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An Act To Reform Insurance Coverage To Include Diagnosis for Autism Spectrum Disorders
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24 MRSA §2317-B, sub-§19, as enacted by PL 1999, c. 256, Pt. M, §10, is amended to read:
 
19. Title 24-A, chapter 67. Medicare supplement insurance policies, Title 24-A, chapter 67; and
Sec. 2. 24 MRSA §2317-B, sub-§20, as amended by PL 2003, c. 428, Pt. G, §1, is further amended to read:
 
20. Title 24-A, chapters 68 and 68-A. Long-term care insurance, nursing home care insurance and home health care insurance, Title 24-A, chapters 68 and 68-A.; and
Sec. 3.  24 MRSA §2317-B, sub-§21  is enacted to read:
 
21.  Title 24-A, sections 2847-Q and 4257.   Coverage for diagnosis and treatment of autism spectrum disorders, Title 24-A, sections 2847-Q and 4257.
Sec. 4.  24-A MRSA §2847-Q  is enacted to read:
§ 2847-Q. Coverage for the diagnosis and treatment of autism spectrum disorders
 
1.  Definitions.   As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
 
A.  "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior.
 
B.  "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, published by the American Psychiatric Association, including autistic disorder, Asperger's disorder and pervasive developmental disorder not otherwise specified.
 
C.  "Treatment of autism spectrum disorders" includes the following types of care prescribed, provided or ordered for an individual diagnosed with an autism spectrum disorder:
 
(1) Habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services necessary to develop, maintain and restore the functioning of an individual to the extent possible;
 
(2) Prescribed pharmaceuticals;
 
(3) Counseling services provided by a licensed psychiatrist, psychologist, clinical professional counselor or clinical social worker; and
 
(4) Therapy services provided by a licensed or certified speech therapist, occupational therapist or physical therapist.
 
2.  Required coverage.   All group health insurance policies, contracts and certificates must provide coverage for autism spectrum disorders for an individual covered under the policy, contract or certificate who is 21 years of age or under in accordance with the following.
 
A.  The policy, contract or certificate must provide coverage for any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder.
 
B.  The policy, contract or certificate must provide coverage for the treatment of autism spectrum disorders when a licensed physician or licensed psychologist has submitted documentation that the treatment is medically necessary health care as defined in section 4301-A, subsection 10-A. A licensed physician or licensed psychologist may be required to confirm and document ongoing medical necessity for coverage provided under this section at least annually.
 
C.  The policy, contract or certificate may not include any limits on the number of visits.
 
D.  The policy, contract or certificate may limit coverage to $36,000 per year, except that, beginning January 1, 2011, the maximum benefit must be adjusted annually for inflation using the medical care component of the United States Department of Labor Consumer Price Index for urban wage earners. An insurer may not apply payments for coverage unrelated to autism spectrum disorders to any maximum benefit established under this paragraph.
 
3.  Limits; coinsurance; deductibles.   Except as otherwise provided in this section, any policy, contract or certificate that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.
 
4.  Individualized education plan.   This section may not be construed to affect any obligation to provide services to an individual with an autism spectrum disorder under an individualized education plan or an individualized family service plan.
 
5.  Exceptions.   This section does not apply to employee group insurance policies issued to employers with fewer than 50 employees insured under the group policy.
Sec. 5.  24-A MRSA §4257  is enacted to read:
§ 4257. Coverage for the diagnosis and treatment of autism spectrum disorders
 
1.  Definitions.   As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
 
A.  "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior.
 
B.  "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, published by the American Psychiatric Association, including autistic disorder, Asperger's disorder and pervasive developmental disorder not otherwise specified.
 
C.  "Treatment of autism spectrum disorders" includes the following types of care prescribed, provided or ordered for an individual diagnosed with an autism spectrum disorder:
 
(1) Habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services necessary to develop, maintain and restore the functioning of an individual to the extent possible;
 
(2) Prescribed pharmaceuticals;
 
(3) Counseling services provided by a licensed psychiatrist, psychologist, clinical professional counselor or clinical social worker; and
 
(4) Therapy services provided by a licensed or certified speech therapist, occupational therapist or physical therapist.
 
2.  Required coverage.   All group health maintenance organization contracts and certificates must provide coverage for autism spectrum disorders for an individual covered under the contract or certificate who is 21 years of age or under in accordance with the following.
 
A.  The contract or certificate must provide coverage for any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder.
 
B.  The contract or certificate must provide coverage for the treatment of autism spectrum disorders when a licensed physician or licensed psychologist has submitted documentation that the treatment is medically necessary health care as defined in section 4301-A, subsection 10-A. A licensed physician or licensed psychologist may be required to confirm and document ongoing medical necessity for coverage provided under this section at least annually.
 
C.  The contract or certificate may not include any limits on the number of visits.
 
D.  The contract or certificate may limit coverage to $36,000 per year, except that, beginning January 1, 2011, the maximum benefit must be adjusted annually for inflation using the medical care component of the United States Department of Labor Consumer Price Index for urban wage earners. A health maintenance organization may not apply payments for coverage unrelated to autism spectrum disorders to any maximum benefit established under this paragraph.
 
3.  Limits; coinsurance; deductibles.   Except as otherwise provided in this section, any contract or certificate that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.
 
4.  Individualized education plan.   This section may not be construed to affect any obligation to provide services to an individual with an autism spectrum disorder under an individualized education plan or an individualized family service plan.
 
5.  Exceptions.   This section does not apply to employee group health maintenance organization contracts issued to employers with fewer than 50 employees insured under the group contract.
Sec. 6. Application. The requirements of this Act apply to all group policies, contracts and certificates subject to this Act that are executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 2010. For purposes of this Act, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
 
SUMMARY
This bill requires group health insurance policies, contracts and certificates covering fewer than 50 members to provide coverage for the diagnosis and treatment of autism spectrum disorders for persons 21 years of age and under. Initially, coverage is subject to a maximum annual benefit of $36,000 per year; beginning January 1, 2011, the maximum benefit must be adjusted annually for inflation using the medical care component of the United States Department of Labor Consumer Price Index. The provisions of this bill apply to group policies, contracts and certificates issued or renewed on or after January 1, 2010.