SF 2837

as introduced - 88th Legislature (2013 - 2014) Posted on 03/24/2014 08:28am

A bill for an act
relating to human services; insurance; modifying autism early intensive
intervention benefit under medical assistance; modifying insurance coverage for
autism spectrum disorder; amending Minnesota Statutes 2012, section 252.27, by
adding a subdivision; Minnesota Statutes 2013 Supplement, sections 62A.3094,
subdivisions 1, 2; 252.27, subdivision 2a; 256B.0949, subdivisions 2, 3, 4, 7, 9;
Laws 2013, chapter 9, section 15; Laws 2013, chapter 108, article 12, section 2.

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

Section 1.

Minnesota Statutes 2013 Supplement, section 62A.3094, subdivision 1,
is amended to read:

Subdivision 1.

Definitions.

(a) For purposes of this section, the terms defined in
paragraphs (b) to (d) have the meanings given.

(b) "Autism spectrum deleted text begin disorders deleted text end new text begin disorder new text end " means deleted text begin the conditions deleted text end new text begin a condition new text end 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.

(c) "Medically necessary care" means health care services appropriate, in terms of
type, frequency, level, setting, and duration, to the enrollee's condition, and diagnostic
testing and preventative services. Medically necessary care must be consistent with
generally accepted practice parameters as determined by physicians and licensed
psychologists who typically manage patients who have autism spectrum deleted text begin disorders deleted text end new text begin disorder
and must meet the requirements in section 62Q.53 new text end .

(d) "Mental health professional" means a mental health professional as defined in
section 245.4871, subdivision 27, deleted text begin clause (1), (2), (3), (4), or (6), deleted text end who has training and
expertise in autism spectrum deleted text begin disorder and child development deleted text end new text begin disorders new text end .

Sec. 2.

Minnesota Statutes 2013 Supplement, section 62A.3094, subdivision 2, is
amended to read:

Subd. 2.

Coverage required.

(a) A health plan deleted text begin issued to a large employer deleted text end , as
defined in section deleted text begin 62Q.18 deleted text end new text begin 62Q.01 new text end , subdivision deleted text begin 1 deleted text end new text begin 3 new text end , must provide coverage for the
diagnosis, evaluation, multidisciplinary assessment, and medically necessary care of
deleted text begin children deleted text end new text begin a child new text end under new text begin age new text end 18 with new text begin an new text end autism spectrum deleted text begin disorders deleted text end new text begin disorder new text end , including but
not limited to the following:

(1) early intensive behavioral and developmental therapy based in behavioral and
developmental science, including, but not limited to, all types of applied behavior analysis,
intensive early intervention behavior therapy, and intensive behavior intervention;

(2) neurodevelopmental and behavioral health treatments and management;

(3) speech therapy;

(4) occupational therapy;

(5) physical therapy; and

(6) medications.

(b) The diagnosis, evaluation, and assessment must include an assessment of the
child's developmental skills, functional behavior, needs, and capacities.

(c) The coverage required under this subdivision must include treatment that is in
accordance with an individualized treatment plan prescribed by the enrollee's treating
physician or mental health professional.

(d) A health carrier 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.

(e) A health carrier may request an updated treatment plan only once every six
months, unless the health carrier and the treating physician or mental health professional
agree that a more frequent review is necessary due to emerging circumstances.

(f) An independent progress evaluation conducted by a mental health professional
with expertise and training in autism spectrum disorder and child development must be
completed to determine if progress toward deleted text begin function deleted text end new text begin functional new text end and generalizable gains, as
determined in the treatment plan, is being made.

Sec. 3.

Minnesota Statutes 2013 Supplement, section 252.27, subdivision 2a, is
amended to read:

Subd. 2a.

Contribution amount.

(a) The natural or adoptive parents of a minor
child, including a child determined eligible for medical assistance without consideration of
parental income, must contribute to the cost of services used by making monthly payments
on a sliding scale based on income, unless the child is married or has been married, parental
rights have been terminated, or the child's adoption is subsidized according to chapter
259A or through title IV-E of the Social Security Act. The parental contribution is a partial
or full payment for medical services provided for diagnostic, therapeutic, curing, treating,
mitigating, rehabilitation, maintenance, and personal care services as defined in United
States Code, title 26, section 213, needed by the child with a chronic illness or disability.

