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House
File
5
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Introduced
HOUSE
FILE
5
BY
ANDREWS
A
BILL
FOR
An
Act
relating
to
insurance
coverage
for
covered
individuals
1
for
the
treatment
of
autism
spectrum
disorder
and
including
2
applicability
provisions.
3
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
4
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Section
1.
Section
514C.22,
subsection
3,
paragraph
g,
Code
1
2025,
is
amended
to
read
as
follows:
2
g.
Autistic
disorders
Autism
spectrum
disorder,
as
that
term
3
is
defined
in
section
514C.28,
subsection
2
.
4
Sec.
2.
Section
514C.22,
subsection
4,
Code
2025,
is
amended
5
to
read
as
follows:
6
4.
The
commissioner,
by
rule,
shall
define
the
biologically
7
based
mental
illnesses
identified
in
subsection
3
,
paragraphs
8
“a”
through
“f”
.
Definitions
established
by
the
commissioner
9
shall
be
consistent
with
definitions
provided
in
the
most
10
recent
edition
of
the
American
psychiatric
association’s
11
diagnostic
and
statistical
manual
of
mental
disorders,
as
such
12
definitions
may
be
amended
from
time
to
time.
The
commissioner
13
may
adopt
the
definitions
provided
in
such
manual
by
reference.
14
Sec.
3.
Section
514C.22,
subsection
7,
Code
2025,
is
amended
15
by
adding
the
following
new
paragraph:
16
NEW
PARAGRAPH
.
c.
Notwithstanding
paragraphs
“a”
and
“b”
,
17
a
group
policy,
contract,
or
plan
covered
under
this
section
18
shall
not
impose
an
aggregate
annual
or
lifetime
limit
on
19
biologically
based
mental
illness
coverage
benefits
for
autism
20
spectrum
disorder.
21
Sec.
4.
Section
514C.22,
subsection
8,
unnumbered
paragraph
22
1,
Code
2025,
is
amended
to
read
as
follows:
23
A
group
policy,
contract,
or
plan
covered
under
this
24
section
shall
at
a
minimum
allow
for
thirty
inpatient
days
25
and
fifty-two
outpatient
visits
annually
,
and
shall
not
26
limit
the
number
of
outpatient
visits
a
covered
individual
27
may
have
with
a
practitioner
for
applied
behavior
analysis
28
under
section
514C.31,
or
with
an
autism
service
provider
for
29
treatment
of
autism
spectrum
disorder
under
section
514C.28
.
30
The
policy,
contract,
or
plan
may
also
include
deductibles,
31
coinsurance,
or
copayments,
provided
the
amounts
and
extent
32
of
such
deductibles,
coinsurance,
or
copayments
applicable
to
33
other
health,
medical,
or
surgical
services
coverage
under
the
34
policy,
contract,
or
plan
are
the
same.
It
is
not
a
violation
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of
this
section
if
the
policy,
contract,
or
plan
excludes
1
entirely
from
coverage
benefits
for
the
cost
of
providing
the
2
following:
3
Sec.
5.
Section
514C.28,
subsections
1,
3,
and
5,
Code
2025,
4
are
amended
to
read
as
follows:
5
1.
Notwithstanding
the
uniformity
of
treatment
requirements
6
of
section
514C.6
,
a
group
plan
established
pursuant
to
chapter
7
509A
for
employees
of
the
state
providing
for
third-party
8
payment
or
prepayment
of
health,
medical,
and
surgical
coverage
9
benefits
shall
provide
coverage
benefits
to
covered
individuals
10
under
twenty-one
years
of
age
for
the
diagnostic
assessment
11
of
autism
spectrum
disorder
and
for
the
treatment
of
autism
12
spectrum
disorder.
13
3.
Coverage
is
required
pursuant
to
this
section
in
a
14
maximum
benefit
amount
of
not
more
than
thirty-six
thousand
15
dollars
per
year
but
shall
not
be
subject
to
any
limits
on
16
the
number
of
visits
to
a
covered
individual
may
have
with
17
an
autism
service
provider
for
treatment
of
autism
spectrum
18
disorder.
The
commissioner
shall,
on
or
before
April
1
of
19
each
calendar
year,
publish
an
adjustment
to
the
maximum
20
benefit
required
equal
to
the
percentage
change
in
the
United
21
States
department
of
labor
consumer
price
index
for
all
urban
22
consumers
in
the
preceding
year,
and
the
published
adjusted
23
maximum
benefit
shall
be
applicable
to
group
policies,
24
contracts,
or
plans
subject
to
this
section
that
are
issued
25
or
renewed
on
or
after
January
1
of
the
following
calendar
26
year.
Payments
made
under
a
group
plan
subject
to
this
section
27
on
behalf
of
a
covered
individual
for
treatment
of
a
health
28
condition
unrelated
to
or
distinguishable
from
the
individual’s
29
autism
spectrum
disorder
shall
not
be
applied
toward
any
30
maximum
benefit
established
under
this
subsection
.
31
5.
Coverage
required
by
this
section
shall
be
provided
32
in
coordination
with
coverage
required
for
the
treatment
of
33
autistic
disorders
autism
spectrum
disorder
pursuant
to
section
34
514C.22
.
