Committee Substitute for HB0751GUS

HOUSE HEALTH AND GOVERNMENT AFFAIRS COMMITTEE SUBSTITUTE FOR

HOUSE BILL 751

49th legislature - STATE OF NEW MEXICO - first session, 2009

AN ACT

RELATING TO HEALTH INSURANCE; REQUIRING COVERAGE FOR DIAGNOSIS OF AND TREATMENT FOR BEHAVIORAL HEALTH CONDITION, DEVELOPMENTAL DISABILITY OR AUTISM SPECTRUM DISORDER.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

Section 1. A new section of the Health Care Purchasing Act is enacted to read:

"[NEW MATERIAL] COVERAGE FOR DEVELOPMENTAL DISABILITY AND AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.--

A. Any group health care coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act on or after the open enrollment period for the 2010 plan year shall provide coverage to employees and their covered dependents who are under nineteen years of age for:

(1) well-baby and well-child screening for diagnosing the presence of developmental disability or autism spectrum disorder; and

(2) treatment of developmental disability or autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.

B. Coverage required pursuant to Subsection A of this section:

(1) shall be limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan;

(2) shall be limited to fifty thousand dollars ($50,000) annually. Beginning January 1, 2011, the maximum benefit shall be adjusted annually on January 1 to reflect any change from the previous year in the medical component of the then-current consumer price index for all urban consumers published by the bureau of labor statistics of the United States department of labor;

(3) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;

(4) may be subject to other general exclusions and limitations of the group health care coverage, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and utilization review of health care services, including the review of medical necessity, case management and other managed care provisions; and

(5) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Act of 2004 and related state laws that place responsibility on state and local school boards for providing specialized education and related services to children three to twenty-two years of age who have developmental disabilities or autism spectrum disorder.

C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits, deductibles or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the group health care coverage plan, except as otherwise provided in Subsection B of this section.

D. An insurer shall not deny or refuse to issue coverage for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict coverage for an individual because the individual is diagnosed as having or receiving treatment for a developmental disability or an autism spectrum disorder.

E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the group health care coverage plan to pay claims appropriately. These elements include:

(1) the diagnosis;

(2) the proposed treatment by types;

(3) the frequency and duration of treatment;

(4) the anticipated outcomes stated as goals;

(5) the frequency with which the treatment plan will be updated; and

(6) the signature of the treating physician.

F. This section shall not be construed as limiting benefits and coverage otherwise available to an insured under a group health care coverage plan.

G. The provisions of this section shall not apply to individual policies intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident only, hospital indemnity or other limited-benefit health insurance policies.

H. As used in this section:

(1) "autism spectrum disorder" means a condition that meets the diagnostic criteria for the pervasive developmental disorders published in the diagnostic and statistical manual of mental disorders, fourth edition, text revision, also known as DSM-IV-TR, published by the American psychiatric association, including autistic disorder; Asperger disorder; pervasive development disorder not otherwise specified, including atypical autism; Rett's disorder; and childhood disintegrative disorder;

(2) "developmental disability" means either a risk, as defined by the department of health, or diagnosis of developmental delay for a child up to two years of age; or a severe chronic disability of a person that:

(a) is attributable to a mental or physical impairment, including the result from trauma to the brain, or combination of mental and physical impairments;

(b) is manifested before the person reaches the age of twenty-two years;

(d) results in substantial functional limitations in three or more of the following areas of major life activity: 1) self-care; 2) receptive and expressive language; 3) learning; 4) mobility; 5) self-direction; 6) capacity for independent living; and 7) economic self-sufficiency; and

(e) reflects the person's need for a combination and sequence of special, interdisciplinary or generic care treatment or other support and services that are of lifelong or extended duration and are individually planned and coordinated; and

(3) "services that are habilitative or rehabilitative" means treatment programs that are necessary to develop, maintain and restore to the maximum extent practicable the functioning of the individual."

Section 2. A new section of the Health Care Purchasing Act is enacted to read:

"[NEW MATERIAL] COVERAGE FOR BEHAVIORAL HEALTH CONDITION DIAGNOSIS AND TREATMENT.--

A. Beginning with the open enrollment period for the 2010 plan year, group health care coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act shall provide coverage to employees and their covered dependents for behavioral health condition diagnosis and treatment.

B. Behavioral health coverage offered shall not impose treatment limitations or financial requirements on the provision of behavioral health benefits if identical limitations or requirements are not imposed on coverage of benefits for other conditions. Behavioral health coverage shall not:

(1) require pre-admission screening prior to the authorization of behavioral health benefits, whether inpatient or outpatient; or

(2) apply limitations that restrict mental health benefits provided under the plan to those that are medically necessary.

