Ohio § 1751.84

§ 1751.84.

(A) Notwithstanding section 3901.71 of the Revised Code , each individual and group health insuring corporation policy, contract, or agreement

providing basic health care services that is delivered, issued for delivery, or renewed

in this state shall provide coverage for the screening, diagnosis, and treatment of

autism spectrum disorder.  A health insuring corporation shall not terminate an individual's coverage, or refuse

to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely

because the individual is diagnosed with or has received treatment for an autism spectrum

disorder.  Nothing in this section shall be applied to nongrandfathered plans in the individual

and small group markets or to medicare supplement, accident-only, specified disease,

hospital indemnity, disability income, long-term care, or other limited benefit hospital

insurance policies.  Except as otherwise provided in division (B) of this section, coverage under this

section shall not be subject to dollar limits, deductibles, or coinsurance provisions

that are less favorable to an enrollee than the dollar limits, deductibles, or coinsurance

provisions that apply to substantially all medical and surgical benefits under the

policy, contract, or agreement. (B) Benefits provided under this section shall cover, at minimum, all of the following: (1) For speech and language therapy or occupational therapy for an enrollee under the

age of fourteen that is performed by a licensed therapist, twenty visits per year

for each service; (2) For clinical therapeutic intervention for an enrollee under the age of fourteen that

is provided by or under the supervision of a professional who is licensed, certified,

or registered by an appropriate agency of this state to perform such services in accordance

with a health treatment plan, twenty hours per week; (3) For mental or behavioral health outpatient services for an enrollee under the age

of fourteen that are performed by any of the following providing consultation, assessment,

development, or oversight of treatment plans, thirty visits per year: (a) A licensed psychologist; (b) A licensed physician, including a psychiatrist; (c) A clinical nurse specialist or certified nurse practitioner, including a psychiatric-mental

health advanced practice registered nurse or a clinical nurse specialist or certified

nurse practitioner specializing in pediatric or family health. (C)(1) Except as provided in division (C)(2) of this section, this section shall not be

construed as limiting benefits that are otherwise available to an individual under

a policy, contract, or agreement. (2) A policy, contract, or agreement shall stipulate that coverage provided under this

section be contingent upon both of the following: (a) The covered individual receiving prior authorization for the services in question; (b) The services in question being prescribed or ordered by a psychologist trained in

autism, a developmental pediatrician, or a clinical nurse specialist or certified

nurse practitioner specializing in pediatric health. (D)(1) Except for inpatient services, if an enrollee is receiving treatment for an autism

spectrum disorder, a health insuring corporation may review the treatment plan annually,

unless the health insuring corporation and the enrollee's treating physician, clinical

nurse specialist, certified nurse practitioner, or psychologist agree that a more

frequent review is necessary. (2) Any such agreement as described in division (D)(1) of this section shall apply only

to a particular enrollee being treated for an autism spectrum disorder and shall not

apply to all individuals being treated for autism spectrum disorder by a physician,

clinical nurse specialist, certified nurse practitioner, or psychologist. (3) The health insuring corporation shall cover the cost of obtaining any review or treatment

plan. (E) This section shall not be construed as affecting any obligation to provide services

to an enrollee under an individualized family service plan, an individualized education

program, or an individualized service plan. (F) As used in this section: (1) “ 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. (2) “ Autism spectrum disorder ” means any of the pervasive developmental disorders or autism spectrum disorder as

defined by the most recent edition of the diagnostic and statistical manual of mental

disorders published by the American psychiatric association available at the time

an individual is first evaluated for suspected developmental delay. (3) “ Clinical therapeutic intervention ” means therapies supported by empirical evidence, which include, but are not limited

to, applied behavioral analysis, that satisfy both of the following: (a) Are necessary to develop, maintain, or restore, to the maximum extent practicable,

the function of an individual; (b) Are provided by or under the supervision of any of the following: (i) A certified Ohio behavior analyst as defined in section 4783.01 of the Revised Code ; (ii) An individual licensed under Chapter 4732. of the Revised Code to practice psychology; (iii) An individual licensed under Chapter 4757. of the Revised Code to practice professional

counseling, social work, or marriage and family therapy. (4) “ Diagnosis of autism spectrum disorder ” means medically necessary assessments, evaluations, or tests to diagnose whether

an individual has an autism spectrum disorder. (5) “ Pharmacy care ” means prescribed medications and any health-related services considered medically

necessary to determine the need or effectiveness of the medications. (6) “ Psychiatric care ” means direct or consultative services provided by a psychiatrist or psychiatric-mental

health advanced practice registered nurse who is licensed in the state in which the

psychiatrist or nurse practices. (7) “ Psychiatric-mental health advanced practice registered nurse ” means an advanced practice registered nurse who is either of the following: (a) A clinical nurse specialist who is certified as a psychiatric-mental health CNS,

or the equivalent of such title, by the American nurses credentialing center; (b) A certified nurse practitioner who is certified as a psychiatric-mental health NP,

or the equivalent of such title, by the American nurses credentialing center or American

academy of nurse practitioners certification board. (8) “ Psychological care ” means direct or consultative services provided by a psychologist licensed in the

state in which the psychologist practices. (9) “ Therapeutic care ” means services provided by a speech therapist, occupational therapist, or physical

therapist licensed or certified in the state in which the person practices. (10) “ Treatment for autism spectrum disorder ” means evidence-based care and related equipment prescribed or ordered for an individual

diagnosed with an autism spectrum disorder, by a licensed physician who is a developmental

pediatrician, licensed psychologist trained in autism, clinical nurse specialist or

certified nurse practitioner specializing in pediatric health, or clinical nurse specialist

or certified nurse practitioner trained in autism who determines the care and related

equipment to be medically necessary, including any of the following: (a) Clinical therapeutic intervention; (b) Pharmacy care; (c) Psychiatric care; (d) Psychological care; (e) Therapeutic care. (G) If any provision of this section or the application thereof to any person or circumstances

is for any reason held to be invalid, the remainder of the section and the application

of such remainder to other persons or circumstances shall not be affected thereby.