This is the summary text of Oregon House Bill 3000, as introduced to the Oregon House of Representatives March 3, 2009 by Representative Peter Buckley (D-5), and is currently, as of 5/1/09, in the House Rules Committee (Reps.Roblan, Berger, C. Edwards,Garrard, Gelser, Jenson, Nolan, and Read).
House Health Care Committee (Reps Greenlick, Harker, Maurer, Bruun, Cannon, Dembrow, Garrett, Kennemer, Kotek, and Thompson) Relating to autism spectrum disorder; creating new provisions; and amending ORS 414.710 and 743A.190. Requires health insurers and state medical assistance program to reimburse for diagnosis and treatment of autism spectrum disorder.
This introduced version may be subject to amendment as the bill moves through the legislative process.
Requires private health insurance companies to provide coverage for the diagnosis and treatment of autism spectrum disorder
Coverage will be provided to individuals under the age of 21
Coverage under this bill is subject to an inflation adjusted maximum benefit of $36,000 annually
Coverage of treatments will be provided when prescribed, provided, or ordered for an individual diagnosed with autism by a psychologist , a psychiatrist, a psychiatric nurse practitioner, a licensed clinical social worker, or an autism service provider or a person, entity or group that works under the direction of an autism service provider who determines the care to be medically necessary
The bill defines "medically necessary" as "in accordance with the definition of medical necessity that is specified in the policy, certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan"
The bill includes coverage of the following treatments: prescription drugs, blood level tests, psychiatric services, psychological services, speech therapy, language therapy, occupational therapy, physical therapy, and Applied Behavior Analysis (ABA)
The bill applies only to fully-funded health plans governed by state
If passed, this bill will go into effect on July 1, 2011
75th OREGON LEGISLATIVE ASSEMBLY--2009 Regular Session
NOTE: Matter within { + braces and plus signs + } in an amended section is new. Matter within { - braces and minus signs - } is existing law to be omitted. New sections are within { + braces and plus signs + } . LC 2549House Bill 3000
Sponsored by Representatives BUCKLEY, GREENLICK, C EDWARDS; Representatives KOTEK, TOMEI, Senator BATES
SUMMARY
The following summary is not prepared by the sponsors of the measure and is not a part of the body thereof subject toconsideration by the Legislative Assembly. It is an editor's brief statement of the essential features of the measure as introduced.
Requires health insurers and state medical assistance program to reimburse for diagnosis and treatment of autism spectrum disorder.
A BILL FOR AN ACT
Relating to autism spectrum disorder; creating new provisions; and amending ORS 414.710 and 743A.190.Be It Enacted by the People of the State of Oregon: SECTION 1. ORS 743A.190 is amended to read: 743A.190. { - (1) A health benefit plan, as defined in ORS743.730, must cover for a child enrolled in the plan who is under18 years of age and who has been diagnosed with a pervasive developmental disorder all medical services, including rehabilitation services, that are medically necessary and areotherwise covered under the plan. - } { - (2) The coverage required under subsection (1) of this section, including rehabilitation services, may be made subject to other provisions of the health benefit plan that apply to covered services, including but not limited to: - } { - (a) Deductibles, copayments or coinsurance; - } { - (b) Prior authorization or utilization review requirements; or - } { - (c) Treatment limitations regarding the number of visits or the duration of treatment. - } { - (3) As used in this section: - } { - (a) 'Medically necessary' means in accordance with the definition of medical necessity that is specified in the policy,certificate or contract for the health benefit plan and that applies uniformly to all covered services under the health benefit plan. - } { - (b) 'Pervasive developmental disorder' means a neurological condition that includes Asperger's syndrome, autism,developmental delay, developmental disability or mental retardation. - } { - (c) 'Rehabilitation services' means physical therapy,occupational therapy or speech therapy services to restore or improve function. - } { - (4) The provisions of ORS 743A.001 do not apply to this section. - } { - (5) The definition of 'pervasive developmental disorder 'is not intended to apply to coverage required under ORS743A.168. - } { + (1) As used in this section: (a) 'Applied behavior analysis' means: (A) The design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function; or (B) The use of direct observation, measurement and functional analysis of the relationship between environment and behavior. (b) 'Autism service provider' means an individual who: (A)(i) Is certified as a behavior analyst by a behavior analyst certification organization approved by the Department of Consumer and Business Services; or (ii) Is working under the supervision of a certified behavior