C. Behavioral health coverage shall include:

(1) inpatient services, including a range of physiological, psychological and other intervention concepts, techniques and processes used in a community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the department of health or in an accredited public hospital to restore psychosocial functioning sufficient to allow maintenance and support of the insured in a less restrictive setting;

(2) outpatient services, including screening, evaluation, consultations, diagnosis and treatment involving use of physiological, psychological and psychosocial evaluative and intervention concepts, techniques and processes provided to individuals and groups; and

(3) licensed mental health professionals, including an accredited public hospital or psychiatric hospital or a community agency certified as a community mental health center by the department of health. These providers shall ensure that services are supervised by an appropriately licensed mental health professional.

D. The provisions of this section shall not apply to individual policies intended to supplement major medical group-type coverages such as medicare supplement, long-term care, disability income, specified disease, accident only, hospital indemnity or other limited-benefit health insurance policies."

Section 3. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] COVERAGE FOR DEVELOPMENTAL DISABILITY AND AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.-- A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state on or after September 17, 2009 shall provide coverage to an eligible individual who is under nineteen years of age for:

(1) well-baby and well-child screening for diagnosing the presence of developmental disability or autism spectrum disorder; and

(2) treatment of developmental disability or autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.

B. Coverage required pursuant to Subsection A of this section:

(1) shall be limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan;

(3) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;

(4) may be subject to other general exclusions and limitations of the insurer's policy or plan, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and utilization review of health care services, including the review of medical necessity, case management and other managed care provisions; and

C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits, deductibles or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the individual or group health insurance policy, health care plan or certificate of health insurance, except as otherwise provided in Subsection B of this section.

E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health insurance plan to pay claims appropriately. These elements include:

(1) the diagnosis;

(2) the proposed treatment by types;

(3) the frequency and duration of treatment;

(4) the anticipated outcomes stated as goals;

(5) the frequency with which the treatment plan will be updated; and

(6) the signature of the treating physician.

F. This section shall not be construed as limiting benefits and coverage otherwise available to an insured under a health insurance plan.

H. As used in this section:

(a) is attributable to a mental or physical impairment, including the result from trauma to the brain, or combination of mental and physical impairments;

(b) is manifested before the person reaches the age of twenty-two years;

Section 4. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:

"[NEW MATERIAL] COVERAGE FOR BEHAVIORAL HEALTH CONDITION DIAGNOSIS AND TREATMENT.--

A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state on or after September 17, 2009 shall provide coverage to employees and their covered dependents for behavioral health condition diagnosis and treatment.

(1) require pre-admission screening prior to the authorization of behavioral health benefits, whether inpatient or outpatient; or

(2) apply limitations that restrict mental health benefits provided under the plan to those that are medically necessary.

C. Behavioral health coverage shall include:

Section 5. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

"[NEW MATERIAL] COVERAGE FOR DEVELOPMENTAL DISABILITY AND AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.--

A. A blanket or group health insurance policy or contract that is delivered, issued for delivery or renewed in this state on or after September 17, 2009 shall provide coverage to an eligible individual who is under nineteen years of age for:

(1) well-baby and well-child screening for diagnosing the presence of developmental disability or autism spectrum disorder; and

(2) treatment of developmental disability or autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.

B. Coverage required pursuant to Subsection A of this section:

(1) shall be limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan;

(3) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;

C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits, deductibles or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the blanket or group health insurance policy or contract, except as otherwise provided in Subsection B of this section.

E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health insurance plan to pay claims appropriately. These elements include:

(1) the diagnosis;

(2) the proposed treatment by types;

(3) the frequency and duration of treatment;

(4) the anticipated outcomes stated as goals;

(5) the frequency with which the treatment plan will be updated; and

(6) the signature of the treating physician.

F. This section shall not be construed as limiting benefits and coverage otherwise available to an insured under a health insurance plan.

H. As used in this section:

(a) is attributable to a mental or physical impairment, including the result from trauma to the brain, or combination of mental and physical impairments;

(b) is manifested before the person reaches the age of twenty-two years;

Section 6. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:

"[NEW MATERIAL] COVERAGE FOR BEHAVIORAL HEALTH CONDITION DIAGNOSIS AND TREATMENT.--

(1) require pre-admission screening prior to the authorization of behavioral health benefits, whether inpatient or outpatient; or

(2) apply limitations that restrict mental health benefits provided under the plan to those that are medically necessary.

