HB 1431

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 term "direct patient
8access"; requiring that certain insurers and health
9maintenance organizations provide direct patient access to
10an appropriate specialist for screening for or evaluation
11or diagnosis of autism spectrum disorder; requiring
12certain insurance policies and health maintenance
13organization contracts to provide a minimum number of
14visits per year for screening for or evaluation or
15diagnosis of autism spectrum disorder; providing an
16effective date.
17
18Be It Enacted by the Legislature of the State of Florida:
19
20     Section 1.  Section 381.986, Florida Statutes, is created
21to read:
22     381.986  Screening for autism spectrum disorder.-
23     (1)  If the parent or legal guardian of a minor believes
24that the minor exhibits symptoms of autism spectrum disorder,
25the parent or legal guardian may report his or her observation
26to a physician licensed in this state. The physician shall
27perform screening in accordance with American Academy of
28Pediatrics' guidelines. If the physician determines that
29referral to a specialist is medically necessary, the physician
30shall refer the minor to an appropriate specialist to determine
31whether the minor meets diagnostic criteria for autism spectrum
32disorder. If the physician determines that referral to a
33specialist is not medically necessary, the physician shall
34inform the parent or legal guardian of the option for the parent
35or guardian to refer the child to the Early Steps Program or
36other specialist in autism. This section does not apply to a
37physician providing care under s. 395.1041.
38     (2)  As used in this section, the term "appropriate
39specialist" means a qualified professional licensed in this
40state who is experienced in the evaluation of autism spectrum
41disorder and has training in validated diagnostic tools. The
42term 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
48by the Children's Medical Services Early Steps Program within
49the Department of Health.
50     Section 2.  Section 627.6686, Florida Statutes, is amended
51to read:
52     627.6686  Coverage for individuals with autism spectrum
53disorder 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,
58implementation, and evaluation of environmental modifications,
59using behavioral stimuli and consequences, to produce socially
60significant improvement in human behavior, including, but not
61limited to, the use of direct observation, measurement, and
62functional analysis of the relations between environment and
63behavior.
64     (b)  "Autism spectrum disorder" means any of the following
65disorders as defined in the most recent edition of the
66Diagnostic and Statistical Manual of Mental Disorders of the
67American Psychiatric Association:
68     1.  Autistic disorder.
69     2.  Asperger's syndrome.
70     3.  Pervasive developmental disorder not otherwise
71specified.
72     (c)  "Direct patient access" means the ability of an
73insured to obtain services from an in-network provider without a
74referral or other authorization before receiving services.
75     (d)(c)  "Eligible individual" means an individual under 18
76years of age or an individual 18 years of age or older who is in
77high school and who has been diagnosed as having a developmental
78disability at 8 years of age or younger.
79     (e)(d)  "Health insurance plan" means a group health
80insurance policy or group health benefit plan offered by an
81insurer which includes the state group insurance program
82provided under s. 110.123. The term does not include a any
83health insurance plan offered in the individual market, a any
84health insurance plan that is individually underwritten, or a
85any health insurance plan provided to a small employer.
86     (f)(e)  "Insurer" means an insurer providing health
87insurance coverage, which is licensed to engage in the business
88of insurance in this state and is subject to insurance
89regulation.
90     (3)  A health insurance plan issued or renewed on or after
91April 1, 2009, shall provide coverage to an eligible individual
92for:
93     (a)  Direct patient access to an appropriate specialist, as
94defined in s. 381.986, for a minimum of three visits per policy
95year for screening for or evaluation or diagnosis of autism
96spectrum disorder.
97     (b)(a)  Well-baby and well-child screening for diagnosing
98the presence of autism spectrum disorder.
99     (c)(b)  Treatment of autism spectrum disorder through
100speech therapy, occupational therapy, physical therapy, and
101applied behavior analysis. Applied behavior analysis services
102shall be provided by an individual certified pursuant to s.
103393.17 or an individual licensed under chapter 490 or chapter
104491.
105     (4)  The coverage required pursuant to subsection (3) is
106subject to the following requirements:
107     (a)  Coverage shall be limited to treatment that is
108prescribed by the insured's treating physician in accordance
109with a treatment plan.
110     (b)  Coverage for the services described in subsection (3)
111shall be limited to $36,000 annually and may not exceed $200,000
112in total lifetime benefits.
113     (c)  Coverage may not be denied on the basis that provided
114services are habilitative in nature.
115     (d)  Coverage may be subject to other general exclusions
116and limitations of the insurer's policy or plan, including, but
117not limited to, coordination of benefits, participating provider
118requirements, restrictions on services provided by family or
119household members, and utilization review of health care
120services, including the review of medical necessity, case
121management, and other managed care provisions.
122     (5)  The coverage required pursuant to subsection (3) may
123not be subject to dollar limits, deductibles, or coinsurance
124provisions that are less favorable to an insured than the dollar
125limits, deductibles, or coinsurance provisions that apply to
126physical illnesses that are generally covered under the health
127insurance plan, except as otherwise provided in subsection (4).
128     (6)  An insurer may not deny or refuse to issue coverage
129for medically necessary services, refuse to contract with, or
130refuse to renew or reissue or otherwise terminate or restrict
131coverage for an individual because the individual is diagnosed
132as having a developmental disability.
133     (7)  The treatment plan required pursuant to subsection (4)
134shall include all elements necessary for the health insurance
135plan to appropriately pay claims. These elements include, but
136are not limited to, a diagnosis, the proposed treatment by type,
137the frequency and duration of treatment, the anticipated
138outcomes stated as goals, the frequency with which the treatment
139plan will be updated, and the signature of the treating
140physician.
