CS for CS for CS for SB 2654 Second Engrossed

20082654e2

A bill to be entitled

An act relating to children with disabilities;

amending s. 409.906, F.S.; creating the "Window of

Opportunity Act"; authorizing the Agency for Health Care

Administration to seek federal approval through a state

plan amendment to provide home and community-based

services for autism spectrum disorder and other

developmental disabilities; specifying eligibility

criteria; specifying limitations on provision of benefits;

requiring reports to the Legislature; requiring

legislative approval for implementation of certain

provisions; creating s. 624.916, F.S.; creating the

"Steven A. Geller Autism Coverage Act"; directing the

Office of Insurance Regulation to establish a workgroup to

develop and execute a compact relating to coverage for

insured persons with developmental disabilities; providing

for membership of the workgroup; requiring the workgroup

to convene within a specified period of time; directing

the office to establish a consumer advisory workgroup and

providing purpose thereof; requiring the compact to

contain specified components; requiring reports to the

Governor and the Legislature; creating s. 627.6686, F.S.;

providing health insurance coverage for individuals with

autism spectrum disorder; providing definitions; providing

coverage for certain screening to diagnose and treat

autism spectrum disorder; providing limitations on

coverage; providing for eligibility standards for benefits

and coverage; prohibiting insurers from denying coverage

under certain circumstances; specifying required elements

of a treatment plan; providing, beginning January 1, 2011,

that the maximum benefit shall be adjusted annually;

clarifying that the section may not be construed as

limiting benefits and coverage otherwise available to an

insured under a health insurance plan; prohibiting the

Office of Insurance Regulation from enforcing certain

provisions against insurers that are signatories to the

developmental disabilities compact by a specified date;

creating s. 641.31098, F.S.; providing coverage under a

health maintenance contract for individuals with autism

spectrum disorder; providing definitions; providing

coverage for certain screening to diagnose and treat

autism spectrum disorder; providing limitations on

coverage; providing for eligibility standards for benefits

and coverage; prohibiting health maintenance organizations

from denying coverage under certain circumstances;

specifying required elements of a treatment plan;

providing, beginning January 1, 2011, that the maximum

benefit shall be adjusted annually; prohibiting the Office

of Insurance Regulation from enforcing certain provisions

against health maintenance organizations that are

signatories to the developmental disabilities compact by a

specified date; providing an effective date.

Be It Enacted by the Legislature of the State of Florida:

Section 1. Subsection (26) is added to section 409.906,

Florida Statutes, to read:

409.906 Optional Medicaid services.--Subject to specific

appropriations, the agency may make payments for services which

are optional to the state under Title XIX of the Social Security

Act and are furnished by Medicaid providers to recipients who are

determined to be eligible on the dates on which the services were

provided. Any optional service that is provided shall be provided

only when medically necessary and in accordance with state and

federal law. Optional services rendered by providers in mobile

units to Medicaid recipients may be restricted or prohibited by

the agency. Nothing in this section shall be construed to prevent

or limit the agency from adjusting fees, reimbursement rates,

lengths of stay, number of visits, or number of services, or

making any other adjustments necessary to comply with the

availability of moneys and any limitations or directions provided

for in the General Appropriations Act or chapter 216. If

necessary to safeguard the state's systems of providing services

to elderly and disabled persons and subject to the notice and

review provisions of s. 216.177, the Governor may direct the

Agency for Health Care Administration to amend the Medicaid state

plan to delete the optional Medicaid service known as

"Intermediate Care Facilities for the Developmentally Disabled."

Optional services may include:

(26) HOME AND COMMUNITY-BASED SERVICES FOR AUTISM SPECTRUM

DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.--The agency is

authorized to seek federal approval through a Medicaid waiver or

a state plan amendment for the provision of occupational therapy,

speech therapy, physical therapy, behavior analysis, and behavior

assistant services to individuals who are 5 years of age and

under and have a diagnosed developmental disability as defined in

s. 393.063, autism spectrum disorder as defined in s. 627.6686,

or Down syndrome, a genetic disorder caused by the presence of

extra chromosomal material on chromosome 21. Causes of the

syndrome may include Trisomy 21, Mosaicism, Robertsonian

Translocation, and other duplications of a portion of chromosome

21. Coverage for such services shall be limited to $36,000

annually and may not exceed $108,000 in total lifetime benefits.

