RD53 - Mandated Coverage for Autism Spectrum Disorder- House Bill 83 (2008)


Executive Summary:
House Bill 83 was referred to the Special Advisory Commission on Mandated Health Insurance Benefits (Advisory Commission) for review by the House Committee on Commerce and Labor after adopting an amendment in the nature of a substitute to mandate coverage for the diagnosis and treatment of Autism Spectrum Disorder (ASD) in individuals under age 21. House Bill 83 was introduced by Delegate Robert Marshall.

House Bill 83 would add § 38.2-3418.15 to the mandated benefits article and would amend § 38.2-4319 of the Code of Virginia to make it applicable to Health Maintenance Organizations (HMOs). The bill applies to insurers that issue group accident and sickness policies providing hospital, medical and surgical or major medical coverage on an expense-incurred basis; corporations providing group accident or sickness subscription contracts and HMOs providing a health care plan.

The bill defines the following terms:

“Applied behavior analysis (ABA)” is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.

“Autism Spectrum Disorder (ASD)” is defined as any of the pervasive developmental disorders known as (i) autistic disorder, (ii) Asperger’s Syndrome, or (iii) Pervasive Developmental Disorder - Not Otherwise Specified, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.

“Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

“Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.

“Pharmacy care” in House Bill 83 is defined as medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

“Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the sate in which the psychiatrist practices.

“Psychological care” means direct or consultative services provided by a psychologist licensed in the sate in which the psychologist practices.

“Therapeutic care” means services provided by licensed or certified speech therapists, occupational therapists, or physical therapists.

“Treatment for autism spectrum disorder” includes the following care prescribed, provided, or ordered for an individual diagnosed with one the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) habilitative or rehabilitative care; (ii) pharmacy care; (iii) psychiatric care; (iv) psychological care; and (v) therapeutic care.

The bill states that, except for inpatient services, an insurer will have the right to request a review of treatment of an individual receiving service for an ASD once every 12 months unless the insurer, corporation or HMO and the individual’s licensed physician or licensed psychologist agrees that a more frequent review is necessary. The cost of obtaining a review shall be covered under the policy, contract or plan, and does not apply to inpatient services.

Proposed coverage for ASD shall neither be different or separate from coverage applicable to any other illness, condition, or disorder for purposes of determining deductibles, benefit year, or lifetime durational limits, benefit dollar limits, lifetime episodes or treatment limits, co-payment and coinsurance factors, and benefit year maximum for deductibles and co-payment and coinsurance factors.

The bill does not apply to (i) short-term travel, accident only, limited or specified disease policies, (ii) short-term non-renewable policies of not more than six months’ duration, (iii) policies, contracts, or plans issued in the individual market or small group markets to employers with 25 or fewer employees, (iv) policies or contracts designed for issuance to persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or federal governmental plans. The bill applies to insurance policies, contracts and health care plans delivered, issued for delivery, reissued or extended on and after January 9, 2009.

The Advisory Commission held a public hearing on September 29, 2008 in Richmond to receive public comments on House Bill 83. In addition to patron Delegate Marshall and Delegate David Poisson, thirty individuals spoke in favor of the proposal. Representatives from Autism Speaks, the Kennedy-Krieger Institute, The Loudoun Project, The Spiritos School, The Allergy and Nutrition Clinic (northern Virginia), and several medical doctors, therapists, and other professionals involved with individuals on the autism spectrum addressed the Commission. Representatives from the Virginia Association of Health Plans (VAHP), the National Federation of Independent Business (NFIB), and the Virginia Chamber of Commerce (VCC) spoke in opposition of the bill.

In addition, written comments were received from Autism Speaks, the Virginia Nutritionists Association, and the Association for Science in Autism Treatment, and the Relationship Development Intervention (RDI) parent group. Seventy-three written letters and electronic letters were submitted from private citizens in support of the proposed legislation. Also, signatures from 265 residents from the tidewater and northern Virginia areas of the Commonwealth were submitted supporting House Bill 83. The VAHP, NFIB, and VCC submitted comments in opposition to the bill.

Delegate Marshall sent revised language to the Advisory Commission prior to the September 29, 2008 meeting and requested that the language be considered by the Advisory Commission. The language was referred to as House Bill 83 - Amended in the review process. Delegate Marshall filed the bill for the 2009 session of the General Assembly, and the bill was drafted as House Bill 1588.

In addition to providing coverage for the diagnosis and treatment of autism spectrum disorder for those under the age of 21, House Bill 83-Amended adds that the insurer can not terminate or otherwise alter coverage solely because an individual is diagnosed with ASD or has been treated for ASD. House Bill 83-Amended adds two additional disorders to the list of conditions in the ASD definition (Rett syndrome and childhood disintegrative disorder). Also, House Bill 83-Amended adds 1) a limit to the coverage, capping the annual maximum benefit at $36,000; 2) a COLA for inflation beginning 1/1/2011 based on CPI-U; and 3) a requirement that provisions of the bill are in addition to the provisions in the early intervention mandate, § 38.2-3418.5.

On November 19, 2008, the Advisory Commission recommended enacting coverage for autism, House Bill 83, as amended in September 2008 (Yes- 6, No- 4). The vote was contingent on language being added to the bill to recognize the need to make changes to comply with the federal Mental Health Parity and Addiction Equity Act of 2008.

The Advisory Commission expressed concern for those Virginia consumers who are in need ASD treatments and services, and would benefit from the provisions of House Bill 83. The Advisory Commission members had questions about evidence-based treatments, alternative treatments, and discussed issues regarding the most effective mechanism of providing assistance to those families affected by autism and autism-related treatments.

After reviewing data from other states with mandates for the treatment of ASDs and reviewing other substantive follow up information, the Advisory Commission voted to recommend House Bill 83–Amended as it was presented by Delegate Marshall at the September 29, 2008 meeting.

NOTE: The Advisory Commission’s deliberations and subsequent vote were based on the provisions incorporated in draft language of House Bill 83 - Amended, which parallel the provisions of House Bill 1588 (2009).