HB 453: Regards insurance, Medicaid coverage of certain autism therapy

As Introduced

136th General Assembly

Regular Session

H. B. No. 453

2025-2026

Representative Lorenz

To amend sections 1751.84, 3923.84, 4783.01, and 1 4783.02 and to enact sections 3901.92 and 2 4783.40 of the Revised Code regarding insurance 3 and Medicaid coverage of applied behavior 4 analysis therapy for autism treatment and to 5 permit exam-eligible technicians to engage in 6 the practice of applied behavior analysis. 7

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1. That sections 1751.84, 3923.84, 4783.01, and 8 4783.02 be amended and sections 3901.92 and 4783.40 of the 9 Revised Code be enacted to read as follows:

Sec. 1751.84.

(A) Notwithstanding section 3901.71 of the 11 Revised Code, each individual and group health insuring 12 corporation policy, contract, or agreement providing basic 13 health care services that is delivered, issued for delivery, or 14 renewed in this state shall provide coverage for the screening, 15 diagnosis, and treatment of autism spectrum disorder. A health 16 insuring corporation shall not terminate an individual's 17 coverage, or refuse to deliver, execute, issue, amend, adjust, 18 or renew coverage to an individual solely because the individual 19 is diagnosed with or has received treatment for an autism 20 spectrum disorder. Nothing in this section shall be applied to 21 nongrandfathered plans in the individual and small group markets ..... 22 or to medicare supplement, accident-only, specified disease, ..... 23 hospital indemnity, disability income, long-term care, or other ..... 24 limited benefit hospital insurance policies. Except as otherwise ..... 25 provided in division (B) of this section, coverage under this ..... 26 section shall not be subject to dollar limits, deductibles, or ..... 27 coinsurance provisions that are less favorable to an enrollee ..... 28 than the dollar limits, deductibles, or coinsurance provisions ..... 29 that apply to substantially all medical and surgical benefits ..... 30 under the policy, contract, or agreement. ..... 31 (B) Benefits provided under this section shall cover, at ..... 32 minimum, all of the following: ..... 33 (1) For speech Speech and language therapy or occupational ..... 34 therapy for an enrollee under the age of fourteen that is ..... 35 performed by a licensed therapist,-twenty-visits per year-for- ..... 36 each service; ..... 37 (2) For-clinical-Clinical therapeutic intervention for-an- ..... 38 enrollee under the age of fourteen that is provided by or under ..... 39 the supervision of a professional who is licensed, certified, or ..... 40 registered by an appropriate agency of this state to perform ..... 41 such services in accordance with a health treatment plan,-twenty ..... 42 hours per week; ..... 43 (3) For-mental-Mental or behavioral health outpatient ..... 44 services for-an-enrollee under the age of fourteen that are ..... 45 performed by any of the following providing consultation, ..... 46 assessment, development, or oversight of treatment plans,-thirty ..... 47 visits per year: ..... 48 (a) A licensed psychologist; ..... 49 (b) A licensed physician, including a psychiatrist; ..... 50 (c) A clinical nurse specialist or certified nurse ..... 51practitioner, including a psychiatric-mental health advanced52 practice registered nurse or a clinical nurse specialist or ..... 53 certified nurse practitioner specializing in pediatric or family ..... 54 health. ..... 55 (4) Adaptive behavior services that are performed by a ..... 56 certified Ohio behavior analyst under Chapter 4783. of the ..... 57 Revised Code, or an exam-eligible technician pursuant to section ..... 58 4783.40 of the Revised Code. (C) (1) Except as provided in division (C) (2) of this ..... 60 section, this section shall not be construed as limiting ..... 61 benefits that are otherwise available to an individual under a ..... 62 policy, contract, or agreement. ..... 63 (2) A policy, contract, or agreement shall stipulate that ..... 64 coverage provided under this section be contingent upon both of ..... 65 the following: ..... 66 (a) The covered individual receiving prior authorization ..... 67 for the services in question; ..... 68 (b) The services in question being prescribed or ordered ..... 69 by a psychologist trained in autism, a developmental ..... 70 pediatrician, or a clinical nurse specialist or certified nurse ..... 71 practitioner specializing in pediatric health. ..... 