SB 321 — Health insurance; definition of autism spectrum disorder.

SESSION ENROLLED VIRGINIA ACTS OF ASSEMBLY ––-- CHAPTER2022 ESESSION NCHAPTER 102 An coverageAct forto autismamend spectrumand disorder;reenact § 38.2-3418.17 of the Code of Virginia, relating to health insurance;

definition.ecoverage offor Virginia,autism relatingspectrum todisorder; health insurancR;

Odefinition. [S 321] L Approved L Be it enacted by the General Assembly of Virginia:

E[S 1.321] Approved April 6, 2022 Be it enacted by the General Assembly of Virginia:

1.

D§ A.38.2-3418.17.

Coverage for autism spectrum disorder.

A.

each corporation providing accident and sickness subscriptioncare contracts;services shall, as provided in this section, provide coverage for the diagnosis of autism spectrumh disorder and the treatment of autism spectrum disorder, in individuals (i) from January 1, 2012, until January 1, 2016, from age two years through age six years;

and(ii) each health maintenance organization providing a health care plan for health care services shall, as provided in this section, provide coverage for the diagnosis of autism spectrum disorder and the treatment of autism spectrum disorder, in individuals (i) from January 1, 2012,2016, until January 1, 2016,2020, from age two years through age six10 years;

(ii)and (iii) from and after January 1, 2016,2020, untilof JanBaryany 1,age, 2020,subject fromto agethe twoannual yearsmaximum throughbenefit agelimitation 10set years;forth in subsection K and to the provisions of subsection G.

andIf (iii)an fromindividual who is being treated for autism spectrum disorder becomes older than the applicable maximum age set forth in the preceding sentence and aftercontinues Januaryto 1,need 2020,treatment, this section does not preclude coverage of any2age,treatment subsectionand G.services.

If an individual who is being treated for autism spectrum disorder becomes older Ehan the applicable maximum age set forth in the preceding sentence and continues to need treatment, this section does not preclude coverage of treatment and services.

"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 thetthe in relationship between environment and behavior.

"Behavioral health treatment" means professional, counseling, and guidance services and treatment functioningprograms ofthat anare individual.onecessary to develop, maintain, or restore, to the maximum extent practicable, the "Diagnosisfunctioning of autism spectrum disorder" means medically necessary assessments, evaluations, or tests to diagnose whether an individualindividual. has an autism spectrum disorder.

"Diagnosis of autism spectrum disorder" means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

or (iii) assist to achieve or maintain maximum functional andcapacity thein functionalperforming capacitiesdaily thatactivities, aretaking appropriateinto foraccount individualsboth of the samefunctional age.pacitycapacity of the individual "Pharmacy care" means medications prescribed by a licensed physician and anythe health-relatedfunctional servicescapacities deemedthat medicallyare necessaryappropriate tofor determineindividuals the need or effectiveness of the medications.same age.

"Pharmacy care" means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

"Therapeutic care" means services provided by licensed or certified speech therapists, occupational the"Treatmenttherapists, forphysical autismtherapists, spectrum disorder" shall be identified in a treatment plan and includes the following care prescribed or orderedclinical forsocial anworkers. individual diagnosed with autism spectrum disorder by a of 3 licensed physician or a licensed psychologist who determines the care to be medically necessary:

(i)"Treatment behavioralfor healthautism treatment,spectrum (ii)disorder" pharmacyshall care,be (iii)identified psychiatricin care,a (iv)treatment psychologicalplan care,and (v)includes therapeuticthe care,following andcare (vi)prescribed appliedor behaviorordered analysisfor whenan providedindividual ordiagnosed supervisedwith byautism aspectrum boarddisorder certifiedby behaviora analystlicensed whophysician shallor bea licensed bypsychologist who determines the Boardcare ofto Medicine.be medically necessary:

(i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) of 3 therapeutic care, and (vi) applied behavior analysis when provided or supervised by a board certified behavior analyst who shall be licensed by the Board of Medicine.

An actuary, affiliated with the insurer, corporation, or health maintenance organization, who is a of 3 member of the American Academy of Actuaries and meets the American Academy of Actuaries' making,professional certifiesqualification instandards writingfor torendering thean Commissioneractuarial ofopinion Insurance that:nion related to health insurEnceinsurance rate (1)making, Basedcertifies onin anwriting analysis to be completed no more frequently than one time per year by each insurer, corporation, or health maintenance organization, or such governmental entity, for the mostCommissioner receRt experience period of atInsurance leastthat: one year's duration, the costs associated with coverage of behavioral health treatment required under this section, and not covered as of December 31, 2011, exceeded one peOcent organization;

andharged(1) overBased theon experiencean periodanalysis to be completed no more frequently than one time per year by theeach insurer, corporation, or health maintLnancemaintenance (2)organization, Thoseor costssuch solelygovernmental wouldentity, leadfor tothe anmost increaserecent inof average3 premiumsexperience chargedperiod of moreat thanleast one percentyear's forduration, allthe insurancecosts policies,associated subscriptionwith contracts,coverage orof behavioral health caretreatment plansrequired commencingunder onthis inceptionsection, orand thenot nextcovered renewalas date,of basedDecember on31, 2011, exceeded one percent of the premiumpremiums ratingcharged methodologyover andthe practicesexperience period by the insurer, E corporation, or health maintenance organization,organization; or such governmental entity, employs;

and D(2) b.Those costs solely would lead to an increase in average premiums charged of more than one percent for all insurance policies, subscription contracts, or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer, corporation, or health maintenance organization, or such governmental entity, employs;

and b.

inception2. or next renewal date of all insurance policies, subscription contracts, or health care plans issued or renewed during the one-year period following the date of the exemption, after which the insurer, corporation, or health maintenance organization, or such governmental entity, shall again provide coverage for behavioral health treatment required under this section;

An exemption allowed under subdivision 1 shall apply for a one-year coverage period following inception or next renewal date of all insurance policies, subscription contracts, or health care plans issued or renewed during the one-year period following the date of the exemption, after which the insurer, corporation, or health maintenance organization, or such governmental entity, shall again provide coverage for behavioral health treatment required under this section;

An insurer, corporation, or health maintenance organization, or such governmental entity, may claim an exemption for a subsequent year, but only if the conditions specified in subdivision 1 again are met;

and exemption for a subsequent year, but only if the conditions specified in subdivision 1Bagain are 4.

R K.

Coverage for applied behavior analysis under this section will be subject to an annual maximum benefit of $35,000, unless the insurer, corporation, or health maintenance organization elects to provide covL.coverage in a greater amount.

L.