Office of the Lieutenant Governor Division of Banking and Insurance Virgin Ielands #5049 Kongens Gade, Charlotte Amalie, St. Thomas, USVI 00802-6487 @ (340) 774-7166 @ Fax (340) 774-9458 1131 King Street, Suite 101, Christiansted, St. Croix, USVI 00820 @ (340) 773-6459 @ Fax (340) 719-3801 BULLETIN 2014-04 TO: INSURERS SELLING HEALTH INSURANCE COVERAGE RE: AUTISM SPECTRUM DISORDERS AND HEARING AID COVERAGE IN INSURANCE HEALTH CARE PLAN 1. Purpose and Scope. Act. No 7592 was approved by Governor John P. de Jongh, Jr. on May 16, 2014, which requires that health insurers provide coverage for the assessment, diagnosis and treatment of autism spectrum disorders and coverage for hearing aids for children. This Bulletin has been created to provide insurers with the implementation date in which these coverages should be available in the health insurance plans. Section 1732 of Title 22, VI Code provides “Coverage required in health care insurance plans by this section must include treatment prescribed, identified and ordered by a licensed physician, psychologist, or a licensed clinical social worker for an insured who are diagnosed with an autism spectrum disorder in accordance with a treatment plan developed by licensed physician, licensed psychologist or licensed clinical social worker pursuant to a comprehensive evaluation or re-evaluation of the insured”. Section 1803(b) of Title 22, VI Code provides “Hearing aid coverage offered must include: the hearing aid evaluation; hearing aid selection; fitting and dispensing services; programming; repairs and modification; auditory training; and car molds, as necessary to maintain optimal fit provided fit provided by a Certified Audiologist licensed in the Virgin Islands. 2. Definitions. “Autism spectrum disorders” means the pervasive developmental disorders set forth in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”, including but not limited to, Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorders, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified. “Hearing aid” means durable medical equipment that is of a design and circuitry to compensate for impaired human hearing and optimize audibility and listening skills in the environment commonly experienced by children. 3. Effective Date. Implementation of Act 7592 which amends Title 22 Virgin Islands Code, Chapter 65 shall be effective September 23, 2014. th Dated this 2'7 — day of August, 2014 at St. Thomas, U.S. Virgin Islands. Gregory R. Francis Lieutenapt Governor’ Commissioner of Insurance BILL NO. 30-0202 THIRTIETH LEGISLATURE OF THE VIRGIN ISLANDS Regular Session 2014 An Act amending title 22, chapter 65, section 1723 of the Virgin Islands Code by requiring that health insurance providers provide coverage for the assessment, diagnosis and treatment of autism spectrum disorders and coverage and coverage for hearing aids for children Be it enacted by the Legislature of the Virgin Islands: SECTION 1. Title 22 Virgin Islands Code, chapter 65 is amended by designating the existing provisions as subchapter I and adding subchapter II to read as follows: “SUBCHAPTER II COVERAGE FOR AUTISM SPECTRUM DISORDERS IN HEALTH CARE PLANS 1731 As used in this subchapter: (a) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior. (b) "Autism services provider" means any person, entity or group that provides treatment for autism spectrum disorders pursuant to this section. (c) "Autism spectrum disorders" means the pervasive developmental disorders set forth in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders", including, but not limited to, Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder and Pervasive Developmental Disorder Not Otherwise Specified. (d) “Behavioral therapy" means any interactive behavioral therapies derived from evidence-based research, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with an autism spectrum disorder, that are: (A) Provided to children younger than fifteen years of age, 2 (B) Provided or supervised by: (i) a behavior analyst who is certified by the Behavior Analyst Certification Board, (ii) a licensed physician, or (iit) a licensed psychologist. (C) For the purposes subparagraph (B), behavioral therapy” supervised by a behaviour analyst" means supervised by a behavior analyst, licensed physician or licensed psychologist when the supervision entails at least one hour of face-to-face supervision of the autism services provider by such behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider. (e) "Diagnosis" means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has an autism spectrum disorder. (f) "Evidence-based treatment" means treatment subject to research that applies rigorous, systematic, and objective procedures to obtain valid knowledge relevant to autism spectrum disorders; (g) “Medically necessary" means reasonably expected to do the following: (A) Prevent the onset of an illness, condition, injury, or disability; (B) Reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or (C) 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. §1732 (a) After the effective date of this subchapter, a health care insurer that offers, issues for delivery, delivers, executes, adjusts, uses, or renews a health care insurance plan shall provide coverage for the costs of the diagnosis and treatment of autism