2023 Ohio Revised Code › Title 39 | Insurance › Chapter 3923 | Sickness and Accident Insurance › Section 3923.84 | Coverage for Autism Spectrum Disorder.

Effective:
April 6, 2017
Latest Legislation:
House Bill 463 - 131st General Assembly
(A) Notwithstanding section 3901.71 of the Revised Code, each individual and group sickness and accident insurance policy that is delivered, issued for delivery, or renewed in this state shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. A sickness and accident insurer shall not terminate an individual's coverage, or refuse to deliver, execute, issue, amend, adjust, o r renew coverage to an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder. Nothing in this section shall be applied to nongrandfathered plans in the individual and small group markets or to medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies. Except as otherwise provided in division (B) of this section, coverage under 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 policy.
(B) Benefits provided under this section shall cover, at minimum, all of the following:
(1) For speech and language therapy or occupational therapy for an insured under the age of fourteen that is performed by a licensed therapist, twenty visits per year for each service;
(2) For clinical therapeutic intervention for an insured under the age of fourteen that is provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform such services in accordance with a health treatment plan, twenty hours per week;
(3) For mental or behavioral health outpatient services for an insured under the age of fourteen that are performed by a licensed psychologist, psychiatrist, or physician providing consultation, assessment, development, or oversight of treatment plans, thirty visits per year.
(C)(1) Except as provided in division (C)(2) of this section, this section shall not be construed as limiting benefits that are otherwise available to an insured under a policy.
(2) A policy of sickness and accident insurance shall stipulate that coverage provided under this section be contingent upon both of the following:
(a) The covered individual receiving prior authorization for the services in question;
(b) The services in question being prescribed or ordered by either a developmental pediatrician or a psychologist trained in autism.
(D)(1) Except for inpatient services, if an insured is receiving treatment for an autism spectrum disorder, a sickness and accident insurer may review the treatment plan annually, unless the insurer and the insured's treating physician or psychologist agree that a more frequent review is necessary.
(2) Any such agreement as described in division (D)(1) of this section shall apply only to a particular insured being treated for an autism spectrum disorder and shall not apply to all individuals being treated for autism spectrum disorder by a physician or psychologist.
(3) The insurer shall cover the cost of obtaining any review or treatment plan.
(E) This section shall not be construed as affecting any obligation to provide services to an insured under an individualized family service plan, an individualized education program, or an individualized service plan.
(F) As used in this section:
(1) "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.
(2) "Autism spectrum disorder" means any of the pervasive developmental disorders or autism spectrum disorder as defined by the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association available at the time an individual is first evaluated for suspected developmental delay.
(3) "Clinical therapeutic intervention" means therapies supported by empirical evidence, which include, but are not limited to, applied behavioral analysis, that satisfy both of the following:
(a) Are necessary to develop, maintain, or restore, to the maximum extent practicable, the function of an individual;
(b) Are provided by or under the supervision of any of the following:
(i) A certified Ohio behavior analyst as defined in section 4783.01 of the Revised Code;
(ii) An individual licensed under Chapter 4732. of the Revised Code to practice psychology;
(iii) An individual licensed under Chapter 4757. of the Revised Code to practice professional counseling, social work, or marriage and family therapy.
(4) "Diagnosis of autism spectrum disorder" means medically necessary assessment, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.
(5) "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.
(6) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
(7) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
(8) "Therapeutic care" means services provided by a speech therapist, occupational therapist, or physical therapist licensed or certified in the state in which the person practices.
(9) "Treatment for autism spectrum disorder" means evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician who is a developmental pediatrician or a licensed psychologist trained in autism who determines the care to be medically necessary, including any of the following:
(a) Clinical therapeutic intervention;
(b) Pharmacy care;
(c) Psychiatric care;
(d) Psychological care;
(e) Therapeutic care.
(G) If any provision of this section or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the section and the application of such remainder to other persons or circumstances shall not be affected thereby.