GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2015
S 1
SENATE BILL 676
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Short Title: Autism Health Insurance Coverage. |
(Public) |
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Sponsors: |
Senators Apodaca, Krawiec (Primary Sponsors); Brock, Ford, Hise, B. Jackson, Lee, Lowe, Pate, Tarte, Van Duyn, and Woodard. |
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Referred to: |
Insurance. |
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March 30, 2015
A BILL TO BE ENTITLED
AN ACT TO provide coverage for the treatment of autism spectrum disorders.
The General Assembly of North Carolina enacts:
SECTION 1. G.S. 58‑3‑220 reads as rewritten:
"§ 58‑3‑220. Mental illness benefits coverage.
(a) Mental Health Equity Requirement. – Except as
provided in subsection (b), an insurer shall provide in each group health
benefit plan benefits for the necessary care and treatment of mental illnesses
that are no less favorable than benefits for physical illness generally,
including application of the same limits. For purposes of this subsection,
mental illnesses are as diagnosed and defined in the Diagnostic and Statistical
Manual of Mental Disorders, DSM‑IV, DSM‑V, or a
subsequent edition published by the American Psychiatric Association, except
those mental disorders coded in the DSM‑IV DSM‑V or
subsequent edition as autism spectrum disorders (299.00), substance‑related
disorders (291.0 through 292.2 and 303.0 through 305.9), those coded as sexual
dysfunctions not due to organic disease (302.70 through 302.79), and those
coded as "V" codes. For purposes of this subsection, "limits"
includes deductibles, coinsurance factors, co‑payments, maximum out‑of‑pocket
limits, annual and lifetime dollar limits, and any other dollar limits or fees
for covered services.
(b) Minimum Required Benefits. – Except as provided in
subsection (c), a group health benefit plan may apply durational limits to
mental illnesses that differ from durational limits that apply to physical
illnesses. A group health benefit plan shall provide at least the following
minimum number of office visits and combined inpatient and outpatient days for
all mental illnesses and disorders not listed in subsection (c), as diagnosed
and defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV,
DSM‑V, or a subsequent edition published by the American
Psychiatric Association, except those mental disorders coded in the DSM‑IV
DSM‑V or subsequent edition as autism spectrum disorders
(299.00), substance‑related disorders (291.0 through 292.2 and 303.0
through 305.9), those coded as sexual dysfunctions not due to organic disease
(302.70 through 302.79), and those coded as "V" codes:
(1) Thirty combined inpatient and outpatient days per year.
(2) Thirty office visits per year.
…
(h) Definitions. – As used in this section:
(1) "Health benefit plan" has the same meaning as in G.S. 58‑3‑167.
(2) "Insurer" has the same meaning as in G.S. 58‑3‑167.
(3) "Mental illness" has the same meaning as
in G.S. 122C‑3(21), with a mental disorder defined in the Diagnostic
and Statistical Manual of Mental Disorders, DSM‑IV, DSM‑V,
or subsequent editions published by the American Psychiatric Association,
except those mental disorders coded in the DSM‑IV DSM‑V or
subsequent editions as autism spectrum disorders (299.00), substance‑related
disorders (291.0 through 292.9 and 303.0 through 305.9), those coded as sexual
dysfunctions not due to organic disease (302.70 through 302.79), and those
coded as "V" codes.
(i) Notwithstanding any other provisions of this
section, a group health benefit plan that covers both medical and surgical
benefits and mental health benefits shall, with respect to the mental health
benefits, comply with all applicable standards of Subtitle B of Title V of Public
Law 110‑343, known as the Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008.2008, and the applicable
regulations, as amended.
(j) Subsection (i) of this section applies
only to a group health benefit plan covering a large employer as defined in G.S. 58‑68‑25(a)(10)."
SECTION 2. Article 3 of Chapter 58 of the General Statutes is amended by adding a new section to read:
"§ 58‑3‑192. Coverage for autism spectrum disorders.
(a) As used in this section, the following definitions apply:
(1) Adaptive behavior treatment. – The systematic management of instructional and environmental factors or the consequences of behavior that have been shown to be clinically effective through research published in peer reviewed scientific journals and based upon randomized, quasi‑experimental, or single subjection designs. Both of the following requirements must be met to meet the definition of behavioral and developmental interventions:
a. The intervention must be necessary to (i) increase appropriate or adaptive behaviors, (ii) decrease maladaptive behaviors, or (iii) develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.
b. The treatment must be ordered by a licensed physician or licensed psychologist and the treatment must be provided or supervised by one of the following licensed professionals, so long as the services provided are commensurate with the licensed professional's training, experience, and scope of practice:
1. A licensed psychologist or psychological associate.
2. A licensed psychiatrist or developmental pediatrician.
3. A licensed speech and language pathologist.
4. A licensed occupational therapist.
5. A licensed clinical social worker.
(2) Autism spectrum disorder. – Any of the pervasive developmental disorders or autism spectrum disorders, as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the most recent edition of the International Statistical Classification of Diseases and Related Health Problems. Autism spectrum disorder is not considered a mental illness as defined in G.S. 58‑3‑220, 58‑51‑55, 58‑65‑90, or 58‑67‑75.
