bill dropping the birthday limit on autism coverage

The text as introduced · 774 words

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.