spectrum disorders that are medically necessary and evidence-based. (b) Coverage required in health care insurance plans by this section must include treatment prescribed, identified and ordered by a licensed physician, psychologist, or a licensed clinical social worker for an insured who is diagnosed with an autism spectrum disorder in accordance with a treatment plan developed by licensed physician, licensed psychologist or licensed clinical social worker pursuant to a comprehensive evaluation or re-evaluation of the insured. (c) Covered treatment must include: Q) Behavioral therapy, including applied behavioural analysis; (2) Direct psychiatric or consultative services provided by a licensed psychiatrist; (3) Direct psychological or consultative services provided by a licensed psychologist; (4) Physical therapy provided by a licensed physical therapist; (5) Speech and language pathology services provided by a licensed speech and language pathologist, and (6) | Occupational therapy provided by a licensed occupational therapist; (7) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, licensed physician assistant or advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorders; and (8) Equipment determined necessary to provide evidence-based treatment. §1733. A healthcare insurance plan must not impose: (1) any limits on the number of visits an insured may make to an autism services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage which places a greater financial burden on an insured for access to the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under the policy. §1734 (a) The insurer may limit the coverage in the insurance health care plan for behavioral therapy to a yearly benefit of $50,000 for a child who is younger than nine years of age, $35,000 for a child who is at least nine years of age but younger than thirteen years of age and $25,000 for a child who is at least thirteen years of age but younger than fifteen years of age. (b) Except for treatments and services received by an insured in an inpatient setting, an insure health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed under section 1732 (b) for an insured, in accordance with its utilization review requirements, not more than once every six months unless the insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary or changes such insured's treatment plan. 4 (c) For the purposes of this section, the results of a diagnosis are valid for a period of not less than twelve months, unless the insured's licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured's diagnosis. §1735. (a) This subchapter does not limit benefits that are otherwise available to an individual under a health benefit plan. (b) Nothing in this subchapter relieves an insurer from an otherwise valid obligation to provide or to pay for services provided to an individual with a disability.” SECTION 2. Title 22 Virgin Islands Code, chapter 65 is amended by adding subchapter III to read as follows: “SUBCHAPTER III COVERAGE OF HEARING AIDS FOR CHILDREN §1801. For the purposes of this subchapter the term, (1) ‘Children’ means persons under the under eighteen years of age, or under twenty- one years of age if still attending high school. (2) ‘Hearing aid’ means durable medical equipment that is of a design and circuitry to compensate for impaired human hearing and optimize audibility and listening skills in the environment commonly experienced by children. §1802. (a) An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in the Virgin Islands must provide coverage for a hearing aid and any related services for the full cost of one hearing aid per hearing-impaired ear up to $2,200 per ear, every thirty-six months for hearing aids for insured children. (b) | The insured may choose a higher priced hearing aid and may pay the difference in cost above the $2,200 limit, as provided in this subsection without financial or contractual penalty to the insured or to the provider of the hearing aid. §1803. (a) An insurer that delivers, issues for delivery or renews in the Virgin Islands an individual or group health insurance policy, health care plan or certificate of health insurance may make available to the policyholder the option of purchasing additional hearing aid coverage that exceeds the services described in this section. (b) Hearing aid coverage offered must include: the hearing aid evaluation; hearing aid selection; fitting and dispensing services; programming; repairs and modification; auditory training; and ear molds, as necessary to maintain optimal fit provided by a Certified Audiologist licensed in the Virgin Islands. §1804 Coverage for hearing aids may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate §1805. This subchapter does not apply to short-term travel, accident-only or limited or specified disease policies Thus passed by the Legislature of the Virgin Islands on April 24, 2014 Witness our Hands and Seal of the Legislature of the Virgin Islands this tt i “Day of April, A.D., 2014. we __ Shawn-Michael Malone President —_— Clk (Las. Jan¢tte Millin Young” F \ ~~. islative Secret ! i] Ae — =n Billi No. 30-0202 is hereby approved Witness my hand and the Seal of the Government of the United States Virgin Islands at Charlotte Amalie, St. Thomas, this th day of May A.D 2014 Jo erngh, Jr