2023 Iowa Code › Title XIII - COMMERCE › Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES › Section 514C.28 - Autism spectrum disorder coverage.

514C.28 Autism spectrum disorder coverage.
1. Notwithstanding the uniformity of treatment requirements of section 514C.6, a group plan established pursuant to chapter 509A for employees of the state providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide coverage benefits to covered individuals under twenty-one years of age for the diagnostic assessment of autism spectrum disorder and for the treatment of autism spectrum disorder.
2. As used in this section, unless the context otherwise requires:
a. “Applied behavioral analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
b. “Autism service provider” means a person, or group providing treatment of autism spectrum disorder. An autism service provider that provides treatment of autism spectrum disorder that includes applied behavioral analysis shall be certified as a behavior analyst by the behavior analyst certification board or shall be a health professional licensed under chapter 147.
c. “Autism spectrum disorder” means a mental health condition that meets the diagnostic criteria for such disorder as published in the most recent edition of the diagnostic and statistical manual of mental disorders as published by the American psychiatric association.
d. “Diagnostic assessment of autism spectrum disorder” means medically necessary assessment, evaluations, or tests performed by a licensed physician, licensed physician assistant, licensed psychologist, or licensed registered nurse practitioner to diagnose whether an individual has autism spectrum disorder.
e. “Pharmacy care” means medications prescribed by a licensed physician, licensed physician assistant, or licensed registered nurse practitioner and any assessment, evaluation, or test prescribed or ordered by a licensed physician, licensed physician assistant, or licensed registered nurse practitioner to determine the need for or effectiveness of such medications.
f. “Psychiatric care” means direct or consultative services provided by a licensed physician who specializes in psychiatry.
g. “Psychological care” means direct or consultative services provided by a licensed psychologist.
h. “Rehabilitative care” means professional services and treatment programs, including applied behavioral analysis, provided by an autism service provider to produce socially significant improvement in human behavior or to prevent loss of attained skill or function.
i. “Therapeutic care” means services provided by a licensed speech pathologist, licensed occupational therapist, or licensed physical therapist.
j. “Treatment of autism spectrum disorder” means treatment that is identified in a treatment plan and includes medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care, and therapeutic care that is one of the following:
(1) Prescribed, ordered, or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed social worker, or licensed registered nurse practitioner.
(2) Provided by an autism service provider.
(3) Provided by a person, entity, or group that works under the direction of an autism service provider.
k. “Treatment plan” means a plan for the treatment of autism spectrum disorder developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in consultation with the patient and the patient’s representative.
3. Coverage is required pursuant to this section in a maximum benefit amount of not more than thirty-six thousand dollars per year but shall not be subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorder. The commissioner shall, on or before April 1 of each calendar year, publish an adjustment to the maximum benefit required equal to the percentage change in the United States department of labor consumer price index for all urban consumers in the preceding year, and the published adjusted maximum benefit shall be applicable to group policies, contracts, or plans subject to this section that are issued or renewed on or after January 1 of the following calendar year. Payments made under a group plan subject to this section on behalf of a covered individual for treatment of a health condition unrelated to or distinguishable from the individual’s autism spectrum disorder shall not be applied toward any maximum benefit established under this subsection.
4. Coverage required pursuant to this section shall be subject to copayment, deductible, and coinsurance provisions, and any other general exclusions or limitations of a group plan to the same extent as other medical or surgical services covered by the group plan.
5. Coverage required by this section shall be provided in coordination with coverage required for the treatment of autistic disorders pursuant to section 514C.22.
6. This section shall not be construed to limit benefits which are otherwise available to an individual under a group plan.
7. This section shall not be construed to require coverage by a group plan of any service solely based on inclusion of the service in an individualized education program. Consistent with federal or state law and upon consent of the parent or guardian of a covered individual, the treatment of autism spectrum disorder may be coordinated with any services included in an individualized education program. However, coverage for the treatment of autism spectrum disorder shall not be contingent upon coordination of services with an individualized education program.
8. This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance, or individual accident and sickness policies issued to individuals or to individual members of a member association.
9. A plan established pursuant to chapter 509A for employees of the state may manage the benefits provided through common methods including but not limited to providing payment of benefits or providing care and treatment under a capitated payment system, prospective reimbursement rate system, utilization control system, incentive system for the use of least restrictive and costly levels of care, a preferred provider contract limiting choice of specific providers, or any other system, method, or organization designed to assure services are medically necessary and clinically appropriate.
10. An insurer may review a treatment plan for treatment of autism spectrum disorder once every six months, subject to its utilization review requirements, including case management, concurrent review, and other managed care provisions. A more or less frequent review may be agreed upon by the insured and the licensed physician or licensed psychologist developing the treatment plan.
11. For the purposes of this section, the results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of not less than twelve months, unless a licensed physician or licensed psychologist determines that a more frequent assessment is necessary.
12. The commissioner shall adopt rules pursuant to chapter 17A to implement and administer this section.
13. This section applies to plans established pursuant to chapter 509A for employees of the state that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011.
2010 Acts, ch 1193, §131; 2022 Acts, ch 1026, §4 – 6, 8
Referred to in §225D.1, 225D.2, 321.189, 321.190, 514C.31
2022 amendments to subsections 1 – 3, 7, and 10 apply to plans established pursuant to chapter 509A for employees of the state that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2023; 2022 Acts, ch 1026, §8
Subsections 1, 3, 7, and 10 amended
Subsection 2, paragraphs b, c, d, j, and k amended