PRIOR PRINTER'S NOS. 1448, 2237 PRINTER'S NO. 2326
THE GENERAL ASSEMBLY OF PENNSYLVANIA
No. 1150 Session of 2007
INTRODUCED BY D. O'BRIEN, DeWEESE, PALLONE, PHILLIPS, RAPP, SCAVELLO, STURLA, BAKER, BASTIAN, BOYD, BROOKS, CALTAGIRONE, CARROLL, CLYMER, COHEN, CONKLIN, DALEY, DALLY, DeLUCA, DePASQUALE, DONATUCCI, EVERETT, FREEMAN, GEIST, GEORGE, GIBBONS, GINGRICH, GOODMAN, GRUCELA, HALUSKA, HARKINS, HENNESSEY, HERSHEY, JAMES, JOSEPHS, KAUFFMAN, W. KELLER, KENNEY, KIRKLAND, KOTIK, KULA, LEACH, LENTZ, MAHONEY, MANDERINO, MANN, MARKOSEK, MARSHALL, McILHATTAN, MOYER, MURT, MUSTIO, McGEEHAN, MYERS, NAILOR, M. O'BRIEN, PASHINSKI, PAYNE, PETRONE, PRESTON, READSHAW, REICHLEY, ROSS, SCHRODER, SEIP, SHAPIRO, SHIMKUS, M. SMITH, SOLOBAY, SONNEY, STABACK, STEIL, SURRA, TANGRETTI, TRUE, VEREB, WATSON, J. WHITE, WOJNAROSKI, YUDICHAK, MACKERETH, MANTZ, BARRAR, HORNAMAN, CAUSER, WALKO, HELM, MELIO, DENLINGER, BRENNAN, RAMALEY, DiGIROLAMO, GERGELY, M. KELLER, FRANKEL, FABRIZIO, YOUNGBLOOD, REED, ROAE, CURRY, K SMITH, GALLOWAY, SIPTROTH AND RUBLEY APRIL 30, 2007
AS AMENDED ON SECOND CONSIDERATION, HOUSE OF REPRESENTATIVES, JULY 13, 2007
AN ACT 1 Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An 2 act relating to insurance; amending, revising, and 3 consolidating the law providing for the incorporation of 4 insurance companies, and the regulation, supervision, and 5 protection of home and foreign insurance companies, Lloyds 6 associations, reciprocal and inter-insurance exchanges, and 7 fire insurance rating bureaus, and the regulation and 8 supervision of insurance carried by such companies, 9 associations, and exchanges, including insurance carried by 10 the State Workmen's Insurance Fund; providing penalties; and 11 repealing existing laws," providing, in health and accident 12 insurance, for autism spectrum disorders coverage and for 13 treatment of autism spectrum disorders; and further providing 14 for quality health care procedures. 15 The General Assembly of the Commonwealth of Pennsylvania 16 hereby enacts as follows:
1 Section 1. The act of May 17, 1921 (P.L.682, No.284), known 2 as The Insurance Company Law of 1921, is amended by adding 3 sections to read: 4 Section 635.2. Autism Spectrum Disorders Coverage.--(a) A 5 health insurance policy or government program shall provide to 6 covered individuals or recipients under twenty-one years of age 7 coverage for the diagnosis of autism spectrum disorders and for 8 the treatment of autism spectrum disorders. TO THE EXTENT THAT <-- 9 THE DIAGNOSIS AND TREATMENT OF AUTISM SPECTRUM DISORDERS ARE NOT 10 ALREADY COVERED BY THE HEALTH INSURANCE POLICY OR GOVERNMENT 11 PROGRAM, COVERAGE UNDER THIS SECTION SHALL BE INCLUDED IN HEALTH 12 INSURANCE POLICIES AND CONTRACTS UNDER A GOVERNMENT PROGRAM 13 WHICH ARE DELIVERED, EXECUTED, ISSUED, AMENDED, ADJUSTED OR 14 RENEWED ON OR AFTER ONE HUNDRED EIGHTY DAYS FROM THE EFFECTIVE 15 DATE OF THIS SECTION, EXCEPT THAT THE APPLICABILITY OF THIS 16 SECTION TO GOVERNMENT PROGRAMS SHALL BE CONTINGENT UPON FEDERAL 17 APPROVAL IF NECESSARY. 18 (b) Except for the Commonwealth's medical assistance program 19 established under the act of June 13, 1967 (P.L.31, No.21), 20 known as the "Public Welfare Code," and except for the 21 Children's Health Care Program established under this act, 22 coverage provided under this section shall be subject to a 23 maximum benefit of thirty-six thousand dollars ($36,000) per 24 year but shall not be subject to any limits on the number of 25 visits to an autism service provider. After December 30, 2009, 26 the Insurance Commissioner shall, on an annual basis, adjust the 27 maximum benefit for inflation using the Medical Price Index <-- 28 (MPI) component of the Department of Labor Consumer Price Index 29 (CPI). CARE COMPONENT OF THE UNITED STATES DEPARTMENT OF LABOR <-- 30 CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS (CPI-U). The 20070H1150B2326 - 2 -
