PRINTER'S NO. 759
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
709
Session of
2017
INTRODUCED BY MURT, HEFFLEY, McNEILL, ROZZI, SCHLOSSBERG AND
SCHWEYER, MARCH 3, 2017
REFERRED TO COMMITTEE ON INSURANCE, MARCH 3, 2017
AN ACT
Amending Title 40 (Insurance) of the Pennsylvania Consolidated
Statutes, providing for autism spectrum disorders coverage.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Title 40 of the Pennsylvania Consolidated
Statutes is amended by adding a part to read:
PART V
SPECIAL PROVISIONS RELATING TO
PARTICULAR CLASSES OF RISK
Chapter
81. Autism Spectrum Disorders Coverage
CHAPTER 81
AUTISM SPECTRUM DISORDERS COVERAGE
Sec.
8101. Scope of chapter.
8102. Definitions.
8103. Coverage for diagnostic assessment and treatment.
8104. Maximum benefit.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
8105. Exclusions or limitations.
8106. General construction of chapter.
8107. Individualized education program.
8108. Applicability.
8109. Licensure or certification of behavior specialists.
8110. Participating provider.
8111. Review of treatment plan.
8112. Validity of assessment.
8113. Review and appeal process.
8114. Autism service provider.
§ 8101. Scope of chapter.
This chapter relates to insurance coverage for autism
spectrum disorders.
§ 8102. Definitions.
The following words and phrases when used in this chapter
shall have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Applied behavioral analysis." 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, including the use of direct observation,
measurement and functional analysis of the relations between
environment and behavior.
"Autism service provider." Any of the following:
(1) A person, entity or group providing treatment of
autism spectrum disorders, pursuant to a treatment plan, that
is licensed or certified in this Commonwealth, including an
individual holding a valid temporary graduate behavior
specialist license.
20170HB0709PN0759 - 2 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
(2) Any person, entity or group providing treatment of
autism spectrum disorders, pursuant to a treatment plan, that
is enrolled in the Commonwealth's medical assistance program
on or before the effective date of this section.
"Autism spectrum disorders." Any of the pervasive
developmental disorders defined by the most recent edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM),
or its successor, including autistic disorder, Asperger's
syndrome and pervasive developmental disorder not otherwise
specified.
"Behavior specialist." An individual who designs, implements
or evaluates a behavior modification intervention component of a
treatment plan, including those based on applied behavioral
analysis, to produce socially significant improvements in human
behavior or to prevent loss of attained skill or function,
through skill acquisition and the reduction of problematic
behavior.
"Board." The State Board of Medicine.
"Diagnostic assessment of autism spectrum disorders."
Medically necessary assessments, evaluations or tests performed
by a licensed physician, licensed physician assistant, licensed
psychologist or certified registered nurse practitioner to
diagnose whether an individual has an autism spectrum disorder.
"Government program." Any of the following:
(1) The Commonwealth's medical assistance program
established under the act of June 13, 1967 (P.L.31, No.21),
known as the Human Services Code.
(2) The adult basic coverage insurance program
established under Chapter 13 of the act of June 26, 2001
(P.L.755, No.77), known as the Tobacco Settlement Act.
20170HB0709PN0759 - 3 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
(3) The children's health insurance program under
Article XXIII-A of the act of May 17, 1921 (P.L.682, No.284),
known as The Insurance Company Law of 1921.
"Health insurance policy." Any individual or group health,
sickness or accident policy, or subscriber contract or
certificate offered, issued or renewed by an entity subject to
one of the following:
(1) The act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921.
(2) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or 63 (relating to professional health services
plan corporations).
"Insurer." Any entity offering a health insurance policy.
"Pharmacy care." Medications prescribed by a licensed
physician, licensed physician assistant or certified registered
nurse practitioner and any assessment, evaluation or test
prescribed or ordered by a licensed physician, licensed
physician assistant or certified registered nurse practitioner
to determine the need or effectiveness of the medications.
"Psychiatric care." Direct or consultative services provided
by a physician who specializes in psychiatry.
