Regarding Implementation of ACT 158:

Transcription

1 AGENCY OF HUMAN SERVICES REPORT TO THE LEGISLATURE OF THE STATE OF VERMONT Regarding Implementation of ACT 158: AN ACT RELATING TO HEALTH INSURANCE COVERAGE FOR EARLY CHILDHOOD DEVELOPMENTAL DISORDERS, INCLUDING AUTISM SPECTRUM DISORDERS JANUARY 2014 Submitted to: Senate Health and Welfare House Health Care

2 Introduction Act 158, an act relating to health insurance coverage for early childhood developmental disorders, including autism spectrum disorders (ASD), was passed May 16, The act requires both private and Medicaid health insurance to cover evidence-based diagnosis and treatment of early childhood developmental disorders (including ASD), including applied behavior analysis, for children birth to age 21. A copy of the statute (8 V.S.A. 4088i.) is included in the appendix ( ). The act requires the Agency Of Human Services (AHS) to submit a report, in consultation with Autism Speaks and health insurers, to the Senate Committee on Health and Welfare and the House Committee on Health Care regarding the implementation of the act, including an assessment of whether eligible individuals are receiving evidence-based services, how such services may be improved, and the fiscal impact of these services. This report is being submitted to meet that requirement. Progress on Implementation of Act 158 Implementation within Medicaid The act took effect on July 1, 2012 for Medicaid. The act requires both private and Medicaid health insurance to cover diagnosis and treatment of early childhood developmental disorders. The specific treatments identified in the act include: Behavioral health treatment (which includes counseling and treatment, including applied behavior analysis) Pharmacy care Psychiatric care Psychological care Therapeutic care (defined as Occupational Therapy(OT), Physical Therapy (PT) and Speech Language Therapy(SLP)) Access to pharmacy, psychiatric and psychological care is not impacted by the enactment of this legislation within Medicaid. Children with Medicaid insurance continue to access these services through private providers or through Vermont s Designated Developmental Disability and Mental Health Agencies (DA). There were some changes made to access for therapeutic care based on the act. On 7/6/12, the Department of Vermont Health Access (DVHA) posted on their website notification that they revised their therapy guidelines to come into compliance with the requirements of the act. The therapy guidelines refer to Occupational Therapy, Physical Therapy and Speech Language Therapy. The guidelines are available at The guidelines expanded the availability of these services to cover all diagnoses that would fall under early childhood developmental disorders under Medicaid. Other minor adjustments were made to the guidelines to bring them into compliance with the act. 2

3 It is difficult to assess the impact of the act at this point in time given the short period of time the changes have been in place. DVHA evaluated Medicaid billing for therapeutic services for children with early childhood developmental disorders from birth to 21 for the first six months of State Fiscal Year (SFY) 2012 compared to the first six months of SFY13, which were the first six months of the implementation of the act. There is no significant change in the number of children accessing these services or the amount spent. There may be several possible reasons for this. First, it often takes a while for providers and families to become aware of changes in available services. In other states where insurance mandates have been enacted for children with autism, utilization of benefits often starts slowly as indicated in - Actuarial Cost Estimate: Vermont Senate Bill S.262. Another possible explanation for the lack of difference in numbers of children accessing these services, is that it is possible that some children who had been accessing these therapies through Medicaid are now accessing them through their private insurance, while others are now accessing these services through Medicaid. Either way, the number of children accessing these services is relatively small, 128 in FY12 and 113 in FY13. Many children receive these therapies in school through special education and do not require additional services outside of school. The most significant change required by the legislation is the requirement to cover a specific behavioral treatment, applied behavior analysis (ABA). ABA is an evidence-based approach used to teach new skills and/or reduce behavior challenges. It has been used to address a wide variety of issues presented by children. ABA services are often cited as an evidence-based treatment in particular for children with ASD. While ABA services have been available primarily in schools in some parts of the state, they have not been a widely available or covered service through Medicaid or private insurance outside of schools. Since the legislation was enacted, the Agency of Human Services has been working across departments to increase the availability of applied behavior analysis services for children. Act 158 was an expansion of Act 127, which had been passed in 2011 and was focused on insurance coverage just for children with ASD, under age 6. Prior to the enactment of Act 127, a legislative study was completed to determine the potential impact of passage ( ). The report identified a number of potential challenges related to implementation of the legislation. One of the barriers noted in the 2011 Legislative Report was having an insufficient number of ABA providers with the required credentials across the state. Act 158 requires ABA services to be provided or supervised by a nationally board certified behavior analyst (BCBA) or by a licensed provider, such as a licensed psychologist with expertise in ABA. There are currently 40 BCBAs in Vermont (Behavior Analysts Certification Board website ) up from 30 in Many of these providers are already providing services to children with disabilities in schools or through the state s Designated Agencies. This limits the expansion of availability of ABA services, or services for additional children because of the small number of ABA providers with the required credentials. In order to expand the number of ABA providers in the state, in August 2013, the Department of Disabilities, Aging and Independent Living (DAIL) provided $90,000 in federal grant funds to 5 3

