SB 175 — Health Insurance Revisions

and} {(E) therapeutic care.} {[(c){]} {(e)} } "Behavioral health treatment" means counseling and treatment programs, including applied behavior analysis, that are:

and - 3 - SB0175 compared with SB0175S02 (ii) provided or supervised by a:

{[(d)(d) "Diagnosis of autism spectrum disorder" means medically necessary assessments, evaluations, or tests:]}tests: {[(i) performed by a licensed physician who is board certified in neurology, psychiatry, or pediatrics and has experience diagnosing autism spectrum disorder, or a licensed psychologist with experience diagnosing autism spectrum disorder;

and]}(i) {[(ii)performed necessaryby toa diagnoselicensed whetherphysician anwho individualis hasboard ancertified autismin spectrumneurology, disorder.]}psychiatry, {[(e){]}or {(f)}pediatrics }and "Pharmacyhas care"experience meansdiagnosing medicationsautism prescribedspectrum bydisorder, or a licensed physicianpsychologist andwith anyexperience health-relateddiagnosing servicesautism consideredspectrum medicallydisorder; necessary to determine the need or effectiveness of the medications.

{[(f){]}and {(g)}(ii) }necessary "Psychiatricto care"diagnose meanswhether directan orindividual consultativehas servicesan providedautism byspectrum adisorder. psychiatrist licensed in the state in which the psychiatrist practices.

{[(g){]}(e) {(h)}"Mental }health "Psychologicaltherapist" care" means directthe orsame consultativeas servicesthat providedterm byis adefined psychologist licensed in theSection state58-60-102. in which the psychologist practices.

(i)(h)[(e)] "Qualified(f) health"Pharmacy carecare" provider" means anmedications individualprescribed who:by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications.

(i)[(f)] has(g) completed"Psychiatric trainingcare" recognizedmeans bydirect medicalor andconsultative mentalservices healthprovided professionsby asa beingpsychiatrist appropriatelicensed andin necessarythe tostate diagnosein whetherwhich anthe individualpsychiatrist haspractices. an autism spectrum disorder;

and[(g)] (ii)(h) is"Psychological care" means direct or consultative services provided by a psychologist licensed asin anythe ofstate in which the following:psychologist practices.

(A) a physician licensed under Title 58, Chapter 67, Utah Medical Practice Act, or Title 58, Chapter 68, Utah Osteopathic Medical Practice Act;

(B) an advanced practice registered nurse licensed under Title 58, Chapter 31b, Nurse Practice Act;

(C) a clinical social worker licensed under Title 58, Chapter 60, Part 2, Social Worker Licensing Act;

{(D) {a marriage and family therapist licensed under Title 58, Chapter 60, Part 3, Marriage and Family Therapist Licensing Act;} } {(E) {a clinical mental health counselor licensed under Title 58, Chapter 60, Part 4, Clinical Mental Health Counselor Licensing Act;} } {(F) {a psychologist licensed under Title 58, Chapter 61, Psychologist Licensing Act;

or} } {(G) {{a physician assistant licensed under Title 58, Chapter 70a, Utah Physician Assistant Act.} } - 4 - SB0175 compared with SB0175S02 {[(h)] (j)} a marriage and family therapist licensed under Title 58, Chapter 60, Part 3, Marriage and Family Therapist Licensing Act;

(E) a clinical mental health counselor licensed under Title 58, Chapter 60, Part 4, Clinical Mental Health Counselor Licensing Act;

(F) a psychologist licensed under Title 58, Chapter 61, Psychologist Licensing Act;

or (G) a physician assistant licensed under Title 58, Chapter 70a, Utah Physician Assistant Act.

[(i)] (j) {"Treatment"Treatment for autism spectrum disorder":]}disorder": {[(i) means evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a physician or a licensed psychologist described in Subsection (1)(d) who determines the care to be medically necessary;

and]}(i) {[(ii)means includes:]}evidence-based {[(A)care behavioraland healthrelated treatment,equipment providedprescribed or supervisedordered for an individual diagnosed with an autism spectrum disorder by a personphysician or a licensed psychologist described in Subsection (1)(c)(1)(d) (ii);]}who {[(B)determines pharmacythe care;]}care {[(C)to psychiatricbe care;]}medically {[(D)necessary; psychological care;

and]} {[(E) therapeutic care.]} (2) (a) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan offered in the individual market or the large group market and entered(ii) intoincludes: or renewed on or after {[January 1, 2016, and before ]} January 1, 2020, shall provide coverage for {[the{]} autism spectrum disorder} diagnosis and {autism spectrum disorder }treatment{[ of autism spectrum disorder]} :

(A) behavioral health treatment, provided or supervised by a person described in Subsection (1)(c)(ii);

- 2 - Enrolled Copy S.B.

