                                 CODE OF VIRGINIA

COVERAGE FOR AUTISM SPECTRUM DISORDER (§ 38.2-3418.17)

A. Notwithstanding the provisions of &#xA7; 38.2-3419 and any other provision of
law, each insurer proposing to issue accident and sickness insurance policies
providing hospital, medical and surgical, or major medical coverage on an
expense-incurred basis; each corporation providing accident and sickness
subscription contracts; and each health maintenance organization providing a
health care plan for health care services shall, as provided in this section,
provide coverage for the diagnosis of autism spectrum disorder and the treatment
of autism spectrum disorder, in individuals (i) from January 1, 2012, until
January 1, 2016, from age two years through age six years; (ii) from January 1,
2016, until January 1, 2020, from age two years through age 10 years; and (iii)
from and after January 1, 2020, of any age, subject to the annual maximum
benefit limitation set forth in subsection K and to the provisions of subsection
G. If an individual who is being treated for autism spectrum disorder becomes
older than the applicable maximum age set forth in the preceding sentence and
continues to need treatment, this section does not preclude coverage of
treatment and services. In addition to the requirements imposed on health
insurance issuers by &#xA7; 38.2-3436, an insurer shall not terminate coverage
or refuse to deliver, issue, amend, adjust, or renew coverage of an individual
solely because the individual is diagnosed with autism spectrum disorder or has
received treatment for autism spectrum disorder.

B. For purposes of this section:
			&#8220;Applied behavior analysis&#8221; 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.
			&#8220;Autism spectrum disorder&#8221; means any pervasive developmental
disorder or autism spectrum disorder, as defined in the most recent edition or
the most recent edition at the time of diagnosis of the Diagnostic and
Statistical Manual of Mental Disorders of the American Psychiatric Association.
			&#8220;Behavioral health treatment&#8221; means professional, counseling, and
guidance services and treatment programs that are necessary to develop,
maintain, or restore, to the maximum extent practicable, the functioning of an
individual.
			&#8220;Diagnosis of autism spectrum disorder&#8221; means medically necessary
assessments, evaluations, or tests to diagnose whether an individual has an
autism spectrum disorder.
			&#8220;Medically necessary&#8221; means in accordance with the generally
accepted standards of mental disorder or condition care and clinically
appropriate in terms of type, frequency, site, and duration, based upon evidence
and reasonably expected to do any of the following: (i) prevent the onset of an
illness, condition, injury, or disability; (ii) reduce or ameliorate the
physical, mental, or developmental effects of an illness, condition, injury, or
disability; or (iii) assist to achieve or maintain maximum functional capacity
in performing daily activities, taking into account both the functional capacity
of the individual and the functional capacities that are appropriate for
individuals of the same age.
			&#8220;Pharmacy care&#8221; means medications prescribed by a licensed
physician and any health-related services deemed medically necessary to
determine the need or effectiveness of the medications.
			&#8220;Psychiatric care&#8221; means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist practices.
			&#8220;Psychological care&#8221; means direct or consultative services
provided by a psychologist licensed in the state in which the psychologist
practices.
			&#8220;Therapeutic care&#8221; means services provided by licensed or
certified speech therapists, occupational therapists, physical therapists, or
clinical social workers.
			&#8220;Treatment for autism spectrum disorder&#8221; shall be identified in a
treatment plan and includes the following care prescribed or ordered for an
individual diagnosed with autism spectrum disorder by a licensed physician or a
licensed psychologist who determines the care to be medically necessary: (i)
behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv)
psychological care, (v) therapeutic care, and (vi) applied behavior analysis
when provided or supervised by a board certified behavior analyst who shall be
licensed by the Board of Medicine. The prescribing practitioner shall be
independent of the provider of applied behavior analysis.
			&#8220;Treatment plan&#8221; means a plan for the treatment of autism
spectrum disorder developed by a licensed physician or a licensed psychologist
pursuant to a comprehensive evaluation or reevaluation performed in a manner
consistent with the most recent clinical report or recommendation of the
American Academy of Pediatrics or the American Academy of Child and Adolescent
Psychiatry.

C. Except for inpatient services, if an individual is receiving treatment for an
autism spectrum disorder, an insurer, corporation, or health maintenance
organization shall have the right to request a review of that treatment,
including an independent review, not more than once every 12 months unless the
insurer, corporation, or health maintenance organization and the
individual&#8217;s licensed physician or licensed psychologist agree that a more
frequent review is necessary. The cost of obtaining any review, including an
independent review, shall be covered under the policy, contract, or plan.

D. Coverage under this section will not be subject to any visit limits, and
shall be neither different nor separate from coverage for any other illness,
condition, or disorder for purposes of determining deductibles, lifetime dollar
limits, copayment and coinsurance factors, and benefit year maximum for
deductibles and copayment and coinsurance factors.

E. Nothing shall preclude the undertaking of usual and customary procedures,
including prior authorization, to determine the appropriateness of, and medical
necessity for, treatment of autism spectrum disorder under this section,
provided that all such appropriateness and medical necessity determinations are
made in the same manner as those determinations are made for the treatment of
any other illness, condition, or disorder covered by such policy, contract, or
plan.

