Bill Text: OR HB2214 | 2011 | Regular Session | Introduced
Bill Title: Relating to health insurance coverage for individuals with disabilities.
Spectrum: Slight Partisan Bill (Democrat 3-1)
Status: (Failed) 2011-06-30 - In committee upon adjournment. [HB2214 Detail]
Download: Oregon-2011-HB2214-Introduced.html
76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 1975
House Bill 2214
Sponsored by Representatives BUCKLEY, THOMPSON, Senator EDWARDS;
Senator BONAMICI (Presession filed.)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Adds new definitions and requirements for health insurance
coverage of autism spectrum disorders.
A BILL FOR AN ACT
Relating to health insurance coverage for individuals with
disabilities; creating new provisions; and amending ORS
743A.190.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2011 Act is added to and made
a part of the Insurance Code. + }
SECTION 2. { + As used in this section and ORS 743A.190:
(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
condition that includes autistic disorder, Asperger's disorder or
pervasive developmental disorder not otherwise specified as
defined in the Diagnostic and Statistical Manual of Mental
Disorders published by the American Psychiatric Association.
(3) 'Certified behavior analyst' means an individual certified
by the Behavior Analyst Certification Board as a 'Board Certified
Behavior Analyst,' or 'Board Certified Associate Behavior
Analyst' or certified by another nationally recognized
organization.
(4) 'Coordination of care' means a service that:
(a) Facilitates linking patients with appropriate services and
resources in a coordinated effort to ensure that patient needs
are met and services are not duplicated by organizations involved
in providing care;
(b) Assists patients and families to more effectively navigate
and use the health care system; or
(c) Maximizes the value of services delivered to patients by
facilitating beneficial, efficient, safe and high-quality patient
experiences and improved health care outcomes.
(5) 'Diagnosis' means medically necessary assessment,
evaluations or tests.
(6) 'Habilitative or rehabilitative care' means professional
counseling, guidance, services and treatment programs, including
applied behavior analysis, developmental approaches and other
behavioral health treatments, that are necessary to develop,
improve, maintain and restore to the maximum possible extent an
individual's functioning and that are provided by a licensed or
certified physician, psychologist, psychiatrist, speech-language
pathologist, occupational therapist, physical therapist or
certified behavior analyst or the line therapists that they
supervise, or a clinical autism spectrum disorder specialist
certified by the Teacher Standards and Practices Commission.
(7) 'Medically necessary' means reasonably expected to do the
following:
(a) Prevent the onset of an illness, condition, injury or
disability;
(b) Reduce or ameliorate the physical, mental or developmental
effects of an illness, condition, injury or disability; or
(c) Assist an individual in achieving or maintaining maximum
functional capacity to perform daily activities, taking into
account both the functional capacity of the individual and the
functional capacities that are appropriate for individuals of the
same age.
(8) 'Pharmacy care' means medications prescribed by a licensed
physician and any health-related services deemed medically
necessary to determine the need or effectiveness of the
medications.
(9) 'Psychiatric care' means direct or consultative services
provided by a psychiatrist licensed in the state where the
psychiatrist practices.
(10) 'Psychological care' means direct or consultative services
provided by a psychologist licensed in the state where the
psychologist practices.
(11) 'Therapeutic care' means services provided by licensed or
certified speech-language pathologists, occupational therapists
or physical therapists.
(12) 'Treatment for autism spectrum disorders' includes, but is
not limited to, the following care prescribed, provided or
ordered for an individual diagnosed with one of the autism
spectrum disorders by licensed physician or licensed psychologist
who determines the care to be medically necessary:
(a) Habilitative or rehabilitative care;
(b) Pharmacy care;
(c) Psychiatric care;
(d) Psychological care;
(e) Therapeutic care;
(f) Augmentative communication devices and other assistive
technology devices;
(g) Coordination of care; and
(h) Any other medically necessary care that meets the same
standard of evidence required for coverage of the prevailing
medical or surgical treatments. + }
SECTION 3. ORS 743A.190 is amended to read:
743A.190. { - (1) A health benefit plan, as defined in ORS
743.730, must cover for a child enrolled in the plan who is under
18 years of age and who has been diagnosed with a pervasive
developmental disorder all medical services, including
rehabilitation services, that are medically necessary and are
otherwise covered under the plan. - }
{ - (2) The coverage required under subsection (1) of this
section, including rehabilitation services, may be made subject
to other provisions of the health benefit plan that apply to
covered services, including but not limited to: - }
{ - (a) Deductibles, copayments or coinsurance; - }
{ - (b) Prior authorization or utilization review
requirements; or - }
{ - (c) Treatment limitations regarding the number of visits
or the duration of treatment. - }
{ - (3) As used in this section: - }
{ - (a) 'Medically necessary' means in accordance with the
definition of medical necessity that is specified in the policy,
certificate or contract for the health benefit plan and that
applies uniformly to all covered services under the health
benefit plan. - }
{ - (b) 'Pervasive developmental disorder' means a
neurological condition that includes Asperger's syndrome, autism,
developmental delay, developmental disability or mental
retardation. - }
{ - (c) 'Rehabilitation services' means physical therapy,
occupational therapy or speech therapy services to restore or
improve function. - }
{ - (4) The provisions of ORS 743A.001 do not apply to this
section. - }
{ - (5) The definition of 'pervasive developmental disorder '
is not intended to apply to coverage required under ORS
743A.168. - }
{ + (1) A health insurance policy that provides coverage for
hospital, surgical or medical care shall provide coverage for the
screening for, diagnosis of and treatment for autism spectrum
disorders. An insurer may not terminate coverage or refuse to
issue or renew coverage to an individual solely because the
individual is diagnosed with one of the autism spectrum disorders
or has received treatment for an autism spectrum disorder.
(2) Coverage under this section may not be subject to
utilization controls regarding the number or frequency of visits
or the duration of treatment.
(3) The coverage under this section may not be subject to
dollar limits, deductibles, copayments or coinsurance provisions
that are less favorable to an insured than the dollar limits,
deductibles, copayments or coinsurance provisions that apply to
physical illness generally under the health insurance policy.
(4) This section does not limit coverage that is otherwise
available to an individual under a health insurance policy or
reduce benefits required under ORS 743A.168.
(5) A claim for services described in this section may not be
denied on the basis that the service is habilitative or
rehabilitative and does not fully restore function.
(6) Coverage required by this section includes medically
necessary treatment provided in the home and in the community.
(7) Except for inpatient services, if an individual is
receiving treatment for autism spectrum disorders, an insurer has
the right to request a review of the treatment not more than once
every 12 months unless the insurer and the individual's licensed
physician or licensed psychologist agrees that a more frequent
review is necessary. The cost of obtaining any review will be
borne by the insurer.
(8) ORS 743A.001 does not apply to this section. + }
SECTION 4. { + Section 2 of this 2011 Act and the amendments
to ORS 743A.190 by section 3 of this 2011 Act apply to policies
or certificates issued or renewed on or after the effective date
of this 2011 Act. + }
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