141     (8)  Beginning January 1, 2011, the maximum benefit under
142paragraph (4)(b) shall be adjusted annually on January 1 of each
143calendar year to reflect any change from the previous year in
144the medical component of the then current Consumer Price Index
145for all urban consumers, published by the Bureau of Labor
146Statistics of the United States Department of Labor.
147     (9)  This section may not be construed as limiting benefits
148and coverage otherwise available to an insured under a health
149insurance plan.
150     (10)  The Office of Insurance Regulation may not enforce
151this section against an insurer that is a signatory no later
152than April 1, 2009, to the developmental disabilities compact
153established under s. 624.916. The Office of Insurance Regulation
154shall enforce this section against an insurer that is a
155signatory to the compact established under s. 624.916 if the
156insurer has not complied with the terms of the compact for all
157health insurance plans by April 1, 2010.
158     Section 3.  Section 641.31098, Florida Statutes, is amended
159to read:
160     641.31098  Coverage for individuals with developmental
161disabilities.-
162     (1)  This section and s. 627.6686 may be cited as the
163"Steven A. Geller Autism Coverage Act."
164     (2)  As used in this section, the term:
165     (a)  "Applied behavior analysis" means the design,
166implementation, and evaluation of environmental modifications,
167using behavioral stimuli and consequences, to produce socially
168significant improvement in human behavior, including, but not
169limited to, the use of direct observation, measurement, and
170functional analysis of the relations between environment and
171behavior.
172     (b)  "Autism spectrum disorder" means any of the following
173disorders as defined in the most recent edition of the
174Diagnostic and Statistical Manual of Mental Disorders of the
175American Psychiatric Association:
176     1.  Autistic disorder.
177     2.  Asperger's syndrome.
178     3.  Pervasive developmental disorder not otherwise
179specified.
180     (c)  "Direct patient access" means the ability of an
181insured to obtain services from an in-network provider without a
182referral or other authorization before receiving services.
183     (d)(c)  "Eligible individual" means an individual under 18
184years of age or an individual 18 years of age or older who is in
185high school and who has been diagnosed as having a developmental
186disability at 8 years of age or younger.
187     (e)(d)  "Health maintenance contract" means a group health
188maintenance contract offered by a health maintenance
189organization. The This term does not include a health
190maintenance contract offered in the individual market, a health
191maintenance contract that is individually underwritten, or a
192health maintenance contract provided to a small employer.
193     (3)  A health maintenance contract issued or renewed on or
194after April 1, 2009, shall provide coverage to an eligible
195individual for:
196     (a)  Direct patient access to an appropriate specialist, as
197defined in s. 381.986, for a minimum of three visits per policy
198year for screening for or evaluation or diagnosis of autism
199spectrum disorder.
200     (b)(a)  Well-baby and well-child screening for diagnosing
201the presence of autism spectrum disorder.
202     (c)(b)  Treatment of autism spectrum disorder through
203speech therapy, occupational therapy, physical therapy, and
204applied behavior analysis services. Applied behavior analysis
205services shall be provided by an individual certified pursuant
206to s. 393.17 or an individual licensed under chapter 490 or
207chapter 491.
208     (4)  The coverage required pursuant to subsection (3) is
209subject to the following requirements:
210     (a)  Coverage shall be limited to treatment that is
211prescribed by the subscriber's treating physician in accordance
212with a treatment plan.
213     (b)  Coverage for the services described in subsection (3)
214shall be limited to $36,000 annually and may not exceed $200,000
215in total benefits.
216     (c)  Coverage may not be denied on the basis that provided
217services are habilitative in nature.
218     (d)  Coverage may be subject to general exclusions and
219limitations of the subscriber's contract, including, but not
220limited to, coordination of benefits, participating provider
221requirements, and utilization review of health care services,
222including the review of medical necessity, case management, and
223other managed care provisions.
224     (5)  The coverage required pursuant to subsection (3) may
225not be subject to dollar limits, deductibles, or coinsurance
226provisions that are less favorable to a subscriber than the
227dollar limits, deductibles, or coinsurance provisions that apply
228to physical illnesses that are generally covered under the
229subscriber's contract, except as otherwise provided in
230subsection (3).
231     (6)  A health maintenance organization may not deny or
232refuse to issue coverage for medically necessary services,
233refuse to contract with, or refuse to renew or reissue or
234otherwise terminate or restrict coverage for an individual
235solely because the individual is diagnosed as having a
236developmental disability.
237     (7)  The treatment plan required pursuant to subsection (4)
238shall include, but is not limited to, a diagnosis, the proposed
239treatment by type, the frequency and duration of treatment, the
240anticipated outcomes stated as goals, the frequency with which
241the treatment plan will be updated, and the signature of the
242treating physician.
243     (8)  Beginning January 1, 2011, the maximum benefit under
244paragraph (4)(b) shall be adjusted annually on January 1 of each
245calendar year to reflect any change from the previous year in
246the medical component of the then current Consumer Price Index
247for all urban consumers, published by the Bureau of Labor
248Statistics of the United States Department of Labor.
249     (9)  The Office of Insurance Regulation may not enforce
250this section against a health maintenance organization that is a
251signatory no later than April 1, 2009, to the developmental
252disabilities compact established under s. 624.916. The Office of
253Insurance Regulation shall enforce this section against a health
254maintenance organization that is a signatory to the compact
255established under s. 624.916 if the health maintenance
256organization has not complied with the terms of the compact for
257all health maintenance contracts by April 1, 2010.
258     Section 4.  This act shall take effect July 1, 2011.


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