4 of the state s Designated Agencies for children with mental health and developmental disabilities to train additional BCBAs. AHS is also in the process of finalizing the procedures for accessing applied behavior analysis services through Medicaid. This work is being completed as part of the Integrated Family Services initiative, which is an effort to integrate all services for children and families across AHS departments. In the last fiscal year, approximately an additional $6 million dollars were transferred from DVHA to the State s Designated Agencies to meet the developmental and mental health treatment needs of children (SFY14 annualized to $8.2M). It s not clear at this time what the demand for these services will be. While quite a few BCBAs work through the Designated Agencies, which are Medicaid enrolled providers, there are also private providers not connected to the Designated Agencies. Increasing access through the private providers has been more challenging. The first issue that needed to be researched was whether Medicaid could enroll individual BCBAs as providers. Most Medicaid covered treatment must be provided by licensed providers. BCBAs are certified by the National Behavior Analyst Certification Board (BACB), but they are not licensed in VT. BCBA is not a profession that is regulated and licensed by the Vermont Office of Professional Regulation. DVHA has been in discussions with the Center for Medicaid Services (CMS) and at this point they are unwilling to allow us to pay providers not licensed with the appropriate licensure (and BCBA) with Medicaid funds. There are other states struggling with this as well and CMS is continuing to explore which options and state plan amendments they would support. It was decided that DVHA would oversee private providers billing Medicaid who are appropriately licensed (such Clinical Mental Health Counselor Social Worker or Psychologist), for now. DVHA, along with other AHS departments, is in the process of developing definitions of allowable services, specific billing codes, reimbursement rates, the prior authorization process, and the provider enrollment process including verification of credentials for Medicaid enrollees. In addition, DVHA will need to determine how to best provide both fiscal and program oversight, as well as deal with appeals if services are denied, reduced or terminated for Medicaid recipients. These functions will require additional staff resources which have been requested in the FY 15 Budget. When the legislation was passed, no additional resources were added to the state budget to oversee and administer the services or to pay for the additional ABA services so that request is happening during FY15 budget process. Parents Experience The State Autism Plan Advisory Committee, which includes parents and professionals, was consulted regarding their experience with accessing diagnosis and treatment coverage through Medicaid. Another parent from the Vermont Autism Task Force, who was involved in the passage of the bill and has provided forums for others parents on how to access services through their insurance, provided her personal experience and anecdotal information shared by other parents. A few service providers were contacted as well as Autism Speaks. One parent indicated that even though Occupational Therapy, Physical Therapy and Speech Language Therapy could be reimbursed through Medicaid, that there was a shortage of clinicians with knowledge in ASD appropriate treatment. Parents also reported that the equipment acquisition process can be protracted. DVHA reports that there are Medicaid-enrolled therapists with skill in ASD treatment throughout the state, with certain parts of the state having more 4