The agency shall submit an annual report beginning on January 1,

2009, to the President of the Senate, the Speaker of the House of

Representatives, and the relevant committees of the Senate and

the House of Representatives regarding progress on obtaining

federal approval and recommendations for the implementation of

these home and community-based services. The agency may not

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implement this subsection without prior legislative approval.

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Section 2. Section 624.916, Florida Statutes, is created to

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read:

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624.916 Developmental disabilities compact.--

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(1) This section may be cited as the "Window of Opportunity

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Act."

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(2) The Office of Insurance Regulation shall convene a

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workgroup by August 31, 2008, for the purpose of negotiating a

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compact that includes a binding agreement among the participants

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relating to insurance and access to services for persons with

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developmental disabilities. The workgroup shall consist of the

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following:

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(a) Representatives of all health insurers licensed under

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this chapter.

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(b) Representatives of all health maintenance organizations

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licensed under part I of chapter 641.

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benefit plans.

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(d) Two designees of the Governor, one of whom must be a

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consumer advocate.

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(e) A designee of the President of the Senate.

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(f) A designee of the Speaker of the House of

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Representatives.

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(3) The Office of Insurance Regulation shall convene a

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consumer advisory workgroup for the purpose of providing a forum

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for comment on the compact negotiated in subsection (2). The

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office shall convene the workgroup prior to finalization of the

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compact.

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(4) The agreement shall include the following components:

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(a) A requirement that each signatory to the agreement

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increase coverage for behavior analysis and behavior assistant

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services as defined in s. 409.815(2)(r) and speech therapy,

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physical therapy, and occupational therapy when medically

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necessary due to the presence of a developmental disability.

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(b) Procedures for clear and specific notice to

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policyholders identifying the amount, scope, and conditions under

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which coverage is provided for behavior analysis and behavior

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assistant services as defined in s. 409.815(2)(r) and speech

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therapy, physical therapy, and occupational therapy when

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medically necessary due to the presence of a developmental

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disability.

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medically necessary services due to the presence of a

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developmental disability.

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(d) Proposals for new product lines that may be offered in

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conjunction with traditional health insurance and provide a more

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appropriate means of spreading risk, financing costs, and

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accessing favorable prices.

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(5) Upon completion of the negotiations for the compact,

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the office shall report the results to the Governor, the

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President of the Senate, and the Speaker of the House of

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Representatives.

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(6) Beginning February 15, 2009, and continuing annually

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thereafter, the Office of Insurance Regulation shall provide a

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report to the Governor, the President of the Senate, and the

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Speaker of the House of Representatives regarding the

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implementation of the agreement negotiated under this section.

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The report shall include:

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(a) The signatories to the agreement.

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(b) An analysis of the coverage provided under the

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agreement in comparison to the coverage required under ss.

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627.6686 and 641.31098.

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signatories, including documented cases of claims denied in

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violation of the agreement.

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(7) The Office of Insurance Regulation shall continue to

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monitor participation, compliance, and effectiveness of the

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agreement and report its findings at least annually.

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(8) As used in this section, the term "developmental

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disabilities" includes:

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(a) The term as defined in s. 393.063;

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(b) Down syndrome, a genetic disorder caused by the

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presence of extra chromosomal material on chromosome 21. Causes

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of the syndrome may include Trisomy 21, Mosaicism, Robertsonian

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Translocation, and other duplications of a portion of chromosome

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21; and

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Section 3. Section 627.6686, Florida Statutes, is created

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to read:

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627.6686 Coverage for individuals with autism spectrum

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disorder required; exception.--

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(1) This section and section 641.31098, may be cited as the

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"Steven A. Geller Autism Coverage Act."

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(2) As used in this section, the term:

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(a) "Applied behavior analysis" means the design,

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implementation, and evaluation of environmental modifications,

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using behavioral stimuli and consequences, to produce socially

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significant improvement in human behavior, including, but not

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limited to, the use of direct observation, measurement, and

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functional analysis of the relations between environment and

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behavior.