"Psychological care." Direct or consultative services
provided by a psychologist.
"Rehabilitative care." Professional services and treatment
programs, including applied behavioral analysis, provided by an
autism service provider to produce socially significant
improvements in human behavior or to prevent loss of attained
skill or function.
20170HB0709PN0759 - 4 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
"Therapeutic care." Services provided by speech language
pathologists, occupational therapists or physical therapists.
"Treatment of autism spectrum disorders." Includes medically
necessary pharmacy care, psychiatric care, psychological care,
rehabilitative care and therapeutic care that is identified in a
treatment plan and:
(1) Prescribed, ordered or provided by a licensed
physician, licensed physician assistant, licensed
psychologist, licensed clinical social worker or certified
registered nurse practitioner.
(2) Provided by an autism service provider.
(3) Provided by a person, entity or group that works
under the direction of an autism service provider.
"Treatment plan." A plan for the treatment of autism
spectrum disorders developed by a licensed physician or licensed
psychologist pursuant to a comprehensive evaluation or
reevaluation performed in a manner consistent with the most
recent clinical report or recommendations of the American
Academy of Pediatrics.
§ 8103. Coverage for diagnostic assessment and treatment.
A health insurance policy or government program covered under
this chapter shall provide to covered individuals or recipients
under 21 years of age coverage for the diagnostic assessment of
autism spectrum disorders and for the treatment of autism
spectrum disorders.
§ 8104. Maximum benefit.
(a) Amount.--Coverage provided under this chapter by an
insurer shall be subject to a maximum benefit of $36,000 per
year but shall not be subject to any limits on the number of
visits to an autism service provider for treatment of autism
20170HB0709PN0759 - 5 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
spectrum disorders.
(b) Adjustment.--
(1) After December 30, 2011, the Insurance Commissioner
shall, on or before April 1 of each calendar year, publish in
the Pennsylvania Bulletin an adjustment to the maximum
benefit equal to the change in the United States Department
of Labor Consumer Price Index for All Urban Consumers (CPI-U)
in the preceding year. The published adjusted maximum benefit
shall be applicable to the following calendar years to health
insurance policies issued or renewed in those calendar years.
(2) Payments made by an insurer on behalf of a covered
individual for treatment of a health condition unrelated to
or distinguishable from the individual's autism spectrum
disorder shall not be applied toward any maximum benefit
established under this section.
§ 8105. Exclusions or limitations.
Coverage under this chapter shall be subject to copayment,
deductible and coinsurance provisions and any other general
exclusions or limitations of a health insurance policy or
government program to the same extent as other medical services
covered by the policy or program are subject to these
provisions.
§ 8106. General construction of chapter.
This chapter shall not be construed as limiting benefits
which are otherwise available to an individual under a health
insurance policy or government program.
§ 8107. Individualized education program.
This chapter shall not be construed as requiring coverage by
insurers of any service based solely on its inclusion in an
individualized education program. Consistent with Federal or
20170HB0709PN0759 - 6 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
State law and upon consent of the parent or guardian of the
covered individual, the treatment of autism spectrum disorders
may be coordinated with any service included in an
individualized education program. Coverage for the treatment of
autism spectrum disorders shall not be contingent upon a
coordination of services with an individualized education
program.
§ 8108. Applicability.
(a) General rule.--Subject to subsection (b), this chapter
shall apply to any health insurance policy offered, issued or
renewed on or after July 1, 2009, in this Commonwealth to groups
of 51 or more employees.
(b) Exception.--This chapter shall not include the following
policies:
(1) Accident only.
(2) Fixed indemnity.
(3) Limited benefit.
(4) Credit.
(5) Dental.
(6) Vision.
(7) Specified disease.
(8) Medicare supplement.
(9) CHAMPUS (Civilian Health and Medical Program of the
Uniformed Services) supplement.
(10) Long-term care or disability income.
(11) Workers' compensation.
(12) Automobile medical payment.