5 coverage than others however as discussed previously there is still a small number of providers that are BCBA and appropriately licensed to bill Medicaid. DVHA also reports that there is a one month trial period required to ensure that the proper speech generating device is prescribed for a child; there is a 3 day turn-around time for authorization of a properly documented request for all devices. Beneficiaries who have primary insurances may experience a longer process for equipment acquisition because the primary insurance must first deny the request before Medicaid becomes primary. Another issue noted by parents and providers is that there is a lack of information regarding requirements of the act and the process for navigating the system to access services. It was reported that physicians do not know what or how to prescribe services or where to refer families. Parents are unclear about the process for accessing services including finding providers, getting a prescription for services, applying for services through a Designated Agency, or how to appeal if denied. There is some information regarding the process for accessing services on the website of the Vermont Family Network, a statewide family support organization. Physicians are more likely to know to prescribe and refer for services that have been available previous to ACT 158 such as for equipment and therapy services. Another parent indicated that he had applied for ABA services through his local designated agency, and although the agency was willing to fund the service, the agency did not have any ABA providers available on staff. They are attempting to sub-contract with a BCBA, but there is a limited pool of them in that part of the state, so it is unclear whether this family will actually be able to access this service for their son. The family does have private insurance, but it is through an employer that self-insures, so the requirements for coverage are not applicable in their situation. AHS efforts In addition to the AHS efforts noted above, there have been other activities in the past several years targeted by AHS to increase access to evidence-based diagnosis and treatment for children with autism which include: Hiring of an autism consultant for Children s Integrated Services Early Intervention programs to help develop appropriate treatment and services for children with autism under age 3. Also, there has been monthly training and support for these programs in evidence-based practices which was funded through a grant. Intensive training and coaching of 12 school districts Essential Early Education Program staff in implementing evidence-based interventions for children with autism. The participating schools demonstrated significant increases in their ability to implement evidence-based practices in their classrooms. Training of approximately 40 clinicians in use of evidence-based tools for the diagnosis of autism. Vermont Department of Health (VDH) sponsored training of primary care physicians in implementing screening within their practices to help identify children who may have a developmental disorder, delay or autism. Children are then referred for diagnosis and 5

6 6 treatment to community providers. Medicaid now also pays for these developmental screenings. Because of these efforts developmental screening has increased from being completed in 41% of practices in 2009 to 79% in Autism screening has increased from 58% to 90%. Through an Autism Systems Implementation grant to VDH, AHS sponsored the Vermont Family Network to develop their website to include information about autism. The website has comprehensive information about diagnosis, treatment and resources for families and professionals. The website was visited by 1,095 individuals in the past 6 months. However, the grant period is now ended; the creation of the website and its maintenance has cost about $55,000 per year. Implementation by Private Insurers and Parents Experience The effective date of implementation for the private insurers was on or after October 1, 2012 on such date as a plan is issued, offered or renewed, but in no event later than October, 1, Again, because it is so soon after insurers have been required to cover diagnosis and treatment of early childhood developmental disorders; it is still early to assess the impact on access to services through private insurance. About 50% of all children in Vermont are covered by private insurance and of that about 25% of those are covered by self-insured health plans that are not subject to this mandate. So, it is estimated that the act impacts only about 25% of Vermont children, those with private insurance subject to the mandate. Anecdotal information provided to AHS from parents and providers indicates that implementation by private insurers is evolving slowly. Private insurers are still working out provider agreements with providers of ABA and are also limited by the small number of qualified providers. As for Speech, Occupational, and Physical Therapies, and Therapeutic Equipment, DVHA experience shows that private insurers covered treatment for individuals on the Autism spectrum, but denied coverage for children with other early childhood developmental disorders which were required by Act 158. This issue was referred to the Vermont Department of Financial Regulation (VDFR), and DVHA decided to cover dual eligible children with developmental disorders pending a decision by VDFR. There has yet to be a decision by VDFR. The State Autism Plan Advisory Committee, which includes parents and professionals, was consulted regarding their experience with accessing diagnosis and treatment coverage through private providers. Another parent from the Vermont Autism Task Force, who was involved in the passage of the bill and has provided forums for others parents on how to access services through their insurance, provided her personal experience as well as anecdotal information shared by other parents. One parent, who had both private insurance and Medicaid for her son with autism, indicated that she dropped her private insurance for her son due to the complications of having two insurance policies. When a person has both private and Medicaid insurance, the private insurance is the

