Section 21.42.397. Coverage for autism spectrum disorders.

   (a) Except for a fraternal benefit society, a health care insurer that offers, issues for delivery, delivers, or renews a health care insurance plan in this state shall provide coverage for the costs of the diagnosis and treatment of autism spectrum disorders. Coverage required by this subsection must include treatment prescribed by a licensed physician, psychologist, or advanced practice registered nurse, provided by or supervised by an autism service provider, and as identified in a treatment plan developed following a comprehensive evaluation. Covered treatment includes medically necessary pharmacy care, psychiatric care, psychological care, habilitative or rehabilitative care, and therapeutic care. In this subsection,
        (1) "habilitative or rehabilitative care" means professional counseling, guidance services, and treatment programs necessary to develop, restore, or maintain the functioning of an individual to the maximum extent practicable, including applied behavior analysis or other structured behavioral therapies; in this paragraph, "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, including direct observation, measurement, and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior or to prevent the loss of an attained skill or function;
        (2) "therapeutic care" means services provided by or under the supervision of a speech-language pathologist licensed under AS 08.11 or an occupational therapist or physical therapist licensed under AS 08.84.
   (b) Coverage under this section
        (1) is required to be provided only to individuals under 21 years of age;
        (2) may not limit the number of visits to an autism service provider for treatment;
        (3) is subject to copayment, deductible, and coinsurance provisions, and other general exclusions or limitations included in a health insurance policy to the same extent as other health care services covered by the policy; and
        (4) must cover medically necessary treatment that is coordinated with an education program, but may not be contingent on the coordination of treatment with an education program.
   (c) An insurer providing health care insurance to a small employer in the group market with 20 or fewer employees is not required to provide insurance coverage to the small employer that includes the coverage required under (a) of this section.
   (d) The director may waive the coverage required in this section for an insurer providing health care insurance to a small employer in the group market with 21 - 25 employees if the small employer demonstrates to the director by actual claims experience over any consecutive 12-month period that compliance with this section has increased the premium cost of the small employer's health insurance policy by three percent or more during the consecutive 12-month period.
   (e) This section does not limit benefits that are otherwise available to an individual under a health care insurance plan.
   (f) A health care insurer may not refuse to deliver, execute, issue, amend, or renew coverage to an individual or terminate coverage because the individual is diagnosed with or has received treatment for autism spectrum disorders.
   (g) In this section,
        (1) "autism service provider" means an individual who is licensed, certified, or registered by the applicable state licensing board or by a nationally recognized certifying organization and who provides direct services to an individual with an autism spectrum disorder;
        (2) "autism spectrum disorders" means pervasive developmental disorders, or a group of conditions having substantially the same characteristics as pervasive developmental disorders, as defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders-IV-TR, as amended or reissued from time to time;
        (3) "health care insurance plan" has the meaning given in AS 21.54.500;
        (4) "health care insurer" has the meaning given in AS 21.54.500;
        (5) "medically necessary" means any care, treatment, intervention, service, or item prescribed by a licensed physician, psychologist, or advanced practice registered nurse in accordance with accepted standards of practice that will, or is reasonably expected to,
             (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;
             (C) assist to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and the functional capacity of other persons of the individual's age.

Notes

Recent Bills that will modify this

SB 53 ADVANCED PRACTICE REGISTERED NURSES

History

(Sec. 1 ch 63 SLA 2012; am Sec. 37, 38 ch 33 SLA 2016)