Florida Senate - 2010 CS for SB 214
By the Committee on Health Regulation; and Senator Ring
588-02715A-10 2010214c1
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
4 appropriate specialist for screening for autism
5 spectrum disorder under certain circumstances;
6 defining the term “appropriate specialist”; amending
7 ss. 627.6686 and 641.31098, F.S.; defining the terms
8 “developmental disability” and “direct patient
9 access”; providing health insurance coverage for
10 individuals with certain developmental disabilities;
11 requiring certain insurers and health maintenance
12 organizations to provide direct patient access to an
13 appropriate specialist for screening, evaluation of,
14 or diagnosis for autism spectrum disorder or other
15 developmental disabilities; requiring the insurer’s
16 policy or the health maintenance organization’s
17 contract to provide a minimum number of visits per
18 year for the screening, evaluation, or diagnosis for
19 autism spectrum disorder or other developmental
20 disabilities; providing an effective date.
21
22 Be It Enacted by the Legislature of the State of Florida:
23
24 Section 1. Section 381.986, Florida Statutes, is created to
25 read:
26 381.986 Screening 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,
29 the parent or legal guardian may report his or her observation
30 to a physician licensed in this state. The physician shall
31 perform screening in accordance with American Academy of
32 Pediatrics’ guidelines. If the physician determines that
33 referral to a specialist is medically necessary, he or she shall
34 refer the minor to an appropriate specialist to determine
35 whether the minor meets diagnostic criteria for autism spectrum
36 disorder. If the physician determines that referral to a
37 specialist is not medically necessary, the physician shall
38 inform the parent or legal guardian that they can self-refer to
39 the Early Steps intervention program or other specialist in
40 autism. This section does not apply to a physician providing
41 care under s. 395.1041.
42 (2) As used in this section, the term “appropriate
43 specialist” means a qualified professional who is experienced in
44 the evaluation of autism spectrum disorder, is licensed in this
45 state, and has training in validated diagnostic tools. The term
46 includes, but is not limited to:
47 (a) A psychologist;
48 (b) A psychiatrist;
49 (c) A neurologist;
50 (d) A developmental or behavioral pediatrician; or
51 (e) A professional whose licensure is deemed appropriate by
52 the Children’s Medical Services Early Steps Program within the
53 Department of Health.
54 Section 2. Section 627.6686, Florida Statutes, is amended
55 to read:
56 627.6686 Coverage for individuals with developmental
57 disabilities autism spectrum disorder required; exception.—
58 (1) This section and s. 641.31098 may be cited as the
59 “Steven A. Geller Autism Coverage Act.”
60 (2) As used in this section, the term:
61 (a) “Applied behavior analysis” means the design,
62 implementation, and evaluation of environmental modifications,
63 using behavioral stimuli and consequences, to produce socially
64 significant improvement in human behavior, including, but not
65 limited to, the use of direct observation, measurement, and
66 functional analysis of the relations between environment and
67 behavior.
68 (b) “Autism spectrum disorder” means any of the following
69 disorders as defined in the most recent edition of the
70 Diagnostic and Statistical Manual of Mental Disorders of the
71 American Psychiatric Association:
72 1. Autistic disorder.
73 2. Asperger’s syndrome.
74 3. Pervasive developmental disorder not otherwise
75 specified.
76 (c) “Developmental disability” means a disorder or syndrome
77 attributable to cerebral palsy or Down syndrome, which manifests
78 before the age of 18 years and constitutes a substantial
79 handicap that can reasonably be expected to continue
80 indefinitely. As used in this section:
81 1. “Cerebral palsy” has the same meaning as in s. 393.063.
82 2. “Down syndrome” means a disorder caused by the presence
83 of an extra chromosome 21.
84 (d) “Direct patient access” means the ability of an insured
85 to obtain services from an in-network provider without a
86 referral or other authorization before receiving services.
87 (e)(c) “Eligible individual” means an individual under 18
88 years of age or an individual 18 years of age or older who is in
89 high school and who has been diagnosed as having a developmental
90 disability at 8 years of age or younger.
91 (f)(d) “Health insurance plan” means a group health
92 insurance policy or group health benefit plan offered by an
93 insurer which includes the state group insurance program
94 provided under s. 110.123. The term does not include a any
95 health insurance plan offered in the individual market, a any
96 health insurance plan that is individually underwritten, or a
97 any health insurance plan provided to a small employer.
98 (g)(e) “Insurer” means an insurer providing health
99 insurance coverage, which is licensed to engage in the business
100 of insurance in this state and is subject to insurance
101 regulation.
102 (3) A health insurance plan issued or renewed on or after
103 April 1, 2009, shall provide coverage to an eligible individual
104 for:
105 (a) Direct patient access to an appropriate specialist, as
106 defined in s. 381.986, for a minimum of three visits per policy
107 year for the screening for, evaluation of, or diagnosis of
108 autism spectrum disorder or other developmental disability.
109 (b)(a) Well-baby and well-child screening for diagnosing
110 the presence of autism spectrum disorder.
111 (c)(b) Treatment of autism spectrum disorder or other
112 developmental disability through speech therapy, occupational
113 therapy, physical therapy, and applied behavior analysis.
114 Applied behavior analysis services shall be provided by an
115 individual certified pursuant to s. 393.17 or an individual
116 licensed under chapter 490 or chapter 491.