analyst and is certified as an assistant behavior analyst by a behavior analyst certification organization approved by the department; or (B)(i) Contracts with an insurer to provide autism services in the insured's service area; (ii) Is a participating provider in the state medical assistance program; and (iii) Agrees to accept the payment rates and other terms and conditions applicable to the insurer's other participating autism service providers. (c) 'Autism spectrum disorder' means autistic disorder,Asperger's disorder, pervasive developmental disorder or any of the pervasive developmental disorders defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association. (d) 'Diagnostic assessment' means medically necessary evaluations or tests performed by a licensed psychologist,psychiatrist or psychiatric nurse practitioner within the past 12 months for the purpose of diagnosing autism spectrum disorder. (2) A health benefit plan, as defined in ORS 743.730, must reimburse the costs of diagnostic assessment and treatment for autism spectrum disorder for enrollees who are under 21 years of age. (3) Coverage is not required under this section unless the treatment is: (a) For an autism spectrum disorder; (b) Identified in a treatment plan that is: (A) Developed by a licensed psychologist, psychiatrist or psychiatric nurse practitioner pursuant to a comprehensive evaluation or reevaluation; and (B) Reviewed no less frequently than once every six months by the treating psychologist, psychiatrist or psychiatric nurse practitioner; and (c) Prescribed, ordered or provided by: (A) A psychologist; (B) A psychiatrist; (C) A psychiatric nurse practitioner; (D) A licensed clinical social worker; or (E) An autism service provider or a person, entity or group that works under the direction of an autism service provider. (4) Treatments that must be covered under this section are: (a) Prescription drugs; (b) Blood level tests; (c) Direct or consultation services of a psychiatrist or a psychologist; (d) Applied behavior analysis; and (e) Speech, language, occupational and physical therapies. (5) Treatments covered under this section: (a) May be limited to costs totaling $36,000 per year,increased annually, beginning January 1, 2012, by the percentage increase in the Portland-Salem Consumer Price Index for All Urban Consumers for All Items as reported by the United States Bureau of Labor Statistics; (b) May not include limits on the number of visits; and (c) May be subject to copayment, deductible and coinsurance provisions, and any other exclusions or limitations, but only to the same extent as other medical services covered by the plan. (6)(a) An insurer must provide an internal review process for a denial of a request for diagnostic assessment or treatment of autism spectrum disorder for an enrollee under 21 years of age. A decision on review must be issued within 15 days from the request for review. (b) A decision on review that is adverse to the insured may be appealed within 30 days to the Department of Consumer and Business Services as a contested case hearing under ORS chapter183. (7) This section is exempt from ORS 743A.001. + } SECTION 2. { + The Department of Consumer and Business Services shall submit a report to the appropriate interim committee of the Legislative Assembly by October 1, 2010, stating, for the calendar year beginning January 1, 2011, the number of children that are expected to benefit from the amendments to ORS 743A.190 by section 1 of this 2009 Act, the anticipated costs to insurers and the anticipated increase in thecost of insurance premiums. + } SECTION 3. ORS 414.710 is amended to read: 414.710. The following services are available to persons eligible for services under ORS 414.025, 414.036, 414.042,414.065 and 414.705 to 414.750 but such services are not subject to ORS 414.720: (1) Nursing facilities and home- and community-based waivered services funded through the Department of Human Services; (2) Medical assistance to eligible persons who receive assistance under ORS 411.706 or to children described in ORS414.025 (2)(f), (i), (j), (k) and (m), 418.001 to 418.034,418.189 to 418.970 and 657A.020 to 657A.460; (3) Institutional, home- and community-based waivered services or community mental health program care for persons with mental retardation, developmental disabilities or severe mental illness and for the treatment of alcohol and drug dependent persons; { - and - } (4) Services to children who are wards of the Department of Human Services by order of the juvenile court and services to children and families for health care or mental health care through the department { - . - } { + ; and (5) Diagnostic assessment and treatment of autism spectrum disorder as described in ORS 743A.190, for individuals under 21years of age. + } SECTION 4. { + (1) The amendments to ORS 414.710 and 743A.190by sections 1 and 3 of this 2009 Act become operative July 1,2011. (2) The amendments to ORS 743A.190 by section 1 of this 2009 Act apply to health benefit plans, health care service contracts and multiple employer welfare arrangements offered or renewed on or after July 1, 2011. + }
