Florida Senate - 2011 SB 100
By Senator Ring
32-00093A-11 2011100__
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 certain insurance
13 policies and health maintenance organization contracts
14 to 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 in this state. The physician shall
27 perform screening in accordance with American Academy of
28 Pediatrics’ guidelines. If the physician determines that
29 referral to a specialist is medically necessary, the physician
30 shall refer the minor to an appropriate specialist to determine
31 whether the minor meets diagnostic criteria for autism spectrum
32 disorder. If the physician determines that referral to a
33 specialist is not medically necessary, the physician shall
34 inform the parent or legal guardian of the option for the parent
35 or guardian to refer the child to the Early Steps Program or
36 other specialist in autism. This section does not apply to a
37 physician providing care under s. 395.1041.
38 (2) As used in this section, the term “appropriate
39 specialist” means a qualified professional licensed in this
40 state who is experienced in the evaluation of autism spectrum
41 disorder and has training in validated diagnostic tools. The
42 term includes, but is not limited to:
43 (a) A psychologist;
44 (b) A psychiatrist;
45 (c) A neurologist;
46 (d) A developmental or behavioral pediatrician; or
47 (e) A professional whose licensure is deemed appropriate by
48 the Children’s Medical Services Early Steps Program within the
49 Department of Health.
50 Section 2. Section 627.6686, Florida Statutes, is amended
51 to read:
52 627.6686 Coverage for individuals with autism spectrum
53 disorder required; exception.—
54 (1) This section and s. 641.31098 may be cited as the
55 “Steven A. Geller Autism Coverage Act.”
56 (2) As used in this section, the term:
57 (a) “Applied behavior analysis” means the design,
58 implementation, and evaluation of environmental modifications,
59 using behavioral stimuli and consequences, to produce socially
60 significant improvement in human behavior, including, but not
61 limited to, the use of direct observation, measurement, and
62 functional analysis of the relations between environment and
63 behavior.
64 (b) “Autism spectrum disorder” means any of the following
65 disorders as defined in the most recent edition of the
66 Diagnostic and Statistical Manual of Mental Disorders of the
67 American Psychiatric Association:
68 1. Autistic disorder.
69 2. Asperger’s syndrome.
70 3. Pervasive developmental disorder not otherwise
71 specified.
72 (c) “Direct patient access” means the ability of an insured
73 to obtain services from an in-network provider without a
74 referral or other authorization before receiving services.
75 (d)(c) “Eligible individual” means an individual under 18
76 years of age or an individual 18 years of age or older who is in
77 high school and who has been diagnosed as having a developmental
78 disability at 8 years of age or younger.
79 (e)(d) “Health insurance plan” means a group health
80 insurance policy or group health benefit plan offered by an
81 insurer which includes the state group insurance program
82 provided under s. 110.123. The term does not include a any
83 health insurance plan offered in the individual market, a any
84 health insurance plan that is individually underwritten, or a
85 any health insurance plan provided to a small employer.
86 (f)(e) “Insurer” means an insurer providing health
87 insurance coverage, which is licensed to engage in the business
88 of insurance in this state and is subject to insurance
89 regulation.
90 (3) A health insurance plan issued or renewed on or after
91 April 1, 2009, shall provide coverage to an eligible individual
92 for:
93 (a) Direct patient access to an appropriate specialist, as
94 defined in s. 381.986, for a minimum of three visits per policy
95 year for screening for or evaluation or diagnosis of autism
96 spectrum disorder.
97 (b)(a) Well-baby and well-child screening for diagnosing
98 the presence of autism spectrum disorder.
99 (c)(b) Treatment of autism spectrum disorder through speech
100 therapy, occupational therapy, physical therapy, and applied
101 behavior analysis. Applied behavior analysis services shall be
102 provided by an individual certified pursuant to s. 393.17 or an
103 individual licensed under chapter 490 or chapter 491.
104 (4) The coverage required pursuant to subsection (3) is
105 subject to the following requirements:
106 (a) Coverage shall be limited to treatment that is
107 prescribed by the insured’s treating physician in accordance
108 with a treatment plan.
109 (b) Coverage for the services described in subsection (3)
110 shall be limited to $36,000 annually and may not exceed $200,000
111 in total lifetime benefits.
112 (c) Coverage may not be denied on the basis that provided
113 services are habilitative in nature.
114 (d) Coverage may be subject to other general exclusions and
115 limitations of the insurer’s policy or plan, including, but not
116 limited to, coordination of benefits, participating provider
117 requirements, restrictions on services provided by family or
118 household members, and utilization review of health care
119 services, including the review of medical necessity, case
120 management, and other managed care provisions.
121 (5) The coverage required pursuant to subsection (3) may
122 not be subject to dollar limits, deductibles, or coinsurance
123 provisions that are less favorable to an insured than the dollar
124 limits, deductibles, or coinsurance provisions that apply to
125 physical illnesses that are generally covered under the health
126 insurance plan, except as otherwise provided in subsection (4).
127 (6) An insurer may not deny or refuse to issue coverage for
128 medically necessary services, refuse to contract with, or refuse
129 to renew or reissue or otherwise terminate or restrict coverage
130 for an individual because the individual is diagnosed as having
131 a developmental disability.
132 (7) The treatment plan required pursuant to subsection (4)
133 shall include all elements necessary for the health insurance
134 plan to appropriately pay claims. These elements include, but
135 are not limited to, a diagnosis, the proposed treatment by type,
136 the frequency and duration of treatment, the anticipated
137 outcomes stated as goals, the frequency with which the treatment
138 plan will be updated, and the signature of the treating
139 physician.