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(b) "Autism spectrum disorder" means any of the following

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disorders as defined in the most recent edition of the Diagnostic

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and Statistical Manual of Mental Disorders of the American

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Psychiatric Association:

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1. Autistic disorder.

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2. Asperger's syndrome.

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3. Pervasive developmental disorder not otherwise

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specified.

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years of age or an individual 18 years of age or older who is in

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high school who has been diagnosed as having a developmental

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disability at 8 years of age or younger.

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(d) "Health insurance plan" means a group health insurance

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policy or group health benefit plan offered by an insurer which

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includes the state group insurance program provided under s.

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110.123. The term does not include any health insurance plan

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offered in the individual market, any health insurance plan that

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is individually underwritten, or any health insurance plan

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provided to a small employer.

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(e) "Insurer" means an insurer providing health insurance

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coverage, which is licensed to engage in the business of

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insurance in this state and is subject to insurance regulation.

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(3) A health insurance plan issued or renewed on or after

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April 1, 2009, shall provide coverage to an eligible individual

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for:

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(a) Well-baby and well-child screening for diagnosing the

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presence of autism spectrum disorder.

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(b) Treatment of autism spectrum disorder through speech

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therapy, occupational therapy, physical therapy, and applied

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behavior analysis. Applied behavior analysis services shall be

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provided by an individual certified pursuant to s. 393.17 or an

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individual licensed under chapter 490 or chapter 491.

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(4) The coverage required pursuant to subsection (3) is

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subject to the following requirements:

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(a) Coverage shall be limited to treatment that is

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prescribed by the insured's treating physician in accordance with

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a treatment plan.

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(b) Coverage for the services described in subsection (3)

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shall be limited to $36,000 annually and may not exceed $200,000

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in total lifetime benefits.

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services are habilitative in nature.

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(d) Coverage may be subject to other general exclusions and

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limitations of the insurer's policy or plan, including, but not

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limited to, coordination of benefits, participating provider

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requirements, restrictions on services provided by family or

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household members, and utilization review of health care

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services, including the review of medical necessity, case

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management, and other managed care provisions.

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(5) The coverage required pursuant to subsection (3) may

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not be subject to dollar limits, deductibles, or coinsurance

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provisions that are less favorable to an insured than the dollar

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limits, deductibles, or coinsurance provisions that apply to

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physical illnesses that are generally covered under the health

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insurance plan, except as otherwise provided in subsection (4).

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(6) An insurer may not deny or refuse to issue coverage for

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medically necessary services, refuse to contract with, or refuse

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to renew or reissue or otherwise terminate or restrict coverage

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for an individual because the individual is diagnosed as having a

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developmental disability.

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(7) The treatment plan required pursuant to subsection (4)

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shall include all elements necessary for the health insurance

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plan to appropriately pay claims. These elements include, but are

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not limited to, a diagnosis, the proposed treatment by type, the

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frequency and duration of treatment, the anticipated outcomes

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stated as goals, the frequency with which the treatment plan will

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be updated, and the signature of the treating physician.

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(8) Beginning January 1, 2011, the maximum benefit under

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paragraph (4)(b) shall be adjusted annually on January 1 of each

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calendar year to reflect any change from the previous year in the

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medical component of the then current Consumer Price Index for

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all urban consumers, published by the Bureau of Labor Statistics

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of the United States Department of Labor.

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(9) This section may not be construed as limiting benefits

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and coverage otherwise available to an insured under a health

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insurance plan.

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(10) The Office of Insurance Regulation may not enforce

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this section against an insurer that is a signatory no later than

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April 1, 2009, to the developmental disabilities compact

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established under s. 624.916. The Office of Insurance Regulation

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shall enforce this section against an insurer that is a signatory

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to the compact established under s. 624.916 if the insurer has

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not complied with the terms of the compact for all health

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insurance plans by April 1, 2010.

