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

2 Co-sponsors

• Hiram Monserrate
• George Onorato

Title of bill

An act to amend the insurance law, in relation to requiring health insurance coverage of the diagnosis and treatment of autism spectrum disorders in persons under twenty-one years of age

Purpose or general idea of bill

To expand required health insurance coverage for the treatment and diagnosis of autism spectrum disorders.

Summary of specific provisions

Section 1: Amends Insurance §32l6-i(25), §3221-i(17) and §4303(ee) 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 rendered to covered persons under the age of twenty-one years.

Defines autism spectrum disorder (including neurobiological conditions that include autism, Asperger syndrome, Rett's syndrome, or pervasive developmental disorder) in accordance with the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.

Defines diagnosis of autism spectrum disorder 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 would reasonably prevent the onset of an illness, condition, injury, disease, or disability; reduce or ameliorate the physical, mental or development effects of said illness; achieve or maintain maximum functional activity in performing daily activities.

Treatment for autism spectrum disorders shall include psychiatric care, including direct, consultative, and diagnostic services; psychological care; habilitative or rehabilitative care; therapeutic care, including behavioral, speech, occupational and physical therapies; providing coverage not to exceed thirty-six thousand dollars per year.

Justification

Insurance companies would be required to cover autism diagnosis and treatment up to $36,000. The action would mark a victory for advocates who say early intervention and therapy is key to helping children with autism gain communication and social skills. The underlying cause of autism is not known.

On the national level, the number of children diagnosed with autism has increased by 500 percent over the past ten years. In New York State alone, the Office of Mental Retardation and Developmental Disabilities serves 16,000 individuals with autism In many cases, families of children with autism are forced to cover treatment costs with personal funds, at costs that can range from $2,000 to $4,000 out-of-pocket per month. The Autism Society of America estimates that the lifetime cost of caring for a child with autism ranges .from $3.5 million to $5 million.

Insurance companies and health maintenance organizations are in a much better position to negotiate lower rates and better quality service. Eventually, coverage costs will decrease as more professionals are trained to work with autism. Coverage will assume the cost of treatment at a lower rate. Children who go without the essential treatment may never have the ability to master basic life skills and they may become a danger to themselves and to the community. For every $1 we spend before the age of 5 we save $7 on lifelong care.

Prior legislative history

New bill.

Fiscal implications

To be determined.

Effective date

This act shall take effect on the first 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.