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COMMISSIONER'S BULLETIN # B-0053-07

December 20, 2007


To: All Insurance Companies, Health Maintenance Organizations, Group Hospital Service Corporations, Fraternal Benefit Societies, Stipulated Premium Companies, and Multiple Employer Welfare Arrangements (Carriers) Offering Certain Group Health Benefit Plans That Provide Benefits for Medical or Surgical Expenses


Re: HB 1919 Autism Spectrum Disorder Mandate

The purpose of this bulletin is to inform carriers that HB 1919, SECTIONS 6 - 9, enacted during the 80th Regular Legislative Session, amended Insurance Code Chapter 1355, Subchapter A, to add a specific group health benefit plan coverage mandate for autism spectrum disorder, as defined in Insurance Code §1355.001(3). HB 1919 became effective September 1, 2007. The Texas Department of Insurance has recently learned that some carriers may be unaware that this change in law applies to a health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2008.

HB 1919 adds new Insurance Code §1355.015, which requires in subsection (a) that group health benefit plans that provide benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness provide, at a minimum, coverage to enrollees older than two years of age and younger than six years of age who are diagnosed with autism spectrum disorder. Section 1355.015(b) requires the health benefit plan to provide coverage for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee's primary care physician in the treatment plan recommended by that physician. Under §1355.015(b), the prescribed treatment must be provided by an appropriately licensed, certified, or registered health care practitioner. Section 1355.015(c) states that generally recognized services may include: (1) evaluation and assessment services; (2) applied behavior analysis; (3) behavior training and behavior management; (4) speech therapy; (5) occupational therapy; (6) physical therapy; or (7) medications or nutritional supplements used to address symptoms of autism spectrum disorder. Under §1355.015(d), the mandated coverage may be subject to annual deductibles, copayments, and coinsurance that are consistent with annual deductibles, copayments, and coinsurance required for other coverage under the health benefit plan.

If you have any questions concerning this bulletin, please contact Margaret Lazaretti, Deputy Commissioner, Health & Workers' Compensation Network Certification and Quality Assurance Division at: (512) 322-4215, or Margaret.Lazaretti@tdi.state.tx.us.

Jennifer Ahrens
Senior Associate Commissioner
Life, Health & Licensing



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