coverage.
1.Notwithstanding the uniformity of treatment requirements of section 514C.6, a group
policy, contract, or plan providing for third-party payment or prepayment of health, medical,
and surgical coverage benefits shall provide coverage benefits for applied behavior analysis
provided by a practitioner to covered individuals for the treatment of autism spectrum
disorder pursuant to a treatment plan if the policy, contract, or plan is either of the following:
a.A policy, contract, or plan issued by a carrier, as defined in section 513B.2, to an
29 SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES, §514C.31
employer who on at least fifty percent of the employer’s working days during the preceding
calendar year employed more than fifty full-time equivalent employees. In determining
the
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coverage.
1. Notwithstanding the uniformity of treatment requirements of section 514C.6, a group
policy, contract, or plan providing for third-party payment or prepayment of health, medical,
and surgical coverage benefits shall provide coverage benefits for applied behavior analysis
provided by a practitioner to covered individuals for the treatment of autism spectrum
disorder pursuant to a treatment plan if the policy, contract, or plan is either of the following:
a. A policy, contract, or plan issued by a carrier, as defined in section 513B.2, to an
29 SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES, §514C.31
employer who on at least fifty percent of the employer’s working days during the preceding
calendar year employed more than fifty full-time equivalent employees. In determining
the number of full-time equivalent employees of an employer, employers who are affiliated
or who are able to file a consolidated tax return for purposes of state taxation shall be
considered one employer.
b. Aplanestablishedpursuanttochapter509Aforpublicemployeesotherthanemployees
of the state.
2. As used in this section, unless the context otherwise requires:
a. “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, andfunctionalanalysisoftherelationshipbetweenenvironmentandbehavior.
b. “Autismspectrumdisorder”meansthesameasdefinedinsection514C.28,subsection2.
c. “Practitioner” means any of the following:
(1) A physician licensed pursuant to chapter 148.
(2) A psychologist licensed pursuant to chapter 154B.
(3) A behavior analyst licensed pursuant to chapter 154D.
d. “Treatment plan” means a plan for the treatment of autism spectrum disorder
developed by a licensed physician or licensed psychologist after a comprehensive evaluation
or reevaluation performed in a manner consistent with the most recent clinical report
or recommendations of the American academy of pediatrics. “Treatment plan” includes
supervisory services, subject to the provisions of subsection 4.
3. Coverage required pursuant to this section may be subject to deductibles, copayments,
or coinsurance provisions that apply to other medical and surgical services under the policy,
contract, or plan.
4. Coverage required pursuant to this section may be subject to care management
provisions of the applicable policy, contract, or plan, including prior authorization and prior
approval.
5. A carrier or plan may request a review of a treatment plan for a covered individual
not more than once every three months during the first year of the treatment plan and not
more than once every six months during every year thereafter, unless the carrier or plan
and the covered individual’s treating physician or psychologist execute an agreement that
a more frequent review is necessary. An agreement giving a carrier or plan the right to
review the treatment plan of a covered individual more frequently applies only to a particular
coveredindividualreceivingappliedbehavioranalysisanddoesnotapplytootherindividuals
receiving applied behavior analysis from a practitioner. The cost of conducting a review
under this section shall be paid by the carrier or plan. A carrier or plan shall not change the
provisions of a treatment plan until the completion of a review of the treatment plan.
6. This section shall not be construed to limit benefits which are otherwise available to an
individual under a group policy, contract, or plan.
7. This section shall not be construed as affecting any obligation to provide services to an
individual under an individualized family service plan, an individualized education program,
or an individualized service plan.
8. This section shall not apply to accident-only, specified disease, short-term hospital
or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement,
long-term care, basic hospital and medical-surgical expense coverage as defined by the
commissioner, disability income insurance coverage, coverage issued as a supplement to
liability insurance, workers’ compensation or similar insurance, or automobile medical
payment insurance, or individual accident and sickness policies issued to individuals or to
individual members of a member association.
9. This section applies to third-party provider payment contracts, policies, or plans
specified in subsection 1, paragraph “a” or to plans established pursuant to chapter 509A for
§514C.31, SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES 30
public employees other than employees of the state, that are delivered, issued for delivery,
continued, or renewed in this state on or after January 1, 2018.