Relates to coverage for the 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 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 and external review of health care services, including case management and other managed care provisions.

Defines "autism spectrum disorder" as Pervasive Developmental Disorders including Autistic Disorder, Asperger's Disorder, Rett's Disorder, Childhood Disintegrative Disorder, and pervasive Developmental Disorder Not otherwise specified, as defined in the most recent edition of the Diagnostic and statistical Manual of Mental Disorders.

Defines "diagnosis of autism spectrum disorders", "behavioral health treatment", "applied behavioral analysis", "treatment of autism spectrum disorder", "pharmacy care", "psychiatric care", "psychological care" and "therapeutic care".

Provides that licensed physician or psychologist are authorized to prescribe care for the following: behavioral health treatment; pharmacy care; psychiatric care; psychological care; therapeutic care and other medical care prescribed by a licensed health care provider.

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 prescribed by a licensed physician or psychologist.

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

Autism is a complex neurobiological disorder that severely affects the way autistic individuals relate to others socially and their ability to communicate and learn. Today the Centers for Disease Control (CDC) estimate that the number of children with autism is 1 in 110 nationwide, making it more common than pediatric cancer, diabetes, and AIDS combined. It occurs in all racial, ethnic, and social groups and is four times more likely to strike boys than girls.

Existing state law requires that insurance coverage for autism "not exclude" the diagnosis and treatment of autism spectrum disorder. Current law does not provide sufficient clarity or an affirmative obligation of health insurance to cover costs relating to autism treatments. Moreover, parents are often faced with significant gaps in treatments which may be needed over and above those provided pursuant to an individualized family, education or service plan. These families often pay as much as they can out-of-pocket for services that can cost upwards of $50,000 per year. In the process, many risk their homes and the education's of their unaffected children essentially mortgaging their futures. This legislation would expedite diagnosis and treatment by providing insurance parity for autism sufferers by requiring equitable coverage of the disorder by insurance companies.

If enacted, New York would join with 23 other states in requiring coverage for conditions relating to autism spectrum disorder.

Legislative history

FISCAL IMPLICATIONS: Treatment of autism spectrum disorders will result in better long-term health outcomes for those afflicted with this condition and should therefore lessen costs which are borne by taxpayers. There will be some minor cost to the State for coverage for it's own employees and their families. Actuarial cost estimates provided by independent actuaries retained by a leading national autism advocacy organization, Autism Speaks, determined that expected impact upon insurance costs were approximately one-half of one percent after full implementation of coverage over a number of years. Cost implications for other 23 states which have enacted such legislation have been very modest.

Effective date

This act shall take effect January 1 after enactment and shall apply to insurance policies issued or renewed after that date.