117 (4) The coverage required pursuant to subsection (3) is
118 subject to the following requirements:
119 (a) Coverage shall be limited to treatment that is
120 prescribed by the insured’s treating physician in accordance
121 with a treatment plan.
122 (b) Coverage for the services described in subsection (3)
123 shall be limited to $36,000 annually and may not exceed $200,000
124 in total lifetime benefits.
125 (c) Coverage may not be denied on the basis that provided
126 services are habilitative in nature.
127 (d) Coverage may be subject to other general exclusions and
128 limitations of the insurer’s policy or plan, including, but not
129 limited to, coordination of benefits, participating provider
130 requirements, restrictions on services provided by family or
131 household members, and utilization review of health care
132 services, including the review of medical necessity, case
133 management, and other managed care provisions.
134 (5) The coverage required pursuant to subsection (3) may
135 not be subject to dollar limits, deductibles, or coinsurance
136 provisions that are less favorable to an insured than the dollar
137 limits, deductibles, or coinsurance provisions that apply to
138 physical illnesses that are generally covered under the health
139 insurance plan, except as otherwise provided in subsection (4).
140 (6) An insurer may not deny or refuse to issue coverage for
141 medically necessary services, refuse to contract with, or refuse
142 to renew or reissue or otherwise terminate or restrict coverage
143 for an individual because the individual is diagnosed as having
144 a developmental disability.
145 (7) The treatment plan required pursuant to subsection (4)
146 shall include all elements necessary for the health insurance
147 plan to appropriately pay claims. These elements include, but
148 are not limited to, a diagnosis, the proposed treatment by type,
149 the frequency and duration of treatment, the anticipated
150 outcomes stated as goals, the frequency with which the treatment
151 plan will be updated, and the signature of the treating
152 physician.
153 (8) Beginning January 1, 2011, the maximum benefit under
154 paragraph (4)(b) shall be adjusted annually on January 1 of each
155 calendar year to reflect any change from the previous year in
156 the medical component of the then current Consumer Price Index
157 for all urban consumers, published by the Bureau of Labor
158 Statistics of the United States Department of Labor.
159 (9) This section may not be construed as limiting benefits
160 and coverage otherwise available to an insured under a health
161 insurance plan.
162 (10) The Office of Insurance Regulation may not enforce
163 this section against an insurer that is a signatory no later
164 than April 1, 2009, to the developmental disabilities compact
165 established under s. 624.916. The Office of Insurance Regulation
166 shall enforce this section against an insurer that is a
167 signatory to the compact established under s. 624.916 if the
168 insurer has not complied with the terms of the compact for all
169 health insurance plans by April 1, 2010.
170 Section 3. Subsections (2) and (3) of section 641.31098,
171 Florida Statutes, are amended to read:
172 641.31098 Coverage for individuals with developmental
173 disabilities.—
174 (2) As used in this section, the term:
175 (a) “Applied behavior analysis” means the design,
176 implementation, and evaluation of environmental modifications,
177 using behavioral stimuli and consequences, to produce socially
178 significant improvement in human behavior, including, but not
179 limited to, the use of direct observation, measurement, and
180 functional analysis of the relations between environment and
181 behavior.
182 (b) “Autism spectrum disorder” means any of the following
183 disorders as defined in the most recent edition of the
184 Diagnostic and Statistical Manual of Mental Disorders of the
185 American Psychiatric Association:
186 1. Autistic disorder.
187 2. Asperger’s syndrome.
188 3. Pervasive developmental disorder not otherwise
189 specified.
190 (c) “Developmental disability” means a disorder or syndrome
191 attributable to cerebral palsy or Down syndrome, which manifests
192 before the age of 18 years and constitutes a substantial
193 handicap that can reasonably be expected to continue
194 indefinitely. As used in this section:
195 1. “Cerebral palsy” has the same meaning as in s. 393.063.
196 2. “Down syndrome” means a disorder caused by the presence
197 of an extra chromosome 21.
198 (d) “Direct patient access” means the ability of an insured
199 to obtain services from an in-network provider without a
200 referral or other authorization before receiving services.
201 (e)(c) “Eligible individual” means an individual under 18
202 years of age or an individual 18 years of age or older who is in
203 high school and who has been diagnosed as having a developmental
204 disability at 8 years of age or younger.
205 (f)(d) “Health maintenance contract” means a group health
206 maintenance contract offered by a health maintenance
207 organization. The This term does not include a health
208 maintenance contract offered in the individual market, a health
209 maintenance contract that is individually underwritten, or a
210 health maintenance contract provided to a small employer.
211 (3) A health maintenance contract issued or renewed on or
212 after April 1, 2009, shall provide coverage to an eligible
213 individual for:
214 (a) Direct patient access to an appropriate specialist, as
215 defined in s. 381.986, for a minimum of three visits per policy
216 year for the screening for, evaluation of, or diagnosis of
217 autism spectrum disorder or other developmental disability.
218 (b)(a) Well-baby and well-child screening for diagnosing
219 the presence of autism spectrum disorder.
220 (c)(b) Treatment of autism spectrum disorder or other
221 developmental disability through speech therapy, occupational
222 therapy, physical therapy, and applied behavior analysis
223 services. Applied behavior analysis services shall be provided
224 by an individual certified pursuant to s. 393.17 or an
225 individual licensed under chapter 490 or chapter 491.
226 Section 4. This act shall take effect July 1, 2010.