CS/HB 107

1
A bill to be entitled
2An act relating to autism; creating s. 381.986, F.S.;
3requiring that a physician refer a minor to an appropriate
4specialist for screening for autism spectrum disorder
5under certain circumstances; defining the term
6"appropriate specialist"; amending ss. 627.6686 and
7641.31098, F.S.; defining the terms "developmental
8disability" and "direct patient access"; providing health
9insurance coverage for individuals with certain
10developmental disabilities; requiring certain insurers and
11health maintenance organizations to provide direct patient
12access to an appropriate specialist for screening,
13evaluation, or diagnosis for autism spectrum disorder or
14other developmental disabilities; requiring the insurer's
15policy or the health maintenance organization's contract
16to provide for a minimum number of visits per year for the
17screening, evaluation, or diagnosis for autism spectrum
18disorder or other developmental disabilities; providing an
19effective date.
20
21Be It Enacted by the Legislature of the State of Florida:
22
23     Section 1.  Section 381.986, Florida Statutes, is created
24to read:
25     381.986  Screening for autism spectrum disorder.-
26     (1)  If the parent or legal guardian of a minor believes
27that the minor exhibits symptoms of autism spectrum disorder,
28the parent or legal guardian may report his or her observation
29to a physician licensed in this state. The physician shall
30perform screening in accordance with American Academy of
31Pediatrics' guidelines. If the physician determines that
32referral to a specialist is medically necessary, he or she shall
33refer the minor to an appropriate specialist to determine
34whether the minor meets diagnostic criteria for autism spectrum
35disorder. If the physician determines that referral to a
36specialist is not medically necessary, the physician shall
37inform the parent or legal guardian that the parent or legal
38guardian may self-refer to the Early Steps program or another
39appropriate specialist in autism. This section does not apply to
40a physician providing care under s. 395.1041.
41     (2)  As used in this section, the term "appropriate
42specialist" means a qualified professional who is experienced in
43the evaluation of autism spectrum disorder, is licensed in this
44state, and has training in validated diagnostic tools. The term
45includes, 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
51by the Children's Medical Services Early Steps program within
52the Department of Health.
53     Section 2.  Section 627.6686, Florida Statutes, is amended
54to read:
55     627.6686  Coverage for individuals with developmental
56disabilities 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,
61implementation, and evaluation of environmental modifications,
62using behavioral stimuli and consequences, to produce socially
63significant improvement in human behavior, including, but not
64limited to, the use of direct observation, measurement, and
65functional analysis of the relations between environment and
66behavior.
67     (b)  "Autism spectrum disorder" means any of the following
68disorders as defined in the most recent edition of the
69Diagnostic and Statistical Manual of Mental Disorders of the
70American Psychiatric Association:
71     1.  Autistic disorder.
72     2.  Asperger's syndrome.
73     3.  Pervasive developmental disorder not otherwise
74specified.
75     (c)  "Developmental disability" means a disorder or
76syndrome attributable to cerebral palsy or Down syndrome which
77manifests before the age of 18 years and constitutes a
78substantial handicap that can reasonably be expected to continue
79indefinitely. 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
82of an extra chromosome 21.
83     (d)  "Direct patient access" means the ability of an
84insured to obtain services from an in-network provider without a
85referral or other authorization before receiving services.
86     (e)(c)  "Eligible individual" means an individual under 18
87years of age or an individual 18 years of age or older who is in
88high school and who has been diagnosed as having a developmental
89disability at 8 years of age or younger.
90     (f)(d)  "Health insurance plan" means a group health
91insurance policy or group health benefit plan offered by an
92insurer which includes the state group insurance program
93provided under s. 110.123. The term does not include a any
94health insurance plan offered in the individual market, a any
95health insurance plan that is individually underwritten, or a
96any health insurance plan provided to a small employer.
97     (g)(e)  "Insurer" means an insurer providing health
98insurance coverage, which is licensed to engage in the business
99of insurance in this state and is subject to insurance
100regulation.
101     (3)  A health insurance plan issued or renewed on or after
102April 1, 2009, shall provide coverage to an eligible individual
103for:
104     (a)  Direct patient access to an appropriate specialist, as
105defined in s. 381.986, for a minimum of three visits per policy
106year for the screening for, evaluation of, or diagnosis of
107autism spectrum disorder or other developmental disability.
108     (b)(a)  Well-baby and well-child screening for diagnosing
109the presence of autism spectrum disorder.
110     (c)(b)  Treatment of autism spectrum disorder or other
111developmental disability through speech therapy, occupational
112therapy, physical therapy, and applied behavior analysis.
113Applied behavior analysis services shall be provided by an
114individual certified pursuant to s. 393.17 or an individual
115licensed under chapter 490 or chapter 491.
116     (4)  The coverage required pursuant to subsection (3) is
117subject to the following requirements:
118     (a)  Coverage shall be limited to treatment that is
119prescribed by the insured's treating physician in accordance
120with a treatment plan.
