Expands required health insurance coverage for the treatment and diagnosis of autism spectrum disorders

Summary of specific provisions

Amends §3216-i(25), §3221-i(17) and §4303(ee) of the Insurance Law to provide coverage in every policy, group policy, and/or medical indemnity, hospital service or health service corporation, for the diagnosis and treatment of autism spectrum disorders.

Defines "autism spectrum disorders" as pervasive developmental disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders IV Revised, including autism, Asperger's disorder and pervasive develop- mental disorders not otherwise specified.

Defines "diagnosis of autism spectrum disorders" as one or more tests, evaluations or assessments to diagnose whether an individual has autism spectrum disorders; which are performed or ordered by a physician or psychologist licensed to practice medicine in the state and having expertise in the diagnosis of autism spectrum disorders.

Defines medically necessary as any care, treatment, intervention, service or item which will or is reasonably expected to prevent the onset of an illness, condition, injury, disease, or disability; reduce or ameliorate the physical, mental or development effects of said illness; assist to achieve or maintain maximum functional activity in performing daily activities.

Provides that treatment for autism spectrum disorders shall include psychiatric care, including direct, consultative, and diagnostic services; psychological care; habilitative or rehabilitative care; pediatric and developmental pediatric care; anesthesiological care and anesthetic services; neurological care; gastroenterologic care; endocri- nological care; therapeutic care, including behavioral, speech, occupa- tional and physical therapies as well as social skills education train- ing; and social skills education training.

Provides that upon request of the coverage provider, a treatment provid- er shall furnish medical records, clinical notes or other necessary data that substantiate that the initial and continued medical treatment is medically necessary and resulting in improved clinical status or the prevention of regression or loss of skills and functioning. When treat- ment is anticipated to require continued services to achieve demonstra- ble progress, the coverage provider may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, antic- ipated duration of treatment, the anticipated outcomes stated as goals, and the frequency by which the treatment plan will be updated.

Provides that a coverage provider shall have in place a procedure under which a covered person with autism spectrum disorder whose condition or disease requires specialized medical care over a prolonged period of time shall receive a referral to a specialist; or to a nonparticipating provider with appropriate training and experience, if an appropriate specialist is not available within the plan, at no additional cost to the enrollee beyond what the enrollee would otherwise pay for services received within the network.

Provides that a coverage provider shall have in place a procedure under which a covered person with autism spectrum disorder whose condition or disease requires ongoing care from a specialist may request and obtain a standing referral to such specialist for treatment of such condition, upon the determination by the primary care provider and the specialist (if any).

Justification

This legislation calls for health insurers regulated by the State of New York to treat people with autism no differently than people with any other health disorder. It calls for the provision of medically necessary health interventions to treat sick people, primarily children. No other health disorder treatment is limited by an annual spending cap under New York State law, nor does New York State law implement an age limit for the treatment of any other disorder.

Autism is the fastest growing disabling disorder affecting American children, with diagnoses increasing by 500 percent over the past ten years. In New York State, the autism rate for children has been increas- ing by approximately 15% per year in that time span. Studies from the year 2000 showed that 1 in 150 children are affected, but more recent studies place the number closer to 1 in 90 children. Currently, there are 17,000 students age 4 to 21 classified by New York schools as having autism. The number of adults with autism has not been well studied.

Historically, autism had been misidentified as a psychiatric disorder and has been excluded from coverage by health insurance carriers. Recent discoveries made possible by significantly increased public investment in autism research has shown that there is a wide range of serious physical health problems associated with autism, including gastro-intestinal issues, seizures, immune disorders, allergies, asthma, chronic inflammation and metabolic issues. Hundreds of studies have shown that intensive behavioral therapies can result in significant improvement in the cognition, communication and functionality of people with autism.

There are substantial financial costs for failing to provide medically necessary treatment for people with autism. Children denied intensive early treatment will have a lower level of functionality and are much more likely to need life-long support services. The lifetime costs of placing an individual with autism in a group-home setting in the New York City/Long Island area is estimated to be approximately $14 million. Conversely, cost analyses show that every dollar spent on early treat- ment will save $5 to $7 in long-term costs.

In the absence of adequate health insurance coverage, a disproportionate cost of autism is borne directly by the families of those affected, many of whom do not have the resources to provide adequate treatment (out-of pocket costs often run as high as $2,000 to $4,000 per month, and the Autism Society of America estimates that the lifetime cost of caring for a child with autism ranges from $3.5 to $5 million); or by the taxpay- ers, through Medicaid and increased demand for services through the schools.

There have been a large number of actuarial studies performed to assess the costs of state-level legislation that compels the inclusion of autism within the range of required coverage. All of these studies have indicated a worst-case scenario cost increase to policy holders of 1% or less. Information on the real costs for mandatory autism coverage from Aetna in Texas shows an increase of less than .1%, while an actuarial analysis of legislation introduced in showed an estimated worse case scenario cost increase of .8% per policy holder. None of the cost analyses done include a quantification of the potential long-term savings from providing appropriate treatment of autism, which as indi- cated above, are significant.

New York State Insurance law regarding autism was significantly changed in 2006 with the passage of Chapter 557 of the laws of 2006, which requires insurers to provide all medical services to people with autism that would be provided to people without autism. This law has helped ameliorate the inequitable coverage provided to people with autism by health insurers, but it does not specify health care services specific to the treatment of autism. Nor does Timothy's Law provide adequate provisions, pertaining only to specified psychiatric disorders co-morbid with autism.

California, Texas, Pennsylvania, Florida, Illinois, Montana, Indiana, Louisiana, Oregon, South Carolina and Arizona, all have laws requiring health insurers to cover autism. And similar legislation is under consideration in several dozen more states. Earlier this year, legis- lation was introduced in the United States Senate (S.B. 819, the Accel- erating the Treatment of Autism Act) calling for modifications to feder- al insurance law that would require autism coverage with no annual spending caps or age limits.

Prior legislative history

New bill.

Fiscal implications

While the cost implications of this program have yet to be fully determined, this legislation would provide relief to an already overburdened Medicaid system by requiring more insurance cover- age for treatments associated with ASD. In addition, if we calculate that an estimated one in ninety children in New York State is diagnosed with some form of ASD, and we calculate that for every $1 we spend before the age of 5 we save $7 on lifelong care, we will ultimately save the state, insurance providers, victims and their families untold millions of dollars over the long-term.

(Additionally, information on the real costs for mandatory autism cover- age from Aetna in Texas shows an increase of less than .1%, while an actuarial analysis of legislation introduced in Massachusetts showed an estimated worse case scenario cost increase of .8% per policy holder)

Effective date

This act shall take effect on the first day of January next succeeding the date on which it shall have become law and shall apply to all policies or contracts issued, renewed, modified, altered or amended on and after such effective date.