72 (D) (1) Except for inpatient services, if an enrollee is ..... 73 receiving treatment for an autism spectrum disorder, a health ..... 74 insuring corporation may review the treatment plan annually, ..... 75 unless the health insuring corporation and the enrollee's ..... 76 treating physician, clinical nurse specialist, certified nurse ..... 77 practitioner, or psychologist agree that a more frequent review ..... 78 is necessary. ..... 79 (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) A health insuring corporation shall use the industry standards of care set forth in the applied behavior analysis practice guidelines for the treatment of autism spectrum disorder published by the council of autism service providers to inform decision-making regarding the use of applied behavioral analysis as a medically necessary treatment service. (F) 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) (G) 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 ..... 109 evaluated for suspected developmental delay. ..... 110 (3) "Clinical therapeutic intervention" means therapies ..... 111 supported by empirical evidence, which include, but are not ..... 112 limited to, applied behavioral analysis, that satisfy both of ..... 113 the following: ..... 114 (a) Are necessary to develop, maintain, or restore, to the ..... 115 maximum extent practicable, the function of an individual; ..... 116 (b) Are provided by or under the supervision of any of the ..... 117 following: ..... 118 (i) A certified Ohio behavior analyst as defined in ..... 119 section 4783.01 of the Revised Code; ..... 120 (ii) An individual licensed under Chapter 4732. of the ..... 121 Revised Code to practice psychology; ..... 122 (iii) An individual licensed under Chapter 4757. of the ..... 123 Revised Code to practice professional counseling, social work, ..... 124 or marriage and family therapy. ..... 125 (4) "Diagnosis of autism spectrum disorder" means ..... 126 medically necessary assessments, evaluations, or tests to ..... 127 diagnose whether an individual has an autism spectrum disorder. ..... 128 (5) "Pharmacy care" means prescribed medications and any ..... 129 health-related services considered medically necessary to ..... 130 determine the need or effectiveness of the medications. ..... 131 (6) "Psychiatric care" means direct or consultative ..... 132 services provided by a psychiatrist or psychiatric-mental health ..... 133 advanced practice registered nurse who is licensed in the state ..... 134 in which the psychiatrist or nurse practices. ..... 135 (7) "Psychiatric-mental health advanced practice ..... 136 registered nurse" means an advanced practice registered nurse ..... 137 who is either of the following: ..... 138 (a) A clinical nurse specialist who is certified as a ..... 139 psychiatric-mental health CNS, or the equivalent of such title, ..... 140 by the American nurses credentialing center; ..... 141 (b) A certified nurse practitioner who is certified as a ..... 142 psychiatric-mental health NP, or the equivalent of such title, ..... 143 by the American nurses credentialing center or American academy ..... 144 of nurse practitioners certification board. ..... 145 (8) "Psychological care" means direct or consultative ..... 146 services provided by a psychologist licensed in the state in ..... 147 which the psychologist practices. ..... 148 (9) "Therapeutic care" means services provided by a speech ..... 149 therapist, occupational therapist, or physical therapist ..... 150 licensed or certified in the state in which the person ..... 151 practices. ..... 152 (10) "Treatment for autism spectrum disorder" means ..... 153 evidence-based care and related equipment prescribed or ordered ..... 154 for an individual diagnosed with an autism spectrum disorder, by ..... 155 a licensed physician who is a developmental pediatrician, ..... 156 licensed psychologist trained in autism, clinical nurse ..... 157 specialist or certified nurse practitioner specializing in ..... 158 pediatric health, or clinical nurse specialist or certified ..... 159 nurse practitioner trained in autism who determines the care and ..... 160 related equipment to be medically necessary, including any of ..... 161 the following: ..... 162 (a) Clinical therapeutic intervention; ..... 163 (b) Pharmacy care; ..... 164 (c) Psychiatric care; (d) Psychological care; (e) Therapeutic care. (G) (H) 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.

