Oklahoma § 36-6060.21 - Screening, diagnosis and treatment of autism spectrum

§ 36-6060.21. Screening, diagnosis and treatment of autism spectrum

disorder.

A. For all plans issued or renewed on or after November 1,

2016, a health benefit plan and the Oklahoma Employees Health

Insurance Plan shall provide coverage for the screening, diagnosis

and treatment of autism spectrum disorder in individuals. No

insurer shall terminate 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.

B. Coverage under this section shall be subject to the

provisions set forth in Section 6060.11 of this title; provided,

however, that coverage shall not be subject to any limits on the

number of visits an individual may make for treatment of autism

spectrum disorder.

C. Coverage under this section shall not be subject to dollar

limits, deductibles or coinsurance provisions that are less

favorable to an insured than the dollar limits, deductibles or

Oklahoma Statutes - Title 36. Insurance

coinsurance provisions that apply to substantially all medical and

surgical benefits under the health benefit plan.

D. This section shall not be construed as limiting benefits

that are otherwise available to an individual under a health benefit

plan.

E. Coverage for applied behavior analysis shall include the

services provided or supervised by a board-certified behavior

analyst, a board-certified assistant behavior analyst or a licensed

doctoral-level psychologist.

F. Except for inpatient services, if an insured is receiving

treatment for an autism spectrum disorder, an insurer shall have the

right to review the treatment plan annually, unless the insurer and

the insured's treating physician or psychologist agree that a more

frequent review is necessary. Any such agreement regarding the

right to review a treatment plan more frequently shall apply only to

a particular insured being treated for an autism spectrum disorder

and shall not apply to all individuals being treated for autism

spectrum disorder by a physician or psychologist. The cost of

obtaining any review or treatment plan shall be borne by the

insurer.

G. This section shall not be construed as affecting any

obligation to provide services to an individual under an

individualized family service plan, an individualized education

program or an individualized service plan.

H. 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 disorders as defined by

the most recent edition of the Diagnostic and Statistical Manual of

Mental Disorders (DSM) or the edition that was in effect at the time

of diagnosis;

3. "Behavioral health treatment" means counseling and treatment

programs including applied behavior analysis, that are:

a.

necessary to develop, maintain or restore, to the

maximum extent practicable, the functioning of an

individual, and

b.

provided or supervised by a board-certified behavior

analyst, a board-certified assistant behavior analyst

or by a licensed doctoral-level psychologist so long

as the services performed are commensurate with the

psychologist's university training and experience;

Oklahoma Statutes - Title 36. Insurance

4. "Diagnosis of autism spectrum disorder" means medically

necessary assessment, evaluations or tests to diagnose whether an

individual has an autism spectrum disorder;

5. "Health benefit plan" means any plan or arrangement as

defined in subsection C of Section 6060.4 of Title 36 of the

Oklahoma Statutes;

6. "Oklahoma Employees Health Insurance Plan" means "Health

Insurance Plan" as defined in Section 1303 of Title 74 of the

Oklahoma Statutes;

7. "Pharmacy care" means medications prescribed by a licensed

physician and any health-related services deemed medically necessary

to determine the need or effectiveness of the medications;

8. "Psychiatric care" means direct or consultative services

provided by a psychiatrist licensed in the state in which the

psychiatrist practices;

9. "Psychological care" means direct or consultative services

provided by a psychologist licensed in the state in which the

psychologist practices;

10. "Therapeutic care" means services provided by licensed or

certified speech therapists, occupational therapists or physical

therapists; and

11. "Treatment for autism spectrum disorder" means evidencebased care and related equipment prescribed or ordered for an

individual diagnosed with an autism spectrum disorder by a licensed

physician or a licensed doctoral-level psychologist who determines

the care to be medically necessary including, but not limited to:

a.

behavioral health treatment,

b.

pharmacy care,

c.

psychiatric care,

d.

psychological care, and

e.

therapeutic care.

Added by Laws 2016, c. 230, § 1, eff. Nov. 1, 2016. Amended by Laws

2019, c. 437, § 2, eff. Nov. 1, 2019; Laws 2022, c. 154, § 8, eff.

Nov. 1, 2022.