Ohio Code 1751.84 – Coverage for autism spectrum disorder
(A) Notwithstanding section 3901.71 of the Revised Code, each individual and group health insuring corporation policy, contract, or agreement providing basic health care services that is delivered, issued for delivery, or renewed in this state shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. A health insuring corporation shall not terminate an individual’s coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder. Nothing in this section shall be applied to nongrandfathered plans in the individual and small group markets or to medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies. Except as otherwise provided in division (B) of this section, coverage under this section shall not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an enrollee than the dollar limits, deductibles, or coinsurance provisions that apply to substantially all medical and surgical benefits under the policy, contract, or agreement.
Terms Used In Ohio Code 1751.84
- Basic health care services: means the following services when medically necessary:
(a) Physician's services, except when such services are supplemental under division (B) of this section;
(b) Inpatient hospital services;
(c) Outpatient medical services;
(d) Emergency health services;
(e) Urgent care services;
(f) Diagnostic laboratory services and diagnostic and therapeutic radiologic services;
(g) Diagnostic and treatment services, other than prescription drug services, for biologically based mental illnesses;
(h) Preventive health care services, including, but not limited to, voluntary family planning services, infertility services, periodic physical examinations, prenatal obstetrical care, and well-child care;
(i) Routine patient care for patients enrolled in an eligible cancer clinical trial pursuant to section 3923. See Ohio Code 1751.01
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Corporation: means a corporation formed under Chapter 1701. See Ohio Code 1751.01
- Enrollee: means any natural person who is entitled to receive health care benefits provided by a health insuring corporation. See Ohio Code 1751.01
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health insuring corporation: means a corporation, as defined in division (H) of this section, that, pursuant to a policy, contract, certificate, or agreement, pays for, reimburses, or provides, delivers, arranges for, or otherwise makes available, basic health care services, supplemental health care services, or specialty health care services, or a combination of basic health care services and either supplemental health care services or specialty health care services, through either an open panel plan or a closed panel plan. See Ohio Code 1751.01
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Oversight: Committee review of the activities of a Federal agency or program.
- Person: includes an individual, corporation, business trust, estate, trust, partnership, and association. See Ohio Code 1.59
- Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
- state: means the state of Ohio. See Ohio Code 1.59
(B) Benefits provided under this section shall cover, at minimum, all of the following:
(1) For speech and language therapy or occupational therapy for an enrollee under the age of fourteen that is performed by a licensed therapist, twenty visits per year for each service;
(2) For clinical therapeutic intervention for an enrollee under the age of fourteen that is provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform such services in accordance with a health treatment plan, twenty hours per week;
(3) For mental or behavioral health outpatient services for an enrollee under the age of fourteen that are performed by a licensed psychologist, psychiatrist, or physician providing consultation, assessment, development, or oversight of treatment plans, thirty visits per year.
(C)(1) Except as provided in division (C)(2) of this section, this section shall not be construed as limiting benefits that are otherwise available to an individual under a policy, contract, or agreement.
(2) A policy, contract, or agreement shall stipulate that coverage provided under this section be contingent upon both of the following:
(a) The covered individual receiving prior authorization for the services in question;
(b) The services in question being prescribed or ordered by either a developmental pediatrician or a psychologist trained in autism.
(D)(1) Except for inpatient services, if an enrollee is receiving treatment for an autism spectrum disorder, a health insuring corporation may review the treatment plan annually, unless the health insuring corporation and the enrollee’s treating physician or psychologist agree that a more frequent review is necessary.
(2) Any such agreement as described in division (D)(1) of this section shall apply only to a particular enrollee being treated for an autism spectrum disorder and shall not apply to all individuals being treated for autism spectrum disorder by a physician or psychologist.
(3) The health insuring corporation shall cover the cost of obtaining any review or treatment plan.
(E) This section shall not be construed as affecting any obligation to provide services to an enrollee under an individualized family service plan, an individualized education program, or an individualized service plan.
(F) As used in this section:
(1) “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.
(2) “Autism spectrum disorder” means any of the pervasive developmental disorders or autism spectrum disorder as defined by the most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association available at the time an individual is first evaluated for suspected developmental delay.
(3) “Clinical therapeutic intervention” means therapies supported by empirical evidence, which include, but are not limited to, applied behavioral analysis, that satisfy both of the following:
(a) Are necessary to develop, maintain, or restore, to the maximum extent practicable, the function of an individual;
(b) Are provided by or under the supervision of any of the following:
(i) A certified Ohio behavior analyst as defined in section 4783.01 of the Revised Code;
(ii) An individual licensed under Chapter 4732 of the Revised Code to practice psychology;
(iii) An individual licensed under Chapter 4757 of the Revised Code to practice professional counseling, social work, or marriage and family therapy.
(4) “Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.
(5) “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.
(6) “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
(7) “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
(8) “Therapeutic care” means services provided by a speech therapist, occupational therapist, or physical therapist licensed or certified in the state in which the person practices.
(9) “Treatment for autism spectrum disorder” means evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician who is a developmental pediatrician or a licensed psychologist trained in autism who determines the care to be medically necessary, including any of the following:
(a) Clinical therapeutic intervention;
(b) Pharmacy care;
(c) Psychiatric care;
(d) Psychological care;
(e) Therapeutic care.
(G) If any provision of this section or the application thereof to any person or circumstances is for any reason held to be invalid, the remainder of the section and the application of such remainder to other persons or circumstances shall not be affected thereby.