225D.2 Autism support program — fund.

1. The department shall implement an autism support program beginning January 1, 2014, to provide payment for the provision of applied behavioral analysis treatment for eligible individuals. The department shall adopt rules, including standards and guidelines pursuant to chapter 17A to implement and administer the program. In adopting the rules, standards, and guidelines for the program, the department shall consult with and incorporate the recommendations of an expert panel convened by the regional autism assistance program to provide expert opinion on clinically relevant practices and guidance on program implementation and administration. The expert panel shall consist of families of individuals with autism; educational, medical, and human services specialists, professionals, and providers; and others with interest in or expertise related to autism. The program shall be implemented and administered in a manner so that payment for services is available throughout the state, including in rural and under-resourced areas.

2. At a minimum, the rules, standards, and guidelines for the program shall address all of the following:

a. A maximum annual benefit amount for an eligible individual of thirty-six thousand dollars.

b. A maximum of twenty-four months of applied behavioral analysis treatment.

c. Notwithstanding the age limitation for an eligible individual, a provision that if an eligible individual reaches fourteen years of age prior to completion of the maximum applied behavioral analysis treatment period specified in paragraph “b”, the individual may complete such treatment in accordance with the individual’s treatment plan, not to exceed the maximum treatment period.

d. A graduated schedule for cost-sharing by an eligible individual based on a percentage of the total benefit amount expended for the eligible individual, annually. Cost-sharing shall be applicable to eligible individuals with household incomes at or above two hundred percent of the federal poverty level in incrementally increased amounts up to a maximum of fifteen percent. The rules shall provide a financial hardship exemption from payment of the cost-sharing based on criteria established by rule of the department.

e. Application, approval, compliance, and appeal processes for eligible individuals as necessary to operate and manage the program.

f. Enrollment, renewal, and reimbursement of claims provisions for autism service providers participating in the program.

g. A requirement of family engagement and participation as part of the eligible individual’s treatment plan.

h. A requirement that the autism service provider coordinate interventions with the school in which the eligible individual is enrolled.

i. A requirement that the administrator of the program utilize the regional autism assistance program to coordinate interventions between eligible individuals and their families receiving support through the autism support program with appropriate medical, educational, and treatment providers, including integrated health homes. The regional autism assistance program shall provide for family navigation and coordination and integration of services through the statewide system of regional child health specialty clinics, utilizing the community child health team model. As necessitated by the availability of resources in the community where services are delivered, telehealth may be used in delivering and coordinating interventions with appropriate providers. To the extent available and accessible to an eligible individual, the eligible individual shall be enrolled in an integrated health home that is an approved provider enrolled in the medical assistance program. Health home services that are covered services under the medical assistance program shall be reimbursed under the autism support program at rates consistent with those established under the medical assistance program.

j. Requirements related to review of treatment plans, which may require review once every six months, subject to utilization review requirements established by rule. A more or less frequent review may be agreed upon by the eligible individual and the licensed physician or licensed psychologist developing the treatment plan.

k. Recognition of the results of a diagnostic assessment of autism as valid for a period of not less than twelve months, unless a licensed physician or licensed psychologist determines that a more frequent assessment is necessary.

l. Proof of eligibility for the autism support program that includes a written denial for coverage or a benefits summary indicating that applied behavioral analysis treatment or applied behavior analysis treatment is not a covered benefit for which the applicant is eligible, under the Medicaid program, section 514C.28, section 514C.31, or other private insurance coverage.

3. Moneys in the autism support fund created under subsection 5 shall be expended only for eligible individuals who are not eligible for coverage for applied behavioral analysis treatment or applied behavior analysis treatment under the medical assistance program, section 514C.28, section 514C.31, or other private insurance. Payment for applied behavioral analysis treatment through the fund shall be limited to only applied behavioral analysis treatment that is clinically relevant and only to the extent approved under the guidelines established by rule of the department.

4. This section shall not be construed as granting an entitlement for any program, service, or other support for eligible individuals. Any state obligation to provide a program, service, or other support pursuant to this section is limited to the extent of the funds appropriated for the purposes of the program. The department may establish a waiting list or terminate participation of eligible individuals if the department determines that moneys in the autism support fund are insufficient to cover future claims for reimbursement beyond ninety days.

5. a. An autism support fund is created in the state treasury under the authority of the department. Moneys appropriated to and all other moneys specified for deposit in the fund shall be deposited in the fund and used for the purposes of the program. Notwithstanding section 12C.7, interest or earnings on moneys in the fund shall be credited to the fund. Notwithstanding section 8.33, moneys credited to the fund that remain unexpended or unobligated at the end of a fiscal year shall not revert to any other fund.

b. The department shall adopt rules pursuant to chapter 17A to administer the fund and reimbursements made from the fund.

c. Moneys in the fund are appropriated to the department and shall be used by the department for the purposes of the autism support program. The department shall be the administrator of the fund for auditing purposes.

d. The department shall submit an annual report to the governor and the general assembly no later than January 1 of each year that includes but is not limited to all of the following:

(1) The total number of applications received under the program for the immediately preceding fiscal year.

(2) The number of applications approved and the total amount of funding expended for reimbursements under the program in the immediately preceding fiscal year.

(3) The cost of administering the program in the immediately preceding fiscal year.

(4) The number of eligible individuals on a waiting list, if any, and the amount of funding necessary to reduce the existing waiting list.

(5) Recommendations for any changes to the program.

2013 Acts, ch 138, §83, 85; 2015 Acts, ch 137, §70, 71, 162, 163; 2016 Acts, ch 1139, §60; 2017 Acts, ch 18, §2, 3, 5

Referred to in §225D.1