Requires that accident and health insurance policies shall provide coverage for screening, diagnosis and treatment of autism spectrum disorder

Summary of provisions

Amends Sections 3216, 3221 and 4303 of the Insurance Law to provide coverage for the screening, diagnosis and treatment of autism spectrum disorders.

Provides that coverage may be subject to annual deductibles, copayments and coinsurance as may be deemed appropriate by the superintendent and shall be consistent with those imposed on other benefits under the contract.

Provides that the legislation shall not be construed as limiting the benefits that are available to an individual under a health insurance policy.

Provides that coverage may be subject to utilization review of health care services, including the review of medical necessity, case management, and other managed care provisions.

Defines "autism spectrum disorder" as a group of neurobiological conditions defined in the Diagnostic and Statistical Manual of Mental Disorders IV Revised, or its successor, as pervasive developmental disorders, or a group possessing substantially the same characteristics as pervasive developmental disorders.

Provides that the commissioner of health, in consultation with the superintendent of insurance, commissioner of the office of mental retardation and developmental disabilities and commissioner of the office of mental health shall promulgate regulations which establish which treatment and therapy options insurers shall cover for the diagnosis and treatment of autism spectrum disorders no later than twelve months after the effective date of the legislation.

Provides that coverage for behavioral therapies required pursuant to the legislation shall not be denied on the basis that such therapies are educational or habilitative in nature unless such treatments are provided pursuant to an individualized education program.

Provides that the provision of services pursuant to an individualized family service plan, an individualized education program or an individualized service plan shall not affect coverage under the policy for services provided on a supplemental basis outside of an educational setting if such services are deemed medically necessary.

Provides that this legislation will not affect any obligation to provide services to an individual under an individualized family service plan or individualized education program or an individualized service plan.

Provides that nothing in the legislation shall be construed to prevent a contract from providing services through a network of participating providers who shall meet certain requirements for participation, including provider credentialing.

Justification

This legislation will close a significant gap in insurance coverage for individuals with autism. The Centers for Disease Control (CDC) have now estimated that the number of children with autism is 1 in 110 nationwide. (Prior CDC estimates had been 1 in 1.50). Existing state law requires that insurance coverage for autism "not exclude" the diagnosis and treatment of autism spectrum disorder. Current law does not provide clarity to consumers or insurers as to the scope of required coverage and does not establish a regulatory process whereby the Commissioner of Health is authorized to promulgate rules which identify treatment and therapy options.

This bill affirmatively requires policies to provide such coverage for individuals with autism spectrum disorder throughout their entire life span. The bill also provides for an updated definition of the term "autism spectrum disorder". The bill amends existing provisions of the insurance law to require coverage under health insurance policies issued by indemnity and nonprofit insurers, as well as health maintenance organizations. Coverage would specifically be required for the group of neurological conditions know as "autism spectrum disorder", limited only by whatever restrictions are otherwise contained in the policy. Coverage would also be subject to utilization review, medical necessity determinations and appropriate case management.

The Commissioner of Health, in consultation with the Insurance Superintendent and the Commissioners of Mental Health and Mental Retardation and Developmental Disabilities, is charged with responsibility for promulgating regulations identifying treatment and therapy options. The legislation insures that only those treatments and therapies which have been determined by recognized medical authority as evidence-based and clinically proven will be covered.

Legislative history

New bill.

Fiscal implications

Anticipated to result in savings to the State.

Effective date

This act shall take effect immediately, provided that sections one, two and three of this act shall take effect upon the promulgation of either emergency or permanent rules and regulations by the commissioner of health outlining the treatment insurers are required to provide to cover autism spectrum disorder as provided for in this act and shall apply to all policies or contracts issued, renewed, modified, altered or amended on and after such effective date; provided that the commissioner of health shall notify the legislative bill drafting commission upon the promulgation of such emergency or permanent rules and regulations in order that the commission may maintain an accurate and timely effective data base of the official text of the laws of the state of New York in furtherance of effectuating the provisions of section 44 of the legislative law and section 70-b of the public officers law.