HF 1071

as introduced - 87th Legislature (2011 - 2012) Posted on 03/14/2011 10:23am

A bill for an act
relating to insurance; providing coverage for autism spectrum disorders;
proposing coding for new law in Minnesota Statutes, chapter 62A.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

new text begin [62A.3094] COVERAGE FOR AUTISM SPECTRUM DISORDERS.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For purposes of this section, the terms defined in
this subdivision have the meanings given.
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new text begin (b) "Autism spectrum disorder" means the following conditions as determined by
criteria set forth in the most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric Association:
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new text begin (1) autism or autistic disorder;
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new text begin (2) Asperger's syndrome; or
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new text begin (3) pervasive developmental disorder, not otherwise specified.
new text end

new text begin (c) "Board-certified behavior analyst" means an individual certified by the Behavior
Analyst Certification Board as a board-certified behavior analyst.
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new text begin (d) "Evidence-based," for purposes of this section only, is as described in subdivision
2, paragraph (c), clause (2).
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new text begin (e) "Health plan" has the meaning given in section 62Q.01, subdivision 3.
new text end

new text begin (f) "Manualized approach" means a self-contained volume, text, or set of
instructional media, which may include videos or compact discs, that codifies in
reasonable detail the procedures for implementing treatment.
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new text begin (g) "Medical necessity" or "medically necessary care" has the meaning given in
section 62Q.53, subdivision 2.
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new text begin (h) "Mental health professional" has the meaning given in section 245.4871,
subdivision 27, clauses (1) to (6).
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new text begin (i) "Qualified mental health behavioral aide" means a mental health behavioral aide
as defined in section 256B.0943, subdivision 7.
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new text begin (j) "Qualified mental health practitioner" means a mental health practitioner as
defined in section 245.4871, subdivision 26.
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new text begin (k) "Statistically superior outcomes" means a research study in which the probability
that the results would be obtained under the null hypothesis is less than five percent.
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new text begin Subd. 2. new text end

new text begin Coverage required. new text end

new text begin (a) For coverage requirements to apply, an individual
must have a diagnosis of autism spectrum disorder made through an evaluation of the
patient, completed within six months prior to the start of treatment, which includes all of
the following:
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new text begin (1) a complete medical and psychological evaluation performed by a licensed
physician and psychologist using empirically validated tools or tests that incorporate
measures for intellectual functioning, language development, adaptive skills, and
behavioral problems, which must include:
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new text begin (i) a developmental history of the child, focusing on developmental milestones
and delays;
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new text begin (ii) a family history, including whether there are other family members with an
autism spectrum disorder, developmental disability, fragile X syndrome, or tuberous
sclerosis;
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new text begin (iii) a medical history, including signs of deterioration, seizure activity, brain injury,
and head circumference;
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new text begin (iv) a physical examination completed within the past 12 months;
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new text begin (v) an evaluation for intellectual functioning;
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new text begin (vi) a lead screening for those children with a developmental disability; and
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new text begin (vii) other evaluations and testing as indicated by the medical evaluation, which
may include neuropsychological testing, occupational therapy, physical therapy, family
functioning, genetic testing, imaging laboratory tests, and electrophysiological testing;
new text end