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Sec.
6.
Section
514C.31,
subsection
1,
unnumbered
paragraph
1
1,
Code
2025,
is
amended
to
read
as
follows:
2
Notwithstanding
the
uniformity
of
treatment
requirements
of
3
section
514C.6
,
a
group
policy,
contract,
or
plan
providing
4
for
third-party
payment
or
prepayment
of
health,
medical,
and
5
surgical
coverage
benefits
shall
provide
coverage
benefits
for
6
applied
behavior
analysis
provided
by
a
practitioner
to
covered
7
individuals
under
nineteen
years
of
age
for
the
treatment
of
8
autism
spectrum
disorder
pursuant
to
a
treatment
plan
if
the
9
policy,
contract,
or
plan
is
either
of
the
following:
10
Sec.
7.
Section
514C.31,
subsection
3,
Code
2025,
is
amended
11
by
striking
the
subsection.
12
Sec.
8.
Section
514C.31,
subsections
4
and
5,
Code
2025,
are
13
amended
to
read
as
follows:
14
4.
Coverage
required
pursuant
to
this
section
may
be
15
subject
to
dollar
limits,
deductibles,
copayments,
or
16
coinsurance
provisions
that
apply
to
other
medical
and
surgical
17
services
under
the
policy,
contract,
or
plan
,
subject
to
the
18
requirements
of
subsection
3
.
19
5.
Coverage
required
pursuant
to
this
section
may
be
20
subject
to
care
management
provisions
of
the
applicable
21
policy,
contract,
or
plan,
including
prior
authorization
,
and
22
prior
approval
,
and
limits
on
the
number
of
visits
a
covered
23
individual
may
make
for
applied
behavior
analysis
.
24
Sec.
9.
APPLICABILITY.
25
1.
The
sections
of
this
Act
amending
section
514C.22
apply
26
to
third-party
payment
provider
policies,
contracts,
and
plans
27
as
specified
in
section
514C.22
that
are
delivered,
issued
28
for
delivery,
continued,
or
renewed
in
this
state
on
or
after
29
January
1,
2026.
30
2.
The
sections
of
this
Act
amending
section
514C.28
apply
31
to
a
group
plan
established
pursuant
to
chapter
509A
for
32
employees
of
the
state
that
are
delivered,
issued
for
delivery,
33
continued,
or
renewed
in
this
state
on
or
after
January
1,
34
2026.
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3.
The
sections
of
this
Act
amending
section
514C.31
1
apply
to
third-party
provider
payment
contracts,
policies,
or
2
plans
specified
in
section
514C.31,
subsection
1,
paragraph
3
“a”,
or
to
plans
established
pursuant
to
chapter
509A
for
4
public
employees
other
than
employees
of
the
state,
that
are
5
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
6
state
on
or
after
January
1,
2026.
7
EXPLANATION
8
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
9
the
explanation’s
substance
by
the
members
of
the
general
assembly.
10
This
bill
relates
to
insurance
coverage
for
covered
11
individuals
for
the
treatment
of
autism
spectrum
disorder
12
(autism).
13
Under
current
law,
a
group
plan
established
pursuant
to
14
Code
chapter
509A
for
employees
of
the
state
that
provides
15
for
third-party
payment
or
prepayment
of
health,
medical,
and
16
surgical
coverage
benefits
(coverage)
shall
provide
coverage
to
17
covered
individuals
under
21
years
of
age
for
the
diagnostic
18
assessment
and
treatment
of
autism,
and
coverage
is
required
19
in
a
maximum
benefit
amount
of
not
more
than
$36,000
per
year.
20
The
bill
eliminates
the
21-year
maximum
age
limit
and
the
21
maximum
benefit
amount.
22
Under
current
law,
a
group
policy,
contract,
or
plan
23
(policy)
providing
for
third-party
payment
or
prepayment
24
of
health,
medical,
and
surgical
coverage
shall
provide
25
coverage
for
applied
behavior
analysis
(analysis)
provided
26
by
a
practitioner
to
covered
individuals
under
19
years
of
27
age
for
the
treatment
of
autism
pursuant
to
a
treatment
plan
28
if
the
policy
is
either
a
policy
issued
by
a
carrier
to
an
29
employer
who
on
at
least
50
percent
of
the
employer’s
working
30
days
during
the
preceding
calendar
year
employed
more
than
50
31
full-time
equivalent
employees,
or
the
policy
is
established
32
pursuant
to
Code
chapter
509A
for
public
employees
other
than
33
employees
of
the
state.
Under
the
bill,
the
age
restriction
34
is
eliminated.
Current
law
requires
that
the
coverage
for
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analysis
shall
provide
an
annual
maximum
benefit
of
not
less
1
than
$36,000
for
individuals
through
age
six,
$25,000
for
2
individuals
age
7
through
13,
and
$12,500
for
individuals
age
3
14
through
18.
The
bill
eliminates
the
maximum
benefit
amounts
4
and
the
age
categories.
5
The
bill
makes
conforming
changes
to
Code
section
514C.22.
6
The
bill
applies
to
plans
specified
in
the
bill
that
are
7
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
8
state
on
or
after
January
1,
2026.
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