1 commissioner shall submit the adjusted maximum benefit to the 2 Legislative Reference Bureau for publication annually in the 3 Pennsylvania Bulletin no later than April 1 of each calendar 4 year, and the published adjusted maximum benefit shall be 5 applicable in the following calendar year to health insurance 6 policies and government programs subject to this act. Payments 7 made by an insurer on behalf of a covered individual for any 8 care, treatment, intervention, service or item, the provision of 9 which was for the treatment of a health condition unrelated to 10 the covered individual's autism spectrum disorder, shall not be 11 applied toward any maximum benefit established under this 12 subsection. 13 (c) Coverage under this section shall be subject to 14 copayment, deductible and coinsurance provisions of a health 15 insurance policy or government program to the extent that other 16 medical services covered by the policy or government program are 17 subject to these provisions. 18 (d) This section shall not be construed as limiting benefits 19 which are otherwise available to an individual under a health 20 insurance policy. 21 (e) This section shall not apply to the following types of 22 policies: 23 (1) Accident only. 24 (2) Limited benefit. 25 (3) Credit. 26 (4) Dental. 27 (5) Vision. 28 (6) Specified disease. 29 (7) Medicare supplement. 30 (8) CHAMPUS (Civilian Health and Medical Program of the 20070H1150B2326 - 3 -
1 Uniformed Services) supplement. 2 (9) Long-term care or disability income. 3 (10) Workers' compensation. 4 (11) Automobile medical payment. 5 (12) Hospital indemnity. 6 (f) As used in this section: 7 (1) "Applied behavioral analysis" means the design, 8 implementation and evaluation of environmental modifications, 9 using behavioral stimuli and consequences, to produce socially 10 significant improvement in human behavior, including the use of 11 direct observation, measurement and functional analysis of the 12 relations between environment and behavior. 13 (2) "Autism service provider" means any person, entity or 14 group that provides treatment of autism spectrum disorders. 15 (3) "Autism spectrum disorders" means any of the pervasive 16 developmental disorders as defined by the most recent edition of 17 the Diagnostic and Statistical Manual of Mental Disorders (DSM), 18 including autistic disorder, Asperger's disorder and pervasive 19 developmental disorder not otherwise specified. 20 (4) "Diagnosis of autism spectrum disorders" means medically 21 necessary assessments, evaluations or tests in order to diagnose 22 whether an individual has an autism spectrum disorder. 23 (5) "Evidenced-based research" means research that applies 24 rigorous, systematic and objective procedures to obtain valid 25 knowledge relevant to autism spectrum disorders. 26 (6) "Government program" means any of the following: 27 (i) The Commonwealth's medical assistance program 28 established under the act of June 13, 1967 (P.L.31, No.21), 29 known as the "Public Welfare Code." 30 (ii) The adult basic coverage insurance program established 20070H1150B2326 - 4 -
1 under Chapter 13 of the act of June 26, 2001 (P.L.755, No.77), 2 known as the "Tobacco Settlement Act." 3 (iii) The Children's Health Care Program established under 4 this act. 5 (7) "Health insurance policy" means any group health, 6 sickness or accident policy or subscriber contract or 7 certificate issued by an insurance entity subject to one of the 8 following: 9 (i) This act. 10 (ii) The act of December 29, 1972 (P.L.1701, No.364), known 11 as the "Health Maintenance Organization Act." 12 (iii) The act of May 18, 1976 (P.L.123, No.54), known as the 13 "Individual Accident and Sickness Insurance Minimum Standards 14 Act." 15 (iv) 40 Pa.C.S. Ch. 61 (relating to hospital plan 16 corporations) or 63 (relating to professional health services 17 plan corporations). 18 (8) "Medically necessary" means any care, treatment, 19 intervention, service or item which is prescribed, provided or 20 ordered by a licensed physician, licensed psychologist or 21 certified registered nurse practitioner in accordance with 22 accepted standards of practice and which will, or is reasonably 23 expected to, do any of the following: 24 (i) Prevent the onset of an illness, condition, injury or 25 disability. 26 (ii) Reduce or ameliorate the physical, mental or 27 developmental effects of an illness, condition, injury or 28 disability. 29 (iii) Assist to achieve or maintain maximum functional 30 capacity in performing daily activities, taking into account 20070H1150B2326 - 5 -
