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The Vermont Statutes Online



Title

08

:
Banking and Insurance






Chapter

107

:
HEALTH INSURANCE






Subchapter

001
:
GENERALLY










 

§

4088i. Coverage for diagnosis and treatment of early childhood developmental

disorders

(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.

(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 111-148, 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, 2014.

(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 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 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. § 4621.

(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. § 9402. 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;

(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; 2013, No. 96 (Adj.

Sess.), § 18.)