121     (b)  Coverage for the services described in subsection (3)
122shall be limited to $36,000 annually and may not exceed $200,000
123in total lifetime benefits.
124     (c)  Coverage may not be denied on the basis that provided
125services are habilitative in nature.
126     (d)  Coverage may be subject to other general exclusions
127and limitations of the insurer's policy or plan, including, but
128not limited to, coordination of benefits, participating provider
129requirements, restrictions on services provided by family or
130household members, and utilization review of health care
131services, including the review of medical necessity, case
132management, and other managed care provisions.
133     (5)  The coverage required pursuant to subsection (3) may
134not be subject to dollar limits, deductibles, or coinsurance
135provisions that are less favorable to an insured than the dollar
136limits, deductibles, or coinsurance provisions that apply to
137physical illnesses that are generally covered under the health
138insurance plan, except as otherwise provided in subsection (4).
139     (6)  An insurer may not deny or refuse to issue coverage
140for medically necessary services, refuse to contract with, or
141refuse to renew or reissue or otherwise terminate or restrict
142coverage for an individual because the individual is diagnosed
143as having a developmental disability.
144     (7)  The treatment plan required pursuant to subsection (4)
145shall include all elements necessary for the health insurance
146plan to appropriately pay claims. These elements include, but
147are not limited to, a diagnosis, the proposed treatment by type,
148the frequency and duration of treatment, the anticipated
149outcomes stated as goals, the frequency with which the treatment
150plan will be updated, and the signature of the treating
151physician.
152     (8)  Beginning January 1, 2011, the maximum benefit under
153paragraph (4)(b) shall be adjusted annually on January 1 of each
154calendar year to reflect any change from the previous year in
155the medical component of the then current Consumer Price Index
156for all urban consumers, published by the Bureau of Labor
157Statistics of the United States Department of Labor.
158     (9)  This section may not be construed as limiting benefits
159and coverage otherwise available to an insured under a health
160insurance plan.
161     (10)  The Office of Insurance Regulation may not enforce
162this section against an insurer that is a signatory no later
163than April 1, 2009, to the developmental disabilities compact
164established under s. 624.916. The Office of Insurance Regulation
165shall enforce this section against an insurer that is a
166signatory to the compact established under s. 624.916 if the
167insurer has not complied with the terms of the compact for all
168health insurance plans by April 1, 2010.
169     Section 3.  Subsections (2) and (3) of section 641.31098,
170Florida Statutes, are amended to read:
171     641.31098  Coverage for individuals with developmental
172disabilities.-
173     (2)  As used in this section, the term:
174     (a)  "Applied behavior analysis" means the design,
175implementation, and evaluation of environmental modifications,
176using behavioral stimuli and consequences, to produce socially
177significant improvement in human behavior, including, but not
178limited to, the use of direct observation, measurement, and
179functional analysis of the relations between environment and
180behavior.
181     (b)  "Autism spectrum disorder" means any of the following
182disorders as defined in the most recent edition of the
183Diagnostic and Statistical Manual of Mental Disorders of the
184American Psychiatric Association:
185     1.  Autistic disorder.
186     2.  Asperger's syndrome.
187     3.  Pervasive developmental disorder not otherwise
188specified.
189     (c)  "Developmental disability" means a disorder or
190syndrome attributable to cerebral palsy or Down syndrome which
191manifests before the age of 18 years and constitutes a
192substantial handicap that can reasonably be expected to continue
193indefinitely. 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
196of an extra chromosome 21.
197     (d)  "Direct patient access" means the ability of an
198insured to obtain services from an in-network provider without a
199referral or other authorization before receiving services.
200     (e)(c)  "Eligible individual" means an individual under 18
201years of age or an individual 18 years of age or older who is in
202high school and who has been diagnosed as having a developmental
203disability at 8 years of age or younger.
204     (f)(d)  "Health maintenance contract" means a group health
205maintenance contract offered by a health maintenance
206organization. The This term does not include a health
207maintenance contract offered in the individual market, a health
208maintenance contract that is individually underwritten, or a
209health maintenance contract provided to a small employer.
210     (3)  A health maintenance contract issued or renewed on or
211after April 1, 2009, shall provide coverage to an eligible
212individual for:
213     (a)  Direct patient access to an appropriate specialist, as
214defined in s. 381.986, for a minimum of three visits per policy
215year for the screening for, evaluation of, or diagnosis of
216autism spectrum disorder or other developmental disability.
217     (b)(a)  Well-baby and well-child screening for diagnosing
218the presence of autism spectrum disorder.
219     (c)(b)  Treatment of autism spectrum disorder or other
220developmental disability through speech therapy, occupational
221therapy, physical therapy, and applied behavior analysis
222services. Applied behavior analysis services shall be provided
223by an individual certified pursuant to s. 393.17 or an
224individual 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.