SB 175

Enrolled Copy  S.B. 175
1Health Insurance Revisions
                                      2026 GENERAL SESSION
                                           STATE OF UTAH
                                    Chief Sponsor: Karen Kwan
                                 House Sponsor: Norman K Thurston
2
3  LONG TITLE
4  General Description:
5      This bill amends provisions regarding autism insurance coverage.
6  Highlighted Provisions:
7      This bill:
8      ▸ defines terms; and
9      ▸ creates a reporting requirement.
10  Money Appropriated in this Bill:
11      None
12  Other Special Clauses:
13      None
14  Utah Code Sections Affected:
15  AMENDS:
16      31A-22-642, as last amended by Laws of Utah 2022, Chapter 415
17      63I-1-231, as last amended by Laws of Utah 2025, Chapters 241, 473
18
19  Be it enacted by the Legislature of the state of Utah:
20Section 1. Section 31A-22-642 is amended to read:
2131A-22-642 . Insurance coverage for autism spectrum disorder.
22  (1) As used in this section:
23      (a) "Applied behavior analysis" means the design, implementation, and evaluation of
24environmental modifications, using behavioral stimuli and consequences, to produce
25socially significant improvement in human behavior, including the use of direct
26observation, measurement, and functional analysis of the relationship between
27environment and behavior.
28      (b) "Autism spectrum disorder" means pervasive developmental disorders as defined by
S.B. 175  Enrolled Copy
29the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
30(DSM).
31(c) "Behavioral health treatment" means counseling and treatment programs, including
32applied behavior analysis, that are:
33(i) necessary to develop, maintain, or restore, to the maximum extent practicable, the
34functioning of an individual; and
35(ii) provided or supervised by a:
36(A) board certified behavior analyst; or
37(B) person licensed under Title 58, Chapter 1, Division of Professional Licensing
38Act, whose scope of practice includes mental health services.
39(d) "Diagnosis of autism spectrum disorder" means medically necessary assessments,
40evaluations, or tests:
41(i) performed by a licensed physician who is board certified in neurology, psychiatry,
42or pediatrics and has experience diagnosing autism spectrum disorder, or a
43licensed psychologist with experience diagnosing autism spectrum disorder; and
44(ii) necessary to diagnose whether an individual has an autism spectrum disorder.
45(e) "Mental health therapist" means the same as that term is defined in Section 58-60-102.
46[(e)] (f) "Pharmacy care" means medications prescribed by a licensed physician and any
47health-related services considered medically necessary to determine the need or
48effectiveness of the medications.
49[(f)] (g) "Psychiatric care" means direct or consultative services provided by a
50psychiatrist licensed in the state in which the psychiatrist practices.
51[(g)] (h) "Psychological care" means direct or consultative services provided by a
52psychologist licensed in the state in which the psychologist practices.
53[(h)] (i) "Therapeutic care" means services provided by licensed or certified speech
54therapists, occupational therapists, or physical therapists.
55[(i)] (j) "Treatment for autism spectrum disorder":
56(i) means evidence-based care and related equipment prescribed or ordered for an
57individual diagnosed with an autism spectrum disorder by a physician or a
58licensed psychologist described in Subsection (1)(d) who determines the care to
59be medically necessary; and
60(ii) includes:
61(A) behavioral health treatment, provided or supervised by a person described in
62Subsection (1)(c)(ii);
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63(B) pharmacy care;
64(C) psychiatric care;
65(D) psychological care; and
66(E) therapeutic care.
67  (2)(a) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan
68      offered in the individual market or the large group market and entered into or
69      renewed on or after January 1, 2016, and before January 1, 2020, shall provide
70      coverage for the diagnosis and treatment of autism spectrum disorder:
71(i) for a child who is at least two years old, but younger than 10 years old; and
72(ii) in accordance with the requirements of this section and rules made by the
73commissioner.
74      (b) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan
75offered in the individual market or the large group market and entered into or
76renewed on or after January 1, 2020, shall provide coverage for the diagnosis and
77treatment of autism spectrum disorder in accordance with the requirements of this
78section and rules made by the commissioner.
