HB564 - Relating to health benefit plan coverage for treatment of autism spectrum disorders.

  89R4932 DNC-F     By: Cortez H.B. No. 564       A BILL TO BE ENTITLED   AN ACT   relating to health benefit plan coverage for treatment of autism   spectrum disorders.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 1355.001(3), Insurance Code, is amended   to read as follows:                (3)  "Autism spectrum disorder" means :                       (A)   a neurobiological disorder that   significantly affects verbal communication, nonverbal   communication, and social interaction and that meets the diagnostic   criteria for autism spectrum disorder specified by the Diagnostic   and Statistical Manual of Mental Disorders, 5th edition, or a later   edition; or                       (B)     a diagnosis made using a previous edition of   the Diagnostic and Statistical Manual of Mental Disorders of   [ includes ] autism, Asperger's syndrome, or Pervasive Developmental   Disorder--Not Otherwise Specified.          SECTION 2.  Section 1355.015, Insurance Code, is amended by   amending Subsections (a-1) and (c) and adding Subsections (a-2) and   (c-2) to read as follows:          (a-1)  At a minimum, a health benefit plan must provide   coverage for any medically necessary treatment of autism spectrum   disorder as provided by this section to an enrollee who is diagnosed   with autism spectrum disorder from the date of diagnosis[ , only if   the diagnosis was in place prior to the child's 10th birthday ].           (a-2)  For purposes of Subsection (a-1):                 (1)     "Medically necessary" means a service or product   that:                       (A)  addresses the specific needs of a patient;                       (B)  is provided for the purpose of:                             (i)     screening for, preventing, diagnosing,   managing, or treating an illness, injury, or condition, or the   symptoms of that illness, injury, or condition, including by   minimizing the progress of an illness, injury, or condition; or                             (ii)     preventing regression or ensuring   maintenance of skills;                       (C)     is delivered in accordance with the generally   recognized independent standards of mental health and substance use   disorder care;                       (D)     is clinically appropriate in terms of type   for the service or product; and                       (E)  is not provided primarily for:                             (i)     the economic benefit of the health   benefit plan issuer or person who purchases the service or product;   or                             (ii)     the convenience of the patient,   treating physician, or other health care provider.                 (2)     "Generally recognized independent standards of   mental health and substance use disorder care" means a standard of   care and clinical practice that:                       (A)     is generally recognized by health care   providers practicing in the applicable clinical specialty,   including in psychiatry, psychology, clinical sociology, addiction   medicine, counseling, applied behavioral analysis, or behavioral   health treatment; and                       (B)     is based on valid, evidence-based sources   reflecting generally accepted standards of mental health and   substance use disorder care, including:                             (i)     peer-reviewed scientific studies or   medical literature; and                             (ii)     the recommendation of a governmental   agency or relevant nonprofit health care provider professional   trade association or specialty society, including:                                   (a)     patient placement criteria   promulgated by the National Library of Medicine;                                   (b)     clinical practice guidelines   promulgated by the National Center for Complementary and   Integrative Health;                                   (c)     the recommendation of a federal   governmental agency;                                   (d)     drug labeling approved by the   United States Food and Drug Administration; and                                   (e)     clinical practice guidelines,   developed and promulgated by the Council of Autism Service   Providers, for the treatment of autism spectrum disorder.          (c)  For purposes of Subsections [ Subsection ] (b) and (c-2) ,   "generally recognized services" may include services such as:                (1)  evaluation and assessment services;                (2)  applied behavior analysis;                (3)  behavior training and behavior management;                (4)  speech therapy;                (5)  occupational therapy;                (6)  physical therapy; or                (7)  medications or nutritional supplements used to   address symptoms of autism spectrum disorder.           (c-2)  The health benefit plan may not:                 (1)     prohibit or place a limitation on a health care   practitioner described by Subsection (b)(1) from performing an   evaluation or reevaluation, or soliciting a confirmation of   diagnosis of autism spectrum disorder from a primary care physician   or a diagnostician who has previously provided a diagnosis of   autism spectrum disorder for an enrollee; or                 (2)     restrict the setting in which generally recognized   services prescribed in relation to autism spectrum disorder are   provided to the enrollee, including assessments, evaluation,   therapeutic intervention, or observations, except for a setting in   which the enrollee qualifies for reimbursable services under the   state Medicaid program, including under the school health and   related services program.          SECTION 3.  Section 1355.015(c-1), Insurance Code, is   repealed.          SECTION 4.  The changes in law made by this Act apply only to   a health benefit plan delivered, issued for delivery, or renewed on   or after January 1, 2026. A health benefit plan delivered, issued   for delivery, or renewed before January 1, 2026, is governed by the   law as it existed immediately before the effective date of this Act,   and that law is continued in effect for that purpose.          SECTION 5.  This Act takes effect September 1, 2025.