Sec. 3901.92.

(A) Third-party payers shall reimburse providers of applied behavior analysis services for performing adaptive behavior assessment and treatment procedures at not less than one hundred per cent of the medicaid fee schedule in effect at the time of service. (B) Nothing in this section prohibits a third-party payer from reimbursing a provider of applied behavior analysis services more than one hundred per cent of the medicaid fee schedule in effect at the time of service.

Sec. 3923.84.

(A) Notwithstanding section 3901.71 of the Revised Code, each individual and group sickness and accident insurance policy 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 sickness and accident insurer 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 ..... 194 limited benefit hospital insurance policies. Except as otherwise ..... 195 provided in division (B) of this section, coverage under this ..... 196 section shall not be subject to dollar limits, deductibles, or ..... 197 coinsurance provisions that are less favorable to an insured ..... 198 than the dollar limits, deductibles, or coinsurance provisions ..... 199 that apply to substantially all medical and surgical benefits ..... 200 under the policy. ..... 201 (B) Benefits provided under this section shall cover, at ..... 202 minimum, all of the following: ..... 203 (1) For speech Speech and language therapy or occupational ..... 204 therapy for an insured under the age of fourteen that is ..... 205 performed by a licensed therapist, twenty visits per year for- ..... 206 each service; ..... 207 (2) For clinical Clinical therapeutic intervention for-an- ..... 208 insured under the age of fourteen that is provided by or under ..... 209 the supervision of a professional who is licensed, certified, or ..... 210 registered by an appropriate agency of this state to perform ..... 211 such services in accordance with a health treatment plan, twenty ..... 212 hours per week; ..... 213 (3) For mental Mental or behavioral health outpatient ..... 214 services for an insured under the age of fourteen that are ..... 215 performed by any of the following providing consultation, ..... 216 assessment, development, or oversight of treatment plans, thirty ..... 217 visits per year: ..... 218 (a) A licensed psychologist; ..... 219 (b) A licensed physician, including a psychiatrist; ..... 220 (c) A clinical nurse specialist or certified nurse ..... 221 practitioner, including a psychiatric-mental health advanced ..... 222 practice registered nurse or a clinical nurse specialist or ..... 223 certified nurse practitioner specializing in pediatric or family ..... 224 health. ..... 225 (4) Adaptive behavior services that are performed by a ..... 226 certified Ohio behavior analyst under Chapter 4783. of the ..... 227 Revised Code, or an exam-eligible technician pursuant to section ..... 228 4783.40 of the Revised Code. ..... 229 (C) (1) Except as provided in division (C) (2) of this ..... 230 section, this section shall not be construed as limiting ..... 231 benefits that are otherwise available to an insured under a ..... 232 policy. ..... 233 (2) A policy of sickness and accident insurance shall ..... 234 stipulate that coverage provided under this section be ..... 235 contingent upon both of the following: ..... 236 (a) The covered individual receiving prior authorization ..... 237 for the services in question; ..... 238 (b) The services in question being prescribed or ordered ..... 239 by a psychologist trained in autism, a developmental ..... 240 pediatrician, or a clinical nurse specialist or certified nurse ..... 241 practitioner specializing in pediatric health. ..... 242 (D) (1) Except for inpatient services, if an insured is ..... 243 receiving treatment for an autism spectrum disorder, a sickness ..... 244 and accident insurer may review the treatment plan annually, ..... 245 unless the insurer and the insured's treating physician, ..... 246 clinical nurse specialist, certified nurse practitioner, or ..... 247 psychologist agree that a more frequent review is necessary. ..... 248 (2) Any such agreement as described in division (D) (1) of ..... 249 this section shall apply only to a particular insured being ..... 250 treated for an autism spectrum disorder and shall not apply to ..... 251 all individuals being treated for autism spectrum disorder by a ..... 252 physician, clinical nurse specialist, certified nurse ..... 253 practitioner, or psychologist. ..... 254 (3) The insurer shall cover the cost of obtaining any ..... 255 review or treatment plan. ..... 256 (E) A sickness and accident insurer shall use the industry ..... 257 standards of care set forth in the applied behavior analysis ..... 258 practice guidelines for the treatment of autism spectrum ..... 