1 both the functional capacity of the recipient and those 2 functional capacities that are appropriate of recipients of the 3 same age. 4 (9) "Pharmacy care" means medications prescribed by a 5 licensed physician or certified registered nurse practitioner 6 and any health-related services deemed medically necessary to 7 determine the need or effectiveness of the medications. 8 (10) "Psychiatric care" means direct or consultative 9 services provided by a psychiatrist licensed in the state in 10 which the psychiatrist practices. 11 (11) "Psychological care" means direct or consultative 12 services provided by a licensed psychologist PSYCHOLOGIST <-- 13 LICENSED in the state in which the psychologist practices. 14 (12) "Rehabilitative care" means professional, counseling 15 and guidance services and treatment programs, including applied 16 behavioral analysis, which are necessary to develop, maintain 17 and restore, to the maximum extent practicable, the functioning 18 of an individual. 19 (13) "Therapeutic care" means services provided by licensed 20 or certified speech therapists, occupational therapists or 21 physical therapists. 22 (14) "Treatment for autism spectrum disorders" shall include 23 the following care prescribed, provided or ordered for an 24 individual diagnosed with an autism spectrum disorder by a 25 licensed physician, licensed psychologist or certified 26 registered nurse practitioner if the care is determined to be 27 medically necessary: 28 (i) Psychiatric care. 29 (ii) Psychological care. 30 (iii) Rehabilitative care. 20070H1150B2326 - 6 -
1 (iv) Therapeutic care. 2 (v) Pharmacy care. 3 (vi) Any care, treatment, intervention, service or item for 4 individuals with an autism spectrum disorder which is determined 5 by the Department of Public Welfare, based upon its review of 6 best practices or evidenced-based research, to be medically 7 necessary and which is published in the Pennsylvania Bulletin. 8 Any such care, treatment, intervention, service or item which 9 was not previously covered shall be included in any health 10 insurance policy or contract under a government program 11 delivered, issued, executed or renewed on or after 120 days 12 following the date of its publication in the Pennsylvania 13 Bulletin. 14 (g) The Department of Public Welfare shall promulgate 15 regulations establishing standards for qualified autism service 16 providers. For purposes of implementing this section, and 17 notwithstanding any other provision of law, THE Secretary of <-- 18 Public Welfare shall promulgate regulations pursuant to section 19 204(1)(iv) of the act of July 31, 1968 (P.L.769, No.240), 20 referred to as the Commonwealth Documents Law, which shall, for 21 120 days from the effective date of this act, be exempt from all 22 OF the following acts: <-- 23 (1) Section 205 of the Commonwealth Documents Law. 24 (2) Section 204(b) of the act of October 15, 1980 (P.L.950, 25 No.164), known as the "Commonwealth Attorneys Act." 26 (3) The act of June 25, 1982 (P.L.633, No.181), known as the 27 "Regulatory Review Act." 28 Once the regulations are promulgated, payment for the treatment 29 of autism spectrum disorders covered under this section shall 30 only be made to autism service providers who meet the standards. 20070H1150B2326 - 7 -
1 (h) To the extent that the diagnosis and treatment of autism <-- 2 spectrum disorders are not already covered by the health 3 insurance policy or government program, coverage under this 4 section shall be included in health insurance policies and 5 contracts under a government program which are delivered, 6 executed, issued, amended, adjusted or renewed on or after one 7 hundred twenty days from the effective date of this section, 8 except that the applicability of this section to government 9 programs shall be contingent upon Federal approval if necessary. 10 Section 2116.1. Treatment of Autism Spectrum Disorders.--(a) 11 Except for government programs, if an enrollee has obtained a 12 referral or other authorization through utilization review from 13 a managed care plan or a licensed insurer to receive any care, 14 treatment, intervention, service or item for an autism spectrum 15 disorder from a health care provider or specialist, the referral 16 or other authorization shall constitute a standing referral for 17 any subsequent care, treatment, intervention, service or item 18 provided by any health care provider or specialist until the 19 care, treatment, intervention, service or item for which the 20 referral or authorization was approved has reached its 21 conclusion. 