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SB2204
THE SENATE
S.B. NO.
2204
THIRTY-THIRD LEGISLATURE, 2026
STATE OF HAWAII
A BILL FOR AN ACT
relating
to INSURANCE
.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
����
SECTION 1.
�
The
legislature finds that autism spectrum disorder (autism) is a lifelong
neurodevelopmental condition that can affect individuals in varying ways across
their lifespan.
�
The legislature further
finds, however, that existing law limits health insurance coverage for applied
behavioral analysis and other therapies for the diagnosis and treatment of
autism to individuals under fourteens years of age.
�
This age limitation denies necessary care to
many adolescents and adults who would continue to benefit from therapeutic
support for autism.
�
The legislature also
finds that the current annual cap of $25,000 on health insurance coverage for
applied behavioral analysis creates additional barriers to accessing adequate
and continuous treatment for autism, as this amount is often insufficient to
cover the full cost of applied behavioral analysis services for many
individuals.
�
The legislature believes
that removing these limitations will ensure equitable access to medically
necessary treatment and improve long-term health outcomes for individuals with
autism in the State.
����
Accordingly, the purpose of this Act is to:
����
(1)
�
Repeal
the fourteen years and under age limit for health insurance coverage
requirements for the diagnosis and treatment of autism; and
����
(2)
�
Repeal
the maximum coverage benefit limit of $25,000 for applied behavioral analysis
services.
����
SECTION
2
.
�
Section 431:10A-133, Hawaii Revised Statutes,
is amended to read as follows:
����
"[
[
]�431:10A-133[
]
]
�
Autism benefits and coverage; notice; definitions.
�
(a)
�
Each individual or group accident and health or sickness insurance
policy issued or renewed in this State after January 1, [
2016,
]
2027,
shall provide to the policyholder and individuals [
under fourteen years of
age
] covered under the policy coverage for the diagnosis
of autism
and
treatment [
of
] for autism.
����
(b)
�
This section shall not apply to disability, accident‑only,
medicare, medicare supplement, student accident and health or sickness
insurance, dental-only, and vision-only policies or policies or renewals of six
months or less.
����
(c)
�
Every insurer shall provide written notice to its policyholders
regarding the coverage required by this section.
�
The notice shall be in writing and
prominently positioned in any literature or correspondence sent to
policyholders and shall be transmitted to policyholders within calendar year
2016 when annual information is made available to policyholders or in any other
mailing to policyholders, but in no case later than December 31, 2016.
����
[
(d)
�
Coverage for applied behavioral analysis provided under this section
shall be subject to a maximum benefit of $25,000 per year for services for
children ages thirteen and under.
�
This
section shall not be construed as limiting benefits that are otherwise
available to an individual under an accident and health or sickness insurance
policy.
�
Payments made by an insurer on
behalf of a covered individual for any care, treatment, intervention, or
service other than applied behavioral analysis shall not be applied toward the
maximum benefit established under this subsection.
]
����
[
(e)
]
(d)
�
Coverage under this section may be subject to
copayment, deductible, and coinsurance provisions of an accident and health or
sickness insurance policy that are no less favorable than the copayment,
deductible, and coinsurance provisions for substantially all medical services
covered by the policy.
����
[
(f)
]
(e)
�
Treatment for autism requests shall include a
treatment plan.
�
Except for inpatient
services, if an individual is receiving treatment for autism, an insurer may
request a review of the treatment plan for continued authorization of coverage
for treatment for autism at the insurer's discretion.
����
[
(g)
]
(f)
�
The medical necessity of treatment covered by
this section shall be determined pursuant to the policy and shall be defined in
the policy in a manner that is consistent with other services covered under the
policy.
�
Except for inpatient services,
if an individual is receiving treatment for autism, an insurer may request a
review of the medical necessity of that treatment at the insurer's discretion.
����
[
(h)
]
(g)
�
This section shall not be construed as
reducing any obligation to provide services to an individual under any publicly
funded program, an individualized family service plan, an individualized
education program, or an individualized service plan.
����
[
(i)
]
(h)
�
Coverage under this section shall exclude
coverage for:
����
(1)
�
Care
that is custodial in nature;
����
(2)
�
Services
and supplies that are not clinically appropriate;
����
(3)
�
Services
provided by family or household members;
����
(4)
�
Treatments
considered experimental; and
����
(5)
�
Services
provided outside of the State.
����
[
(j)
]
(i)
�
Insurers shall include in their network of
approved autism service providers only those providers who have cleared state
and federal criminal background checks as determined by the insurer.
