Texas 2025 - 89th Regular

Texas House Bill HB564 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	89R4932 DNC-F
2	2	By: Cortez H.B. No. 564
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5	5
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to health benefit plan coverage for treatment of autism
10	10	spectrum disorders.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 1355.001(3), Insurance Code, is amended
13	13	to read as follows:
14	14	(3) "Autism spectrum disorder" means:
15	15	(A) a neurobiological disorder that
16	16	significantly affects verbal communication, nonverbal
17	17	communication, and social interaction and that meets the diagnostic
18	18	criteria for autism spectrum disorder specified by the Diagnostic
19	19	and Statistical Manual of Mental Disorders, 5th edition, or a later
20	20	edition; or
21	21	(B) a diagnosis made using a previous edition of
22	22	the Diagnostic and Statistical Manual of Mental Disorders of
23	23	[includes] autism, Asperger's syndrome, or Pervasive Developmental
24	24	Disorder--Not Otherwise Specified.
25	25	SECTION 2. Section 1355.015, Insurance Code, is amended by
26	26	amending Subsections (a-1) and (c) and adding Subsections (a-2) and
27	27	(c-2) to read as follows:
28	28	(a-1) At a minimum, a health benefit plan must provide
29	29	coverage for any medically necessary treatment of autism spectrum
30	30	disorder as provided by this section to an enrollee who is diagnosed
31	31	with autism spectrum disorder from the date of diagnosis[, only if
32	32	the diagnosis was in place prior to the child's 10th birthday].
33	33	(a-2) For purposes of Subsection (a-1):
34	34	(1) "Medically necessary" means a service or product
35	35	that:
36	36	(A) addresses the specific needs of a patient;
37	37	(B) is provided for the purpose of:
38	38	(i) screening for, preventing, diagnosing,
39	39	managing, or treating an illness, injury, or condition, or the
40	40	symptoms of that illness, injury, or condition, including by
41	41	minimizing the progress of an illness, injury, or condition; or
42	42	(ii) preventing regression or ensuring
43	43	maintenance of skills;
44	44	(C) is delivered in accordance with the generally
45	45	recognized independent standards of mental health and substance use
46	46	disorder care;
47	47	(D) is clinically appropriate in terms of type
48	48	for the service or product; and
49	49	(E) is not provided primarily for:
50	50	(i) the economic benefit of the health
51	51	benefit plan issuer or person who purchases the service or product;
52	52	or
53	53	(ii) the convenience of the patient,
54	54	treating physician, or other health care provider.
55	55	(2) "Generally recognized independent standards of
56	56	mental health and substance use disorder care" means a standard of
57	57	care and clinical practice that:
58	58	(A) is generally recognized by health care
59	59	providers practicing in the applicable clinical specialty,
60	60	including in psychiatry, psychology, clinical sociology, addiction
61	61	medicine, counseling, applied behavioral analysis, or behavioral
62	62	health treatment; and
63	63	(B) is based on valid, evidence-based sources
64	64	reflecting generally accepted standards of mental health and
65	65	substance use disorder care, including:
66	66	(i) peer-reviewed scientific studies or
67	67	medical literature; and
68	68	(ii) the recommendation of a governmental
69	69	agency or relevant nonprofit health care provider professional
70	70	trade association or specialty society, including:
71	71	(a) patient placement criteria
72	72	promulgated by the National Library of Medicine;
73	73	(b) clinical practice guidelines
74	74	promulgated by the National Center for Complementary and
75	75	Integrative Health;
76	76	(c) the recommendation of a federal
77	77	governmental agency;
78	78	(d) drug labeling approved by the
79	79	United States Food and Drug Administration; and
80	80	(e) clinical practice guidelines,
81	81	developed and promulgated by the Council of Autism Service
82	82	Providers, for the treatment of autism spectrum disorder.
83	83	(c) For purposes of Subsections [Subsection] (b) and (c-2),
84	84	"generally recognized services" may include services such as:
85	85	(1) evaluation and assessment services;
86	86	(2) applied behavior analysis;
87	87	(3) behavior training and behavior management;
88	88	(4) speech therapy;
89	89	(5) occupational therapy;
90	90	(6) physical therapy; or
91	91	(7) medications or nutritional supplements used to
92	92	address symptoms of autism spectrum disorder.
93	93	(c-2) The health benefit plan may not:
94	94	(1) prohibit or place a limitation on a health care
95	95	practitioner described by Subsection (b)(1) from performing an
96	96	evaluation or reevaluation, or soliciting a confirmation of
97	97	diagnosis of autism spectrum disorder from a primary care physician
98	98	or a diagnostician who has previously provided a diagnosis of
99	99	autism spectrum disorder for an enrollee; or
100	100	(2) restrict the setting in which generally recognized
101	101	services prescribed in relation to autism spectrum disorder are
102	102	provided to the enrollee, including assessments, evaluation,
103	103	therapeutic intervention, or observations, except for a setting in
104	104	which the enrollee qualifies for reimbursable services under the
105	105	state Medicaid program, including under the school health and
106	106	related services program.
107	107	SECTION 3. Section 1355.015(c-1), Insurance Code, is
108	108	repealed.
109	109	SECTION 4. The changes in law made by this Act apply only to
110	110	a health benefit plan delivered, issued for delivery, or renewed on
111	111	or after January 1, 2026. A health benefit plan delivered, issued
112	112	for delivery, or renewed before January 1, 2026, is governed by the
113	113	law as it existed immediately before the effective date of this Act,
114	114	and that law is continued in effect for that purpose.
115	115	SECTION 5. This Act takes effect September 1, 2025.