22 SECTION 2116.1. TREATMENT OF AUTISM SPECTRUM DISORDERS.--(A) <-- 23 EXCEPT FOR INPATIENT SERVICES, IF AN ENROLLEE HAS OBTAINED 24 AUTHORIZATION THROUGH UTILIZATION REVIEW FROM A MANAGED CARE 25 PLAN, GOVERNMENT PROGRAM OR A LICENSED INSURER TO RECEIVE ANY 26 CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM FOR AN AUTISM 27 SPECTRUM DISORDER, THE AUTHORIZATION SHALL BE VALID FOR TWELVE 28 MONTHS, UNLESS THE ENROLLEE'S PRIMARY CARE PROVIDER DETERMINES 29 THAT AN EARLIER RE-EVALUATION IS NECESSARY IN ORDER TO 30 ADEQUATELY ADDRESS THE CLINICAL NEEDS OF THE ENROLLEE. 20070H1150B2326 - 8 -
1 (A.1) IN APPLYING SUBSECTION (A), IF WITHIN THE TWELVE-MONTH 2 PERIOD FOLLOWING THE EFFECTIVE DATE OF THIS SECTION A HEALTH 3 INSURANCE POLICY IS DELIVERED, ISSUED, EXECUTED OR RENEWED AND 4 AT THE TIME OF SUCH DELIVERY, ISSUANCE, EXECUTION OR RENEWAL AN 5 ENROLLEE IS RECEIVING ANY INPATIENT OR OUTPATIENT CARE, 6 TREATMENT, INTERVENTION, SERVICE OR ITEM FOR AN AUTISM SPECTRUM 7 DISORDER PURSUANT TO AN AUTHORIZATION OBTAINED FROM A GOVERNMENT 8 PROGRAM, AND THE CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM 9 IS COVERED UNDER THE HEALTH INSURANCE POLICY BEING DELIVERED, 10 ISSUED, EXECUTED OR RENEWED, THE AUTHORIZATION FROM THE 11 GOVERNMENT PROGRAM SHALL REMAIN VALID FOR THE REMAINDER OF THE 12 EXISTING AUTHORIZATION PERIOD AS TO ANY MANAGED CARE PLAN OR 13 PRIVATE INSURER AND SUCH AUTHORIZATION SHALL BE HONORED BY ANY 14 MANAGED CARE PLAN OR PRIVATE INSURER PROVIDING COVERAGE TO THE 15 ENROLLEE. 16 (b) If a health care provider provides care, treatments, 17 interventions, services or items to an enrollee, the coverage of 18 which is required under section 635.2 and the provider is 19 enrolled in the Commonwealth's medical assistance program but is 20 not a network provider with the enrollee's private insurance 21 plan, the provider shall be reimbursed under the terms and 22 conditions applicable to the plan's participating providers. 23 This requirement shall not be subject to any time limitation or 24 transition period, but shall otherwise be in accord with all 25 terms applicable to nonparticipating providers under the managed 26 care continuity of care provisions then in effect. 27 Section 2. Section 2121 of the act, added June 17, 1998 28 (P.L.464, No.68), is amended to read: 29 Section 2121. Procedures.--(a) A managed care plan shall 30 establish a credentialing process to enroll qualified health 20070H1150B2326 - 9 -
1 care providers and create an adequate provider network. The 2 process shall be approved by the department and shall include 3 written criteria and procedures for initial enrollment, renewal, 4 restrictions and termination of credentials for health care 5 providers. 6 (b) [The] Except as provided under subsection (b.1), the 7 department shall establish credentialing standards for managed 8 care plans. The department may adopt nationally recognized 9 accrediting standards to establish the credentialing standards 10 for managed care plans. 11 (b.1) Pursuant to section 635.2(g), the Department of Public 12 Welfare shall establish standards to be utilized by managed care 13 plans for the credentialing of health care providers providing 14 care, treatments, interventions, services or items to enrollees 15 for an autism spectrum disorder as defined under section 635.2. 16 In addition, the department may require that a managed care plan 17 grant credentials to any health care provider whom the 18 Department of Public Welfare determines meets or exceeds the 19 Department of Public Welfare's credentialing standards. 20 (b.2) With respect to autism service providers, a managed <-- 21 care plan or licensed insurer shall inform credentialing 22 applicants of a decision within ninety days after the complete 23 application has been submitted to the managed care plan or 24 insurer. A managed care plan or insurer shall not require a 25 health care provider to submit an application for credentialing 26 as a result of a change of employers if the provider's new 27 employer is in the managed care plan's service area or network. 28 (c) A managed care plan shall submit a report to the 29 department regarding its credentialing process at least every 30 two (2) years or as may otherwise be required by the department. 20070H1150B2326 - 10 -
