Adds new GS 58-3-192 requiring health benefit plans, including the State Health Plan for Teachers and State Employees (State Plan), to provide coverage for autism spectrum disorders, subject to the same deductibles, co-payments and coinsurance terms that apply to other covered medical services under the health benefit plan.
Prohibits every health benefit plan, including the 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. Establishes a maximum annual benefit of $75,000 for behavioral therapy for autism spectrum disorders. Prohibits applying payments made by the insurer on behalf of the individual for any care, treatment, intervention, service, or item unrelated to autism spectrum disorders 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.
Amends GS 135-45 to direct the Executive Administrator and Board of Trustees of the State Plan not to change the plan’s comprehensive health benefit coverage, co-payments, deductible, out-of-pocket expenditures, and lifetime maximum in effect on January 1, 2012, (was, July 1, 2009) that would result in a net increased cost to the State Plan or a reduction in benefits to plan members until the General Assembly directs that such changes be made. Makes conforming changes to GS 135-45 to synchronize its provisions with those of proposed GS 58-3-192.
Provides that the act becomes effective January 1, 2012, and applies to all health benefit plans that are delivered, issued for delivery, or renewed within North Carolina, or outside of the state if the health benefit plan is insuring North Carolina residents, on and after the effective date.
Bill Summaries: S115 (2011-2012 Session)
Bill S 115 (2011-2012)Summary date: Feb 23 2011 - View summary