Section 191.35.40. Autism spectrum disorders coverage.

         35.40(1) Purpose. This rule implements Iowa Code section 514C.28, relating to autism spectrum disorders coverage in a group plan established pursuant to Iowa Code chapter 509A for employees of the state that provides for third-party payment or prepayment of health, medical, and surgical coverage benefits.

         35.40(2) Definitions. For purposes of this rule, the definitions found in Iowa Code section 514C.28(2) shall apply. In addition, the following definitions shall apply:

“Autism spectrum disorders” means the following neurological disorders as defined under the following diagnostic classes within the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, edition DSM-IV-TR:

            1.      Autistic disorders. Diagnostic code 299.00.

            2.      Rett’s Disorder. Diagnostic code 299.80.

            3.      Childhood Disintegrative Disorder. Diagnostic code 299.10.

            4.      Asperger’s Disorder. Diagnostic code 299.80.

            5.      Pervasive Developmental Disorder NOS. Diagnostic code 299.80.

“Commissioner” means the commissioner of insurance.

“Group plan”  or “group health plan”  means a group health plan established for the employees of the state of Iowa under Iowa Code chapter 509A.

         35.40(3) Services. A group plan is not required to provide coverage for any of the following:

            a.               Acupuncture.

            b.               Animal-based therapy including hippotherapy.

            c.               Auditory integration training.

            d.               Chelation therapy.

            e.               Child care.

            f.                Cranial sacral therapy.

            g.               Custodial or respite care.

            h.               Hyperbaric oxygen therapy.

            i.                Special diets or supplements.

         35.40(4) Parents or legal guardians of children diagnosed with autism spectrum disorders. A group plan shall not be required to pay for treatment rendered by parents or legal guardians who are otherwise qualified providers, supervising providers, therapists, professionals or paraprofessionals for treatment rendered to their own children.

         35.40(5) Locations for services.

            a.               A group plan shall provide coverage for treatments, therapies and services to an insured diagnosed with autism spectrum disorders by an autism service provider in locations including the provider’s office or clinic or in a setting conducive to the acquisition of the target skill. Treatments may be provided in schools when the treatments, therapies, and services are related to the goals of the treatment plan and do not duplicate services provided by a school.

            b.               A group health plan is not required to provide coverage for therapy, treatment or services when the therapy, treatment or services are provided to an insured who is residing in a residential treatment center or inpatient treatment or day treatment facility.

         35.40(6) Verification of qualified provider. A group health plan is required to verify the licensure, certification and all training or other credentials of a qualified provider or health professional. A group health plan shall not deny payment or reimbursement for the necessary diagnosis or treatment provided by a certified behavior analyst or a health professional licensed under Iowa Code chapter 147.

         35.40(7) Annual publication CPI adjustment. The commissioner shall publish on or before April 1 of each year beginning April 1, 2014, an adjustment to the required maximum benefit equal to the percentage change in the United States Department of Labor Consumer Price Index for all urban consumers in the preceding year. The adjusted maximum benefit published each April shall be used by group health plans in order to comply with this rule and shall be effective January 1 for group plans issued or renewed on or after January 1 of the following calendar year.

         35.40(8) Notice to insureds. A group plan shall provide written notice to the insured regarding claims submitted and processed for the treatment of autism spectrum disorders and shall include the total amount expended to date for the current policy year. The notice may be included with the explanation of benefits form or in a separate communication provided on a periodic basis during the course of treatment.

This rule is intended to implement Iowa Code section 514C.28.

[ARC 9500B, IAB 5/4/11, effective 6/8/11]