(3) Diagnosis of autism spectrum disorder. – Any medically necessary assessments, evaluations, or tests to determine whether an individual has autism spectrum disorder.
(4) Health benefit plan. – As defined in G.S. 58‑3‑167.
(5) Pharmacy care. – Medications prescribed by a licensed health care provider.
(6) Psychiatric care. – Direct or consultative services provided by a licensed psychiatrist.
(7) Psychological care. – Direct or consultative services provided by a licensed psychologist or licensed psychological associate.
(8) Therapeutic care. – Direct or consultative services provided by a licensed speech therapist, licensed occupational therapist, licensed physical therapist, licensed clinical social worker, or licensed professional counselor.
(9) Treatment for autism spectrum disorders. – Any of the following care for an individual diagnosed with autism spectrum disorder, or equipment related to that care, ordered by a licensed physician or a licensed psychologist who determines the care to be medically necessary:
a. Adaptive behavior treatment.
b. Pharmacy care.
c. Psychiatric care.
d. Psychological care.
e. Therapeutic care.
(b) Except as provided in subsection (d), health benefit plans shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder for individuals 18 years of age or younger. No insurer shall terminate coverage or refuse to issue, amend, or renew coverage to an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spectrum disorder.
(c) Coverage under this section may not be subject to any limits on the number of visits an individual may have for treatment of autism spectrum disorder.
(d) Coverage for adaptive behavior treatments under this section may be subject to a maximum benefit of up to forty thousand dollars ($40,000) per year.
(e) Coverage under this section may not be denied on the basis that the treatments are habilitative or educational in nature.
(f) Coverage under this section may be subject to co‑payment, deductible, and coinsurance provisions of a health benefit plan that are not less favorable than the co‑payment, deductible, and coinsurance provisions that apply to substantially all medical services covered by the health benefit plan.
(g) This section shall not be construed as limiting benefits that are otherwise available to an individual under a health benefit plan.
(h) Nothing in this section shall apply to non‑grandfathered health plans in the individual and small group markets that are subject to the requirement to cover the essential health benefit package under 45 C.F.R. § 147.150(a). For purposes of this subsection, "non‑grandfathered health plan" is a health benefit plan not included in the plans defined under G.S. 58‑50‑110(10a).
(i) This section shall not 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.
(j) Except as provided in subsection (d), every health benefit plan shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder in accordance with all applicable standards of Subtitle B of Title V of Public Law 110‑343, known as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, and the applicable regulations, as amended."
SECTION 3. G.S. 58‑51‑55(a) reads as rewritten:
"(a) Definitions. – As used in this section, the term:
(1) "Mental illness" has the same meaning as
defined in G.S. 122C‑3(21), with a mental disorder defined in the
Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV, DSM‑V,
or a subsequent edition published by the American Psychiatric Association,
except those mental disorders coded in the DSM‑IV DSM‑V or
subsequent editions as autism spectrum disorders (299.00), substance‑related
disorders (291.0 through 292.9 and 303.0 through 305.9), those coded as sexual
dysfunctions not due to organic disease (302.70 through 302.79), and those
coded as "V" codes.
(2) "Chemical dependency" has the same
meaning as defined in G.S. 58‑51‑50, with a mental disorder
defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV,
DSM‑V, or subsequent editions published by the American
Psychiatric Association."
SECTION 4. G.S. 58‑67‑75(a) reads as rewritten:
"(a) Definitions. – As used in this section, the term:
(1) "Mental illness" has the same meaning as
defined in G.S. 122C‑3(21), with a mental disorder defined in the
Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV, DSM‑V,
or subsequent editions published by the American Psychiatric Association,
except those mental disorders coded in the DSM‑IV DSM‑V or
subsequent editions as autism spectrum disorders (299.00), substance‑related
disorders (291.0 through 292.9 and 303.0 through 305.9), those coded as sexual
dysfunctions not due to organic disease (302.70 through 302.79), and those
coded as "V" codes.
(2) "Chemical dependency" has the same
meaning as defined in G.S. 58‑67‑70, with a mental disorder
defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV,
DSM‑V or subsequent editions published by the American
Psychiatric Association."
SECTION 5. G.S. 58‑65‑90(a) reads as rewritten:
"(a) Definitions. – As used in this section, the term:
(1) "Mental illness" has the same meaning as
defined in G.S. 122C‑3(21), with a mental disorder defined in the
Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV, DSM‑V,
or subsequent editions published by the American Psychiatric Association,
except those mental disorders coded in the DSM‑IV DSM‑V or
subsequent editions as substance‑related disorders (291.0 through 292.9
and 303.0 through 305.9), those coded as autism spectrum disorders (299.00),
sexual dysfunctions not due to organic disease (302.70 through 302.79), and
those coded as "V" codes.
(2) "Chemical dependency" has the same
meaning as defined in G.S. 58‑65‑75, with a mental disorder
defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM‑IV,
DSM‑V, or subsequent editions published by the American
Psychiatric Association."
SECTION 6. This act becomes effective October 1, 2015, and applies to insurance contracts issued, renewed, or amended on or after that date.