new text begin (2) a communication assessment conducted by a speech pathologist; and
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new text begin (3) a comprehensive hearing test conducted by an audiologist. An audiologist with
experience in testing very young children must conduct the test if an audiologist with this
experience is available.
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new text begin (b) A health plan must provide coverage for the diagnosis, evaluation, assessment,
and medically necessary care of autism spectrum disorders that is evidence-based,
including but not limited to:
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new text begin (1) neurodevelopmental and behavioral health treatments, instruction, and
management;
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new text begin (2) applied behavior analysis and intensive early intervention services, including
service package models such as intensive early intervention behavior therapy services
and Lovaas therapy;
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new text begin (3) speech therapy;
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new text begin (4) occupational therapy;
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new text begin (5) physical therapy; and
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new text begin (6) prescription medications.
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new text begin (c) Coverage required under this section must include treatment that is in accordance
with:
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new text begin (1) an individualized treatment plan prescribed by the insured's treating physician or
mental health professional as defined in this section; and
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new text begin (2) medically and scientifically accepted evidence that meets the criteria of a
peer-reviewed, published study that is one of the following:
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new text begin (i) a randomized study with adequate statistical power, including a sample size of
30 or more for each group, that shows statistically superior outcomes to a pill placebo
group, psychological placebo group, another treatment group, or a wait list control group,
or that is equivalent to another evidence-based treatment that meets the above standard
for the specified problem area;
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new text begin (ii) a series of at least three single-case design experiments with clear specification
of the subjects and with clear specification of the treatment approach that:
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new text begin (A) use robust experimental designs;
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new text begin (B) show statistically superior outcomes to pill placebo, psychological placebo,
or another treatment group; and
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new text begin (C) either use a manualized approach or are conducted by at least two independent
investigators or teams.
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new text begin Where evidence meeting the standards of this subdivision does not exist for the
treatment of a diagnosed condition or for an individual matching the demographic
characteristics for which the evidence is valid, coverage required under this section must
include treatment that is in accordance with practice guidelines based on consensus of
Minnesota health care professionals knowledgeable in the treatment of individuals with
autism spectrum disorders.
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new text begin (d) Early intensive behavior therapies that meet the criteria set forth in paragraphs
(b) and (c) must also meet the following best practices standards:
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new text begin (1) the services must be prescribed by a mental health professional as an appropriate
treatment option for the individual child;
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new text begin (2) regular reporting of services provided and the child's progress must be submitted
to the prescribing mental health professional;
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new text begin (3) care must include appropriate parent or legal guardian education and
involvement;
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new text begin (4) the medically prescribed treatment and frequency of services should be
coordinated between the school and provider for all children up to age 21; and
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new text begin (5) services must be provided by a mental health professional or, as appropriate, a
board-certified behavior analyst, a qualified mental health practitioner, or a qualified
mental health behavioral aide.
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new text begin (e) Providers under this section must work with the commissioner in implementing
evidence-based practices and, specifically for children under age 21, the Minnesota
Evidence-Based Practice Database of research-informed practice elements and specific
constituent practices.
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new text begin (f) A health plan company may not refuse to renew or reissue, or otherwise terminate
or restrict coverage of an individual solely because the individual is diagnosed with an
autism spectrum disorder.
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new text begin (g) A health plan company may request an updated treatment plan only once every
six months, unless the health plan company and the treating physician or mental health
professional agree that a more frequent review is necessary due to emerging circumstances.
new text end

new text begin Subd. 3. new text end

new text begin Supervision of certain practitioners, analysts, and aides. new text end

new text begin A mental
health professional who uses the services of a qualified mental health practitioner,
board-certified behavior analyst, or qualified mental health behavioral aide for the
purpose of assisting in the provision of services to patients who have autism spectrum
disorder is responsible for functions performed by these service providers. The qualified
mental health professional must maintain clinical supervision of services the professional
provides and accept full responsibility for his or her actions. The services provided
must be medically necessary and identified in the child's individual treatment plan.
Service providers must document their activities in written progress notes that reflect
implementation of the individual treatment plan.
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new text begin Subd. 4. new text end

new text begin State health care programs. new text end

new text begin This section does not affect benefits
available under the medical assistance, MinnesotaCare, and general assistance medical
care programs. These programs must maintain current levels of coverage, and section
256B.0644 shall continue to apply. The state employee group insurance plan is not subject
to this section until January 1, 2014, but must fully comply with this section on and after
that date. The commissioner shall monitor these services and report to the chairs of the
house of representatives and senate standing committees that have jurisdiction over health
and human services by February 1, 2012, whether there are gaps in the level of service
provided by these programs and the state employee group insurance plan, and the level of
service provided by private health plans following enactment of this section.
new text end

new text begin Subd. 5. new text end

new text begin No effect on other law. new text end

new text begin Nothing in this section limits in any way the
coverage required under sections 62Q.47 and 62Q.53.
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new text begin EFFECTIVE DATE. new text end

new text begin This section is effective August 1, 2011, and applies to
coverage offered, issued, sold, renewed, or continued as defined in Minnesota Statutes,
section 60A.02, subdivision 2a, on or after that date.
new text end