(c) Contracts.--This chapter shall apply to any contract
executed on or after July 1, 2009, by:
(1) the adult basic coverage insurance program
20170HB0709PN0759 - 7 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
established under Chapter 13 of the act of June 26, 2001
(P.L.755, No.77), known as the Tobacco Settlement Act;
(2) the children's health insurance program under
Article XXIII-A of the act of May 17, 1921 (P.L.682, No.284),
known as The Insurance Company Law of 1921; or
(3) a successor program of either program under
paragraph (1) or (2).
(d) Report.--On January 1, 2011, insurers shall make a
report to the department, in a form and manner as determined by
the department, to evaluate the implementation of this chapter.
§ 8109. Licensure or certification of behavior specialists.
(a) Regulations.--In consultation with the Department of
Human Services, the board shall promulgate regulations providing
for the licensure or certification of behavior specialists.
(b) Disciplinary provisions.--Behavior specialists licensed
or certified by the board shall be subject to all disciplinary
provisions applicable to medical doctors as set forth in the act
of December 20, 1985 (P.L.457, No.112), known as the Medical
Practice Act of 1985.
(c) Fees.--The board may charge reasonable fees as set by
board regulation for licensure or certificates or applications
permitted by the Medical Practice Act of 1985.
(d) Application.--An applicant applying for a license or
certificate as a behavior specialist shall submit a written
application on forms provided by the board evidencing and
insuring to the satisfaction of the board that the applicant:
(1) Is of good moral character.
(2) Has received a master's or higher degree from a
board-approved, accredited college or university, including a
major course of study in school, clinical or counseling
20170HB0709PN0759 - 8 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
psychology, special education, social work, speech therapy,
occupational therapy or another related field.
(3) Has at least one year of experience involving
functional behavior assessments, including the development
and implementation of behavioral supports or treatment plans.
(4) Has completed at least 1,000 hours in direct
clinical experience with individuals with behavioral
challenges or at least 1,000 hours' experience in a related
field with individuals with autism spectrum disorders.
(5) Has completed relevant training programs, including
professional ethics, autism-specific training, assessments
training, instructional strategies and best practices, crisis
intervention, comorbidity and medications, family
collaboration and addressing specific skill deficits
training.
(e) Conviction.--
(1) The board shall not issue a license or certificate
to an applicant who has been convicted of a felony under the
act of April 14, 1972 (P.L.233, No.64), known as The
Controlled Substance, Drug, Device and Cosmetic Act, or if an
offense under the laws of another jurisdiction which, if
committed in this Commonwealth, would be a felony under The
Controlled Substance, Drug, Device and Cosmetic Act, unless:
(i) At least 10 years have elapsed from the date of
conviction.
(ii) The applicant satisfactorily demonstrates to
the board that he has made significant progress in
personal rehabilitation since the conviction such that
licensure of the applicant should not be expected to
create a substantial risk of harm to the health and
20170HB0709PN0759 - 9 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
safety of his patients or the public or a substantial
risk of further criminal violations.
(iii) The applicant otherwise satisfies the
qualifications contained in or authorized by this
chapter.
(2) As used in this subsection, the term "convicted"
shall include a judgment, an admission of guilt or a plea of
nolo contendere.
(f) Temporary license.-- Beginning on the effective date of
this subsection, the board shall issue a temporary graduate
behavior specialist license, valid for one year only, to an
applicant who meets all of the qualifications for licensure
under subsection (d) except for the experience and training
requirements of subsection (d)(3), (4) and (5). The following
apply:
(1) A temporary graduate behavior specialist license
shall allow the licensee to practice as a behavior specialist
only while under the supervision of a licensed physician,
licensed physician assistant, licensed psychologist, licensed
clinical social worker, certified registered nurse
practitioner or licensed behavior specialist. The physical
presence of the supervisor is not required provided the
supervisor is readily available for consultation.
(2) An applicant for a temporary graduate behavior
specialist license shall submit an application on a form
provided by the board and remit the required fee.
(3) A temporary graduate behavior specialist license
shall only be valid for up to one year from the date of
issuance.
§ 8110. Participating provider.
