Bill S5845-2011

Relates to coverage for the screening, diagnosis and treatment of autism spectrum disorder

Relates to coverage for the screening, diagnosis and treatment of autism spectrum disorder.

Details

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Actions

  • Nov 1, 2011: SIGNED CHAP.596
  • Oct 31, 2011: DELIVERED TO GOVERNOR
  • Jun 23, 2011: returned to senate
  • Jun 23, 2011: passed assembly
  • Jun 23, 2011: message of necessity - 3 day message
  • Jun 23, 2011: ordered to third reading rules cal.604
  • Jun 23, 2011: substituted for a8512
  • Jun 23, 2011: referred to insurance
  • Jun 22, 2011: DELIVERED TO ASSEMBLY
  • Jun 22, 2011: PASSED SENATE
  • Jun 22, 2011: MESSAGE OF NECESSITY
  • Jun 22, 2011: ORDERED TO THIRD READING CAL.1523
  • Jun 22, 2011: REFERRED TO RULES

Votes

Memo

BILL NUMBER:S5845

TITLE OF BILL: An act to amend the insurance law, in relation to coverage for the screening, diagnosis and treatment of autism spectrum disorder; and to amend a chapter of the laws of 2011 amending the insurance law relating to coverage for the screening, diagnosis and treatment of autism spectrum disorder, as proposed in legislative bill numbers S.4005-A and A.6305-A, in relation to the effectiveness of such chapter

PURPOSE: To provide for insurance coverage for the screening, diagnosis and treatment of autism spectrum disorders.

SUMMARY OF PROVISIONS: Section 1: Amends section 3216 of the insurance law to provide for an annual benefit for applied behavior analysis of $45,000 per year per covered person. The Commissioner of education is required to be consulted on the promulgation of regulations by the superintendent with respect to standards of professionalism, supervision and relevant experience for behavioral analysis. The term "related medical equipment" is amended to "assistive communication device".

Section 2: Section 3221 of the insurance law is amended to provide for the aforementioned provisions.

Section 3: Section 4303 of the insurance law is amended to provide for the aforementioned provisions.

Sections 4 & 5: Provides for an effective date of the original chapter of one year following enactment.

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 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 cover- age for conditions relating to autism spectrum disorder.

LEGISLATIVE HISTORY: New bill.

FISCAL IMPLICATIONS: Undetermined.

EFFECTIVE DATE: Section 4: Amends the effective state of the original chapter to one year following enactment.

Section 5: Provides that this act shall take effect immediately provided that sections 1-3 shall take effect on the same date as the original chapter.