7 primary plan. Medicaid is the payer of last resort. In order to get a service covered, it has to be first approved by the private provider. If it is approved, Medicaid will be secondary. If the service is denied, Medicaid might authorize coverage of the service. The parent indicated that having to navigate this process was too cumbersome and time consuming, so she just dropped the private insurance because it was easier to deal with just one insurer. She also indicated that she was interested in services such as Occupational Therapy, Physical Therapy or Speech Language Therapy; however the in-network therapy providers for her insurance company did not have sufficient knowledge or experience in autism to make their services of value to her son. She reported that she had heard from some other families who only had private insurance, that high deductibles for their plan presented a barrier to them accessing services. Medicaid will cover treatment for individuals during the time their deductibles have not yet been met so that there should be no barrier to accessing services for persons with both private insurance and Medicaid One of the potential benefits of Act 158, for children with both private insurance and Medicaid, is the unification of the definitions of mandated coverage, so that private insurers and Medicaid have the same rules governing medical necessity. However, as described below, the implementation of the federal Affordable Care Act rules may allow private insurers to revert to coverage mandated under Act 127 only, not the expansion under Act 158. We are waiting for final interpretation from the Centers for Medicare and Medicaid Services on the impact of ACA on these types of laws. Another parent, the person who worked on passage of the bill, reported on her experience. She has both private insurance and Medicaid for her child. She said that it took approximately 4 months for her private insurer to approve ABA services. She got a prescription for the service from her primary physician and called the insurer for a list of approved providers. They sent an outdated list of providers. She said the insurance company had misinformation regarding the requirements of the act. She proposed using a specific BCBA. The insurance company first denied the request because the provider did not have a license. She pointed out that licensure was not required if the provider was a BCBA. She filed a complaint through the Department of Financial Regulation. After a while, the insurer enrolled the provider and reached an agreement regarding the rate of reimbursement. Her child has been receiving ABA services for several months and has just recently been authorized for an additional 6 months. One DA has been providing ABA services to a few children with ASD who have private insurance. The DA currently has a contract with one insurer. In one case, it took 8 months to finalize the contract because the insurer had been offering reimbursement rates that were not sufficient to cover the DA s cost to provide the service. In another case, they have reached a single case agreement, which applies only to one child, but they are still negotiating for a regular contract with an acceptable reimbursement rate. 7

8 Several family advocates have approached the VDFR to engage them in ensuring that the state s private insurers are complying with the Act. VDFR said that they would get involved if there were any complaints from families. The Vermont Family Network has information regarding Act 158 and how families can access treatment services through their insurance. They are also sponsoring a WIKI that allows families and professionals to share information regarding their experiences to date. This includes some information about the requirements of the act, information for families regarding how to file a complaint with VDFR, and how BCBAs can sign up with Medicaid to be providers. From the perspective of the insurers, there are several factors which are affecting implementation of the Act: 8 1. Limited availability of qualified BCBAs who can provide ABA services: One insurer [CIGNA] reported that there are 11 BCBAs in their network in Vermont, included within 42 autism specialists, and the insurer is willing to contract with BCBAs as individuals, or with agencies providing BCBA. The insurer will not contract with ABA associates, but only with the certified individuals overseeing them. At the national level, the company has a group which is focusing on building out the network. 2. Determination of medically necessary services vs educational services: Private insurance cannot be used to provide developmental services (ABA, OT, PT, SLP) in a school setting, only in the home or community. The insurer will not provide services for a target behavior that occurs only in school, for example. Nor will insurance cover tuition for the child to attend a specialized school. One insurer has authorized one hour a month for the child s BCBA provider to meet with the school s IEP team and family to make sure that the treatment plans are lining up. Another insurer emphasized that the child s schoolbased services need to be optimized, because the insurance only covers services outside of school, if needed. The insurer views the mandate as targeted to children with ASD, or children with moderate to severe/profound intellectual disability, or cerebral palsy. Children with milder disabilities are expected to be able to have their service needs met within schools, unless there are other co-morbid conditions. 3. Evolving process, policies, and procedures: Because other states have also passed coverage mandates, and these mandates are different in some ways, one insurer has established an autism specialty care management team, dedicated to autism and developmental disability questions. Referrals come from prescribing primary care physicians or BCBA providers or agencies, and all new referrals are directed to this autism care management team. The team then has conversations with families and others, about what the state mandates, what is covered under the child s policy, and also works with the family to help them understand autism, and resources. The BCBA talks with the insurer, validates the child s need, and requests a certain number of ABA hours of services. The insurer then has a couple of PhDs who get engaged with the provider about what is the right amount of service for that child. There is follow-up review every