C. Behavioral health coverage shall include:

Section 7. A new section of the Health Maintenance Organization Law is enacted to read:

"[NEW MATERIAL] COVERAGE FOR DEVELOPMENTAL DISABILITY AND AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.--

A. An individual or group health maintenance contract that is delivered, issued for delivery or renewed in this state on or after September 17, 2009 shall provide coverage to an eligible individual who is under nineteen years of age for:

(1) well-baby and well-child screening for diagnosing the presence of developmental disability or autism spectrum disorder; and

(2) treatment of developmental disability or autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.

B. Coverage required pursuant to Subsection A of this section:

(1) shall be limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan;

(3) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;

C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits, deductibles or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the individual or group health maintenance contract, except as otherwise provided in Subsection B of this section.

E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health insurance plan to pay claims appropriately. These elements include:

(1) the diagnosis;

(2) the proposed treatment by types;

(3) the frequency and duration of treatment;

(4) the anticipated outcomes stated as goals;

(5) the frequency with which the treatment plan will be updated; and

(6) the signature of the treating physician.

F. This section shall not be construed as limiting benefits and coverage otherwise available to an insured under a health insurance plan.

H. As used in this section:

(a) is attributable to a mental or physical impairment, including the result from trauma to the brain, or combination of mental and physical impairments;

(b) is manifested before the person reaches the age of twenty-two years;

Section 8. A new section of the Health Maintenance Organization Law is enacted to read:

"[NEW MATERIAL] COVERAGE FOR BEHAVIORAL HEALTH CONDITION DIAGNOSIS AND TREATMENT.--

(1) require pre-admission screening prior to the authorization of behavioral health benefits, whether inpatient or outpatient; or

(2) apply limitations that restrict behavioral health benefits provided under the plan to those that are medically necessary.

C. Behavioral health coverage shall include:

Section 9. A new section of the Nonprofit Health Care Plan Law is enacted to read:

"[NEW MATERIAL] COVERAGE FOR DEVELOPMENTAL DISABILITY AND AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.--

A. Beginning with the open enrollment period for the 2010 plan year, group health care coverage, an individual or group health insurance policy, health care plan or certificate of health insurance delivered or issued for delivery in this state shall provide coverage to an eligible individual who is under nineteen years of age for:

(1) well-baby and well-child screening for diagnosing the presence of developmental disability or autism spectrum disorder; and

(2) treatment of developmental disability or autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.

B. Coverage required pursuant to Subsection A of this section:

(1) shall be limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan;

(3) shall not be denied on the basis that the services are habilitative or rehabilitative in nature;

(4) may be subject to other general exclusions and limitations of the insurer's policy, plan or certificate, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and utilization review of health care services, including the review of medical necessity, case management and other managed care provisions; and

C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits, deductibles or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the individual or group health insurance policy, health care plan or certificate of health insurance, except as otherwise provided in Subsection B of this section.

E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health insurance plan to pay claims appropriately. These elements include:

(1) the diagnosis;

(2) the proposed treatment by types;

(3) the frequency and duration of treatment;

(4) the anticipated outcomes stated as goals;

(5) the frequency with which the treatment plan will be updated; and

(6) the signature of the treating physician.

F. This section shall not be construed as limiting benefits and coverage otherwise available to an insured under a health insurance policy, health care plan or certificate of health insurance.

H. As used in this section:

(a) is attributable to a mental or physical impairment, including the result from trauma to the brain, or combination of mental and physical impairments;

(b) is manifested before the person reaches the age of twenty-two years;

Section 10. A new section of the Nonprofit Health Care Plan Law is enacted to read:

"[NEW MATERIAL] COVERAGE FOR BEHAVIORAL HEALTH CONDITION DIAGNOSIS AND TREATMENT.--

A. Beginning with the open enrollment period for the 2010 plan year, group health care coverage or an individual or group health insurance policy, health care plan or certificate of health insurance delivered or issued for delivery in this state shall provide coverage for behavioral health and developmental disability diagnosis and treatment.

(1) require pre-admission screening prior to the authorization of behavioral health benefits, whether inpatient or outpatient; or

(2) apply limitations that restrict mental health benefits provided under the plan to those that are medically necessary.

C. Behavioral health coverage shall include:

(1) inpatient services, including a range of physiological, psychological and other intervention concepts, techniques and processes used in a community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the department of health, or in an accredited public hospital to restore psychosocial functioning sufficient to allow maintenance and support of the insured in a less restrictive setting;

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