House committee substitute makes the following changes to the 2nd edition.
Amends proposed GS 58-3-192 to remove a licensed clinical social worker from the persons recognized to diagnose autism spectrum disorder and whose diagnosis may serve as a basis for ordering medicalcare or equipment for treatment. Limits required coverage undera health benefit plan for the screening, diagnosis, and treatment of an autism spectrum disorderto individuals 23 years of age or younger. Requires that persons must be diagnosed as having an autism spectrum disorder prior to the age of eight to qualify for required health benefit plan coverage under this section. Provides that coverage for behavioral health treatment under this section may be subject to a maximum benefit of up to $36,000 per year (was, $75,000).
Adds two new subsections, (k) and (l), to GS 58-3-192. Subsection (k) directs the Commissioner of Insurance (Commissioner) to grant a waiver to a small employer carrier as defined in GS 58-50-110(23) from the provisions of this section if the small employer carrier demonstrates via actual claims experience that compliance with this section has increased the cost of the health benefit plan by 2.5% or greater in the premium rate charged to a small employer over the most recent calendar year. Subsection (l) requires the Commissioner to grant a waiver to a health benefit plan issuer that can show that the cost of thehealth benefit plan has increased by1% or greater in the premium rate charged under the plan over the most recent calendar year. Effective October 1, 2013.
Requires the Department of theState Treasurer to submit a report to the General Assembly no later than March 1, 2015, and every March 1st subsequently, on the implementation of coverage underthe State Health Plan for Teachers and State Employees as required under this section. Requires the report to contain: (1) total number of insured persons diagnosed with autism spectrum disorder;(2) total costs of all claims paid out in the previous fiscal year for the coverage required by this section;(3) cost of coverage required under this section per insured, per month;and (4) average cost per insured for coverage of any treatment involving applied behavior analysis. Effective January 1, 2014.
House amendments make the following changes to the 3rd edition.
Amendment #1 deletes GS 58-3-192(k), which concerned granting a waiver for a small employer carrier.
Amendment #2 deletes the provision in GS 58-3-192(g) that required the Commissioner of Insurance to annually adjust the maximum benefit for inflation, as well as the provision prohibiting payments made by an insurer on behalf of a covered individual for care and items other than behavioral health treatment from being applied toward any maximum benefit.
Summary date: May 14 2013 - View summary
House committee substitute makes the following changes to the 1st edition:
Amends bill short title to delete the word "Mandate".
Amends GS 58-3-192(a)(9) and (a)(10) to add services provided by a licensed clinical social worker to the definitions of therapeutic care and treatment for autism spectrum disorders; amends subsection (h) by substituting "insurer" for "health benefit plan"; rewrites subsection (i) to provide that the requirements for coverage of autism spectrum disorders does not apply to certified qualified health plans as defined in 45 CFR § 155.20 if the federal government determines that the State must make payments for a state-required benefit that is in excess of essential health benefits.
Revises the effective date clause to make changes to GS 135-48.51 effective January 1, 2014.
Summary date: Apr 2 2013 - View summary
Adds new GS 58-3-192 requiring health benefit plans, to provide coverage for autism spectrum disorders, that may be subject to the same deductibles, co-payments and coinsurance terms that apply to substantially all other covered medical services under the health benefit plan. Prohibits every health benefit plan, including the State Health Plan for Teachers and State Employees (State Plan), from terminating coverage or refusing coverage to an individual solely because the individual is diagnosed with one of the autism spectrum disorders or has received treatment for autism spectrum disorders. Provides that there will be no limits on the number of visits an individual may make to an autism services provider. Prohibits denying coverage because the treatments are habilitative or educational in nature. Directs that coverage under these provisions must not be construed as limiting benefits that are otherwise available to an individual under a health benefit plan. Allows for a maximum annual benefit of $75,000 for behavioral therapy for autism spectrum disorders. Requires the Commissioner of Insurance, after December 31, 2014, to adjust the maximum benefit for inflation. Prohibits applying payments made by the insurer on behalf of the individual for any care, treatment, intervention, service, or item unrelated to behavioral health treatment toward the maximum benefit. Provides that if an individual is receiving treatment for an autism spectrum disorder, with the exception of inpatient services, a health benefit plan has the right to request a review of the treatment no more than once every 12 months unless the individual's licensed medical doctor or licensed psychologist agrees that a more frequent review is needed. Requires the insurer to pay any costs for the review. Includes applicable definitions in proposed GS 58-3-192. Provides that the statute does not apply to a qualified health plan offered on a health benefit exchange operating in the state and that is established pursuant to specified regulations to the extent that this statute requires benefits that exceed the essential health benefits. Provides that the statute is not to be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.
Amends GS 90-270.4 to provide that nothing in the Psychology Practice Act is to be construed to prevent a Board Certified Behavior Analyst (BCBA) or a Board Certified Assistant Behavior Analyst (BCaBA) from offering services within the scope of practice authorized by the Behavior Analyst Certification Board, in accordance with professional standards, if (1) the BCBA or BCaBA is certified and in good standing with the Behavior Analyst Certification Board; and (2) the BCBA or BCaBA does not hold himself or herself out to the public by any title or description stating or implying BCBA or BCaBA is a psychologist or is licensed, certified, or registered to practice psychology in the state.
Makes conforming and technical changes to GS 135-48.51.
Provides that the act becomes effective October 1, 2013, and applies to all insurance contracts issued, renewed, or amended on or after that date.