9 6 months. Another insurer describes that, currently, services are determined on a case by case basis, but that the insurer is working with a provider agency in the state to develop policies about eligibility and services. Case by case, the insurer gathers reports about the child s diagnoses and functioning levels (e.g., on the Vineland). 4. The need for carryover of services at home and other settings: Awareness that the Medicaid Children s Personal Care Services (CPCS) program (providing Personal Care Attendants for children with functional limitations) is implementing more consistent eligibility criteria based on medical necessity has led to one insurer to want to be sure that insurance-funded autism services are not filling the gap in PCA hours. Personal care services address needs with activities of daily living (ADLs) such as bathing, toileting and transferring. ABA services are about skill development and behavior modification. They are not the same services. Parent training and carryover of the goals and activities with the child are essential components of the overall plan of care. One insurer commented that, at the 6 month review, the insurer wants to see that the child has made progress. 5. Therapies other than ABA; therapies for children with developmental disabilities other than ASD: One insurer reported there are no limits on number of visits, outside of school, for OT, PT, and SLP for children with developmental disabilities. Anecdotally, there are mixed experiences. One provider said that some families have found that more OT, PT and SLP services are being covered; another provider said he was noting no expansion of insurance-covered services for children with developmental disabilities in these areas, before and after implementation of Act Parent and provider awareness of changes in coverage: One insurer s behavioral health website has a section for autism-related services which outlines the principles of medical necessity and the considerations that go into determining which services (and how much) a child may need. In addition, the website makes available a monthly schedule of webinars on topics of interest to families whose children have ASD. These are archived as well. In addition, another insurer has posted a Corporate Medical Policy, effective date 1/1/2014, concerning its coverage of services for individuals with ASD, following an earlier Corporate Medical Policy with an effective date of 10/1/2013, for Early Childhood Developmental Disorders (ECDD), Including Autism. The implementation of the Federal Affordable Care Act (ACA) may have a significant impact on the requirements for coverage by private insurers. Act 158 includes a clause that specifies that any benefits required after January 1, 2014 that exceed the essential health benefits specified in the Affordable Care Act would not be required in private insurance plans. States are only permitted to include in the essential health benefits state mandated coverage that was passed by the state prior to December, 31, However, a competing interpretation of the ACA indicates there may be age discrimination if the benefit is eliminated. We are waiting for final interpretation from CMS before we can clarify the impact from ACA on Act 158. Regardless, Act 127, which requires coverage for diagnosis and treatment for children with autism spectrum 9

10 disorders under age 6, will continue to be included as an essential health benefit in private insurance plans as it was passed prior to 12/31/11. ( ) It was estimated in the 2011 legislative report that there would be savings to the state for children who had both private insurance and Medicaid. The report estimated that 18% of children with autism spectrum disorders between ages 6-18 had both private and Medicaid insurance. Savings were expected to be realized as private insurance began to cover some treatments that had been denied previously. If the effect of the ACA is to eliminate Act 158, there would be no savings realized from services to children over age 6. Medicaid remains obligated to provide medically necessary treatment to enrolled children. Summary of Implementation A major focus of Act 158 was increasing access to ABA services, which are considered evidence based. Overall, the implementation of this component of Act 158 has been gradual for both private and Medicaid insurance. Major barriers to implementation include: Limited number of BCBAs to provide ABA services CMS limit on provider type (licensure) and support to amend the state plan Challenges negotiating reimbursement rates between providers and insurers Lack of funding for ABA services in Medicaid and for DVHA resources to oversee and administer the services Lack of information for parents, physicians and providers Recommendations for improvements As of January 1, 2014, most of the benefits of Act 158 may no longer be required from private insurers. Private insurance coverage of diagnosis and treatment, including ABA, will continue to be required for children with ASD under 6 years old, regardless. Medicaid will continue to be required to cover medically necessary diagnosis and treatment for all eligible children. Therefore, recommendations for improvements related to private insurance will be limited to children with ASD under 6, with other recommendations pertaining to Medicaid coverage for all children. Activities by AHS or private insurers to continue implementation of Act 158 include: 1) AHS completing its work to define ABA services, establish rates and billing codes, enroll providers and develop a prior authorization process to allow for private providers to provide services with Medicaid reimbursement. 2) If approved in the FY 15 budget DVHA hiring additional professional level personnel trained in ABA to oversee and administer ABA services. This oversight will be aligned with expectations of the other AHS Departments for DAs and with Integrated Family Services. 3) Because some children have both private and Medicaid insurance, DHVA and the private insurers will need to coordinate to develop a common understanding of the requirements in order to allow for smoother coordination of benefits. This would encourage families to maintain their private insurance and allow for potentials savings in Medicaid. 4) Private insurers need to develop their network of ABA providers. The VDFR may need to get involved when insurers are not responding in a timely manner. 10

