§1050. Requirement for coverage of diagnosis and treatment of autism spectrum disorders in individuals less than twenty-one years of age

A.(1) Except as otherwise provided in Subsection H of this Section, any health coverage plan specified in Paragraph (G)(6) of this Section which is issued for delivery, delivered, renewed, or otherwise contracted for in this state on or after January 1, 2014, shall provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals less than twenty-one years of age.

(2) No insurer or other issuer of a health coverage plan may terminate coverage or refuse to deliver, execute, issue, amend, adjust, 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.

B. Coverage under this Section shall not be subject to any limits on the number of visits an individual may make to an autism services provider.

C. Coverage under this Section may be subject to copayment, deductible, and coinsurance provisions of a health coverage plan to the extent that other medical services covered by the plan are subject to these provisions.

D.(1) Coverage under this Section shall be subject to a maximum benefit of thirty-six thousand dollars per year.

(2) Payments made by an insurer or issuer of a health coverage plan on behalf of a covered individual for any care, treatment, intervention, service, or item unrelated to autism spectrum disorders shall not be applied towards the maximum established under this Subsection.

E. This Section shall not be construed as limiting benefits not related to the treatment of autism spectrum disorders that are otherwise available to an individual under a health coverage plan.

F. A health coverage plan may review proposed treatment of autism spectrum disorders according to medical necessity criteria that may be based in part on evidence of continued improvement as a result of the treatment. Medical necessity determinations shall be subject to appeal rights as described in R.S. 22:1121 et seq.

G. As used in this Section:

(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 relations between environment and behavior.

(2) "Autism services provider" means any person, entity, or group which provides treatment of autism spectrum disorders. When the treatment provided by the autism services provider is applied behavior analysis as defined in this Subsection, such provider shall be certified as a behavior analyst by the Behavior Analyst Certification Board or shall provide, if requested, documented evidence of equivalent education, professional training, and supervised experience in applied behavior analysis.

(3) "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.

(4) "Diagnosis of autism spectrum disorders" means medically necessary assessment, evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders.

(5) "Habilitative or rehabilitative care" means professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual.

(6) "Health coverage plan" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract or agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan and the Office of Group Benefits programs.

(7) "Pharmacy care" means medications prescribed by a licensed physician.

(8) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in this state.

(9) "Psychological care" means direct or consultative services provided by a psychologist licensed in this state.

(10) "Therapeutic care" means services provided by licensed or certified speech therapists, occupational therapists, or physical therapists licensed or certified in this state.

(11) "Treatment of autism spectrum disorders" shall include the following care prescribed, provided, or ordered for an individual diagnosed with one of the autism spectrum disorders by a physician or psychologist who shall be licensed in this state and who shall supervise provision of such care:

(a) Habilitative or rehabilitative care.

(b) Pharmacy care.

(c) Psychiatric care.

(d) Psychological care.

(e) Therapeutic care.

H. The provisions of this Section shall not apply to:

(1) Repealed by Acts 2012, No. 208, §2.

(2) Individually underwritten, guaranteed renewable health insurance policies.

(3) Limited benefit health insurance policies or contracts.

Acts 2008, No. 648, §1; Acts 2009, No. 419, §1; Acts 2010, No. 919, §1, eff. Jan. 1, 2011; Acts 2012, No. 208, §§1, 2.