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Section 4. Section 641.31098, Florida Statutes, is created

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to read:

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641.31098 Coverage for individuals with developmental

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disabilities.--

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(1) This section and section 627.6686, may be cited as the

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"Steven A. Geller Autism Coverage Act."

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(2) As used in this section, the term:

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(a) "Applied behavior analysis" means the design,

283

implementation, and evaluation of environmental modifications,

284

using behavioral stimuli and consequences, to produce socially

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significant improvement in human behavior, including, but not

286

limited to, the use of direct observation, measurement, and

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functional analysis of the relations between environment and

288

behavior.

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(b) "Autism spectrum disorder" means any of the following

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disorders as defined in the most recent edition of the Diagnostic

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and Statistical Manual of Mental Disorders of the American

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Psychiatric Association:

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1. Autistic disorder.

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2. Asperger's syndrome.

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3. Pervasive developmental disorder not otherwise

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specified.

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(b) "Eligible individual" means an individual under 18

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years of age or an individual 18 years of age or older who is in

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high school who has been diagnosed as having a developmental

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disability at 8 years of age or younger.

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maintenance contract offered by a health maintenance

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organization. This term does not include a health maintenance

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contract offered in the individual market, a health maintenance

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contract that is individually underwritten, or a health

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maintenance contract provided to a small employer.

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(3) A health maintenance contract issued or renewed on or

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after April 1, 2009, shall provide coverage to an eligible

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individual for:

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(a) Well-baby and well-child screening for diagnosing the

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presence of autism spectrum disorder.

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(b) Treatment of autism spectrum disorder through speech

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therapy, occupational therapy, physical therapy, and applied

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behavior analysis services. Applied behavior analysis services

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shall be provided by an individual certified pursuant to s.

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393.17 or an individual licensed under chapter 490 or chapter

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491.

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(4) The coverage required pursuant to subsection (3) is

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subject to the following requirements:

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(a) Coverage shall be limited to treatment that is

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prescribed by the subscriber's treating physician in accordance

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with a treatment plan.

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(b) Coverage for the services described in subsection (3)

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shall be limited to $36,000 annually and may not exceed $200,000

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in total benefits.

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services are habilitative in nature.

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(d) Coverage may be subject to general exclusions and

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limitations of the subscriber's contract, including, but not

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limited to, coordination of benefits, participating provider

331

requirements, and utilization review of health care services,

332

including the review of medical necessity, case management, and

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other managed care provisions.

334

(5) The coverage required pursuant to subsection (3) may

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not be subject to dollar limits, deductibles, or coinsurance

336

provisions that are less favorable to a subscriber than the

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dollar limits, deductibles, or coinsurance provisions that apply

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to physical illnesses that are generally covered under the

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subscriber's contract, except as otherwise provided in subsection

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(3).

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(6) A health maintenance organization may not deny or

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refuse to issue coverage for medically necessary services, refuse

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to contract with, or refuse to renew or reissue or otherwise

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terminate or restrict coverage for an individual solely because

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the individual is diagnosed as having a developmental disability.

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(7) The treatment plan required pursuant to subsection (4)

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shall include, but is not limited to, a diagnosis, the proposed

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treatment by type, the frequency and duration of treatment, the

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anticipated outcomes stated as goals, the frequency with which

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the treatment plan will be updated, and the signature of the

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treating physician.

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(8) Beginning January 1, 2011, the maximum benefit under

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paragraph (4)(b) shall be adjusted annually on January 1 of each

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calendar year to reflect any change from the previous year in the

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medical component of the then current Consumer Price Index for

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all urban consumers, published by the Bureau of Labor Statistics

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of the United States Department of Labor.

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(9) The Office of Insurance Regulation may not enforce this

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section against a health maintenance organization that is a

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signatory no later than April 1, 2009, to the developmental

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disabilities compact established under s. 624.916. The Office of

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Insurance Regulation shall enforce this section against a health

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maintenance organization that is a signatory to the compact

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established under s. 624.916 if the health maintenance

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organization has not complied with the terms of the compact for

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all health maintenance contracts by April 1, 2010.

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Section 5. This act shall take effect July 1, 2008.

CODING: Words stricken are deletions; words underlined are additions.