11 5) AHS will collaborate with a statewide family organization to disseminate information. Families need information regarding available benefits, how to access them and how to advocate for them when they are denied or not provided in a timely manner. Fiscal Impact The fiscal impact of Act 158 had previously been examined in part in the 2011 Report to the Legislature on Act 127: an Act Relating to Insurance Coverage for Autism Diagnosis and Treatment ( ). For children under age 6 with ASD, it was estimated that the cost to Medicaid in FY14 would be in the range of $1,545,738 to provide ABA services to an additional 29 children and could be up to $11,208,044 to serve 185 children, which is the estimate of the total number of children with ASD under age 6. This estimate does not include other children with other early childhood developmental disorders. The needs of those children were not evaluated in the 2011 legislative report. It is not clear what additional services would be accessed by this group of children as a result of Act 158, although some of their families may also wish to access ABA services. Given the number of qualified providers available to provide ABA services and the fact not all families are interested in ABA services, it is most likely that the lowest estimate of $1,545,738 reflects the near term potential fiscal impact for children under 6 within Medicaid. For children with ASD between the ages of 6-18, the legislative study estimated that the cost to Medicaid in FY14 could be in the range of $531,130 to provide ABA services for an additional 40 children and could be up to $10,967,850 to provide ABA services to all 826 children with ASD in this age range. Because of the potential impact of the ACA on the mandate, there would be no offset from private insurance for the age range, however it was estimated that there would be a reduction of other Medicaid services used for children accessing ABA services. The cost estimates reflect these adjustments. The estimate does not include children with other early childhood developmental disorders. Some of these children may be interested in ABA services as well. Given the available providers and the fact that not all families are interested in ABA services, it is likely that the lower estimate of $531,130 reflects the near term potential fiscal impact for children age It should be noted that young adults age would also qualify for this service in Medicaid, so additional funds would likely be needed for them as well. As the number of ABA providers increases, costs to Medicaid will increase over time. As the funding stream becomes available, more people will enter the profession. However, given the time required for training and the rigor of the certification process for BCBAs, the rate of growth in BCBAs will likely be slow. The other fiscal impact is the need for some additional resources at DHVA to oversee and administer ABA services. They are likely to need to cover the cost of a staff or contractor with an ABA background to authorize services. There will also likely be an increase in time for legal support around handling appeals and grievances. Funds for these purposes have been included in DVHA s FY15 budget request. 11

12 APPENDIX The Vermont Statutes Online Title 8: Banking and Insurance Chapter 107: HEALTH INSURANCE Sub-Chapter 001: Generally 8 V.S.A. 4088i. Coverage for diagnosis and treatment of early childhood developmental disorders 4088i. Coverage for diagnosis and treatment of early childhood developmental disorders 12

13 (a)(1) A health insurance plan shall provide coverage for the evidence-based diagnosis and treatment of early childhood developmental disorders, including applied behavior analysis supervised by a nationally board-certified behavior analyst, for children, beginning at birth and continuing until the child reaches age 21. Subdivision (a)(2) effective until January 1, 2014; see also subdivision (a)(2) effective January 1, 2014 set out below. (2) Coverage provided pursuant to this section by Medicaid, the Vermont Health Access Plan, or any other public health care assistance program shall comply with all federal requirements imposed by the Centers for Medicare and Medicaid Services. Subdivision (a)(2) effective January 1, 2014; see also subdivision (a)(2) effective until January 1, 2014 set out above. (2) Coverage provided pursuant to this section by Medicaid or any other public health care assistance program shall comply with all federal requirements imposed by the Centers for Medicare and Medicaid Services. (3) Any benefits required by this section that exceed the essential health benefits specified under Section 1302(b) of the Patient Protection and Affordable Care Act, Public Law , as amended, shall not be required in a health insurance plan offered in the individual, small group, and large group markets on and after January 1, (b) The amount, frequency, and duration of treatment described in this section shall be based on medical necessity and may be subject to a prior authorization requirement under the health insurance plan. (c) A health insurance plan shall not impose greater coinsurance, co-payment, deductible, or other cost-sharing requirements for coverage of the diagnosis or treatment of early childhood developmental disorders than apply to the diagnosis and treatment of any other physical or mental health condition under the plan. (d)(1) A health insurance plan shall provide coverage for applied behavior analysis when the services are provided or supervised by a licensed provider who is working within the scope of his or her license or who is a nationally board-certified behavior analyst. (2) A health insurance plan shall provide coverage for services under this section delivered in the natural environment when the services are furnished by a provider working within the scope of his or her license or under the direct supervision of a licensed provider or, for applied behavior analysis, by or under the supervision of a nationally board-certified behavior analyst. (e) Except for inpatient services, if an individual is receiving treatment for an early developmental delay, the health insurance plan may require treatment plan reviews based on the needs of the individual beneficiary, consistent with reviews for other diagnostic areas and with rules established by the Department of Financial Regulation. A health insurance plan may review 13