259 disorder published by the council of autism service providers to ..... 260 inform decision-making regarding the use of applied behavioral ..... 261 analysis as a medically necessary treatment service. ..... 262 (F) This section shall not be construed as affecting any ..... 263 obligation to provide services to an insured under an ..... 264 individualized family service plan, an individualized education ..... 265 program, or an individualized service plan. ..... 266 (F) (G) As used in this section: ..... 267 (1) "Applied behavior analysis" means the design, ..... 268 implementation, and evaluation of environmental modifications, ..... 269 using behavioral stimuli and consequences, to produce socially ..... 270 significant improvement in human behavior, including the use of ..... 271 direct observation, measurement, and functional analysis of the ..... 272 relationship between environment and behavior. ..... 273 (2) "Autism spectrum disorder" means any of the pervasive ..... 274 developmental disorders or autism spectrum disorder as defined ..... 275 by the most recent edition of the diagnostic and statistical ..... 276 manual of mental disorders published by the American psychiatric ..... 277 association available at the time an individual is first ..... 278 evaluated for suspected developmental delay. ..... 279 (3) "Clinical therapeutic intervention" means therapies ..... 280 supported by empirical evidence, which include, but are not ..... 281 limited to, applied behavioral analysis, that satisfy both of ..... 282 the following: ..... 283 (a) Are necessary to develop, maintain, or restore, to the ..... 284 maximum extent practicable, the function of an individual; ..... 285 (b) Are provided by or under the supervision of any of the ..... 286 following: ..... 287 (i) A certified Ohio behavior analyst as defined in ..... 288 section 4783.01 of the Revised Code; ..... 289 (ii) An individual licensed under Chapter 4732. of the ..... 290 Revised Code to practice psychology; ..... 291 (iii) An individual licensed under Chapter 4757. of the ..... 292 Revised Code to practice professional counseling, social work, ..... 293 or marriage and family therapy. ..... 294 (4) "Diagnosis of autism spectrum disorder" means ..... 295 medically necessary assessment, evaluations, or tests to ..... 296 diagnose whether an individual has an autism spectrum disorder. ..... 297 (5) "Industry standards of care" means the standards of ..... 298 care used in the applied behavior analysis practice guidelines ..... 299 for the treatment of autism spectrum disorder published by the ..... 300 council of autism service providers. ..... 301 (6) "Pharmacy care" means prescribed medications and any ..... 302 health-related services considered medically necessary to ..... 303 determine the need or effectiveness of the medications. ..... 304 (6) (7) "Psychiatric care" means direct or consultative ..... 305 services provided by a psychiatrist or psychiatric-mental health ..... 306 advanced practice registered nurse who is licensed in the state ..... 307 in which the psychiatrist or nurse practices. ..... 308 (7) (8) "Psychiatric-mental health advanced practice 309 registered nurse" means an advanced practice registered nurse 310 who is either of the following: (a) A clinical nurse specialist who is certified as a 312 psychiatric-mental health CNS, or the equivalent of such title, 313 by the American nurses credentialing center; (b) A certified nurse practitioner who is certified as a 315 psychiatric-mental health NP, or the equivalent of such title, 316 by the American nurses credentialing center or American academy 317 of nurse practitioners certification board. (8) (9) "Psychological care" means direct or consultative 319 services provided by a psychologist licensed in the state in 320 which the psychologist practices. (9) (10) "Therapeutic care" means services provided by a 322 speech therapist, occupational therapist, or physical therapist 323 licensed or certified in the state in which the person 324 practices. (10) (11) "Treatment for autism spectrum disorder" means 326 evidence-based care and related equipment prescribed or ordered 327 for an individual diagnosed with an autism spectrum disorder, by 328 a licensed physician who is a developmental pediatrician, 329 licensed psychologist trained in autism, clinical nurse 330 specialist or certified nurse practitioner specializing in 331 pediatric health, or clinical nurse specialist or certified 332 nurse practitioner trained in autism who determines the care and 333 related equipment to be medically necessary, including any of 334 the following: (a) Clinical therapeutic intervention; (b) Pharmacy care; (c) Psychiatric care; (d) Psychological care; (e) Therapeutic care. (G) (H) 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.

