GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 2009

H                                                                                                                                                   5

HOUSE BILL 589*

Committee Substitute Favorable 5/26/09

Committee Substitute #2 Favorable 6/3/09
Fourth Edition Engrossed 7/22/09

Senate Appropriations/Base Budget Committee Substitute Adopted 8/5/09

 

Short Title:        Ins.&St. Hlth Plan Cover/Hearing Aids/Autism.

(Public)

Sponsors:

 

Referred to:

 

March 16, 2009

A BILL TO BE ENTITLED

AN ACT TO REQUIRE HEALTH BENEFIT PLANS AND THE STATE HEALTH PLAN TO COVER HEARING AIDS AND REPLACEMENT HEARING AIDS; and to require the state health plan for teachers and state employees to provide coverage for autism treatment disorders.

The General Assembly of North Carolina enacts:

SECTION 1.  Article 3 of Chapter 58 of the General Statutes is amended by adding the following new section to read:

"§ 58-3-285.  Coverage for hearing aids.

(a)        Every health benefit plan, including the State Health Plan for Teachers and State Employees, shall provide coverage for one hearing aid per hearing-impaired ear up to two thousand five hundred dollars ($2,500) per hearing aid every 36 months for covered individuals under the age of 22 years subject to subsection (b) of this section. The coverage shall include all medically necessary hearing aids and services that are ordered by a physician or an audiologist licensed in this State. Coverage shall be as follows:

(1)        Initial hearing aids and replacement hearing aids not more frequently than every 36 months.

(2)        A new hearing aid when alterations to the existing hearing aid cannot adequately meet the needs of the covered individual.

(3)        Services, including the initial hearing aid evaluation, fitting, and adjustments, and supplies, including ear molds.

(b)        The same deductibles, coinsurance, and other limitations as apply to similar services covered under the health benefit plan apply to hearing aids and related services and supplies required to be covered under this section.

(c)        Nothing in this section prevents an insurer from applying utilization review criteria to determine medical necessity as defined by G.S. 58-50-61 as long as it does so in accordance with all requirements for utilization review programs and medical necessity determinations specified in that section, including the offering of an insurer appeal process and where applicable, health benefit plans external review as provided in Part 4 of Article 50 of Chapter 58 of the General Statutes."

SECTION 2.  G.S. 135-45.8(13), as amended by Section 2(d) of Session Law 2009-16, reads as rewritten:

"§ 135-45.8.  General limitations and exclusions.

The following shall in no event be considered covered expenses nor will benefits described in G.S. 135-45.6 through G.S. 135-45.11 be payable for:

…

(13)      Charges for routine eye examinations, eyeglasses or other corrective lenses (except for cataract lenses certified as medically necessary for aphakia persons) andand, except as authorized under G.S. 58-3-280, hearing aids or examinations for the prescription or fitting thereof.

.…"

SECTION 3.(a)  Part 3 of Article 3A of Chapter 135 of the General Statutes is amended by adding the following new section to read:

"§ 135-45.8A.  Coverage for autism spectrum disorders.

(a)        Benefits for the diagnosis and treatment of autism spectrum disorders for individuals is covered by the Plan and, except as otherwise provided in this section, shall be subject to the same deductibles and coinsurance factors as are benefits for physical illness generally.

(b)        Coverage under this section shall not be subject to any limits on the number of visits an individual may make to an autism services provider.

(c)        Coverage for behavioral therapy under this section is subject to a maximum benefit of seventy-five thousand dollars ($75,000) per year. After December 31, 2009, the Executive Administrator shall, on an annual basis, adjust the maximum benefit for inflation by using the Medical Care Component of the United States Department of Labor Consumer Price Index for all urban consumers (CPI-U). The Executive Administrator shall submit the adjusted maximum benefit for publication no later than June of each calendar year; and the published adjusted maximum benefit shall be applicable in the following Plan year. Payments made by the Plan on behalf of a covered individual for any care, treatment, intervention, service, or item unrelated to autism spectrum disorders shall not be applied towards any maximum benefit established under this section.

(d)        Except for inpatient services, if a Plan member is receiving treatment for autism spectrum disorders, the Plan may request a review of that treatment not more than once every 12 months unless the Plan member's licensed medical doctor or licensed psychologist agrees that a more frequent review is necessary. The cost of obtaining any review shall be borne by the Plan."

SECTION 3.(b)  G.S. 135-45.1 is amended by adding the following new subdivisions in alphabetical order to read with subdivision designations to be assigned by the Revisor of Statutes:

(*)        "Autism spectrum disorders." - Any of the pervasive developmental disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or subsequent edition published by the American Psychiatric Association, or the International Statistical Classification of Diseases and Related Health Problems (ICD-10), or subsequent edition published by the World Health Organization.

(*)        "Behavioral therapy." - Interactive therapies derived from evidence-based research, including, but not limited to, applied behavior analysis. 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, but not limited to, the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

(*)        "Habilitative or rehabilitative care." - Professional, counseling, and guidance services and treatment programs, including behavioral therapy, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.

(*)        "Pharmacy care." - Medications prescribed by a licensed medical doctor and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

(*)        "Therapeutic care." - Services provided by licensed or certified speech therapists, occupational therapists, or physical therapists.

(*)        "Treatment for autism spectrum disorders." - Includes the following care  prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed medical doctor or a licensed psychologist who determines the care to be medically necessary:

a.         Habilitative or rehabilitative care.

b.         Pharmacy care.

c.         Psychiatric care.

d.         Psychological care.

e.         Therapeutic care."

SECTION 4.  Section 3 of this act becomes effective January 1, 2010. The remainder of this act becomes effective March 1, 2010, and applies to health benefit plans that are delivered, issued for delivery, or renewed on and after that date.