14 the treatment plan for children under the age of eight no more frequently than once every six months. (f) 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. The term includes the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. (2) "Autism spectrum disorders" means one or more pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger's disorder. (3) "Behavioral health treatment" means evidence-based counseling and treatment programs, including applied behavior analysis, that are: (A) necessary to develop skills and abilities for the maximum reduction of physical or mental disability and for restoration of an individual to his or her best functional level, or to ensure that an individual under the age of 21 achieves proper growth and development; (B) provided or supervised by a nationally board-certified behavior analyst or by a licensed provider, so long as the services performed are within the provider's scope of practice and certifications. (4) "Diagnosis of early childhood developmental disorders" means medically necessary assessments, evaluations, or tests to determine whether an individual has an early childhood developmental delay, including an autism spectrum disorder. (5) "Early childhood developmental disorder" means a childhood mental or physical impairment or combination of mental and physical impairments that results in functional limitations in major life activities, accompanied by a diagnosis defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Disease (ICD). The term includes autism spectrum disorders, but does not include a learning disability. (6) "Evidence-based" means the same as in 18 V.S.A Subdivision (f)(7) effective until January 1, 2014; see also subdivision (f)(7) effective January 1, 2014 set out below. (7) "Health insurance plan" means Medicaid, the Vermont Health Access Plan, and any other public health care assistance program, any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this State by a 14

15 health insurer, as defined in 18 V.S.A The term does not include benefit plans providing coverage for specific diseases or other limited benefit coverage. Subdivision (f)(7) effective January 1, 2014; see also subdivision (f)(7) effective until January 1, 2014 set out above. (7) "Health insurance plan" means Medicaid and any other public health care assistance program, any individual or group health insurance policy, any hospital or medical service corporation or health maintenance organization subscriber contract, or any other health benefit plan offered, issued, or renewed for any person in this State by a health insurer, as defined in 18 V.S.A The term does not include benefit plans providing coverage for specific diseases or other limited benefit coverage. (8) "Medically necessary" describes health care services that are appropriate in terms of type, amount, frequency, level, setting, and duration to the individual's diagnosis or condition, are informed by generally accepted medical or scientific evidence, and are consistent with generally accepted practice parameters. Such services shall be informed by the unique needs of each individual and each presenting situation, and shall include a determination that a service is needed to achieve proper growth and development or to prevent the onset or worsening of a health condition. (9) "Natural environment" means a home or child care setting. (10) "Pharmacy care" means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need for or effectiveness of a medication. (11) "Psychiatric care" means direct or consultative services provided by a licensed physician certified in psychiatry by the American Board of Medical Specialties. (12) "Psychological care" means direct or consultative services provided by a psychologist licensed pursuant to 26 V.S.A. chapter 55. (13) "Therapeutic care" means services provided by licensed or certified speech language pathologists, occupational therapists, or physical therapists. (14) "Treatment for early developmental disorders" means evidence-based care and related equipment prescribed or ordered for an individual by a licensed health care provider or a licensed psychologist who determines the care to be medically necessary, including: (A) behavioral health treatment; (B) pharmacy care; (C) psychiatric care; 15

16 (D) psychological care; and (E) therapeutic care. (g) Nothing in this section shall be construed to affect any obligation to provide services to an individual under an individualized family service plan, individualized education program, or individualized service plan. A health insurance plan shall not reimburse services provided under 16 V.S.A. 2959a. (h) It is the intent of the general assembly that the Department of Financial Regulation facilitate and encourage health insurance plans to bundle co-payments accrued by beneficiaries receiving services under this section to the extent possible. (Added 2009, No. 127 (Adj. Sess.), 2, eff. July 1, 2011; amended 2011, No. 158 (Adj. Sess.), 1; 2013, No. 79, 8, eff. Jan. 1, 2014.) 16