Florida Senate - 2013 SB 128
By Senator Ring
29-00086-13 2013128__
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 term
8 “direct patient access”; requiring that certain
9 insurers and health maintenance organizations provide
10 direct patient access to an appropriate specialist for
11 screening for or evaluation or diagnosis of autism
12 spectrum disorder; requiring that certain insurance
13 policies and health maintenance organization contracts
14 provide a minimum number of visits per year for
15 screening for or evaluation or diagnosis of autism
16 spectrum disorder; providing an effective date.
17
18 Be It Enacted by the Legislature of the State of Florida:
19
20 Section 1. Section 381.986, Florida Statutes, is created to
21 read:
22 381.986 Screening for autism spectrum disorder.—
23 (1) If the parent or legal guardian of a minor believes
24 that the minor exhibits symptoms of autism spectrum disorder,
25 the parent or legal guardian may report his or her observation
26 to a physician licensed under chapter 458 or chapter 459. The
27 physician shall perform screening in accordance with the
28 guidelines of the American Academy of Pediatrics’ guidelines. If
29 the physician determines that referral to a specialist is
30 medically necessary, the physician shall refer the minor to an
31 appropriate specialist to determine whether the minor meets
32 diagnostic criteria for autism spectrum disorder. If the
33 physician determines that referral to a specialist is not
34 medically necessary, the physician shall inform the parent or
35 legal guardian of the option for the parent or guardian to refer
36 the child to the Early Steps Program or other specialist in
37 autism. This section does not apply to a physician providing
38 care under s. 395.1041.
39 (2) As used in this section, the term “appropriate
40 specialist” means a qualified professional licensed in this
41 state who is experienced in the evaluation of autism spectrum
42 disorder and has training in validated diagnostic tools. The
43 term includes, but is not limited to:
44 (a) A psychologist;
45 (b) A psychiatrist;
46 (c) A neurologist; or
47 (d) A developmental or behavioral pediatrician.
48 Section 2. Section 627.6686, Florida Statutes, is amended
49 to read:
50 627.6686 Coverage for individuals with autism spectrum
51 disorder required; exception.—
52 (1) This section and s. 641.31098 may be cited as the
53 “Steven A. Geller Autism Coverage Act.”
54 (2) As used in this section, the term:
55 (a) “Applied behavior analysis” means the design,
56 implementation, and evaluation of environmental modifications,
57 using behavioral stimuli and consequences, to produce socially
58 significant improvement in human behavior, including, but not
59 limited to, the use of direct observation, measurement, and
60 functional analysis of the relations between environment and
61 behavior.
62 (b) “Autism spectrum disorder” means any of the following
63 disorders as defined in the most recent edition of the
64 Diagnostic and Statistical Manual of Mental Disorders of the
65 American Psychiatric Association:
66 1. Autistic disorder.
67 2. Asperger’s syndrome.
68 3. Pervasive developmental disorder not otherwise
69 specified.
70 (c) “Direct patient access” means the ability of an insured
71 to obtain services from a contracted provider without a referral
72 or other authorization before receiving services.
73 (d)(c) “Eligible individual” means an individual under 18
74 years of age or an individual 18 years of age or older who is in
75 high school who has been diagnosed as having a developmental
76 disability at 8 years of age or younger.
77 (e)(d) “Health insurance plan” means a group health
78 insurance policy or group health benefit plan offered by an
79 insurer which includes the state group insurance program
80 provided under s. 110.123. The term does not include any health
81 insurance plan offered in the individual market, any health
82 insurance plan that is individually underwritten, or any health
83 insurance plan provided to a small employer.
84 (f)(e) “Insurer” means an insurer providing health
85 insurance coverage, which is licensed to engage in the business
86 of insurance in this state and is subject to insurance
87 regulation.
88 (3) A health insurance plan issued or renewed on or after
89 January 1, 2014 April 1, 2009, shall provide coverage to an
90 eligible individual for:
91 (a) Direct patient access to an appropriate specialist, as
92 defined in s. 381.986, for a minimum of three visits per policy
93 year for screening for or evaluation or diagnosis of autism
94 spectrum disorder.
95 (b)(a) Well-baby and well-child screening for diagnosing
96 the presence of autism spectrum disorder.
97 (c)(b) Treatment of autism spectrum disorder through speech
98 therapy, occupational therapy, physical therapy, and applied
99 behavior analysis. Applied behavior analysis services shall be
100 provided by an individual certified pursuant to s. 393.17 or an
101 individual licensed under chapter 490 or chapter 491.
102 (4) The coverage required pursuant to subsection (3) is
103 subject to the following requirements:
104 (a) Coverage shall be limited to treatment that is
105 prescribed by the insured’s treating physician in accordance
106 with a treatment plan.
107 (b) Coverage for the services described in subsection (3)
108 shall be limited to $36,000 annually and may not exceed $200,000
109 in total lifetime benefits.
110 (c) Coverage may not be denied on the basis that provided
111 services are habilitative in nature.
112 (d) Coverage may be subject to other general exclusions and
113 limitations of the insurer’s policy or plan, including, but not
114 limited to, coordination of benefits, participating provider
115 requirements, restrictions on services provided by family or
116 household members, and utilization review of health care
117 services, including the review of medical necessity, case
118 management, and other managed care provisions.
119 (5) The coverage required pursuant to subsection (3) may
120 not be subject to dollar limits, deductibles, or coinsurance
121 provisions that are less favorable to an insured than the dollar
122 limits, deductibles, or coinsurance provisions that apply to
123 physical illnesses that are generally covered under the health
124 insurance plan, except as otherwise provided in subsection (4).