(b) For households with adjusted gross income equal to or greater than 275 percent
of federal poverty guidelines, the parental contribution shall be computed by applying the
following schedule of rates to the adjusted gross income of the natural or adoptive parents:

(1) if the adjusted gross income is equal to or greater than 275 percent of federal
poverty guidelines and less than or equal to 545 percent of federal poverty guidelines,
the parental contribution shall be determined using a sliding fee scale established by the
commissioner of human services which begins at deleted text begin 2.76 deleted text end new text begin one new text end percent of adjusted gross
income at 275 percent of federal poverty guidelines and increases to deleted text begin 7.5 deleted text end new text begin two new text end percent of
adjusted gross income for those with adjusted gross income up to 545 percent of federal
poverty guidelines;

(2) if the adjusted gross income is greater than 545 percent of federal poverty
guidelines and less than 675 percent of federal poverty guidelines, the parental
contribution shall be deleted text begin 7.5 deleted text end new text begin determined using a sliding fee scale which begins at two percent
of adjusted gross income at 545 percent of the federal poverty guidelines and increases to
three new text end percent of adjusted gross income new text begin for those with adjusted gross income up to 675
percent of the federal poverty guidelines new text end ;

(3) if the adjusted gross income is equal to or greater than 675 percent of federal
poverty guidelines and less than 975 percent of federal poverty guidelines, the parental
contribution shall be determined using a sliding fee scale established by the commissioner
of human services which begins at deleted text begin 7.5 deleted text end new text begin four new text end percent of adjusted gross income at 675 percent
of federal poverty guidelines and increases to deleted text begin ten deleted text end new text begin five new text end percent of adjusted gross income for
those with adjusted gross income up to 975 percent of federal poverty guidelines; and

(4) if the adjusted gross income is equal to or greater than 975 percent of federal
poverty guidelines, the parental contribution shall be deleted text begin 12.5 deleted text end new text begin six new text end percent of adjusted gross
income.

If the child lives with the parent, the annual adjusted gross income is reduced by
$2,400 prior to calculating the parental contribution. If the child resides in an institution
specified in section 256B.35, the parent is responsible for the personal needs allowance
specified under that section in addition to the parental contribution determined under this
section. The parental contribution is reduced by any amount required to be paid directly to
the child pursuant to a court order, but only if actually paid.

(c) The household size to be used in determining the amount of contribution under
paragraph (b) includes natural and adoptive parents and their dependents, including the
child receiving services. Adjustments in the contribution amount due to annual changes
in the federal poverty guidelines shall be implemented on the first day of July following
publication of the changes.

(d) For purposes of paragraph (b), "income" means the adjusted gross income of the
natural or adoptive parents determined according to the previous year's federal tax form,
except, effective retroactive to July 1, 2003, taxable capital gains to the extent the funds
have been used to purchase a home shall not be counted as income.

(e) The contribution shall be explained in writing to the parents at the time eligibility
for services is being determined. The contribution shall be made on a monthly basis
effective with the first month in which the child receives services. Annually upon
redetermination or at termination of eligibility, if the contribution exceeded the cost of
services provided, the local agency or the state shall reimburse that excess amount to
the parents, either by direct reimbursement if the parent is no longer required to pay a
contribution, or by a reduction in or waiver of parental fees until the excess amount is
exhausted. All reimbursements must include a notice that the amount reimbursed may be
taxable income if the parent paid for the parent's fees through an employer's health care
flexible spending account under the Internal Revenue Code, section 125, and that the
parent is responsible for paying the taxes owed on the amount reimbursed.

(f) The monthly contribution amount must be reviewed deleted text begin at least every 12 months;
deleted text end new text begin annually, new text end when there is a change in household size deleted text begin ; deleted text end new text begin , new text end and deleted text begin when there is a loss of or gain
in income from one month to another in excess of ten percent deleted text end new text begin when a parent requests a
review due to a substantial decrease in income or an extreme hardship new text end . The local agency
shall mail a written notice 30 days in advance of the effective date of a change in the
contribution amount. A decrease in the contribution amount is effective in the month that
the parent verifies a reduction in income or change in household size.

(g) Parents of a minor child who do not live with each other shall each pay the
contribution required under paragraph (a). An amount equal to the annual court-ordered
child support payment actually paid on behalf of the child receiving services shall be
deducted from the adjusted gross income of the parent making the payment prior to
calculating the parental contribution under paragraph (b).

(h) The contribution under paragraph (b) shall be increased by an additional five
percent if the local agency determines that insurance coverage is available but not obtained
for the child. For purposes of this section, "available" means the insurance is a benefit of
employment for a family member at an annual cost of no more than five percent of the
deleted text begin family's deleted text end new text begin parent's new text end annual income. For purposes of this section, "insurance" means health
and accident insurance coverage, enrollment in a nonprofit health service plan, health
maintenance organization, self-insured plan, or preferred provider organization.

Parents who have more than one child receiving services shall not be required
to pay more than the amount for the child with the highest expenditures. There shall
be no resource contribution from the parents. The parent shall not be required to pay
a contribution in excess of the cost of the services provided to the child, not counting
payments made to school districts for education-related services. Notice of an increase in
fee payment must be given at least 30 days before the increased fee is due.

