Section 27-54A-2

Treatment under certain policies and contracts.

(a) As used in this section, the following words have the following meanings:

(1) APPLIED BEHAVIOR ANALYSIS. The design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.

(2) AUTISM SPECTRUM DISORDER. Any of the pervasive developmental disorders or autism spectrum disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the edition that was in effect at the time of diagnosis.

(3) BEHAVIORAL HEALTH TREATMENT. Counseling and treatment programs, including applied behavior analysis that are both of the following:

a. Necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.

b. Provided or supervised, either in person or by telemedicine, by a Board Certified Behavior Analyst, licensed in the State of Alabama, or a psychologist, licensed in the State of Alabama, so long as the services performed are commensurate with the psychologist's formal university training and supervised experience.

c. Behavioral health treatment does not include psychological testing, neuropsychology, psychotherapy, intellectual assessment, cognitive therapy, sex therapy, psychoanalysis, hypotherapy, and long-term counseling as treatment modalities.

(4) DIAGNOSIS OF AUTISM SPECTRUM DISORDER. Medically necessary assessment, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

(5) HEALTH BENEFIT PLAN. Any group insurance plan, policy, or contract for health care services that covers hospital, medical, or surgical expenses, health maintenance organizations, preferred provider organizations, medical service organizations, physician-hospital organizations, or any other person, firm, corporation, joint venture, or other similar business entity that pays for, purchases, or furnishes group health care services to patients, insureds, or beneficiaries in this state. For the purposes of this section, a health benefit plan located or domiciled outside of the State of Alabama is deemed to be subject to this section if the plan, policy, or contract is issued or delivered in the State of Alabama. The term includes, but is not limited to, entities created pursuant to Article 6, Chapter 20, Title 10A. On and after December 31, 2018, the term includes health insurance plans administered or offered by the State Employees Insurance Board and the Public Education Employees Health Insurance Plan. The term does not include the Alabama Health Insurance Plan or the Alabama Small Employer Allocation Program provided in Chapter 52 of this title. The term also includes the terms health insurance policy and health insurance plan. The term does not include non-grandfathered plans in the individual and small group markets that were required to provide essential health benefits under the Patient Protection and Affordable Care Act as of January 1, 2017, or accident-only, specified disease, individual hospital indemnity, credit, dental-only, Medicare-supplement, long-term care, or disability income insurance, other limited benefit health insurance policies, coverage issued as a supplemental to liability insurance, workers' compensation or similar insurance, or automobile medical-payment insurance.

(6) PHARMACY CARE. Medications prescribed by a licensed physician and any health related services deemed medically necessary to determine the need or effectiveness of the medications.

(7) PSYCHIATRIC CARE. Direct or consultative services provided by a psychiatrist licensed in the State of Alabama.

(8) PSYCHOLOGICAL CARE. Direct or consultative services provided by a psychologist licensed in the State of Alabama.

(9) THERAPEUTIC CARE. Services provided by licensed and certified speech therapists, occupational therapists, or physical therapists.

(10) TREATMENT FOR AUTISM SPECTRUM DISORDER. Evidence-based care prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary, including, but not limited to, all of the following:

a. Behavioral health treatment.

b. Pharmacy care.

c. Psychiatric care.

d. Psychological care.

e. Therapeutic care.

(b)(1) A health benefit plan shall cover the screening, diagnosis, and treatment of Autism Spectrum Disorder for an insured 18 years of age or under in policies and contracts issued or delivered in the State of Alabama to employers with at least 51 employees for at least 50 percent of its working days during the preceding calendar year. Coverage provided under this section is limited to treatment that is prescribed by the insured's treating licensed physician or licensed psychologist in accordance with a treatment plan.

(2) To the extent that the screening, diagnosis, and treatment of autism spectrum disorder are not already covered by a health insurance policy, a health benefit plan shall include coverage under this section in policies and contracts that are delivered, executed, issued, amended, adjusted, or renewed in the State of Alabama on or after October 1, 2017.

(3) A health benefit plan may not deny or refuse to issue coverage on, refuse to contract with, or refuse to renew or refuse to reissue or otherwise terminate or restrict coverage on an individual solely because the individual is diagnosed with Autism Spectrum Disorder.

(c)(1) Except as provided in subsection (g), the coverage required pursuant to 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 substantially all medical and surgical benefits under the health insurance plan.

(2) The coverage required pursuant to subsection (b) may be subject to other general exclusions and limitations of the health benefit plan, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, utilization review of health care services including review of medical necessity, case management, and other managed care provisions.

(d) Coverage under this section shall not be subject to any limits on the number of visits an individual may make for treatment of autism spectrum disorder.

(e) This section may not be construed as limiting benefits that are otherwise available to an individual under a health insurance policy.

(f) Coverage for applied behavior analysis shall include the services of the personnel who work under the supervision of the board certified behavior analyst or the licensed psychologist overseeing the program.

(g)(1) Except as provided in subdivision (2), coverage provided under this section for applied behavior analysis shall be subject to a maximum benefit as follows:

a. Forty thousand dollars ($40,000) per year for an insured individual between zero and nine years of age.

b. Thirty thousand dollars ($30,000) per year for an insured individual between 10 and 13 years of age.

c. Twenty thousand dollars ($20,000) per year for an insured individual between 14 and 18 years of age.

(2) The maximum benefit limit may be exceeded, upon prior approval by the insurer administering a health benefit plan, if the provision of applied behavior analysis services beyond the maximum limit is medically necessary for the insured individual. Payments made by a health benefit plan on behalf of an individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition unrelated to the individual's autism spectrum disorder, shall not be applied toward any maximum benefit established under this subsection. Any coverage required under this section, other than the coverage for applied behavior analysis, shall not be subject to the dollar limitations described in this subsection.

(h) This section may not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.

(i) The treatment plan required pursuant to subsection (b) shall include all elements necessary for the health insurance plan to appropriately pay claims. These elements include, but are not limited to, a diagnosis, proposed treatment by type, frequency, and duration of treatment, the anticipated outcomes stated as goals, the frequency by which the treatment plan will be updated, and the treating licensed physician's or licensed psychologist's signature. The health insurance plan may request an updated treatment plan only once every six months from the treating licensed physician or licensed psychologist to review medical necessity, unless the health insurance plan and the treating licensed physician or licensed psychologist agree that a more frequent review is necessary for a particular patient. Any agreement regarding the right to review a treatment plan more frequently applies only to a particular insured being treated for an autism spectrum disorder and does not apply to all individuals being treated for autism spectrum disorder by a physician or psychologist. The cost of obtaining any review or treatment plan shall be borne by the insurer.

(Act 2012-298, p. 647, §2; Act 2017-337, §1.)