175 (B) pharmacy care;

(C) psychiatric care;

(D) psychological care;

and (E) therapeutic care.

(2)(a) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan offered in the individual market or the large group market and entered into or renewed on or after January 1, 2016, and before January 1, 2020, shall provide coverage for the diagnosis and treatment of autism spectrum disorder:

{[(b)(b) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan offered in the individual market or the large group market and entered into or renewed on or after January 1, 2020, shall provide coverage for the diagnosis and treatment of autism spectrum disorder in accordance with the requirements of this section and rules made by the commissioner.]}commissioner. - 5 - SB0175 compared with SB0175S02 (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to set the minimum standards of coverage for {[the{]} autism spectrum disorder} treatment{[ of autism spectrum disorder]} .

(4)(3) SubjectThe tocommissioner Subsectionmay (5),adopt the rules described in Subsectionaccordance (3)with shallTitle establish63G, durationalChapter limits,3, amountUtah limits,Administrative deductibles,Rulemaking copayments,Act, andto coinsuranceset forthe {[the{]}minimum autismstandards spectrumof disorder}coverage for the treatment {[ofof autism spectrum disorderdisorder. ]} that are similar to, or identical to, the coverage provided for other illnesses or diseases.

(5)(4) (a)Subject Coverageto forSubsection behavioral(5), healththe treatmentrules fordescribed ain personSubsection with(3) anshall establish durational limits, amount limits, deductibles, copayments, and coinsurance for the treatment of autism spectrum disorder shallthat coverare atsimilar leastto, 600or hoursidentical ato, year.the coverage provided for other illnesses or diseases.

(5)(a) Coverage for behavioral health treatment for a person with an autism spectrum disorder shall cover at least 600 hours a year.

(d) Notwithstanding Section 31A-45-303, a health benefit plan providing treatment under Subsections (5)(a) and (b) shall include in the plan's provider network both board certified behavior analysts and mental health providers qualified under Subsection- {[(1)(c)(ii){]}3 (1)(e)(ii)}.- S.B.

{(e)}175 ExceptEnrolled asCopy providedSubsection in(1)(c)(ii). this section, a health benefit plan may implement cost containment strategies, including prior authorization requirements, for autism spectrum disorder treatment.} (6) (a) A health care provider shall submit a treatment plan for autism spectrum disorder to the insurer within 14 business days of starting treatment for an individual.

(b)(6)(a) IfA anhealth individualcare isprovider receivingshall {autismsubmit spectruma disordertreatment }treatment{[plan for an autism spectrum disorder]}disorder ,to anthe insurer {[shallwithin have14 thebusiness rightdays to{]} may} request a review of thatstarting treatment notfor morean thanindividual. once every three months.

(b) If an individual is receiving treatment for an autism spectrum disorder, an insurer shall have the right to request a review of that treatment not more than once every three months.

- 6 - SB0175 compared with SB0175S02 (d) If an insurer makes a determination to stop treatment as a result of the review of the treatment plan under this [subsection] Subsection (6), the determination of the insurer may be reviewed under Section 31A-22-629.

(7)(7)(a) (a) Before July 1, 2027, and before July 1 each year after, a health benefit plan shall report the following to the department for the prior insurance plan year:

(c) Beginning September 1, 2027, the department shall provide on the department's website, in a form that is easily accessible, information regarding which health benefit plans reimburse a qualifiedmental health caretherapist provider that is not a physician or a psychologist- for4 autism- spectrumEnrolled disorderCopy treatment.S.B.

175 psychologist for autism spectrum disorder treatment.

63I-1-231.63I-1-231 .

- 7 - SB0175 compared with SB0175S02 [(3)] (4) Subsection 31A-22-650(8), regarding the rulemaking for the preauthorization reporting requirement, is repealed July 1, 2029.

Effective date.

2-8-26 9:19 PM - 85 -