88R7287 JES-F
By: Cortez H.B. No. 4505
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for treatment of autism
spectrum disorders.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1355.001(3), Insurance Code, is amended
to read as follows:
(3) "Autism spectrum disorder" means:
(A) a neurobiological disorder or developmental
disability that significantly affects verbal communication,
nonverbal communication, and social interaction and that meets the
diagnostic criteria for autism spectrum disorder specified by the
Diagnostic and Statistical Manual of Mental Disorders, 5th edition,
or a later edition; or
(B) a diagnosis made using a previous edition of
the Diagnostic and Statistical Manual of Mental Disorders of
[includes] autism, Asperger's syndrome, or Pervasive Developmental
Disorder--Not Otherwise Specified.
SECTION 2. Section 1355.015, Insurance Code, is amended by
amending Subsections (a-1), (c), and (c-1) and adding Subsections
(a-2) and (c-2) to read as follows:
(a-1) At a minimum, a health benefit plan must provide
coverage for any medically necessary treatment of autism spectrum
disorder as provided by this section to an enrollee who is diagnosed
with autism spectrum disorder from the date of diagnosis[, only if
the diagnosis was in place prior to the child's 10th birthday].
(a-2) For purposes of Subsection (a-1):
(1) "Medically necessary" means a service or product
that:
(A) addresses the specific needs of a patient;
(B) is provided for the purpose of screening for,
preventing, diagnosing, managing, or treating an illness, injury,
or condition, or the symptoms of that illness, injury, or
condition, including by minimizing the progression of an illness,
injury, condition, or symptom;
(C) is delivered in accordance with the generally
recognized independent standards of mental health and substance use
disorder care;
(D) is clinically appropriate in terms of type,
frequency, extent, site, and duration, as applicable, for the
service or product; and
(E) is not provided primarily for:
(i) the economic benefit of the health
benefit plan issuer or person who purchases the service or product;
or
(ii) the convenience of the patient,
treating physician, or other health care provider.
(2) "Generally recognized independent standards of
mental health and substance use disorder care" means a standard of
care and clinical practice that:
(A) is generally recognized by health care
providers practicing in the applicable clinical specialty,
including in psychiatry, psychology, clinical sociology, addiction
medicine, counseling, or behavioral health treatment; and
(B) is based on valid, evidence-based sources
reflecting generally accepted standards of mental health and
substance use disorder care, including:
(i) peer-reviewed scientific studies or
medical literature; and
(ii) the recommendation of a governmental
agency or relevant nonprofit health care provider professional
association or specialty society, including:
(a) patient placement criteria
promulgated by the National Library of Medicine;
(b) clinical practice guidelines
promulgated by the National Center for Complementary and
Integrative Health;
(c) the recommendation of a federal
governmental agency; and
(d) drug labeling approved by the
United States Food and Drug Administration.
(c) For purposes of Subsections [Subsection] (b) and (c-2),
"generally recognized services" may include services such as:
(1) evaluation and assessment services;
(2) applied behavior analysis;
(3) behavior training and behavior management;
(4) speech therapy;
(5) occupational therapy;
(6) physical therapy; or
(7) medications or nutritional supplements used to
address symptoms of autism spectrum disorder.
(c-1) The health benefit plan may [is] not require [required
to provide coverage under Subsection (b) for benefits for] an
enrollee to be evaluated for autism spectrum disorder more than
once every 10 years [of age or older for applied behavior analysis
in an amount that exceeds $36,000 per year].
(c-2) The health benefit plan may not:
(1) prohibit or place a limitation on a health care
practitioner described by Subsection (b)(1) from performing an
evaluation or reevaluation, or soliciting a confirmation of
diagnosis of autism spectrum disorder from a primary care physician
or a diagnostician who has previously provided a diagnosis of
autism spectrum disorder for an enrollee; or
(2) restrict the setting in which generally recognized
services prescribed in relation to autism spectrum disorder are
provided to the enrollee, including assessments, evaluation,
therapeutic intervention, or observations, except for a setting in
which the enrollee qualifies for reimbursable services under the
state Medicaid program, including under the school health and
related services program.
SECTION 3. The changes in law made by this Act apply only to
a health benefit plan delivered, issued for delivery, or renewed on
or after January 1, 2024. A health benefit plan delivered, issued
for delivery, or renewed before January 1, 2024, is governed by the
law as it existed immediately before the effective date of this Act,
and that law is continued in effect for that purpose.
SECTION 4. This Act takes effect September 1, 2023.