(i) The contribution under paragraph (b) shall be reduced by $300 per fiscal year if,
in the 12 months prior to July 1:

(1) the parent applied for insurance for the child;

(2) the insurer denied insurance;

(3) the parents submitted a complaint or appeal, in writing to the insurer, submitted
a complaint or appeal, in writing, to the commissioner of health or the commissioner of
commerce, or litigated the complaint or appeal; and

(4) as a result of the dispute, the insurer reversed its decision and granted insurance.

For purposes of this section, "insurance" has the meaning given in paragraph (h).

A parent who has requested a reduction in the contribution amount under this
paragraph shall submit proof in the form and manner prescribed by the commissioner or
county agency, including, but not limited to, the insurer's denial of insurance, the written
letter or complaint of the parents, court documents, and the written response of the insurer
approving insurance. The determinations of the commissioner or county agency under this
paragraph are not rules subject to chapter 14.

Sec. 4.

Minnesota Statutes 2012, section 252.27, is amended by adding a subdivision
to read:

new text begin Subd. 2d. new text end

new text begin Fees limited. new text end

new text begin Notwithstanding subdivision 2a, the fee a parent is required
to contribute to the cost of services under medical assistance for an individual child shall
not exceed the maximum insurance premium charged in Minnesota under the federal
Patient Protection and Affordable Care Act, Public Law 111-148, as amended, for a
child-only policy for a child with the same amount of income.
new text end

Sec. 5.

Minnesota Statutes 2013 Supplement, section 256B.0949, subdivision 2,
is amended to read:

Subd. 2.

Definitions.

(a) For the purposes of this section, the terms defined in
this subdivision have the meanings given.

(b) "Autism spectrum disorder diagnosis" is defined by diagnostic code 299 in the
current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

(c) "Child" means a person under the age of 18.

(d) "Commissioner" means the commissioner of human services, unless otherwise
specified.

(e) "Early intensive intervention benefit" means autism treatment options based in
behavioral and developmental science, which may include modalities such as applied
behavior analysis, developmental treatment approaches, and naturalistic and parent
training models.

(f) "Generalizable goals" means results or gains that are observed during a variety
of activities with different people, such as providers, family members, other adults, and
children, and in different environments including, but not limited to, clinics, homes,
schools, and the community.

(g) "Mental health professional" deleted text begin has the meaning given deleted text end new text begin means a mental health
professional as defined new text end in section 245.4871, subdivision 27, deleted text begin clauses (1) to (6) deleted text end new text begin who has
training and expertise in autism spectrum disorders new text end .

Sec. 6.

Minnesota Statutes 2013 Supplement, section 256B.0949, subdivision 3,
is amended to read:

Subd. 3.

Initial eligibility.

This benefit is available to a child enrolled in medical
assistance who deleted text begin :
deleted text end

deleted text begin (1) deleted text end has an autism spectrum disorder diagnosis deleted text begin ; deleted text end new text begin for services that meet the criteria for
medically necessary care under Minnesota Rules, part 9505.0175, subpart 25.
new text end

deleted text begin (2) has had a diagnostic assessment described in subdivision 5, which recommends
early intensive intervention services; and
deleted text end

deleted text begin (3) meets the criteria for medically necessary autism early intensive intervention
services.
deleted text end

Sec. 7.

Minnesota Statutes 2013 Supplement, section 256B.0949, subdivision 4,
is amended to read:

Subd. 4.

Diagnosis.

(a) A diagnosis must:

(1) be based upon current DSM criteria including direct observations of the child
and reports from parents or primary caregivers; and

(2) be completed by deleted text begin both deleted text end new text begin either (i) new text end a licensed physician or advanced practice
registered nurse deleted text begin and deleted text end new text begin or (ii) new text end a mental health professional.

(b) Additional diagnostic assessment information may be considered including from
special education evaluations and licensed school personnel, and from professionals
licensed in the fields of medicine, speech and language, psychology, occupational therapy,
and physical therapy.

deleted text begin (c) If the commissioner determines there are access problems or delays in diagnosis
for a geographic area due to the lack of qualified professionals, the commissioner shall
waive the requirement in paragraph (a), clause (2), for two professionals and allow a
diagnosis to be made by one professional for that geographic area. This exception must be
limited to a specific period of time until, with stakeholder input as described in subdivision
8, there is a determination of an adequate number of professionals available to require two
professionals for each diagnosis.
deleted text end

Sec. 8.

Minnesota Statutes 2013 Supplement, section 256B.0949, subdivision 7,
is amended to read:

Subd. 7.

Ongoing eligibility.

(a) deleted text begin An independent deleted text end new text begin A new text end progress evaluation conducted
by a licensed mental health professional with expertise and training in autism spectrum
disorder and child development must be completed after deleted text begin each deleted text end new text begin the first new text end six months of
treatment new text begin and not more than once every 12 months thereafter new text end , deleted text begin or more frequently as
determined by the commissioner deleted text end new text begin unless the treating licensed mental health professional
determines more frequent evaluations are necessary new text end , to determine if progress is being
made toward achieving generalizable goals and meeting functional goals contained in
the treatment plan.

