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31A-22-642
63I-1-231
31A-22-642
63I-1-231
0
Health Insurance Revisions
2026 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Karen Kwan
House Sponsor: Norman K Thurston
LONG TITLE
General Description:
This bill amends provisions regarding autism insurance coverage.
Highlighted Provisions:
This bill:
defines terms; and
creates a reporting requirement.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
31A-22-642
, as last amended by Laws of Utah 2022, Chapter 415
63I-1-231
, as last amended by Laws of Utah 2025, Chapters 241, 473
Be it enacted by the Legislature of the state of Utah:
Section 1. Section
31A-22-642
is amended to read:
31A-22-642
. Insurance coverage for autism spectrum disorder.
(1)
As used in this section:
(a)
"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 relationship between
environment and behavior.
(b)
"Autism spectrum disorder" means pervasive developmental disorders as defined by
the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM).
(c)
"Behavioral health treatment" means counseling and treatment programs, including
applied behavior analysis, that are:
(i)
necessary to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual; and
(ii)
provided or supervised by a:
(A)
board certified behavior analyst; or
(B)
person licensed under
Title 58, Chapter 1, Division of Professional Licensing
Act
, whose scope of practice includes mental health services.
(d)
"Diagnosis of autism spectrum disorder" means medically necessary assessments,
evaluations, or 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
(ii)
necessary to diagnose whether an individual has an autism spectrum disorder.
(e)
"Mental health therapist" means the same as that term is defined in Section
58-60-102
.
(e)
(f)
"Pharmacy care" means medications prescribed by a licensed physician and any
health-related services considered medically necessary to determine the need or
effectiveness of the medications.
(f)
(g)
"Psychiatric care" means direct or consultative services provided by a
psychiatrist licensed in the state in which the psychiatrist practices.
(g)
(h)
"Psychological care" means direct or consultative services provided by a
psychologist licensed in the state in which the psychologist practices.
(h)
(i)
"Therapeutic care" means services provided by licensed or certified speech
therapists, occupational therapists, or physical therapists.
(i)
(j)
"Treatment for autism spectrum 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
(ii)
includes:
(A)
behavioral health treatment, provided or supervised by a person described in
Subsection
(1)(c)(ii)
;
(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:
(i)
for a child who is at least two years old, but younger than 10 years old; and
(ii)
in accordance with the requirements of this section and rules made by the
commissioner.
(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.
(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
treatment of autism spectrum disorder.
(4)
Subject to Subsection
(5)
, the rules described in Subsection
(3)
shall establish durational
limits, amount limits, deductibles, copayments, and coinsurance for the treatment of
autism spectrum disorder that are similar to, or identical to, 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.
(b)
Notwithstanding Subsection
(5)(a)
, for 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, coverage for behavioral health treatment for a person with an autism spectrum
disorder may not have a limit on the number of hours covered.
(c)
Other terms and conditions in the health benefit plan that apply to other benefits
covered by the health benefit plan apply to coverage required by this section.
(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)
.
(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)
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.
(c)
A review of treatment under this Subsection
(6)
may include a review of treatment
goals and progress toward the treatment goals.
(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)
(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:
(i)
the average wait time for an enrollee to receive an autism assessment;
(ii)
if the health benefit plan has prior authorization requirements related to autism
assessment or treatment;
(iii)
the number of enrollees under age 18 that were diagnosed with autism spectrum
disorder;
(iv)
of the number of diagnoses described in Subsection
(7)(a)(iii)
, the number of
diagnoses disaggregated based on provider license type that made the diagnosis;
(v)
of the number of diagnoses described in Subsection
(7)(a)(iii)
, the number of
enrollees that received applied behavior analysis treatment;
(vi)
for enrollees that received applied behavior analysis treatment:
(A)
the average number of hours of applied behavior analysis treatment received;
and
(B)
the average cost of applied behavior analysis treatment received; and
(vii)
if the health benefit plan accepts state defrayal payments under Subsection
31A-30-118(2)
for coverage described in this section.
(b)
The department shall compile the information described in Subsection
(7)(a)
and
provide a report to the Health and Human Services Interim Committee on or before
September 1.
(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 mental health therapist that is not a physician or a
psychologist for autism spectrum disorder treatment.
Section 2. Section
63I-1-231
is amended to read:
63I-1-231
. Repeal dates: Title
31A
.
(1)
Section
31A-2-217
, Coordination with other states, is repealed July 1, 2033.
(2)
Subsection
31A-22-642(7)
, regarding the reporting requirement for autism coverage, is
repealed January 1, 2030.
(2)
(3)
Subsection
31A-22-650(5)(b)
, regarding the reporting requirement that includes the
number of preauthorizations that were approved and denied, is repealed July 1, 2029.
(3)
(4)
Subsection
31A-22-650(8)
, regarding the rulemaking for the preauthorization
reporting requirement, is repealed July 1, 2029.
(4)
(5)
Section
31A-22-627.1
, Ground ambulance reimbursement, is repealed July 1, 2027.
Section 3.
Effective Date.
This bill takes effect on
May 6, 2026
.
3-6-26 8:45 AM