20170HB0709PN0759 - 10 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
An insurer shall be required to contract with and to accept
as a participating provider any autism service provider within
its service area and enrolled in the Commonwealth's medical
assistance program who agrees to accept the payment levels,
terms and conditions applicable to the insurer's other
participating providers for the service.
§ 8111. Review of treatment plan.
An insurer may review a treatment plan for treatment of
autism spectrum disorders once every six months, subject to its
utilization review requirements, including case management,
concurrent review and other managed care provisions. A more or
less frequent review can be agreed upon by the insurer and the
licensed physician or licensed psychologist developing the
treatment plan.
§ 8112. Validity of assessment.
For purposes of this chapter, the results of a diagnostic
assessment of autism spectrum disorder shall be valid for a
period of not less than 12 months unless a licensed physician or
licensed psychologist determines an earlier assessment is
necessary.
§ 8113. Review and appeal process.
(a) Review process.--Upon denial or partial denial by an
insurer of a claim for diagnostic assessment of autism spectrum
disorders or a claim for treatment of autism spectrum disorders,
a covered individual or an authorized representative shall be
entitled to an expedited internal review process pursuant to the
procedures set forth in Article XXI of the act of May 17, 1921
(P.L.682, No.284), known as The Insurance Company Law of 1921,
followed by an expedited independent external review process
established and administered by the department.
20170HB0709PN0759 - 11 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
(b) Appeal.--An insurer or covered individual or an
authorized representative may appeal to a court of competent
jurisdiction an order of an expedited independent external
review disapproving a denial or partial denial. Pending a ruling
of such court, the insurer shall pay for those services, if any,
that have been authorized or ordered until the ruling.
(c) Rules and regulations.--The Insurance Commissioner may
promulgate rules and regulations as may be necessary or
appropriate to implement and administer this section.
§ 8114. Autism service provider.
For purposes of this chapter, the term "autism service
provider" shall include any behavior specialist in this
Commonwealth providing treatment of autism spectrum disorders
pursuant to a treatment plan until one year from the time that
regulations under section 8109 (relating to licensure or
certification of behavior specialists) are promulgated or until
three years from the effective date of this chapter, whichever
is later.
Section 2. Repeals are as follows:
(1) The General Assembly declares that the repeal under
paragraph (2) is necessary to effectuate the addition of 40
Pa.C.S. Ch. 81.
(2) Section 635.2 of the act of May 17, 1921 (P.L.682,
No.284), known as The Insurance Company Law of 1921, is
repealed.
(3) All other acts or parts of acts are repealed insofar
as they are inconsistent with this act.
Section 3. The addition of 40 Pa.C.S. Ch. 81 is a
continuation of section 635.2 of the act of May 17, 1921
(P.L.682, No.284), known as The Insurance Company Law of 1921.
20170HB0709PN0759 - 12 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
The following apply:
(1) Except as otherwise provided in 40 Pa.C.S. Ch. 81,
all activities initiated under section 635.2 of The Insurance
Company Law of 1921 shall continue and remain in full force
and effect and may be completed under 40 Pa.C.S. Ch. 81.
Orders, regulations, rules and decisions which were made
under section 635.2 of The Insurance Company Law of 1921 and
which are in effect on the effective date of 40 Pa.C.S. Ch.
81 shall remain in full force and effect until revoked,
vacated or modified under 40 Pa.C.S. Ch. 81. Contracts,
obligations and collective bargaining agreements entered into
under section 635.2 of The Insurance Company Law of 1921 are
not affected nor impaired by the repeal of section 635.2 of
The Insurance Company Law of 1921.
(2) Except as otherwise provided in 40 Pa.C.S. Ch. 81,
any difference in language between 40 Pa.C.S. Ch. 81 and
section 635.2 of The Insurance Company Law of 1921 is
intended only to conform to the style of the Pennsylvania
Consolidated Statutes and is not intended to change or affect
the legislative intent, judicial construction or
administration and implementation of section 635.2 of The
Insurance Company Law of 1921.
Section 4. This act shall take effect immediately.
20170HB0709PN0759 - 13 -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23