����
[
(k)
]
(j)
�
If an individual has been diagnosed as having
autism meeting the diagnostic criteria described in the Diagnostic and
Statistical Manual of Mental Disorders available at the time of diagnosis, upon
publication of a more recent edition of the Diagnostic and Statistical Manual
of Mental Disorders, that individual may be required to undergo repeat
evaluation to remain eligible for coverage under this section.
����
[
(l)
]
(k)
�
Treatment for autism shall not be covered
pursuant to this section unless provided by an autism service provider that is
licensed by a state licensure board.
�
If
a state licensure board that licenses providers to provide autism services is
unavailable, the autism service provider shall:
����
(1)
�
Be
certified by the Behavior Analyst Certification Board, Inc.; provided that
certification by the Behavior Analyst Certification Board, Inc., shall be valid
for purposes of this subsection for no more than one year; or
����
(2)
�
Meet
any existing credentialing requirements determined by the insurer.
����
[
(m)
]
(l)
�
As used in this section[
, unless the
context clearly requires otherwise
]:
����
"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 the relations between environment and
behavior.
����
"Autism" means autism spectrum
disorder as defined by the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders.
����
"Autism service provider" means
any person, entity, or group that provides treatment for autism and meets the
minimum requirements pursuant to subsection [
(l).
]
(k).
����
"Behavioral health treatment"
means evidence based counseling and treatment programs, including applied
behavior analysis, that are:
����
(1)
�
Necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual; and
����
(2)
�
Provided
or supervised by an autism service provider.
����
"Diagnosis of autism" means
medically necessary assessments, evaluations, or tests conducted to diagnose
whether an individual has autism.
����
"Pharmacy care" means medications
prescribed by a licensed physician or registered nurse practitioner and any
health-related services that are deemed medically necessary to determine the
need or effectiveness of the medications.
����
"Psychiatric care" means direct
or consultative services provided by a licensed psychiatrist.
����
"Psychological care" means direct
or consultative services provided by a licensed psychologist.
����
"Therapeutic care" means services
provided by licensed speech pathologists, registered occupational therapists,
licensed social workers, licensed clinical social workers, or licensed physical
therapists.
����
"Treatment for autism" includes
the following care prescribed or ordered for an individual diagnosed with
autism by a licensed physician, psychiatrist, psychologist, licensed clinical
social worker, or registered nurse practitioner if the care is determined to be
medically necessary:
����
(1)
�
Behavioral
health treatment;
����
(2)
�
Pharmacy
care;
����
(3)
�
Psychiatric
care;
����
(4)
�
Psychological
care; and
����
(5)
�
Therapeutic
care."
����
SECTION
3
.
�
Section 432:1-614, Hawaii Revised Statutes,
is amended to read as follows:
����
"[
[
]
�432:1-614[
]
]
�
Autism
benefits and coverage; notice; definitions.
�
(a)
�
Each hospital and medical
service plan contract issued or renewed in this State after January 1,
[
2016,
]
2027,
shall provide to the
member and individuals [
under fourteen years of age
] covered under the
plan contract coverage for the diagnosis
of autism
and treatment [
of
]
for
autism.
����
(b)
�
This section shall not apply to disability, accident‑only,
medicare, medicare supplement, student accident and health or sickness
insurance, dental-only, and vision-only policies or policies or renewals of six
months or less.
����
(c)
�
Every mutual benefit society shall provide written notice to its members
regarding the coverage required by this section.
�
The notice shall be in writing and
prominently positioned in any literature or correspondence sent to members and
shall be transmitted to members within calendar year [
2016,
]
2027,
when annual information is made available to members or in any other mailing to
members, but in no case later than December 31, [
2016.
]
2027.
����
[
(d)
�
Coverage for applied behavioral analysis provided under this section
shall be subject to a maximum benefit of $25,000 per year for services for
children ages thirteen and under.
�
This
section shall not be construed as limiting benefits that are otherwise
available to a member under a hospital and medical service plan contract.
�
Payments made on behalf of a member for any
care, treatment, intervention, or service other than applied behavioral
analysis shall not be applied toward the maximum benefit established under this
subsection.
]
����
[
(e)
]
(d)
�
Coverage under this section may be subject to
copayment, deductible, and coinsurance provisions of a policy that are no less
favorable than the copayment, deductible, and coinsurance provisions for
substantially all medical services covered by the plan contract.
����
[
(f)
]
(e)
�
Treatment for autism requests shall include a
treatment plan.
�
Except for inpatient
services, if an individual is receiving treatment for autism, a mutual benefit
society may request a review of the treatment plan for continued authorization
of coverage for treatment for autism at the mutual benefit society's
discretion.
