AUTHOR'S / SPONSOR'S STATEMENT OF INTENT
Section 1355.015(a), Insurance Code, currently requires that a health benefit plan, at a minimum, provide coverage as provided by this section to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis until the enrollee completes nine years of age.
Autism is a medical illness that does not necessarily go away by the time a child is 10 years of age. Therefore, the purpose of this bill is to remove the age restriction within the Insurance Code to ensure continued coverage while the autism diagnosis is in place.
S.B. 1484 amends current law relating to health benefit plan coverage for enrollees diagnosed with autism spectrum disorder.
RULEMAKING AUTHORITY
This bill does not expressly grant any additional rulemaking authority to a state officer, institution, or agency.
SECTION BY SECTION ANALYSIS
SECTION 1. Amends Section 1355.015, Insurance Code, by amending Subsection (a) and adding Subsections (c-1) and (f), as follows:
(a) Requires that a health benefit plan, at a minimum, provide coverage as provided by this section (Required Coverage For Certain Children) to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis, only if the diagnosis was in place prior to the child's 10th birthday. Deletes existing text requiring that a health benefit plan, at a minimum, provide coverage as provided by this section to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis until the enrollee completes nine years of age. Deletes existing text providing that, if an enrollee who is being treated for autism spectrum disorder becomes 10 years of age or older and continues to need treatment, this subsection does not preclude coverage of treatment and services described by Subsection (b) (relating to requiring that the health benefit plan provide coverage under this section to the enrollee for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee's primary care physician in the treatment plan recommended by that physician).
(c-1) Provides that the health benefit plan is not required to provide coverage under Subsection (b) (relating to requiring that the health benefit plan provide coverage under this section to the enrollee for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee's primary care physician in the treatment plan recommended by that physician) for benefits for an enrollee 10 years of age or older for applied behavior analysis in an amount that exceeds $36,000 per year.
(f) Provides that, to the extent that this section would otherwise require this state to make a payment under 42 U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 C.F.R. Section 155.20, is not required to provide a benefit under this section that exceeds the specified essential health benefits required under 42 U.S.C. Section 18022(b).
SECTION 2. Amends the heading to Section 1355.015, Insurance Code, to read as follows:
Sec. 1355.015. REQUIRED COVERAGE FOR CERTAIN ENROLLEES.
SECTION 3. Provides that Section 1355.015, Insurance Code, as amended by this Act, applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after the effective date of this Act. Provides that a health benefit plan that is delivered, issued for delivery, or renewed before the effective date of this Act is covered by the law in effect at the time the health benefit plan is delivered, issued for delivery, or renewed, and that law is continued in effect for that purpose.
SECTION 4. Effective date: September 1, 2013.