HB 951

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
4appropriate specialist for screening for autism
5spectrum disorder under certain circumstances;
6defining the term "appropriate specialist"; amending
7ss. 627.6686 and 641.31098, F.S.; defining the term
8"direct patient access"; requiring that certain
9insurers and health maintenance organizations provide
10direct patient access to an appropriate specialist for
11screening for or evaluation or diagnosis of autism
12spectrum disorder; requiring certain insurance
13policies and health maintenance organization contracts
14to provide a minimum number of visits per year for
15screening for or evaluation or diagnosis of autism
16spectrum disorder; providing an effective 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 under chapter 458 or chapter 459. The
27physician shall perform screening in accordance with American
28Academy of Pediatrics' guidelines. If the physician determines
29that referral to a specialist is medically necessary, the
30physician shall refer the minor to an appropriate specialist to
31determine whether the minor meets diagnostic criteria for autism
32spectrum disorder. If the physician determines that referral to
33a specialist 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; or
46     (d)  A developmental or behavioral pediatrician.
47     Section 2.  Section 627.6686, Florida Statutes, is amended
48to read:
49     627.6686  Coverage for individuals with autism spectrum
50disorder required; exception.-
51     (1)  This section and s. 641.31098 may be cited as the
52"Steven A. Geller Autism Coverage Act."
53     (2)  As used in this section, the term:
54     (a)  "Applied behavior analysis" means the design,
55implementation, and evaluation of environmental modifications,
56using behavioral stimuli and consequences, to produce socially
57significant improvement in human behavior, including, but not
58limited to, the use of direct observation, measurement, and
59functional analysis of the relations between environment and
60behavior.
61     (b)  "Autism spectrum disorder" means any of the following
62disorders as defined in the most recent edition of the
63Diagnostic and Statistical Manual of Mental Disorders of the
64American Psychiatric Association:
65     1.  Autistic disorder.
66     2.  Asperger's syndrome.
67     3.  Pervasive developmental disorder not otherwise
68specified.
69     (c)  "Direct patient access" means the ability of an
70insured to obtain services from a contracted provider without a
71referral or other authorization before receiving services.
72     (d)(c)  "Eligible individual" means an individual under 18
73years of age or an individual 18 years of age or older who is in
74high school and who has been diagnosed as having a developmental
75disability at 8 years of age or younger.
76     (e)(d)  "Health insurance plan" means a group health
77insurance policy or group health benefit plan offered by an
78insurer which includes the state group insurance program
79provided under s. 110.123. The term does not include a any
80health insurance plan offered in the individual market, a any
81health insurance plan that is individually underwritten, or a
82any health insurance plan provided to a small employer.
83     (f)(e)  "Insurer" means an insurer providing health
84insurance coverage, which is licensed to engage in the business
85of insurance in this state and is subject to insurance
86regulation.
87     (3)  A health insurance plan issued or renewed on or after
88April 1, 2009, shall provide coverage to an eligible individual
89for:
90     (a)  Direct patient access to an appropriate specialist, as
91defined in s. 381.986, for a minimum of three visits per policy
92year for screening for or evaluation or diagnosis of autism
93spectrum disorder.
94     (b)(a)  Well-baby and well-child screening for diagnosing
95the presence of autism spectrum disorder.
96     (c)(b)  Treatment of autism spectrum disorder through
97speech therapy, occupational therapy, physical therapy, and
98applied behavior analysis. Applied behavior analysis services
99shall be provided by an individual certified pursuant to s.
100393.17 or an individual licensed under chapter 490 or chapter
101491.
102     (4)  The coverage required pursuant to subsection (3) is
103subject to the following requirements:
104     (a)  Coverage shall be limited to treatment that is
105prescribed by the insured's treating physician in accordance
106with a treatment plan.
107     (b)  Coverage for the services described in subsection (3)
108shall be limited to $36,000 annually and may not exceed $200,000
109in total lifetime benefits.
110     (c)  Coverage may not be denied on the basis that provided
111services are habilitative in nature.
112     (d)  Coverage may be subject to other general exclusions
113and limitations of the insurer's policy or plan, including, but
114not limited to, coordination of benefits, participating provider
115requirements, restrictions on services provided by family or
116household members, and utilization review of health care
117services, including the review of medical necessity, case
118management, and other managed care provisions.
119     (5)  The coverage required pursuant to subsection (3) may
120not be subject to dollar limits, deductibles, or coinsurance
121provisions that are less favorable to an insured than the dollar
122limits, deductibles, or coinsurance provisions that apply to
123physical illnesses that are generally covered under the health
124insurance plan, except as otherwise provided in subsection (4).
125     (6)  An insurer may not deny or refuse to issue coverage
126for medically necessary services, refuse to contract with, or
127refuse to renew or reissue or otherwise terminate or restrict
128coverage for an individual because the individual is diagnosed
129as having a developmental disability.
130     (7)  The treatment plan required pursuant to subsection (4)
131shall include all elements necessary for the health insurance
132plan to appropriately pay claims. These elements include, but
133are not limited to, a diagnosis, the proposed treatment by type,
134the frequency and duration of treatment, the anticipated
135outcomes stated as goals, the frequency with which the treatment
136plan will be updated, and the signature of the treating
137physician.
