Utah Code § 31A-22-642 — Utah Code / Title 31A / Chapter 31A-22 / § 31A-22-642
§ 31A-22-642. Insurance coverage for autism spectrum disorder.
Status: in_force

(1) As used in this section: (a) "Applied behavior analysis" means 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. (b) "Autism spectrum disorder" means pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). (c) "Behavioral health treatment" means counseling and treatment programs, including applied behavior analysis, that are: (i) necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual; and (ii) provided or supervised by a: (A) board certified behavior analyst; or (B) person licensed under Title 58, Chapter 1, Division of Professional Licensing Act, whose scope of practice includes mental health services. (d) "Diagnosis of autism spectrum disorder" means medically necessary assessments, evaluations, or tests: (i) performed by a licensed physician who is board certified in neurology, psychiatry, or pediatrics and has experience diagnosing autism spectrum disorder, or a licensed psychologist with experience diagnosing autism spectrum disorder; and (ii) necessary to diagnose whether an individual has an autism spectrum disorder. (e) "Mental health therapist" means the same as that term is defined in Section 58-60-102. (f) "Pharmacy care" means medications prescribed by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications. (g) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. (h) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. (i) "Therapeutic care" means services provided by licensed or certified speech therapists, occupational therapists, or physical therapists. (j) "Treatment for autism spectrum disorder": (i) means evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a physician or a licensed psychologist described in Subsection (1)(d) who determines the care to be medically necessary; and (ii) includes: (A) behavioral health treatment, provided or supervised by a person described in Subsection (1)(c)(ii); (B) pharmacy care; (C) psychiatric care; (D) psychological care; and (E) therapeutic care. (2) (a) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan offered in the individual market or the large group market and entered into or renewed on or after January 1, 2016, and before January 1, 2020, shall provide coverage for the diagnosis and treatment of autism spectrum disorder: (i) for a child who is at least two years old, but younger than 10 years old; and (ii) in accordance with the requirements of this section and rules made by the commissioner. (b) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan offered in the individual market or the large group market and entered into or renewed on or after January 1, 2020, shall provide coverage for the diagnosis and treatment of autism spectrum disorder in accordance with the requirements of this section and rules made by the commissioner. (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to set the minimum standards of coverage for the treatment of autism spectrum disorder. (4) Subject to Subsection (5), the rules described in Subsection (3) shall establish durational limits, amount limits, deductibles, copayments, and coinsurance for the treatment of autism spectrum disorder that are similar to, or identical to, the coverage provided for other illnesses or diseases. (5) (a) Coverage for behavioral health treatment for a person with an autism spectrum disorder shall cover at least 600 hours a year. (b) Notwithstanding Subsection (5)(a), for a health benefit plan offered in the individual market or the large group market and entered into or renewed on or after January 1, 2020, coverage for behavioral health treatment for a person with an autism spectrum disorder may not have a limit on the number of hours covered. (c) Other terms and conditions in the health benefit plan that apply to other benefits covered by the health benefit plan apply to coverage required by this section. (d) Notwithstanding Section 31A-45-303, a health benefit plan providing treatment under Subsections (5)(a) and (b) shall include in the plan's provider network both board certified behavior analysts and mental health providers qualified under Subsection (1)(c)(ii). (6) (a) A health care provider shall submit a treatment plan for autism spectrum disorder to the insurer within 14 business days of starting treatment for an individual. (b) If an individual is receiving treatment for an autism spectrum disorder, an insurer shall have the right to request a review of that treatment not more than once every three months. (c) A review of treatment under this Subsection (6) may include a review of treatment goals and progress toward the treatment goals. (d) If an insurer makes a determination to stop treatment as a result of the review of the treatment plan under this Subsection (6), the determination of the insurer may be reviewed under Section 31A-22-629. (7) (a) Before July 1, 2027, and before July 1 each year after, a health benefit plan shall report the following to the department for the prior insurance plan year: (i) the average wait time for an enrollee to receive an autism assessment; (ii) if the health benefit plan has prior authorization requirements related to autism assessment or treatment; (iii) the number of enrollees under age 18 that were diagnosed with autism spectrum disorder; (iv) of the number of diagnoses described in Subsection (7)(a)(iii), the number of diagnoses disaggregated based on provider license type that made the diagnosis; (v) of the number of diagnoses described in Subsection (7)(a)(iii), the number of enrollees that received applied behavior analysis treatment; (vi) for enrollees that received applied behavior analysis treatment: (A) the average number of hours of applied behavior analysis treatment received; and (B) the average cost of applied behavior analysis treatment received; and (vii) if the health benefit plan accepts state defrayal payments under Subsection 31A-30-118(2) for coverage described in this section. (b) The department shall compile the information described in Subsection (7)(a) and provide a report to the Health and Human Services Interim Committee on or before September 1. (c) Beginning September 1, 2027, the department shall provide on the department's website, in a form that is easily accessible, information regarding which health benefit plans reimburse a mental health therapist that is not a physician or a psychologist for autism spectrum disorder treatment.