Text

STATE OF NEW YORK ________________________________________________________________________ 5845 2011-2012 Regular Sessions IN SENATE June 22, 2011 ___________
Introduced by COMMITTEE ON RULES -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the insurance law, in relation to coverage for the screening, diagnosis and treatment of autism spectrum disorder; and to amend a chapter of the laws of 2011 amending the insurance law relat- ing to coverage for the screening, diagnosis and treatment of autism spectrum disorder, as proposed in legislative bill numbers S. 4005-A and A. 6305-A, in relation to the effectiveness of such chapter THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subparagraphs (B) and (C) of paragraph 25 of subsection (i) of section 3216 of the insurance law, as added by a chapter of the laws of 2011 amending the insurance law relating to coverage for the screen- ing, diagnosis and treatment of autism spectrum disorder, as proposed in legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as follows: (B) Every policy which provides physician services, medical, major medical or similar comprehensive-type coverage shall provide coverage for the screening, diagnosis and treatment of autism spectrum disorder in accordance with this paragraph and shall not exclude coverage for the screening, diagnosis or treatment of medical conditions otherwise covered by the policy because the individual is diagnosed with autism spectrum disorder. Such coverage may be subject to annual deductibles, copayments and coinsurance as may be deemed appropriate by the super- intendent and shall be consistent with those imposed on other benefits under the policy. COVERAGE FOR APPLIED BEHAVIOR ANALYSIS SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF FORTY-FIVE THOUSAND DOLLARS PER YEAR PER COVERED INDIVIDUAL AND SUCH MAXIMUM ANNUAL BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE MEDICAL COMPONENT OF THE CONSUMER PRICE INDEX. This paragraph shall not be construed as limiting the benefits that are otherwise available
to an individual under the policy, provided however that such policy shall not contain any limitations on visits that are solely applied to the treatment of autism spectrum disorder. No insurer shall terminate coverage or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spec- trum disorder. Coverage shall be subject to utilization review and external appeals of health care services pursuant to article forty-nine of this chapter as well as, case management, and other managed care provisions. (C) For purposes of this paragraph: (i) "autism spectrum disorder" means any pervasive developmental disorder as defined in the most recent edition of the diagnostic and statistical manual of mental disorders, including autistic disorder, Asperger's disorder, Rett's disorder, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified (PDD-NOS). (ii) "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behav- ior. (iii) "behavioral health treatment" means counseling and treatment programs, when provided by a licensed provider, and applied behavior analysis, when provided or supervised by a behavior analyst certified pursuant to the behavior analyst certification board, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual. Individuals that provide behavioral health treatment under the supervision of a certified behavior analyst pursuant to this paragraph shall be subject to standards of professionalism, SUPERVISION and relevant experience pursuant to regulations promulgated by the superintendent in consultation with the [commissioner] COMMIS- SIONERS of health AND EDUCATION. (iv) "diagnosis of autism spectrum disorder" means assessments, evalu- ations, or tests to diagnose whether an individual has autism spectrum disorder. (v) "pharmacy care" means medications prescribed by a licensed health care provider legally authorized to prescribe under title eight of the education law. (vi) "psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist prac- tices. (vii) "psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychol- ogist practices. (viii) "therapeutic care" means services provided by licensed or certified speech therapists, occupational therapists, social workers, or physical therapists. (ix) "treatment of autism spectrum disorder" shall include the follow- ing care and [related equipment] ASSISTIVE COMMUNICATION DEVICES prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist: (1) behavioral health treatment; (2) psychiatric care; (3) psychological care; (4) medical care provided by a licensed health care provider;
(5) therapeutic care, including therapeutic care which is deemed habi- litative or nonrestorative, in the event that the policy provides cover- age for therapeutic care; and (6) pharmacy care in the event that the policy provides coverage for prescription drugs. S 2. Subparagraphs (B) and (C) of paragraph 17 of subsection (l) of section 3221 of the insurance law, as added by a chapter of the laws of 2011 amending the insurance law relating to coverage for the screening, diagnosis and treatment of autism spectrum disorder, as proposed in legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as follows: (B) Every group or blanket policy which provides physician services, medical, major medical or similar comprehensive-type coverage shall provide coverage for the screening, diagnosis and treatment of autism spectrum disorder in accordance with this paragraph and shall not exclude coverage for the screening, diagnosis or treatment of medical conditions otherwise covered by the policy because the individual is diagnosed with autism spectrum disorder. Such coverage may be subject to annual deductibles, copayments and coinsurance as may be deemed appro- priate by the superintendent and shall be consistent with those imposed on other benefits under the group or blanket policy. COVERAGE FOR APPLIED BEHAVIOR ANALYSIS SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF FORTY-FIVE THOUSAND DOLLARS PER YEAR PER COVERED INDIVIDUAL AND SUCH MAXIMUM ANNUAL BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE MEDICAL COMPONENT OF THE CONSUMER PRICE INDEX. This paragraph shall not be construed as limiting the benefits that are otherwise available to an individual under the group or blanket policy, provided however that such policy shall not contain any limitations on visits that are solely applied to the treatment of autism spectrum disorder. No insurer shall terminate coverage or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spec- trum disorder. Coverage shall be subject to utilization review and external appeals of health care services pursuant to article forty-nine of this chapter as well as, case management, and other managed care provisions. (C) For purposes of this paragraph: (i) "autism spectrum disorder" means any pervasive developmental disorder as defined in the most recent edition of the diagnostic and statistical manual of mental disorders, including autistic disorder, Asperger's disorder, Rett's disorder, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified (PDD-NOS). (ii) "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behav- ior. (iii) "behavioral health treatment" means counseling and treatment programs, when provided by a licensed provider, and applied behavior analysis, when provided or supervised by a behavior analyst certified pursuant to the behavior analyst certification board, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual. Individuals that provide behavioral health treatment under the supervision of a certified behavior analyst pursuant
