Coverage for autism spectrum disorder

(1) As used in this section: (a) (i) "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. (ii) "Applied behavior analysis" includes the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. (b) "Autism spectrum disorder" means pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders. (c) "Behavioral health treatment" means counseling and treatment programs, including applied behavior analysis, 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) a board certified behavior analyst; or (B) an individual licensed under Title 58, Occupations and Professions, whose scope of practice includes mental health services. (d) "Diagnosis of autism spectrum disorder" means medically necessary assessments, evaluations, or tests: (i) performed by: (A) a licensed physician who is board certified in neurology, psychiatry, or pediatrics and has experience diagnosing autism spectrum disorder; or (B) a licensed psychologist with experience diagnosing autism spectrum disorder; and (ii) necessary to diagnose whether an individual has an autism spectrum disorder. (e) "Pharmacy care" means medications prescribed by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications. (f) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. (g) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. (h) "Therapeutic care" means services provided by a licensed or certified speech therapist, occupational therapist, or physical therapist. (i) (i) "Treatment for autism spectrum disorder" means evidence-based care and related equipment prescribed or ordered for an enrollee diagnosed with an autism spectrum disorder by a physician or a licensed psychologist described in Subsection (1)(d) who determines the care to be medically necessary. (ii) "Treatment for autism spectrum disorder" includes: (A) behavioral health treatment, provided or supervised by a person described in Subsection (1)(c)(ii); (B) pharmacy care; (C) psychiatric care; (D) psychological care; and (E) therapeutic care. (2) The department shall request a state plan amendment with CMS to provide treatment for autism spectrum disorder for an enrollee diagnosed with autism spectrum disorder.