HOUSE BILL 367
53rd legislature - STATE OF NEW MEXICO - first session, 2017
INTRODUCED BY
Elizabeth "Liz" Thomson
AN ACT
RELATING TO HEALTH COVERAGE; AMENDING SECTIONS OF THE HEALTH CARE PURCHASING ACT, THE NEW MEXICO INSURANCE CODE, THE HEALTH MAINTENANCE ORGANIZATION LAW AND THE NONPROFIT HEALTH CARE PLAN LAW TO REMOVE LIMITS ON COVERAGE FOR AUTISM SPECTRUM DISORDER TREATMENT.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. Section 13-7-16 NMSA 1978 (being Laws 2013, Chapter 185, Section 1) is amended to read:
"13-7-16. COVERAGE FOR AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT--PERMISSIBLE LIMITATIONS.--
A. Group health coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act shall provide coverage [for] to an [eligible individual who is nineteen years of age or younger, or an eligible individual who is twenty-two years of age or younger and is enrolled in high school] enrollee for:
(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and
(2) treatment of 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] enrollee's treating physician in accordance with a treatment plan;
(2) shall not be denied on the basis that the services are habilitative or rehabilitative services in nature;
(3) may be subject to other general exclusions of the group health 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
(4) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement 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 autism spectrum disorder.
C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits or age restrictions. The coverage required pursuant to Paragraph (1) of Subsection A of this section shall not be subject to deductibles or coinsurance. The coverage required pursuant to Paragraph (2) of Subsection A of this section shall not be subject to deductibles or coinsurance provisions that are less favorable to [a covered individual] an enrollee than the deductibles or coinsurance provisions that apply to physical illnesses that are generally covered under the group health coverage, except as otherwise provided in Subsection B of this section.
D. A group health plan shall not deny or refuse health coverage for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict health coverage for an individual because the individual is diagnosed as having autism spectrum disorder.
E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the group health coverage to pay claims appropriately. These elements include [but are not limited to]:
(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 group health coverage.
G. The provisions of this section shall not apply to plans or 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] autism spectrum disorder published in any edition of the Diagnostic and Statistical Manual of Mental Disorders, [current edition] published by the American psychiatric association [including autistic disorder; Asperger's disorder; pervasive development disorder not otherwise specified; Rett's disorder; and childhood disintegrative disorder]; and
(2) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain [and] or restore to the maximum extent practicable the functioning of an individual [and
(3) "high school" means a school providing instruction for any of the grades nine through twelve]."
SECTION 2. Section 59A-22-49 NMSA 1978 (being Laws 2009, Chapter 74, Section 1) is amended to read:
"59A-22-49. COVERAGE FOR 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 shall provide coverage to an [eligible individual who is nineteen years of age or younger, or an eligible individual who is twenty-two years of age or younger and is enrolled in high school] insured for:
(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and
(2) treatment of 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 thirty-six thousand dollars ($36,000) annually and shall not exceed two hundred thousand dollars ($200,000) in total lifetime benefits. 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)] (2) shall not be denied on the basis that the services are habilitative or rehabilitative services in nature;
[(4)] (3) may be subject to other general exclusions and limitations of the [insurer's] health insurance policy, [or] health care plan or certificate of health insurance, including [but not limited to] 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)] (4) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement 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 autism spectrum disorder.
C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits or age restrictions. The coverage required pursuant to Paragraph (1) of Subsection A of this section shall not be subject to [dollar limits] deductibles or coinsurance. The coverage required pursuant to Paragraph (2) of Subsection A of this section shall not be subject to 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.
D. An insurer shall not deny or refuse to issue health insurance coverage for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict health insurance coverage for an individual because the individual is diagnosed as having autism spectrum disorder.
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 [but are not limited to]:
(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.
G. The provisions of this section shall not apply to 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] autism spectrum disorder published in any edition of 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's disorder; pervasive development disorder not otherwise specified; Rett's disorder; and childhood disintegrative disorder]; and
(2) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain [and] or restore to the maximum extent practicable the functioning of an individual [and
(3) "high school" means a school providing instruction for any of the grades nine through twelve]."
SECTION 3. Section 59A-23-7.9 NMSA 1978 (being Laws 2009, Chapter 74, Section 2) is amended to read:
"59A-23-7.9. COVERAGE FOR AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.--
A. A blanket or group health insurance policy, health care plan or [contract] certificate of health insurance that is delivered, issued for delivery or renewed in this state shall provide coverage to an [eligible individual who is nineteen years of age or younger, or an eligible individual who is twenty-two years of age or younger and is enrolled in high school] insured for:
(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and
(2) treatment of 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 thirty-six thousand dollars ($36,000) annually and shall not exceed two hundred thousand dollars ($200,000) in total lifetime benefits. 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)] (2) shall not be denied on the basis that the services are habilitative or rehabilitative services in nature;
[(4)] (3) may be subject to other general exclusions and limitations of the [insurer's] health insurance policy, [or] health care plan or certificate of health insurance, including [but not limited to] 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)] (4) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement 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 autism spectrum disorder.
