GENERAL ASSEMBLY OF NORTH CAROLINA
SENATE BILL 115
Short Title: Coverage for Treatment of Autism Disorders.
Senators Purcell, Garrou, Mansfield; and Atwater.
February 24, 2011
A BILL TO BE ENTITLED
AN ACT to REQUIRE HEALTH BENEFIT PLANS, inCLUDING THE STATE HEALTH PLAN FOR TEACHERS AND STATE EMPLOYEES, TO PROVIDE COVERAGE FOR TREATMENT OF AUTISM SPECTRUM DISORDERS.
The General Assembly of North Carolina enacts:
SECTION 1. 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) Definitions. - As used in this section:
(1) Autism services provider. - Any person, entity, or group that provides treatment of autism spectrum disorders.
(2) 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.
(3) Behavioral care. - Any practices for the purpose of any or all of the following:
a. Increasing appropriate or adaptive behaviors.
b. Decreasing maladaptive behaviors.
c. Developing, maintaining, or restoring, to the maximum extent practicable, the functioning of an individual, including the systematic management of environmental factors or the consequences of behaviors.
(4) Diagnosis of autism spectrum disorder. - Any medically necessary assessment, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.
(5) Health plan. - As defined in G.S. 58-3-167. For purposes of this section, "health benefit plan" includes the State Health Plan for Teachers and State Employees.
(6) Licensed or certified. - Licensed or certified by the State of North Carolina for services provided in North Carolina or by the state in which the care is provided.
(7) Medically necessary. - Any care, treatment, intervention, service, or item that does, or is reasonably expected to do any of the following:
a. Prevent the onset or worsening of an illness, condition, injury, or disability.
b. Reduce or ameliorate the physical, mental, behavioral, or developmental effects of an illness, condition, injury, or disability.
c. Assist to achieve or maintain functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacities that are appropriate for individuals the same age.
(8) Pharmacy care. - Medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need for or effectiveness of the medications.
(9) Psychiatric care. - Direct or consultative services provided by a licensed psychiatrist.
(10) Psychological care. - Direct or consultative services provided by a licensed psychologist or licensed psychological associate.
(11) Therapeutic care. - Services provided by a licensed or certified speech therapist, occupational therapist, or physical therapist.
(12) Treatment for autism spectrum disorders. - Any of the following care prescribed or ordered by a licensed physician or a licensed psychologist for an individual diagnosed with an autism spectrum disorder:
a. Behavioral care, when provided or supervised by a licensed or certified health care professional as defined in G.S. 58-3-192(6) within the scope of practice as defined by law.
b. Pharmacy care.
c. Psychiatric care.
d. Psychological care.
e. Therapeutic care.
(b) Every health benefit plan, including the State Health Plan for Teachers and State Employees, shall provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals. No insurer shall terminate coverage or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with one of the autism spectrum disorders or has received treatment for autism spectrum disorders.
(c) 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.
(d) Coverage under this section shall not be denied on the basis that the treatments are habilitative or educational in nature.
(e) 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 other medical services covered by the health benefit plan.
(f) This section shall not be construed as limiting benefits that are otherwise available to an individual under a health benefit plan.
(g) Coverage for behavioral therapy under this section will be subject to a maximum benefit of seventy-five thousand dollars ($75,000) per year. Payments made by an insurer on behalf of a covered individual for any care, treatment, intervention, service, or item unrelated to autism spectrum disorders shall not be applied toward any maximum benefit established under this section.
(h) Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, a health benefit plan shall have the right to request a review of that treatment not more than once every 12 months unless the insurer and the individual's licensed medical doctor or licensed psychologist agree that a more frequent review is necessary. The cost of obtaining any review shall be borne by the insurer."
SECTION 2. G.S. 135-45 reads as rewritten:
"§ 135-45. Undertaking.
(a) The State of North Carolina undertakes to make available a State Health Plan (hereinafter called the "Plan") exclusively for the benefit of eligible employees, eligible retired employees, and certain of their eligible dependents, which will pay benefits in accordance with the terms of this Article. The Plan shall have all the powers and privileges of a corporation and shall be known as the State Health Plan for Teachers and State Employees. The Executive Administrator and Board of Trustees shall carry out their duties and responsibilities as fiduciaries for the Plan. The Plan shall administer one or more group health plans that are comprehensive in coverage and shall provide eligible employees and retired employees coverage on a noncontributory basis under at least one of the group plans with benefits equal to that specified in subsection (g) of this section. The Executive Administrator and Board of Trustees may operate group plans as a preferred provider option, or health maintenance, point-of-service, or other organizational arrangement and may offer the plans to employees and retirees on a noncontributory or partially contributory basis. Plans offered on a partially contributory basis must provide benefits that are additional to that specified in subsection (g) of this section and may not be offered unless approved in an act of the General Assembly.
(g) The Executive
Administrator and Board of Trustees shall not change the Plan's comprehensive
health benefit coverage, co-payments, deductibles, out-of-pocket expenditures,
and lifetime maximums in effect on
July 1, 2009,January 1, 2012,
that would result in a net increased cost to the Plan or in a reduction in
benefits to Plan members unless and until the proposed changes are directed to
be made in an act of the General Assembly.
(h) The Plan shall provide coverage under its Basic and Standard PPO options for the diagnosis and treatment of lymphedema. The coverage shall be the equivalent of coverage under G.S. 58-3-280.
(i) The Plan shall provide coverage under its Basic and Standard PPO options for the diagnosis and treatment of autism spectrum disorder. The coverage shall be the equivalent of coverage under G.S. 58-3-192."
SECTION 3. This act becomes effective January 1, 2012, and applies to all health benefit plans that are delivered, issued for delivery, or renewed within this State, or outside this State if insuring North Carolina residents, on and after that date.