140 (8) Beginning January 1, 2011, the maximum benefit under
141 paragraph (4)(b) shall be adjusted annually on January 1 of each
142 calendar year to reflect any change from the previous year in
143 the medical component of the then current Consumer Price Index
144 for all urban consumers, published by the Bureau of Labor
145 Statistics of the United States Department of Labor.
146 (9) This section may not be construed as limiting benefits
147 and coverage otherwise available to an insured under a health
148 insurance plan.
149 (10) The Office of Insurance Regulation may not enforce
150 this section against an insurer that is a signatory no later
151 than April 1, 2009, to the developmental disabilities compact
152 established under s. 624.916. The Office of Insurance Regulation
153 shall enforce this section against an insurer that is a
154 signatory to the compact established under s. 624.916 if the
155 insurer has not complied with the terms of the compact for all
156 health insurance plans by April 1, 2010.
157 Section 3. Section 641.31098, Florida Statutes, is amended
158 to read:
159 641.31098 Coverage for individuals with developmental
160 disabilities.—
161 (1) This section and s. 627.6686 may be cited as the
162 “Steven A. Geller Autism Coverage Act.”
163 (2) As used in this section, the term:
164 (a) “Applied behavior analysis” means the design,
165 implementation, and evaluation of environmental modifications,
166 using behavioral stimuli and consequences, to produce socially
167 significant improvement in human behavior, including, but not
168 limited to, the use of direct observation, measurement, and
169 functional analysis of the relations between environment and
170 behavior.
171 (b) “Autism spectrum disorder” means any of the following
172 disorders as defined in the most recent edition of the
173 Diagnostic and Statistical Manual of Mental Disorders of the
174 American Psychiatric Association:
175 1. Autistic disorder.
176 2. Asperger’s syndrome.
177 3. Pervasive developmental disorder not otherwise
178 specified.
179 (c) “Direct patient access” means the ability of an insured
180 to obtain services from an in-network provider without a
181 referral or other authorization before receiving services.
182 (d)(c) “Eligible individual” means an individual under 18
183 years of age or an individual 18 years of age or older who is in
184 high school and who has been diagnosed as having a developmental
185 disability at 8 years of age or younger.
186 (e)(d) “Health maintenance contract” means a group health
187 maintenance contract offered by a health maintenance
188 organization. The This term does not include a health
189 maintenance contract offered in the individual market, a health
190 maintenance contract that is individually underwritten, or a
191 health maintenance contract provided to a small employer.
192 (3) A health maintenance contract issued or renewed on or
193 after April 1, 2009, shall provide coverage to an eligible
194 individual for:
195 (a) Direct patient access to an appropriate specialist, as
196 defined in s. 381.986, for a minimum of three visits per policy
197 year for screening for or evaluation or diagnosis of autism
198 spectrum disorder.
199 (b)(a) Well-baby and well-child screening for diagnosing
200 the presence of autism spectrum disorder.
201 (c)(b) Treatment of autism spectrum disorder through speech
202 therapy, occupational therapy, physical therapy, and applied
203 behavior analysis services. Applied behavior analysis services
204 shall be provided by an individual certified pursuant to s.
205 393.17 or an individual licensed under chapter 490 or chapter
206 491.
207 (4) The coverage required pursuant to subsection (3) is
208 subject to the following requirements:
209 (a) Coverage shall be limited to treatment that is
210 prescribed by the subscriber’s treating physician in accordance
211 with a treatment plan.
212 (b) Coverage for the services described in subsection (3)
213 shall be limited to $36,000 annually and may not exceed $200,000
214 in total benefits.
215 (c) Coverage may not be denied on the basis that provided
216 services are habilitative in nature.
217 (d) Coverage may be subject to general exclusions and
218 limitations of the subscriber’s contract, including, but not
219 limited to, coordination of benefits, participating provider
220 requirements, and utilization review of health care services,
221 including the review of medical necessity, case management, and
222 other managed care provisions.
223 (5) The coverage required pursuant to subsection (3) may
224 not be subject to dollar limits, deductibles, or coinsurance
225 provisions that are less favorable to a subscriber than the
226 dollar limits, deductibles, or coinsurance provisions that apply
227 to physical illnesses that are generally covered under the
228 subscriber’s contract, except as otherwise provided in
229 subsection (3).
230 (6) A health maintenance organization may not deny or
231 refuse to issue coverage for medically necessary services,
232 refuse to contract with, or refuse to renew or reissue or
233 otherwise terminate or restrict coverage for an individual
234 solely because the individual is diagnosed as having a
235 developmental disability.
236 (7) The treatment plan required pursuant to subsection (4)
237 shall include, but is not limited to, a diagnosis, the proposed
238 treatment by type, the frequency and duration of treatment, the
239 anticipated outcomes stated as goals, the frequency with which
240 the treatment plan will be updated, and the signature of the
241 treating physician.
242 (8) Beginning January 1, 2011, the maximum benefit under
243 paragraph (4)(b) shall be adjusted annually on January 1 of each
244 calendar year to reflect any change from the previous year in
245 the medical component of the then current Consumer Price Index
246 for all urban consumers, published by the Bureau of Labor
247 Statistics of the United States Department of Labor.
248 (9) The Office of Insurance Regulation may not enforce this
249 section against a health maintenance organization that is a
250 signatory no later than April 1, 2009, to the developmental
251 disabilities compact established under s. 624.916. The Office of
252 Insurance Regulation shall enforce this section against a health
253 maintenance organization that is a signatory to the compact
254 established under s. 624.916 if the health maintenance
255 organization has not complied with the terms of the compact for
256 all health maintenance contracts by April 1, 2010.
257 Section 4. This act shall take effect July 1, 2011.