§ 49-20-411. Autism Spectrum Disorder Treatment Program. (Effective 5/13/2014)

(1) As used in this section:

(a) "Applied behavior analysis" 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 that are:

(i) necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual; and

(ii) provided or supervised by a board certified behavior analyst or a licensed psychologist with equivalent university training and supervised experience.

(b) "Autism spectrum disorder" is as defined by the most recent edition of the Diagnostic and Statistical Manual on Mental Disorders or a recent edition of a professionally accepted diagnostic manual.

(c) "Health plan" does not include the health plan offered by the Public Employees' Benefit and Insurance Program that is the state's designated essential health benefit package for purposes of the PPACA, as defined in Section 31A-1-401.

(d) "Parent" means a parent of a qualified child.

(e) "Program" means the autism spectrum disorder treatment program created in Subsection (2).

(f) "Qualified child" means a child who is:

(i) at least two years of age but less than seven years of age;

(ii) diagnosed with an autism spectrum disorder by a qualified professional; and

(iii) the eligible dependent of a state employee who is enrolled in a health plan that is offered under this chapter.

(g) "Treatment" means any treatment generally accepted by the medical community or the American Academy of Pediatrics as an effective treatment for an individual with an autism spectrum disorder, including applied behavior analysis.

(2) The Public Employees' Benefit and Insurance Program shall offer a program for the treatment of autism spectrum disorders in accordance with Subsection (3).

(3) The program shall offer qualified children:

(a) diagnosis of autism spectrum disorder by a physician or qualified mental health professional, and the development of a treatment plan;

(b) applied behavior analysis provided by a certified behavior analyst or someone with equivalent training; and

(c) an annual cost-shared maximum benefit of $30,000 toward the cost of treatment that the program covers, where, for each qualified child, for the cost of the treatment:

(i) the parent pays the first $250;

(ii) after the first $250, the program pays 80% and the parent pays 20%;

(iii) the program pays no more than $150 per day; and

(iv) the program pays no more than $24,000 total.

(4) The purpose of the program is to study the efficacy of providing autism treatment and is not a mandate for coverage of autism treatment within the health plans offered by the Public Employees' Benefit and Insurance Program.

(5) The program shall be funded on an ongoing basis through the risk pool established in Subsection 49-20-202(1)(a).

Amended by Chapter 302, 2014 General Session