23-99-418. Coverage for autism spectrum disorders required — Definitions.

23-99-418. Coverage for autism spectrum disorders required — Definitions. (a) As used in this section: (1) “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications by a board-certified behavior analyst 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 relationship between environment and behavior; (2) “Autism services provider” means a person, entity, or group that provides diagnostic evaluations and treatment of autism spectrum disorders, including licensed physicians, licensed psychiatrists, licensed speech therapists, licensed occupational therapists, licensed physical therapists, licensed psychologists, and board-certified behavior analysts; (3) “Autism spectrum disorder” means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including: (A) Autistic disorder; (B) Asperger's disorder; and (C) Pervasive developmental disorder not otherwise specified; (4) “Board-certified behavior analyst” means an individual certified by the nationally accredited Behavior Analyst Certification Board, a nationally accredited nongovernmental agency that certifies individuals who have completed academic, examination, training, and supervision requirements in applied behavior analysis; (5)(A) “Diagnosis” means medically necessary assessment, evaluations, or tests to diagnose whether or not an individual has an autism spectrum disorder. (B) Diagnostic evaluations do not need to be completed concurrently to diagnose autism spectrum disorder; (6) “Evidence-based treatment” means treatment subject to research that applies rigorous, systematic, and objective procedures to obtain valid knowledge relevant to autism spectrum disorders; (7)(A) “Health benefit plan” means any group or blanket plan, policy, or contract for healthcare services issued or delivered in this state by healthcare insurers, including indemnity and managed care plans and the plans providing health benefits to state and public school employees under § 21-5-401 et seq., but excluding individual major medical plans and plans providing healthcare services under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, § 11-9-101 et seq., and the Public Employee Workers' Compensation Act, § 21-5-601 et seq. (B) “Health benefit plan” does not include an accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income, or other limited benefit health insurance policy; (8) “Healthcare insurer” means any insurance company, hospital and medical service corporation, or health maintenance organization issuing or delivering health benefit plans in this state and subject to any of the following laws: (A) The insurance laws of this state; (B) Section 23-75-101 et seq., pertaining to hospital and medical service corporations; and (C) Section 23-76-101 et seq., pertaining to health maintenance organizations; (9) “Medically necessary” means reasonably expected to do the following: (A) Prevent the onset of an illness, condition, injury, or disability; (B) Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or (C) Assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals of the same age; (10) “Pharmacy care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications; (11) “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices; (12) “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices; (13) “Therapeutic care” means services provided by licensed speech therapists, occupational therapists, or physical therapists; and (14) “Treatment” includes: (A) The following care prescribed, provided, or ordered for a specfic individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary and evidence-based, including without limitation: (i) Applied behavior analysis when provided by or supervised by a board-certified behavior analyst; (ii) Pharmacy care; (iii) Psychiatric care; (iv) Psychological care; (v) Therapeutic care; and (vi) Equipment determined necessary to provide evidence-based treatment; and (B) Any care for an individual with autism spectrum disorder that is determined by a licensed physician to be: (i) Medically necessary; and (ii) Evidence-based. (b) To the extent that the diagnosis and treatment of autism spectrum disorders are not already covered by a health benefit plan, coverage under this section shall be included in a health benefit plan that is delivered, executed, issued, amended, adjusted, or renewed in this state on or after October 1, 2011. (c) Applied behavior analysis services shall: (1) Have an annual limitation of fifty thousand dollars ($50,000); and (2) Be limited to children under eighteen (18) years of age. (d)(1) The coverage required by this section is not subject to: (A) Any limits on the number of visits an individual may make to an autism services provider; or (B) Dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to a physical illness generally under a health benefit plan. (2) The coverage may be subject to other general exclusions and limitations of the health insurance plan, including without limitation coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and utilization review of healthcare services, including review of medical necessity, case management, and other managed care provisions. (e) This section does not limit benefits that are otherwise available to an individual under a health benefit plan. (f) Coverage for treatment under this section shall not be denied on the basis that the treatment is habilitative in nature. (g)(1) If an individual is receiving treatment for an autism spectrum disorder, an insurer shall not request a review of the medical necessity of the treatment for autism spectrum disorder to a greater extent than it does for other illnesses covered in the policy. (2) The cost of obtaining the review shall be borne by the insurer. (h)(1) This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program under the Individuals with Disabilities Education Act, Pub. L. No. 101-476, or an individualized service plan. (2) In accordance with the Individuals with Disabilities Education Act, Pub. L. No. 101-476, nothing in this section relieves an insurer from an otherwise valid obligation to provide or to pay for services provided to an individual with a disability. (i) On and after January 1, 2014: (1) To the extent that this section requires benefits that exceed the essential health benefits specified under section 1302(b) of the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended, the specific benefits that exceed the specified essential health benefits shall not be required of a health benefit plan when the health benefit plan is offered by a healthcare insurer in this state through the state medical exchange; and (2) This section continues to apply to plans offered outside the state medical exchange.