F. The provisions of this section shall not apply to (i) short-term travel,
accident only, limited, or specified disease policies; (ii) short-term
nonrenewable policies of not more than six months&#8217; duration; or (iii)
policies or contracts designed for issuance to persons eligible for coverage
under Title XVIII of the Social Security Act, known as Medicare, or any other
similar coverage under state or federal governmental plans.

G. The requirements of this section requiring that coverage be provided with
regard to individuals from age two years through age six years shall apply to
all insurance policies, subscription contracts, and health care plans delivered,
issued for delivery, reissued, or extended on or after January 1, 2012, but
prior to January 1, 2016; the requirements of this section requiring that
coverage be provided with regard to individuals from age two years through age
10 years shall apply to all insurance policies, subscription contracts, and
health care plans delivered, issued for delivery, reissued, or extended on or
after January 1, 2016, but prior to January 1, 2020; the requirements of this
section requiring that coverage be provided with regard to individuals of any
age shall apply to all insurance policies, subscription contracts, and health
care plans delivered, issued for delivery, reissued, or extended on or after
January 1, 2020, and to all such policies, contracts, or plans to which a term
is changed or any premium adjustment is made on or after such date; and the
requirements of this section requiring that coverage be provided by policies,
contracts, or plans issued in the individual market or small group markets shall
apply to all insurance policies, subscription contracts, and health care plans
in the individual and small group markets delivered, issued for delivery,
reissued, or extended on or after January 1, 2021, and to all such policies,
contracts, or plans to which a term is changed or any premium adjustment is made
on or after such date.

H. Any coverage required pursuant to this section shall be in addition to the
coverage required by &#xA7; 38.2-3418.5 and other provisions of law. This
section shall not be construed as diminishing any coverage required by &#xA7;
38.2-3412.1. This section shall not be construed as affecting any obligation to
provide services to an individual under an individualized family service plan,
an individualized education program, or an individualized service plan.

I. Pursuant to the provisions of &#xA7; 2.2-2818.2, this section shall apply to
health coverage offered to state employees pursuant to &#xA7; 2.2-2818 and to
health insurance coverage offered to employees of local governments, local
officers, teachers, and retirees, and the dependents of such employees,
teachers, and retirees pursuant to &#xA7; 2.2-1204.

J. Notwithstanding any provision of this section to the contrary:

   1. An insurer, corporation, or health maintenance organization, or a
   governmental entity providing coverage for such treatment pursuant to
   subsection I, is exempt from providing coverage for behavioral health
   treatment required under this section and not covered by the insurer,
   corporation, health maintenance organization, or governmental entity providing
   coverage for such treatment pursuant to subsection I as of December 31, 2011,
   if:
   				a. An actuary, affiliated with the insurer, corporation, or health
   maintenance organization, who is a member of the American Academy of Actuaries
   and meets the American Academy of Actuaries&#8217; professional qualification
   standards for rendering an actuarial opinion related to health insurance rate
   making, certifies in writing to the Commissioner of Insurance that:

      1. Based on an analysis to be completed no more frequently than one time per
      year by each insurer, corporation, or health maintenance organization, or
      such governmental entity, for the most recent experience period of at least
      one year&#8217;s duration, the costs associated with coverage of behavioral
      health treatment required under this section, and not covered as of December
      31, 2011, exceeded one percent of the premiums charged over the experience
      period by the insurer, corporation, or health maintenance organization; and

      2. Those costs solely would lead to an increase in average premiums charged
      of more than one percent for all insurance policies, subscription contracts,
      or health care plans commencing on inception or the next renewal date, based
      on the premium rating methodology and practices the insurer, corporation, or
      health maintenance organization, or such governmental entity, employs; and
      					b. The Commissioner approves the certification of the actuary;

   2. An exemption allowed under subdivision 1 shall apply for a one-year
   coverage period following inception or next renewal date of all insurance
   policies, subscription contracts, or health care plans issued or renewed
   during the one-year period following the date of the exemption, after which
   the insurer, corporation, or health maintenance organization, or such
   governmental entity, shall again provide coverage for behavioral health
   treatment required under this section;

   3. An insurer, corporation, or health maintenance organization, or such
   governmental entity, may claim an exemption for a subsequent year, but only if
   the conditions specified in subdivision 1 again are met; and

   4. Notwithstanding the exemption allowed under subdivision 1, an insurer,
   corporation, or health maintenance organization, or such a governmental
   entity, may elect to continue to provide coverage for behavioral health
   treatment required under this section.

K. Coverage for applied behavior analysis under this section will be subject to
an annual maximum benefit of $35,000, unless the insurer, corporation, or health
maintenance organization elects to provide coverage in a greater amount.

L. As of January 1, 2014, to the extent that this section requires benefits that
exceed the essential health benefits specified under &#xA7; 1302(b) of the
federal Patient Protection and Affordable Care Act (H.R. 3590), as amended (the
ACA), the specific benefits that exceed the specified essential health benefits
shall not be required of a qualified health plan when the plan is offered in the
Commonwealth by a health carrier through a health benefit exchange established
under &#xA7; 1311 of the ACA. Nothing in this subsection shall nullify
application of this section to plans offered outside such an exchange.

HISTORY: 2011, cc. 876, 878; 2015, cc. 649, 650; 2019, cc. 451, 452; 2020, cc.
305, 613; 2022, cc. 101, 102.