2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31098 - Coverage for individuals with developmental disabilities.

641.31098 Coverage for individuals with developmental disabilities.—
(1) This section and s. 627.6686 may be cited as the “Steven A. Geller Autism Coverage Act.”
(2) As used in this section, the term:
(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, but not limited to, the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
(b) “Autism spectrum disorder” means any of the following disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association:
1. Autistic disorder.
2. Asperger’s syndrome.
3. Pervasive developmental disorder not otherwise specified.
(c) “Eligible individual” means an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developmental disability at 8 years of age or younger.
(d) “Health maintenance contract” means a group health maintenance contract offered by a health maintenance organization. This term does not include a health maintenance contract offered in the individual market, a health maintenance contract that is individually underwritten, or a health maintenance contract provided to a small employer.
(3) A health maintenance contract issued or renewed on or after April 1, 2009, shall provide coverage to an eligible individual for:
(a) Well-baby and well-child screening for diagnosing the presence of autism spectrum disorder.
(b) Treatment of autism spectrum disorder and Down syndrome, through speech therapy, occupational therapy, physical therapy, and applied behavior analysis services. Applied behavior analysis services shall be provided by an individual certified pursuant to s. 393.17 or an individual licensed under chapter 490 or chapter 491.
(4) The coverage required pursuant to subsection (3) is subject to the following requirements:
(a) Coverage shall be limited to treatment that is prescribed by the subscriber’s treating physician in accordance with a treatment plan.
(b) Coverage for the services described in subsection (3) shall be limited to $36,000 annually and may not exceed $200,000 in total benefits.
(c) Coverage may not be denied on the basis that provided services are habilitative in nature.
(d) Coverage may be subject to general exclusions and limitations of the subscriber’s contract, including, but not limited to, coordination of benefits, participating provider requirements, and utilization review of health care services, including the review of medical necessity, case management, and other managed care provisions.
(5) The coverage required pursuant to subsection (3) may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to a subscriber than the dollar limits, deductibles, or coinsurance provisions that apply to physical illnesses that are generally covered under the subscriber’s contract, except as otherwise provided in subsection (3).
(6) A health maintenance organization may not deny or refuse to issue coverage for medically necessary services, refuse to contract with, or refuse to renew or reissue or otherwise terminate or restrict coverage for an individual solely because the individual is diagnosed as having a developmental disability.
(7) The treatment plan required pursuant to subsection (4) shall include, but is not limited to, a diagnosis, the proposed treatment by type, the frequency and duration of treatment, the anticipated outcomes stated as goals, the frequency with which the treatment plan will be updated, and the signature of the treating physician.
(8) The maximum benefit under paragraph (4)(b) shall be adjusted annually on January 1 of each calendar year 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.
History.—s. 4, ch. 2008-30; s. 14, ch. 2012-27; s. 161, ch. 2014-17; s. 2, ch. 2016-222.