79  (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah
80      Administrative Rulemaking Act, to set the minimum standards of coverage for the
81      treatment of autism spectrum disorder.
82  (4) Subject to Subsection (5), the rules described in Subsection (3) shall establish durational
83      limits, amount limits, deductibles, copayments, and coinsurance for the treatment of
84      autism spectrum disorder that are similar to, or identical to, the coverage provided for
85      other illnesses or diseases.
86  (5)(a) Coverage for behavioral health treatment for a person with an autism spectrum
87      disorder shall cover at least 600 hours a year.
88      (b) Notwithstanding Subsection (5)(a), for a health benefit plan offered in the individual
89market or the large group market and entered into or renewed on or after January 1,
902020, coverage for behavioral health treatment for a person with an autism spectrum
91disorder may not have a limit on the number of hours covered.
92      (c) Other terms and conditions in the health benefit plan that apply to other benefits
93covered by the health benefit plan apply to coverage required by this section.
94      (d) Notwithstanding Section 31A-45-303, a health benefit plan providing treatment
95under Subsections (5)(a) and (b) shall include in the plan's provider network both
96board certified behavior analysts and mental health providers qualified under
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97Subsection (1)(c)(ii).
98   (6)(a) A health care provider shall submit a treatment plan for autism spectrum disorder
99to the insurer within 14 business days of starting treatment for an individual.
100(b) If an individual is receiving treatment for an autism spectrum disorder, an insurer
101shall have the right to request a review of that treatment not more than once every
102three months.
103(c) A review of treatment under this Subsection (6) may include a review of treatment
104goals and progress toward the treatment goals.
105(d) If an insurer makes a determination to stop treatment as a result of the review of the
106treatment plan under this [subsection] Subsection (6), the determination of the insurer
107may be reviewed under Section 31A-22-629.
108   (7)(a) Before July 1, 2027, and before July 1 each year after, a health benefit plan shall
109report the following to the department for the prior insurance plan year:
110(i) the average wait time for an enrollee to receive an autism assessment;
111(ii) if the health benefit plan has prior authorization requirements related to autism
112assessment or treatment;
113(iii) the number of enrollees under age 18 that were diagnosed with autism spectrum
114disorder;
115(iv) of the number of diagnoses described in Subsection (7)(a)(iii), the number of
116diagnoses disaggregated based on provider license type that made the diagnosis;
117(v) of the number of diagnoses described in Subsection (7)(a)(iii), the number of
118enrollees that received applied behavior analysis treatment;
119(vi) for enrollees that received applied behavior analysis treatment:
120(A) the average number of hours of applied behavior analysis treatment received;
121and
122(B) the average cost of applied behavior analysis treatment received; and
123(vii) if the health benefit plan accepts state defrayal payments under Subsection
12431A-30-118(2) for coverage described in this section.
125(b) The department shall compile the information described in Subsection (7)(a) and
126provide a report to the Health and Human Services Interim Committee on or before
127September 1.
128(c) Beginning September 1, 2027, the department shall provide on the department's
129website, in a form that is easily accessible, information regarding which health
130benefit plans reimburse a mental health therapist that is not a physician or a
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131psychologist for autism spectrum disorder treatment.
132Section 2. Section 63I-1-231 is amended to read:
13363I-1-231 . Repeal dates: Title 31A.
134  (1) Section 31A-2-217, Coordination with other states, is repealed July 1, 2033.
135  (2) Subsection 31A-22-642(7), regarding the reporting requirement for autism coverage, is
136      repealed January 1, 2030.
137  [(2)] (3) Subsection 31A-22-650(5)(b), regarding the reporting requirement that includes the
138      number of preauthorizations that were approved and denied, is repealed July 1, 2029.
139  [(3)] (4) Subsection 31A-22-650(8), regarding the rulemaking for the preauthorization
140      reporting requirement, is repealed July 1, 2029.
141  [(4)] (5) Section 31A-22-627.1, Ground ambulance reimbursement, is repealed July 1, 2027.
142Section 3. Effective Date.
143  This bill takes effect on May 6, 2026.
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