����
[
(g)
]
(f)
�
The medical necessity of treatment covered by
this section shall be determined pursuant to the plan contract and shall be
defined in the plan contract in a manner that is consistent with other services
covered under the plan contract.
�
Except
for inpatient services, if an individual is receiving treatment for autism, a
mutual benefit society may request a review of the medical necessity of that
treatment at the society's discretion.
����
[
(h)
]
(g)
�
This section shall not be construed as
reducing any obligation to provide services to an individual under any publicly
funded program, an individualized family service plan, an individualized
education program, or an individualized service plan.
����
[
(i)
]
(h)
�
Coverage under this section shall exclude
coverage for:
����
(1)
�
Care
that is custodial in nature;
����
(2)
�
Services
and supplies that are not clinically appropriate;
����
(3)
�
Services
provided by family or household members;
����
(4)
�
Treatments
considered experimental; and
����
(5)
�
Services
provided outside of the State.
����
[
(j)
]
(i)
�
Mutual benefit societies shall include in
their network of approved autism service providers only those providers who
have cleared state and federal criminal background checks as determined by the
society.
����
[
(k)
]
(j)
�
If an individual has been diagnosed as having
autism meeting the diagnostic criteria described in the Diagnostic and
Statistical Manual of Mental Disorders available at the time of diagnosis, upon
publication of a more recent edition of the Diagnostic and Statistical Manual
of Mental Disorders, that individual may be required to undergo repeat
evaluation to remain eligible for coverage under this section.
����
[
(l)
]
(k)
�
Treatment for autism shall not be covered
pursuant to this section unless provided by an autism service provider that is
licensed by a state licensure board.
�
If
a state licensure board that licenses providers to provide autism services is
unavailable, the autism service provider shall:
����
(1)
�
Be
certified by the Behavior Analyst Certification Board, Inc.; provided that
certification by the Behavior Analyst Certification Board, Inc., shall be valid
for purposes of this subsection for no more than one year; or
����
(2)
�
Meet
any existing credentialing requirements determined by the mutual benefit
society.
����
[
(m)
]
(l)
�
As used in this section[
, unless the
context clearly requires otherwise
]:
����
"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 the relations between environment and
behavior.
����
"Autism" means autism spectrum
disorder as defined by the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders.
����
"Autism service provider" means
any person, entity, or group that provides treatment for autism and meets the
minimum requirements pursuant to subsection [
(l).
]
(k).
����
"Behavioral health treatment"
means evidence based counseling and treatment programs, including applied
behavior analysis, that are:
����
(1)
�
Necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual; and
����
(2)
�
Provided
or supervised by an autism service provider.
����
"Diagnosis of autism" means
medically necessary assessments, evaluations, or tests conducted to diagnose
whether an individual has autism.
����
"Pharmacy care" means medications
prescribed by a licensed physician or registered nurse practitioner and any
health‑related services that are deemed medically necessary to determine
the need or effectiveness of the medications.
����
"Psychiatric care" means direct
or consultative services provided by a licensed psychiatrist.
����
"Psychological care" means direct
or consultative services provided by a licensed psychologist.
����
"Therapeutic care" means services
provided by licensed speech pathologists, registered occupational therapists,
licensed social workers, licensed clinical social workers, or licensed physical
therapists.
����
"Treatment for autism" includes
the following care prescribed or ordered for an individual diagnosed with
autism by a licensed physician, psychiatrist, psychologist, licensed clinical
social worker, or registered nurse practitioner if the care is determined to be
medically necessary:
����
(1)
�
Behavioral
health treatment;
����
(2)
�
Pharmacy
care;
����
(3)
�
Psychiatric
care;
����
(4)
�
Psychological
care; and
����
(5)
�
Therapeutic
care."
����
SECTION
4.
�
The benefit to be provided by health
maintenance organizations corresponding to the benefit provided under section
431:10A-133, Hawaii Revised Statutes, as amended, in section 2 of this Act,
shall take effect for all policies, contracts, plans, or agreements issued or
renewed in the State after December 31, 2026.
����
SECTION 5.
�
Statutory material to be repealed is bracketed and stricken.
�
New statutory material is underscored.
����
SECTION 6.
�
This Act shall take effect on January 1, 2027.
INTRODUCED BY:
_____________________________
Report Title:
Health
Insurance; Autism; Benefits; Coverage; Age; Limit; Repeal
Description:
Beginning
1/1/2027, repeals the fourteen years and under age limit for health insurance
coverage requirements for the diagnosis and treatment of autism.
�
Repeals the maximum coverage benefit limit of
$25,000 for applied behavioral analysis services.
The summary description
of legislation appearing on this page is for informational purposes only and is
not legislation or evidence of legislative intent.