138     (8)  Beginning January 1, 2011, the maximum benefit under
139paragraph (4)(b) shall be adjusted annually on January 1 of each
140calendar year to reflect any change from the previous year in
141the medical component of the then current Consumer Price Index
142for all urban consumers, published by the Bureau of Labor
143Statistics of the United States Department of Labor.
144     (9)  This section may not be construed as limiting benefits
145and coverage otherwise available to an insured under a health
146insurance plan.
147     (10)  The Office of Insurance Regulation may not enforce
148this section against an insurer that is a signatory no later
149than April 1, 2009, to the developmental disabilities compact
150established under s. 624.916. The Office of Insurance Regulation
151shall enforce this section against an insurer that is a
152signatory to the compact established under s. 624.916 if the
153insurer has not complied with the terms of the compact for all
154health insurance plans by April 1, 2010.
155     Section 3.  Section 641.31098, Florida Statutes, is amended
156to read:
157     641.31098  Coverage for individuals with developmental
158disabilities.-
159     (1)  This section and s. 627.6686 may be cited as the
160"Steven A. Geller Autism Coverage Act."
161     (2)  As used in this section, the term:
162     (a)  "Applied behavior analysis" means the design,
163implementation, and evaluation of environmental modifications,
164using behavioral stimuli and consequences, to produce socially
165significant improvement in human behavior, including, but not
166limited to, the use of direct observation, measurement, and
167functional analysis of the relations between environment and
168behavior.
169     (b)  "Autism spectrum disorder" means any of the following
170disorders as defined in the most recent edition of the
171Diagnostic and Statistical Manual of Mental Disorders of the
172American Psychiatric Association:
173     1.  Autistic disorder.
174     2.  Asperger's syndrome.
175     3.  Pervasive developmental disorder not otherwise
176specified.
177     (c)  "Direct patient access" means the ability of an
178insured to obtain services from an in-network provider without a
179referral or other authorization before receiving services.
180     (d)(c)  "Eligible individual" means an individual under 18
181years of age or an individual 18 years of age or older who is in
182high school and who has been diagnosed as having a developmental
183disability at 8 years of age or younger.
184     (e)(d)  "Health maintenance contract" means a group health
185maintenance contract offered by a health maintenance
186organization. The This term does not include a health
187maintenance contract offered in the individual market, a health
188maintenance contract that is individually underwritten, or a
189health maintenance contract provided to a small employer.
190     (3)  A health maintenance contract issued or renewed on or
191after April 1, 2009, shall provide coverage to an eligible
192individual for:
193     (a)  Direct patient access to an appropriate specialist, as
194defined in s. 381.986, for a minimum of three visits per policy
195year for screening for or evaluation or diagnosis of autism
196spectrum disorder.
197     (b)(a)  Well-baby and well-child screening for diagnosing
198the presence of autism spectrum disorder.
199     (c)(b)  Treatment of autism spectrum disorder through
200speech therapy, occupational therapy, physical therapy, and
201applied behavior analysis services. Applied behavior analysis
202services shall be provided by an individual certified pursuant
203to s. 393.17 or an individual licensed under chapter 490 or
204chapter 491.
205     (4)  The coverage required pursuant to subsection (3) is
206subject to the following requirements:
207     (a)  Coverage shall be limited to treatment that is
208prescribed by the subscriber's treating physician in accordance
209with a treatment plan.
210     (b)  Coverage for the services described in subsection (3)
211shall be limited to $36,000 annually and may not exceed $200,000
212in total benefits.
213     (c)  Coverage may not be denied on the basis that provided
214services are habilitative in nature.
215     (d)  Coverage may be subject to general exclusions and
216limitations of the subscriber's contract, including, but not
217limited to, coordination of benefits, participating provider
218requirements, and utilization review of health care services,
219including the review of medical necessity, case management, and
220other managed care provisions.
221     (5)  The coverage required pursuant to subsection (3) may
222not be subject to dollar limits, deductibles, or coinsurance
223provisions that are less favorable to a subscriber than the
224dollar limits, deductibles, or coinsurance provisions that apply
225to physical illnesses that are generally covered under the
226subscriber's contract, except as otherwise provided in
227subsection (3).
228     (6)  A health maintenance organization may not deny or
229refuse to issue coverage for medically necessary services,
230refuse to contract with, or refuse to renew or reissue or
231otherwise terminate or restrict coverage for an individual
232solely because the individual is diagnosed as having a
233developmental disability.
234     (7)  The treatment plan required pursuant to subsection (4)
235shall include, but is not limited to, a diagnosis, the proposed
236treatment by type, the frequency and duration of treatment, the
237anticipated outcomes stated as goals, the frequency with which
238the treatment plan will be updated, and the signature of the
239treating physician.
240     (8)  Beginning January 1, 2011, the maximum benefit under
241paragraph (4)(b) shall be adjusted annually on January 1 of each
242calendar year to reflect any change from the previous year in
243the medical component of the then current Consumer Price Index
244for all urban consumers, published by the Bureau of Labor
245Statistics of the United States Department of Labor.
246     (9)  The Office of Insurance Regulation may not enforce
247this section against a health maintenance organization that is a
248signatory no later than April 1, 2009, to the developmental
249disabilities compact established under s. 624.916. The Office of
250Insurance Regulation shall enforce this section against a health
251maintenance organization that is a signatory to the compact
252established under s. 624.916 if the health maintenance
253organization has not complied with the terms of the compact for
254all health maintenance contracts by April 1, 2010.
255     Section 4.  This act shall take effect July 1, 2012.


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