(b) The progress evaluation must include:

(1) the treating provider's report;

(2) parental or caregiver input;

(3) an deleted text begin independent deleted text end observation of the child which can be performed by the child's
licensed special education staff;

(4) any treatment plan modifications; and

(5) recommendations for continued treatment services.

(c) Progress evaluations must be submitted to the commissioner in a manner
determined by the commissioner for this purpose.

(d) A child who continues to achieve generalizable goals and treatment goals as
specified in the treatment plan new text begin and who is recommended for continued treatment services
by the treating mental health professional under paragraph (b), clause (5), new text end is eligible to
continue receiving this benefit.

(e) new text begin The commissioner may consider an alternative eligibility recommendation to the
recommendation of the treating mental health professional under paragraph (b), clause (5),
if there is a detailed report provided by a licensed mental health professional with expertise
treating children with autism spectrum disorder using the relevant treatment modality
showing that progress is not being made in a particular case. In this case, treatment shall
not be interrupted and shall continue to be reimbursed until a final determination is made.
new text end

new text begin (f) new text end A child's treatment shall continue new text begin to be reimbursed new text end during the progress evaluation
deleted text begin using the deleted text end process deleted text begin determined under subdivision 8, clause (8) deleted text end new text begin until a final determination is
made new text end . Treatment may continue during an appeal pursuant to section 256.045.

Sec. 9.

Minnesota Statutes 2013 Supplement, section 256B.0949, subdivision 9,
is amended to read:

Subd. 9.

Revision of treatment options.

(a) The commissioner may deleted text begin revise deleted text end new text begin add
new text end covered treatment options as needed based on outcome data and other evidence.

(b) Before the changes become effective, the commissioner must provide public
notice of the changes, the reasons for the change, and a 30-day public comment period
to those who request notice through an electronic list accessible to the public on the
department's Web site.

Sec. 10.

Laws 2013, chapter 9, section 15, is amended to read:

Sec. 15. MINNESOTA COMPREHENSIVE HEALTH ASSOCIATION
TERMINATION.

new text begin (a) new text end The commissioner of commerce, in consultation with the board of directors of the
Minnesota Comprehensive Health Association, has the authority to develop and implement
the phase-out and eventual appropriate termination of coverage provided by the Minnesota
Comprehensive Health Association under Minnesota Statutes, chapter 62E. The phase-out
of coverage shall begin no sooner than January 1, 2014, or upon the effective date of the
operation of the Minnesota Insurance Marketplace and the ability to purchase qualified
health plans through the Minnesota Insurance Marketplace, whichever is later, and shall,
to the extent practicable, ensure the least amount of disruption to the enrollees' health care
coverage. The member assessments established under Minnesota Statutes, section 62E.11,
shall take into consideration any phase-out of coverage implemented under this section.

new text begin (b)(1) Notwithstanding paragraph (a), the Minnesota Comprehensive Health
Association shall continue beyond any phaseout or termination specified in paragraph (a)
for the purpose of providing coverage for autism spectrum disorder as defined in Minnesota
Statutes, section 62A.3094, subdivision 1, paragraph (b), for children under the age 18.
new text end

new text begin (2) The coverage provided under clause (1) must comply with Minnesota Statutes,
section 62A.3094, subdivision 2.
new text end

new text begin (3) The Minnesota Comprehensive Health Association may charge a premium for
the coverage required under this section, not to exceed the average cost of a child-only
insurance premium in Minnesota under the federal Patient Protection and Affordable Care
Act, Public Law 111-148, as amended. The association may continue to use its current
procedures for assessing the association's members for costs the association incurs, or
expects to incur, in excess of premiums it receives under this clause.
new text end

new text begin (4) This paragraph expires if and when coverage of autism spectrum disorder is
included in the essential health benefit set required under the federal Patient Protection
and Affordable Care Act.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective if legislation is not enacted by August
1, 2014, to expand the private insurance mandate to cover children under age 18 with an
autism spectrum disorder under Minnesota Statutes, section 62A.3094, subdivision 2, and
to limit medical assistance fees under Minnesota Statutes, section 252.27, subdivision 2d.
The commissioner of human services shall notify the revisor of statutes if this section
becomes effective and place a notice in the State Register.
new text end

Sec. 11.

Laws 2013, chapter 108, article 12, section 2, the effective date, is amended to
read:

EFFECTIVE DATE.

This section is effective deleted text begin January deleted text end new text begin July new text end 1, deleted text begin 2016 deleted text end new text begin 2014 new text end , or the
date a collective bargaining agreement or compensation plan that includes changes to this
section is approved under Minnesota Statutes, section 3.855, whichever is earlier.