SENATE BILL No. 24
AN ACT concerning insurance; relating to coverage for autism spectrum disorder; changing
the required number of employees contained in the definitions of "large employer" and
"small employer"; amending K.S.A. 40-2,194 and repealing the existing section.
Be it enacted by the Legislature of the State of Kansas:
Section 1. K.S.A. 40-2,194 is hereby amended to read as follows:
40-2,194. (a) (1) (A) Any large group health insurance policy, medical
service plan, contract, hospital service corporation contract, hospital and
medical service corporation contract, fraternal benefit society or health
maintenance organization which provides coverage for accident and
health services and which is delivered, issued for delivery, amended or
renewed on or after January 1, 2015, shall provide coverage for the
diagnosis and treatment of autism spectrum disorder in any covered
individual whose age is less than 12 years.
(B) Any grandfathered individual or group health insurance policy,
medical service plan, contract, hospital service corporation contract,
hospital and medical service corporation contract, fraternal benefit society
or health maintenance organization which that provides coverage for
accident and health services and which that is delivered, issued for
delivery, amended or renewed on or after January 1, 2016, shall provide
coverage for the diagnosis and treatment of autism spectrum disorder in
any covered individual whose age is less than 12 years.
(2) Such coverage shall be provided in a manner determined in
consultation with the autism services provider and the patient. Services
provided by autism services providers under this section shall include
applied behavior analysis when required by a licensed physician, licensed
psychologist or licensed specialist clinical social worker but otherwise
shall be limited to the care, services and related equipment prescribed or
ordered by a licensed physician, licensed psychologist or licensed
specialist clinical social worker.
(3) Coverage provided under this section for applied behavior
analysis shall be subject to a limitation of:
(A) 1,300 hours per calendar year for four years beginning on the
later of the date of diagnosis or January 1, 2015, for any covered
individual diagnosed with autism spectrum disorder between birth and
five years of age; and
(B) except as provided in subparagraph (A), 520 hours per calendar
year for any covered individual less than 12 years of age.
Upon prior approval by the health benefit plan, such maximum benefit
limit may be exceeded if the provision of applied behavior analysis
services beyond the maximum limit is medically necessary for such
individual. Any payment made by an insurer on behalf of a covered
individual for any care, treatment, intervention, service or item, the
provision of which was for the treatment of a health condition unrelated to
such covered individual's autism spectrum disorder, shall not be applied
toward any maximum benefit established under this paragraph. Except for
the coverage for applied behavior analysis, no coverage required under
this section shall be subject to the age and hour limitations described in
this paragraph.
(4) On or after January 1, 2015, through June 30, 2016,
reimbursement shall be allowed only for services provided by a provider
licensed, trained and qualified to provide such services or by an autism
specialist or an intensive individual service provider as such terms are
defined by the Kansas department for aging and disability services Kansas
autism waiver. On or after July 1, 2016, reimbursement shall be allowed
only for services provided by an autism service provider licensed or
exempt from licensure under the applied behavior analysis licensure act,
except that reimbursement shall be allowed for services provided by an
autism specialist, an intensive individual service provider or any other SENATE BILL No. 24—page 2
individual qualified to provide services under the home and community
based services autism waiver administered by the Kansas department
for aging and disability services.
(5) Any insurer or other entity which that administers claims for
services provided for the treatment of autism spectrum disorder under
this section shall have the right and obligation to deny any claim for
services based upon medical necessity or a determination that the
covered individual has reached the maximum medical improvement for
the covered individual's autism spectrum disorder.
(6) Except for inpatient services, if an insured is receiving
treatment for autism spectrum disorder, such insurer shall have the right
to review the treatment plan not more than once in a period of six
consecutive months, unless the insurer and the insured's treating
physician or psychologist agree that a more frequent review is
necessary. Any such agreement regarding the right to review a
treatment plan more frequently shall apply only to a particular insured
being treated for autism spectrum disorder and shall 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.
(7) No insurer can terminate coverage, or refuse to deliver,
execute, issue, amend, adjust or renew coverage to an individual solely
because the individual is diagnosed with or has received treatment for
autism spectrum disorder.