C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits or age restrictions. The coverage required pursuant to Paragraph (1) of Subsection A of this section shall not be subject to [dollar limits] deductibles or coinsurance. The coverage required pursuant to Paragraph (2) of Subsection A of this section shall not be subject to 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.
D. An insurer shall not deny or refuse to issue health insurance coverage for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict health insurance coverage for an individual because the individual is diagnosed as having autism spectrum disorder.
E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the [health insurance plan] insurer to pay claims appropriately. These elements include [but are not limited to]:
(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.
G. The provisions of this section shall not apply to 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] autism spectrum disorder published in any edition of 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's disorder; pervasive development disorder not otherwise specified; Rett's disorder; and childhood disintegrative disorder]; and
(2) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain [and] or restore to the maximum extent practicable the functioning of an individual [and
(3) "high school" means a school providing instruction for any of the grades nine through twelve]."
SECTION 4. Section 59A-46-50 NMSA 1978 (being Laws 2009, Chapter 74, Section 3) is amended to read:
"59A-46-50. COVERAGE FOR 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 shall provide coverage to an [eligible individual who is nineteen years of age or younger, or an eligible individual who is twenty-two years of age or younger and is enrolled in high school] enrollee for:
(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and
(2) treatment of 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] enrollee's treating physician in accordance with a treatment plan;
[(2) shall be limited to thirty-six thousand dollars ($36,000) annually and shall not exceed two hundred thousand dollars ($200,000) in total lifetime benefits. 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)] (2) shall not be denied on the basis that the services are habilitative or rehabilitative services in nature;
[(4)] (3) may be subject to other general exclusions and limitations of the [insurer's policy or plan] health maintenance organization contract, including [but not limited to] 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)] (4) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement 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 autism spectrum disorder.
C. The coverage required pursuant to Paragraph (1) of Subsection A of this section shall not be subject to [dollar limits] deductibles or coinsurance. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits or age restrictions. The coverage required pursuant to Paragraph (2) of Subsection A of this section shall not be subject to deductibles or coinsurance provisions that are less favorable to an [insured] enrollee 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.
D. [An insurer] A carrier shall not deny or refuse to issue [health insurance] coverage pursuant to a health maintenance organization contract for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict health [insurance] maintenance organization coverage for an individual because the individual is diagnosed as having autism spectrum disorder.
E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the [health insurance plan] carrier to pay claims appropriately. These elements include [but are not limited to]:
(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] enrollee under a health [insurance plan] maintenance organization contract.
G. The provisions of this section shall not apply to plans or 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] autism spectrum disorder published in any edition of 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's disorder; pervasive development disorder not otherwise specified; Rett's disorder; and childhood disintegrative disorder]; and
(2) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain [and] or restore to the maximum extent practicable the functioning of an individual [and
(3) "high school" means a school providing instruction for any of the grades nine through twelve]."
SECTION 5. Section 59A-47-45 NMSA 1978 (being Laws 2009, Chapter 74, Section 4) is amended to read:
"59A-47-45. COVERAGE FOR AUTISM SPECTRUM DISORDER DIAGNOSIS AND TREATMENT.--
A. 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 twenty-two years of age or younger and is enrolled in high school] a subscriber for:
(1) well-baby and well-child screening for diagnosing the presence of autism spectrum disorder; and
(2) treatment of 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] subscriber's treating physician in accordance with a treatment plan;
[(2) shall be limited to thirty-six thousand dollars ($36,000) annually and shall not exceed two hundred thousand dollars ($200,000) in total lifetime benefits. 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)] (2) shall not be denied on the basis that the services are habilitative or rehabilitative services in nature;
[(4)] (3) may be subject to other general exclusions and limitations of the [insurer's] subscriber's policy or plan, including [but not limited to] 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)] (4) may be limited to exclude coverage for services received under the federal Individuals with Disabilities Education Improvement 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 autism spectrum disorder.
C. The coverage required pursuant to Subsection A of this section shall not be subject to dollar limits or age restrictions. The coverage required pursuant to Paragraph (1) of Subsection A of this section shall not be subject to [dollar limits] deductibles or coinsurance. The coverage required pursuant to Paragraph (2) of Subsection A of this section shall not be subject to deductibles or coinsurance provisions that are less favorable to [an insured] a subscriber 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] care plan, except as otherwise provided in Subsection B of this section.
D. [An insurer] A health care plan shall not deny or refuse to issue health [insurance] care plan coverage for medically necessary services or refuse to contract with, renew, reissue or otherwise terminate or restrict health [insurance] care plan coverage for an individual because the individual is diagnosed as having autism spectrum disorder.
E. The treatment plan required pursuant to Subsection B of this section shall include all elements necessary for the health [insurance] care plan to pay claims appropriately. These elements include [but are not limited to]:
(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] care plan.
G. The provisions of this section shall not apply to plans or 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] autism spectrum disorder published in any edition of 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's disorder; pervasive development disorder not otherwise specified; Rett's disorder; and childhood disintegrative disorder]; and
(2) "habilitative or rehabilitative services" means treatment programs that are necessary to develop, maintain [and] or restore to the maximum extent practicable the functioning of an individual [and
(3) "high school" means a school providing instruction for any of the grades nine through twelve]."
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