Sec. 4783.01.

As used in this chapter: (A) "Certified Ohio behavior analyst" means an individual holding a current, valid certificate issued under section 4783.04 of the Revised Code. (B) (1) (B) "Exam-eligible technician" means an individual who has met the requirements of division (B) of section 4783.40 of the Revised Code. (C) (1) "Practice of applied behavior analysis" means the design, implementation, and evaluation of instructional and environmental modifications to produce socially significant improvements in human behavior and includes the following: (a) The empirical identification of functional relations between behavior and environmental factors, known as functional assessment and analysis; (b) Interventions based on scientific research and the direct observation and measurement of behavior and the environment; (c) Utilization of contextual factors, motivating operations, antecedent stimuli, positive reinforcement, and other consequences to help people develop new behaviors, ..... 365 increase or decrease existing behaviors, and emit behaviors ..... 366 under specific environmental conditions. ..... 367 (2) "Practice of applied behavior analysis" does not ..... 368 include psychological testing, diagnosis of a mental or physical ..... 369 disorder, neuropsychology, psychotherapy, cognitive therapy, sex ..... 370 therapy, psychoanalysis, hypnotherapy, and long-term counseling ..... 371 as treatment modalities. ..... 372

Sec. 4783.02.

(A) Except as otherwise provided in division ..... 373 (B) of this section and section 4783.40 of the Revised Code, no ..... 374 person shall do either of the following: ..... 375 (1) Engage in the practice of applied behavior analysis in ..... 376 this state without holding a certificate issued under section ..... 377 4783.04 of the Revised Code; ..... 378 (2) Hold the person's self out to be a certified Ohio ..... 379 behavior analyst unless the person holds a certificate issued ..... 380 under section 4783.04 of the Revised Code. ..... 381 (B) This chapter does not apply to any of the following: ..... 382 (1) An individual licensed under Chapter 4732. of the ..... 383 Revised Code to practice psychology, if the practice of applied ..... 384 behavior analysis engaged in by the licensed psychologist is ..... 385 within the licensed psychologist's education, training, and ..... 386 experience; ..... 387 (2) An individual licensed under Chapter 4757. of the ..... 388 Revised Code to practice counseling, social work, or marriage ..... 389 and family therapy, if the practice of applied behavior analysis ..... 390 engaged in by the licensed professional counselor, licensed ..... 391 professional clinical counselor, licensed social worker, or ..... 392 licensed marriage and family therapist is within the licensee's ..... 393 education, training, and experience; (3) An individual acting under the authority and direction of an individual described in division (B) (1) or (2) of this section; (4) An individual practicing applied behavior analysis who is supervised by a certified Ohio behavior analyst and acting under the authority and direction of that certified Ohio behavior analyst; (5) The delivery of interventions by a direct care provider or family member to implement components of an applied behavior analysis treatment plan. (6) A behavior analyst who practices with nonhuman or nonpatient clients or consumers, including applied animal behaviorists and practitioners of organizational behavior management; (7) A licensed professional authorized to practice in this state who, in the offering or rendering of services, does not represent oneself in any printed materials or verbally by incorporating the term "applied behavior analyst," if the services of the licensed professional are within the scope of practice of the licensing law governing the licensed professional and the services performed are commensurate with the licensed professional's education, training, and experience; (8) A matriculated graduate student or postdoctoral trainee whose activities are part of a defined program of study or professional training; (9) An individual employed by the department of developmental disabilities, a county board of developmental disabilities, or a council of government consisting of county boards of developmental disabilities, when the individual is ..... 423 acting in the scope of that employment; ..... 424 (10) A professional employed in a school or other setting ..... 425 that falls under the regulation of the state board of education ..... 426 when the professional is acting within the scope of that ..... 427 employment. ..... 428 (C) For purposes of division (B) (3) or (4) of this ..... 429 section, an individual is not subject to this chapter only if ..... 430 the licensed psychologist, the licensed professional counselor, ..... 431 the licensed professional clinical counselor, the licensed ..... 432 social worker, the licensed marriage and family therapist, or ..... 433 the certified Ohio behavior analyst under whose authority and ..... 434 direction the individual is acting pursuant to division (B) (3) ..... 435 or (4) of this section signs an attestation stating that the ..... 436 licensed psychologist, licensed professional counselor, licensed ..... 437 professional clinical counselor, licensed social worker, ..... 438 licensed marriage and family therapist, or certified Ohio ..... 439 behavior analyst is responsible for the care provided by the ..... 440 individual. ..... 441