(b) For the purposes of 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 a neurobiological disorder,
an illness of the nervous system, which that includes:
(A) "Autistic disorder," which is:
(i) Six or more items from (a), (b) and (c) of this subparagraph,
with at least two items from (a) of this subparagraph, and one item each
from (b) and (c) of this subparagraph:
(a) Qualitative impairment in social interaction, as manifested by
at least two of the following:
(1) Marked impairment in the use of multiple nonverbal behaviors
such as eye-to-eye gaze, facial expression, body postures and gestures
to regulate social interaction;
(2) failure to develop peer relationships appropriate to
developmental level;
(3) a lack of spontaneous seeking to share enjoyment, interests or
achievements with other people; or
(4) lack of social or emotional reciprocity;
(b) qualitative impairments in communication as manifested by at
least one of the following:
(1) Delay in, or total lack of, the development of spoken language;
(2) in individuals with adequate speech, marked impairment in the
ability to initiate or sustain a conversation with others;
(3) stereotyped and repetitive use of language or idiosyncratic
language; or
(4) lack of varied, spontaneous make-believe play or social
imitative play appropriate to developmental level;
(c) restricted repetitive and stereotyped patterns of behavior,
interests and activities, as manifested by at least one of the following:
(1) Encompassing preoccupation with one or more stereotyped SENATE BILL No. 24—page 3
and restricted patterns of interest that is abnormal either in intensity or
focus;
(2) apparently inflexible adherence to specific, nonfunctional
routines or rituals;
(3) stereotyped and repetitive motor mannerisms; or
(4) persistent preoccupation with parts of objects;
(ii) delays or abnormal functioning in at least one of the following
areas, with onset prior to age three years, including social interaction,
language as used in social communication or symbolic or imaginative
play; and
(iii) the disturbance is not better accounted for by Rett's disorder
or childhood disintegrative disorder;
(B) "Asperger's disorder," which is:
(i) A qualitative impairment in social interaction, as manifested by
at least two of the following:
(a) Marked impairment in the use of multiple nonverbal behaviors
such as eye-to-eye gaze, facial expression, body postures and gestures
to regulate social interaction;
(b) failure to develop peer relationships appropriate to
developmental level;
(c) lack of spontaneous seeking to share enjoyment, interests or
achievements with other people; or
(d) lack of social or emotional reciprocity;
(ii) restricted repetitive and stereotyped patterns of behavior,
interests and activities, as manifested by at least one of the following:
(a) Encompassing preoccupation with one or more stereotyped
and restricted patterns of interest that is abnormal either in intensity or
focus;
(b) apparently inflexible adherence to specific, nonfunctional
routines or rituals;
(c) stereotyped and repetitive motor mannerisms; or
(d) persistent preoccupation with parts of objects;
(iii) the disturbance causes clinically significant impairment in
social, occupational or other important areas of functioning;
(iv) there is no clinically significant general delay in language;
(v) there is no clinically significant delay in cognitive
development or in the development of age-appropriate self-help skills,
adaptive behavior (other than in social interaction), and curiosity about
the environment in childhood; and
(vi) criteria are not met for another specific pervasive
developmental disorder or schizophrenia;
(C) "pervasive developmental disorder not otherwise specified," is
a severe and pervasive impairment in the development of reciprocal
social interaction associated with impairment in either verbal or
nonverbal communication skills or with the presence of stereotyped
behavior, interests and activities, but the criteria are not met for a
specific pervasive developmental disorder, schizophrenia, schizotypal
personality disorder, or avoidant personality disorder;
(D) "Rett's disorder," includes:
(i) All of the following:
(a) Apparently normal prenatal and perinatal development;
(b) apparently normal psychomotor development through the first
five months after birth; and
(c) normal head circumference at birth;
(ii) onset of all of the following after the period of normal
development:
(a) Deceleration of head growth between ages five and 48 months;
(b) loss of previously acquired purposeful hand skills between
ages five and 30 months with the subsequent development of SENATE BILL No. 24—page 4
stereotyped hand movements;
(c) loss of social engagement early in the course of development;
(d) appearance of poorly coordinated gait or trunk movements;
and
(e) severely impaired expressive and receptive language
development with severe psychomotor retardation;
(E) "childhood disintegrative disorder," is:
(i) Apparently normal development for at least the first two years
after birth as manifested by the presence of age-appropriate verbal and
nonverbal communication, social relationships, play and adaptive
behavior;
(ii) clinically significant loss of previously acquired skills in at
least two of the following areas: Expressive or receptive language,
social skills or adaptive behavior, bowel or bladder control or play and
motor skills;
(iii) abnormalities of functioning in at least two of the following
areas: Qualitative impairment in social interaction; qualitative
impairments in communication; restricted, repetitive and stereotyped
patterns of behavior, interests and activities, including motor
stereotypies and mannerisms; and
(iv) the disturbance is not better accounted for by another specific
pervasive developmental disorder or by schizophrenia.
(3) "Diagnosis of autism spectrum disorder" means any medically
necessary assessment, evaluation or test performed by a licensed
physician, licensed psychologist or licensed specialist clinical social
worker to determine whether an individual has autism spectrum
disorder.