to this paragraph shall be subject to standards of professionalism, SUPERVISION and relevant experience pursuant to regulations promulgated by the superintendent in consultation with the [commissioner] COMMIS- SIONERS of health AND EDUCATION. (iv) "diagnosis of autism spectrum disorder" means assessments, evalu- ations, or tests to diagnose whether an individual has autism spectrum disorder. (v) "pharmacy care" means medications prescribed by a licensed health care provider legally authorized to prescribe under title eight of the education law. (vi) "psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist prac- tices. (vii) "psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychol- ogist practices. (viii) "therapeutic care" means services provided by licensed or certified speech therapists, occupational therapists, social workers, or physical therapists. (ix) "treatment of autism spectrum disorder" shall include the follow- ing care and [related equipment] ASSISTIVE COMMUNICATION DEVICES prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist: (1) behavioral health treatment; (2) psychiatric care; (3) psychological care; (4) medical care provided by a licensed health care provider; (5) therapeutic care, including therapeutic care which is deemed habi- litative or nonrestorative, in the event that the policy provides cover- age for therapeutic care; and (6) pharmacy care in the event that the policy provides coverage for prescription drugs. S 3. Subsection (ee) of section 4303 of the insurance law, as added by a chapter of the laws of 2011 amending the insurance law relating to coverage for the screening, diagnosis and treatment of autism spectrum disorder, as proposed in legislative bill numbers S. 4005-A and A. 6305-A, is amended to read as follows: (ee) (1) A medical expense indemnity corporation, a hospital service corporation or a health service corporation which provides coverage for hospital or surgical care coverage shall not exclude coverage for screening, diagnosis and treatment of medical conditions otherwise covered by the [policy] CONTRACT solely because the treatment is provided to diagnose or treat autism spectrum disorder. (2) Every [policy] CONTRACT which provides physician services, medical, major medical or similar comprehensive-type coverage shall provide coverage for the screening, diagnosis and treatment of autism spectrum disorder in accordance with this subsection and shall not exclude coverage for the screening, diagnosis or treatment of medical conditions otherwise covered by the [policy] CONTRACT because the indi- vidual is diagnosed with autism spectrum disorder. Such 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 [policy] CONTRACT. COVERAGE FOR APPLIED BEHAVIOR ANALYSIS SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF FORTY-FIVE THOUSAND DOLLARS PER YEAR PER COVERED INDIVIDUAL AND SUCH MAXIMUM ANNUAL BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE
AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE MEDICAL COMPONENT OF THE CONSUMER PRICE INDEX. This paragraph shall not be construed as limiting the benefits that are otherwise available to an individual under the [policy] CONTRACT, provided however that such [policy] CONTRACT shall not contain any limitations on visits that are solely applied to the treatment of autism spectrum disorder. No insurer shall terminate coverage or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spectrum disorder. Coverage shall be subject to utilization review and external appeals of health care services pursuant to article forty-nine of this chapter as well as, case management, and other managed care provisions. (3) For purposes of this subsection: (A) "autism spectrum disorder" means any pervasive developmental disorder as defined in the most recent edition of the diagnostic and statistical manual of mental disorders, including autistic disorder, Asperger's disorder, Rett's disorder, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified (PDD-NOS). (B) "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behav- ior. (C) "behavioral health treatment" means counseling and treatment programs, when provided by a licensed provider, and applied behavior analysis, when provided or supervised by a behavior analyst certified pursuant to the behavior analyst certification board, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual. Individuals that provide behavioral health treatment under the supervision of a certified behavior analyst pursuant to this subsection shall be subject to standards of professionalism, SUPERVISION and relevant experience pursuant to regulations promulgated by the superintendent in consultation with the [commissioner] COMMIS- SIONERS of health AND EDUCATION. (D) "diagnosis of autism spectrum disorder" means assessments, evalu- ations, or tests to diagnose whether an individual has autism spectrum disorder. (E) "pharmacy care" means medications prescribed by a licensed health care provider legally authorized to prescribe under title eight of the education law. (F) "psychiatric care" means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist prac- tices. (G) "psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the psychol- ogist practices. (H) "therapeutic care" means services provided by licensed or certi- fied speech therapists, occupational therapists, social workers, or physical therapists. (I) "treatment of autism spectrum disorder" shall include the follow- ing care and [related equipment] ASSISTIVE COMMUNICATION DEVICES prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist: (i) behavioral health treatment;
(ii) psychiatric care; (iii) psychological care; (iv) medical care provided by a licensed health care provider; (v) therapeutic care, including therapeutic care which is deemed habi- litative or nonrestorative, in the event that the policy provides cover- age for therapeutic care; and (vi) pharmacy care in the event that the [policy] CONTRACT provides coverage for prescription drugs. (4) Coverage may be denied on the basis that such treatment is being provided to the covered person pursuant to an individualized education plan under article eighty-nine of the education law. The provision of services pursuant to an individualized family service plan under section twenty-five hundred forty-five of the public health law, an individual- ized education plan under article eighty-nine of the education law, or an individualized service plan pursuant to regulations of the office for persons with developmental disabilities 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 physi- cian or licensed psychologist. (5) Nothing in this subsection shall be construed to affect any obli- gation to provide services to an individual under an individualized family service plan under section twenty-five hundred forty-five of the public health law, an individualized education plan under article eight- y-nine of the education law, or an individualized service plan pursuant to regulations of the office for persons with developmental disabili- ties. (6) Nothing in this subsection shall be construed to affect any obli- gation to provide coverage for otherwise-covered services solely on the basis that the services constitute early intervention program services pursuant to section three thousand two hundred thirty-five-a of this article or an individualized service plan pursuant to regulations of the office for persons with developmental disabilities. (7) Nothing in this subsection shall be construed to prevent a [poli- cy] CONTRACT from providing services through a network of participating providers who shall meet certain requirements for participation, includ- ing provider credentialing. S 4. Section 5 of a chapter of the laws of 2011 amending the insurance law relating to coverage for the screening, diagnosis and treatment of autism spectrum disorder, as proposed in legislative bill numbers S. 4005-A and A. 6305-A, is amended to read as follows: S 5. This act shall take effect [on the first of January next succeed- ing the date on which] ONE YEAR AFTER it shall have become a law and shall apply to all policies and contracts issued, renewed, modified, altered or amended on or after such date. S 5. This act shall take effect immediately; provided, however, that sections one, two and three of this act shall take effect on the same date and in the same manner as a chapter of the laws of 2011 amending the insurance law relating to coverage for the screening, diagnosis and treatment of autism spectrum disorder, as proposed in legislative bill numbers S. 4005-A and A. 6305-A, takes effect.

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