Sec. 4783.40.

(A) Notwithstanding section 4783.02 of the ..... 442 Revised Code, an exam-eligible technician may engage in the ..... 443 practice of applied behavior analysis in this state in ..... 444 accordance with this section. ..... 445 (B) To be eligible to practice as an exam-eligible ..... 446 technician pursuant to this section, an individual must be ..... 447 either of the following: ..... 448 (1) The individual is in the process of becoming a ..... 449 registered behavior technician certified by the behavior analyst ..... 450 certification board and is practicing under the supervision of a ..... 451 certified Ohio behavior analyst or a board certified assistant ..... 452 behavior analyst holding a valid certification from the behavior ..... 453 analyst certification board. ..... 454 (2) The individual has satisfied all of the following ..... 455 criteria: ..... 456 (a) The individual holds a high school diploma or higher ..... 457 degree. ..... 458 (b) The individual has completed any equivalent coursework ..... 459 or training requirements for registered behavior technicians ..... 460 required by the behavior analyst certification board or its ..... 461 successor organization. ..... 462 (c) The individual has passed an initial competency ..... 463 assessment, or otherwise been found eligible, to sit for a ..... 464 psychometrically valid examination administered by a nationally ..... 465 accredited credentialing organization. ..... 466 (C) An exam-eligible technician meeting the requirements ..... 467 of this section may engage in the practice of applied behavior ..... 468 analysis in this state under the supervision of a certified Ohio ..... 469 behavior analyst for a period of ninety days after the date the ..... 470 individual meets the requirements of division (B) (1) of this ..... 471 section. If the individual does not achieve certification as a ..... 472 certified Ohio behavior analyst by the end of that ninety-day ..... 473 period, the individual is no longer eligible to engage in the ..... 474 practice of applied behavior analysis as an exam-eligible ..... 475 technician. ..... 476

Section 2.

That existing sections 1751.84, 3923.84, ..... 477 4783.01, and 4783.02 of the Revised Code are hereby repealed. ..... 478

Section 3. PAYMENT RATES FOR ABA THERAPY SERVICES

For fiscal year 2027, the Department of Medicaid shall ..... 479 establish payment rates under the care management system ..... 480 established under section 5167.03 of the Revised Code, for ..... 481 applied behavior analysis therapy services used to treat ..... 482 Medicaid enrollees with a diagnosis of autism spectrum disorder. ..... 483 These payment rates shall equal one hundred per cent of the fee- ..... 484 for-service rate for current procedural terminology codes 97151 ..... 485 through 97158 . ..... 486