urban Consumers (CPI-U) as published by the United States Department of Labor's Bureau of Labor Statistics. The Commissioner shall submit the adjusted maximum benefit for publication annually no later than July 1 of each calendar year, and the published adjusted maximum benefit shall be applicable in the following calendar year to health insurance policies subject to this Code section. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item unrelated to applied behavior analysis shall not be applied towards any maximum benefit established under this subsection.

(h) An insurer subject to this Code section shall only be required to provide coverage to a person until he or she attains the age of 18.

(i) This Code section shall not apply to an accident and sickness contract, policy, or benefit plan offered by an employer to its employees if such employer has 25 or fewer employees."

SECTION 3.

All laws and parts of laws in conflict with this Act are repealed.