(4) "Grandfathered health benefit plan" shall have the meaning
ascribed to such term means the same as defined in 42 U.S.C. § 18011.
The term "grandfathered health benefit plan" includes both small
employer group health benefit plans that are grandfathered and
individual health benefit plans that are grandfathered.
(5) "Health benefit plan" shall have the meaning ascribed to such
term means the same as defined in K.S.A. 40-4602, and amendments
thereto.
(6) "Large employer" means, in connection with a group health
benefit plan with respect to a calendar year and a plan year, an
employer who employed an average of at least 101 51 employees on
business days during the preceding calendar year and who employs at
least one employee on the first day of the plan year.
(7) "Small employer" means, in connection with a group health
benefit plan with respect to a calendar year and a plan year, an
employer who employed an average of at least one two but not more
than 100 50 employees on business days during the preceding calendar
year and who employs at least one employee on the first day of the plan
year.
(c) If an individual has been diagnosed as having autism spectrum
disorder meeting the diagnostic criteria described in the edition of the
diagnostic and statistical manual of mental disorders available at the
time of diagnosis, then that individual shall not be required to undergo
any additional or repeated evaluation based upon the adoption of a
subsequent edition of the diagnostic and statistical manual of mental
disorders adopted by rules and regulations of the behavioral sciences
regulatory board in order to remain eligible for coverage under this
section.
(d) Except as otherwise provided in subsection (a), no individual
or group health insurance policy, medical service plan, contract,
hospital service corporation contract, hospital and medical service
corporation contract, fraternal benefit society or health maintenance SENATE BILL No. 24—page 5
organization which that provides coverage for accident and health
services and which provides coverage with respect to autism spectrum
disorder shall impose on the coverage required by this section:
(1) Impose on the coverage required by this section Any dollar
limits, deductibles or coinsurance provisions that are less favorable to
an insured than the dollar limits, deductibles or coinsurance provisions
that apply to physical illness generally under the accident and sickness
insurance policy; or
(2) impose on the coverage required by this section any limit upon
the number of visits that a covered individual may make for treatment
of autism spectrum disorder.
(e) The provisions of this section shall not apply to any policy or
certificate which that provides coverage for any specified disease,
specified accident or accident-only coverage, credit, dental, disability
income, hospital indemnity, long-term care insurance as defined by
K.S.A. 40-2227, and amendments thereto, vision care or any other
limited supplemental benefit nor to any medicare supplement policy of
insurance as defined by the commissioner of insurance by rules and
regulations, any coverage issued as a supplement to liability insurance,
workers' compensation or similar insurance, automobile medical-
payment insurance or any insurance under which benefits are payable
with or without regard to fault, whether written on a group, blanket or
individual basis.
(f) This section shall not be construed as limiting benefits that are
otherwise available to an individual under any individual or group
health insurance policy, medical service plan, contract, hospital service
corporation contract, hospital and medical service corporation contract,
fraternal benefit society or health maintenance organization which
provides coverage for accident and health services.
(g) The provisions of K.S.A. 40-2249a, and amendments thereto,
shall not apply to the provisions of this section.
(h) The commissioner of the department of insurance shall grant a
small employer with a group health benefit plan a waiver from the
provisions of this section, if the small employer demonstrates to the
commissioner by actual claims experience over any consecutive
twelve-month 12-month period that compliance with this section has
increased the cost of the health insurance policy by an amount of two
and a half percent 2.5% or greater over the period of a calendar year in
premium costs to the small employer.
(i) Nothing contained in this section shall require coverage for or
payment of full or partial day care or habilitation services, community
support services, services at intermediate care facilities, school-based
rehabilitative services or overnight, boarding and extended stay
services at facilities for autism patients. Only services actually rendered
on an hourly basis or fractional portion thereof by certified applied
behavior analysis (ABA) providers as herein defined shall be required
to be covered under this section. Nothing in this section shall require
coverage or payment hereunder for services that are otherwise
provided, authorized or required to be provided by public or private
schools receiving any state or federal funding for such services.
Sec. 2. K.S.A. 40-2,194 is hereby repealed. SENATE BILL No. 24—page 6
Sec. 3. This act shall take effect and be in force from and after its
publication in the statute book.
I hereby certify that the above BILL originated in the
SENATE, and passed that body
_________________________
_________________________
President of the Senate.
_________________________
Secretary of the Senate.
Passed the HOUSE ________________________
_________________________
Speaker of the House.
_________________________
Chief Clerk of the House.
APPROVED ____________________________
_________________________
Governor.