125 (6) An insurer may not deny or refuse to issue coverage for
126 medically necessary services, refuse to contract with, or refuse
127 to renew or reissue or otherwise terminate or restrict coverage
128 for an individual because the individual is diagnosed as having
129 a developmental disability.
130 (7) The treatment plan required pursuant to subsection (4)
131 must shall include all elements necessary for the health
132 insurance plan to appropriately pay claims. These elements
133 include, but are not limited to, a diagnosis, the proposed
134 treatment by type, the frequency and duration of treatment, the
135 anticipated outcomes stated as goals, the frequency with which
136 the treatment plan will be updated, and the signature of the
137 treating physician.
138 (8) Beginning January 1, 2011, The maximum benefit under
139 paragraph (4)(b) shall be adjusted annually on January 1 of each
140 calendar year to reflect any change from the previous year in
141 the medical component of the then current Consumer Price Index
142 for All Urban Consumers, published by the Bureau of Labor
143 Statistics of the United States Department of Labor.
144 (9) This section does may not limit be construed as
145 limiting benefits and coverage otherwise available to an insured
146 under a health insurance plan.
147 Section 3. Section 641.31098, Florida Statutes, is amended
148 to read:
149 641.31098 Coverage for individuals with developmental
150 disabilities.—
151 (1) This section and s. 627.6686 may be cited as the
152 “Steven A. Geller Autism Coverage Act.”
153 (2) As used in this section, the term:
154 (a) “Applied behavior analysis” means the design,
155 implementation, and evaluation of environmental modifications,
156 using behavioral stimuli and consequences, to produce socially
157 significant improvement in human behavior, including, but not
158 limited to, the use of direct observation, measurement, and
159 functional analysis of the relations between environment and
160 behavior.
161 (b) “Autism spectrum disorder” means any of the following
162 disorders as defined in the most recent edition of the
163 Diagnostic and Statistical Manual of Mental Disorders of the
164 American Psychiatric Association:
165 1. Autistic disorder.
166 2. Asperger’s syndrome.
167 3. Pervasive developmental disorder not otherwise
168 specified.
169 (c) “Direct patient access” means the ability of an insured
170 to obtain services from an in-network provider without a
171 referral or other authorization before receiving services.
172 (d)(c) “Eligible individual” means an individual under 18
173 years of age or an individual 18 years of age or older who is in
174 high school who has been diagnosed as having a developmental
175 disability at 8 years of age or younger.
176 (e)(d) “Health maintenance contract” means a group health
177 maintenance contract offered by a health maintenance
178 organization. This term does not include a health maintenance
179 contract offered in the individual market, a health maintenance
180 contract that is individually underwritten, or a health
181 maintenance contract provided to a small employer.
182 (3) A health maintenance contract issued or renewed on or
183 after January 1, 2014 April 1, 2009, shall provide coverage to
184 an eligible individual for:
185 (a) Direct patient access to an appropriate specialist, as
186 defined in s. 381.986, for a minimum of three visits per policy
187 year for screening for or evaluation or diagnosis of autism
188 spectrum disorder.
189 (b)(a) Well-baby and well-child screening for diagnosing
190 the presence of autism spectrum disorder.
191 (c)(b) Treatment of autism spectrum disorder through speech
192 therapy, occupational therapy, physical therapy, and applied
193 behavior analysis services. Applied behavior analysis services
194 shall be provided by an individual certified pursuant to s.
195 393.17 or an individual licensed under chapter 490 or chapter
196 491.
197 (4) The coverage required pursuant to subsection (3) is
198 subject to the following requirements:
199 (a) Coverage shall be limited to treatment that is
200 prescribed by the subscriber’s treating physician in accordance
201 with a treatment plan.
202 (b) Coverage for the services described in subsection (3)
203 shall be limited to $36,000 annually and may not exceed $200,000
204 in total benefits.
205 (c) Coverage may not be denied on the basis that provided
206 services are habilitative in nature.
207 (d) Coverage may be subject to general exclusions and
208 limitations of the subscriber’s contract, including, but not
209 limited to, coordination of benefits, participating provider
210 requirements, and utilization review of health care services,
211 including the review of medical necessity, case management, and
212 other managed care provisions.
213 (5) The coverage required pursuant to subsection (3) may
214 not be subject to dollar limits, deductibles, or coinsurance
215 provisions that are less favorable to a subscriber than the
216 dollar limits, deductibles, or coinsurance provisions that apply
217 to physical illnesses that are generally covered under the
218 subscriber’s contract, except as otherwise provided in
219 subsection (3).
220 (6) A health maintenance organization may not deny or
221 refuse to issue coverage for medically necessary services,
222 refuse to contract with, or refuse to renew or reissue or
223 otherwise terminate or restrict coverage for an individual
224 solely because the individual is diagnosed as having a
225 developmental disability.
226 (7) The treatment plan required pursuant to subsection (4)
227 must shall include, but need is not be limited to, a diagnosis,
228 the proposed treatment by type, the frequency and duration of
229 treatment, the anticipated outcomes stated as goals, the
230 frequency with which the treatment plan will be updated, and the
231 signature of the treating physician.
232 (8) Beginning January 1, 2011, The maximum benefit under
233 paragraph (4)(b) shall be adjusted annually on January 1 of each
234 calendar year to reflect any change from the previous year in
235 the medical component of the then current Consumer Price Index
236 for All Urban Consumers, published by the Bureau of Labor
237 Statistics of the United States Department of Labor.
238 Section 4. This act shall take effect July 1, 2013.