1 (d) A managed care plan shall disclose relevant 2 credentialing criteria and procedures to health care providers 3 that apply to participate or that are participating in the 4 plan's provider network. A managed care plan shall also disclose 5 relevant credentialing criteria and procedures pursuant to a 6 court order or rule. Any individual providing information during 7 the credentialing process of a managed care plan shall have the 8 protections set forth in the act of July 20, 1974 (P.L.564, 9 No.193), known as the "Peer Review Protection Act." 10 (e) No managed care plan shall exclude or terminate a health 11 care provider from participation in the plan due to any of the 12 following: 13 (1) The health care provider engaged in any of the 14 activities set forth in section 2113(c). 15 (2) The health care provider has a practice that includes a 16 substantial number of patients with expensive medical 17 conditions. 18 (3) The health care provider objects to the provision of or 19 refuses to provide a health care service on moral or religious 20 grounds. 21 (f) If a managed care plan denies enrollment or renewal of 22 credentials to a health care provider, the managed care plan 23 shall provide the health care provider with written notice of 24 the decision. The notice shall include a clear rationale for the 25 decision. 26 Section 3. This act shall take effect in 180 days. <-- 27 SECTION 3. THIS ACT SHALL TAKE EFFECT AS FOLLOWS: <-- 28 (1) THE FOLLOWING PROVISIONS SHALL TAKE EFFECT IN 90 29 DAYS: 30 (I) THE ADDITION OF SECTION 635.2(F) AND (G) OF THE 20070H1150B2326 - 11 -
1 ACT. 2 (II) THE AMENDMENT OF SECTION 2121 OF THE ACT. 3 (III) THIS SECTION. 4 (2) THE REMAINDER OF THIS ACT SHALL TAKE EFFECT IN 210 5 DAYS. D25L40MSP/20070H1150B2326 - 12 -
Autistic people have fought the inclusion of ABA in therapy for us since before Autism Speaks, and other non-Autistic-led autism organizations, started lobbying legislation to get it covered by insurances and Medicaid.
ABA is a myth originally sold to parents that it would keep their Autistic child out of an institution. Today, parents are told that with early intervention therapy their child will either be less Autistic or no longer Autistic by elementary school, and can be mainstreamed in typical education classes. ABA is very expensive to pay out of pocket. Essentially, Autism Speaks has justified the big price tag up front will offset the overall burden on resources for an Autistic’s lifetime. The recommendation for this therapy is 40 hours a week for children and toddlers.
The original study that showed the success rate of ABA to be at 50% has never been replicated. In fact, the study of ABA by United States Department of Defense was denounced as a failure. Not just once, but multiple times. Simply stated: ABA doesn’t work. In study after repeated study: ABA (conversion therapy) doesn’t work.
What more recent studies do show: Autistics who experienced ABA therapy are at high risk to develop PTSD and other lifelong trauma-related conditions. Historically, the autism organizations promoting ABA as a cure or solution have silenced Autistic advocates’ opposition. ABA is also known as gay conversion therapy.
The ‘cure’ for Autistics not born yet is the prevention of birth.
The ‘cure’ is a choice to terminate a pregnancy based on ‘autism risk.’ The cure is abortion. This is the same ‘cure’ society has for Down Syndrome.
This is eugenics 2021. Instead of killing Autistics and disabled children in gas chambers or ‘mercy killings’ like in Aktion T4, it’ll happen at the doctor’s office, quietly, one Autistic baby at a time. Different approaches yes, but still eugenics and the extinction of an entire minority group of people.
Fact: You can’t cure Autistics from being Autistic.
Fact: You can’t recover an Autistic from being Autistic.
Fact: You can groom an Autistic to mask and hide their traits. Somewhat. … however, this comes at the expense of the Autistic child, promotes Autistic Burnout (this should not be confused with typical burnout, Autistic Burnout can kill Autistics), and places the Autistic child at high risk for PTSD and other lifelong trauma-related conditions.
[Note: Autism is NOT a disease, but a neurodevelopmental difference and disability.]
Fact: Vaccines Do Not Cause Autism.