Texas 2023 - 88th Regular

Texas House Bill HB4505 Compare Versions

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1	1	88R7287 JES-F
2	2	By: Cortez H.B. No. 4505
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan coverage for treatment of autism
8	8	spectrum disorders.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 1355.001(3), Insurance Code, is amended
11	11	to read as follows:
12	12	(3) "Autism spectrum disorder" means:
13	13	(A) a neurobiological disorder or developmental
14	14	disability that significantly affects verbal communication,
15	15	nonverbal communication, and social interaction and that meets the
16	16	diagnostic criteria for autism spectrum disorder specified by the
17	17	Diagnostic and Statistical Manual of Mental Disorders, 5th edition,
18	18	or a later edition; or
19	19	(B) a diagnosis made using a previous edition of
20	20	the Diagnostic and Statistical Manual of Mental Disorders of
21	21	[includes] autism, Asperger's syndrome, or Pervasive Developmental
22	22	Disorder--Not Otherwise Specified.
23	23	SECTION 2. Section 1355.015, Insurance Code, is amended by
24	24	amending Subsections (a-1), (c), and (c-1) and adding Subsections
25	25	(a-2) and (c-2) to read as follows:
26	26	(a-1) At a minimum, a health benefit plan must provide
27	27	coverage for any medically necessary treatment of autism spectrum
28	28	disorder as provided by this section to an enrollee who is diagnosed
29	29	with autism spectrum disorder from the date of diagnosis[, only if
30	30	the diagnosis was in place prior to the child's 10th birthday].
31	31	(a-2) For purposes of Subsection (a-1):
32	32	(1) "Medically necessary" means a service or product
33	33	that:
34	34	(A) addresses the specific needs of a patient;
35	35	(B) is provided for the purpose of screening for,
36	36	preventing, diagnosing, managing, or treating an illness, injury,
37	37	or condition, or the symptoms of that illness, injury, or
38	38	condition, including by minimizing the progression of an illness,
39	39	injury, condition, or symptom;
40	40	(C) is delivered in accordance with the generally
41	41	recognized independent standards of mental health and substance use
42	42	disorder care;
43	43	(D) is clinically appropriate in terms of type,
44	44	frequency, extent, site, and duration, as applicable, for the
45	45	service or product; and
46	46	(E) is not provided primarily for:
47	47	(i) the economic benefit of the health
48	48	benefit plan issuer or person who purchases the service or product;
49	49	or
50	50	(ii) the convenience of the patient,
51	51	treating physician, or other health care provider.
52	52	(2) "Generally recognized independent standards of
53	53	mental health and substance use disorder care" means a standard of
54	54	care and clinical practice that:
55	55	(A) is generally recognized by health care
56	56	providers practicing in the applicable clinical specialty,
57	57	including in psychiatry, psychology, clinical sociology, addiction
58	58	medicine, counseling, or behavioral health treatment; and
59	59	(B) is based on valid, evidence-based sources
60	60	reflecting generally accepted standards of mental health and
61	61	substance use disorder care, including:
62	62	(i) peer-reviewed scientific studies or
63	63	medical literature; and
64	64	(ii) the recommendation of a governmental
65	65	agency or relevant nonprofit health care provider professional
66	66	association or specialty society, including:
67	67	(a) patient placement criteria
68	68	promulgated by the National Library of Medicine;
69	69	(b) clinical practice guidelines
70	70	promulgated by the National Center for Complementary and
71	71	Integrative Health;
72	72	(c) the recommendation of a federal
73	73	governmental agency; and
74	74	(d) drug labeling approved by the
75	75	United States Food and Drug Administration.
76	76	(c) For purposes of Subsections [Subsection] (b) and (c-2),
77	77	"generally recognized services" may include services such as:
78	78	(1) evaluation and assessment services;
79	79	(2) applied behavior analysis;
80	80	(3) behavior training and behavior management;
81	81	(4) speech therapy;
82	82	(5) occupational therapy;
83	83	(6) physical therapy; or
84	84	(7) medications or nutritional supplements used to
85	85	address symptoms of autism spectrum disorder.
86	86	(c-1) The health benefit plan may [is] not require [required
87	87	to provide coverage under Subsection (b) for benefits for] an
88	88	enrollee to be evaluated for autism spectrum disorder more than
89	89	once every 10 years [of age or older for applied behavior analysis
90	90	in an amount that exceeds $36,000 per year].
91	91	(c-2) The health benefit plan may not:
92	92	(1) prohibit or place a limitation on a health care
93	93	practitioner described by Subsection (b)(1) from performing an
94	94	evaluation or reevaluation, or soliciting a confirmation of
95	95	diagnosis of autism spectrum disorder from a primary care physician
96	96	or a diagnostician who has previously provided a diagnosis of
97	97	autism spectrum disorder for an enrollee; or
98	98	(2) restrict the setting in which generally recognized
99	99	services prescribed in relation to autism spectrum disorder are
100	100	provided to the enrollee, including assessments, evaluation,
101	101	therapeutic intervention, or observations, except for a setting in
102	102	which the enrollee qualifies for reimbursable services under the
103	103	state Medicaid program, including under the school health and
104	104	related services program.
105	105	SECTION 3. The changes in law made by this Act apply only to
106	106	a health benefit plan delivered, issued for delivery, or renewed on
107	107	or after January 1, 2024. A health benefit plan delivered, issued
108	108	for delivery, or renewed before January 1, 2024, is governed by the
109	109	law as it existed immediately before the effective date of this Act,
110	110	and that law is continued in effect for that purpose.
111	111	SECTION 4. This Act takes effect September 1, 2023.