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S6123 - REFERRED TO RULES - Aug 10, 2009

S6123 Memo

BILL NUMBER: S6123

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



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

SUMMARY OF 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 developmental 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; endocrinological care; therapeutic care, including behavioral, speech, occupational and physical therapies as well as social skills education training; and social skills education training. Provides that upon request of the coverage provider, a treatment provider 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 treatment is anticipated to require continued services to achieve demonstrable progress, the coverage provider may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated 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 increasing 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 treatment 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 taxpayers, 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 indicated 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, legislation was introduced in the United States Senate (S.B. 819, the Accelerating the Treatment of Autism Act) calling for modifications to federal insurance law that would require autism coverage with no annual spending caps or age limits.

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 coverage 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 coverage 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.

S6123 Text

S T A T E O F N E W Y O R K
6123
2009-2010 Regular Sessions I N SENATE August 10, 2009
Introduced by Sen. HUNTLEY -- 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 requiring health insurance coverage of the diagnosis and treatment of autism spectrum disorders
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM BLY, DO ENACT AS FOLLOWS:


Section 1. Paragraph 25 of subsection (i) of section 3216 of the insurance law, as added by chapter 557 of the laws of 2006, is amended to read as follows:
(25) (A) Every policy which provides coverage for hospital, surgical, or medical care coverage shall [not exclude] PROVIDE coverage for THE diagnosis and treatment of [medical conditions otherwise covered by the policy solely because the treatment is provided to diagnose or treat] autism spectrum [disorder] DISORDERS. (B) For purposes of this [section, "autism] PARAGRAPH:
(I) "AUTISM spectrum [disorder" means a neurobiological condition that includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel opmental disorder] DISORDERS" MEANS 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. (II) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS, EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM SPECTRUM DISORDERS OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A PHYSI CIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST LICENSED TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAGNOSING AUTISM SPECTRUM DISORDERS. (III) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM WHICH WILL OR IS REASONABLY EXPECTED TO DO ANY OF THE FOLLOWING:
(I) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD10358-05-9
S. 6123 2 (II) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL OR DEVELOPMENTAL EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR (III) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL ACTIVITY IN PERFORMING DAILY ACTIVITIES. (IV) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE BUT NOT BE LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
(I) PSYCHIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY; (II) PSYCHOLOGICAL CARE, INCLUDING DIRECT OR CONSULTATIVE SERVICES PROVIDED BY A LICENSED PSYCHOLOGIST; (III) HABILITATIVE OR REHABILITATIVE CARE, INCLUDING PROFESSIONAL, COUNSELING AND GUIDANCE SERVICES AND TREATMENT PROGRAMS THAT ARE INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID UAL; (IV) PEDIATRIC AND DEVELOPMENTAL PEDIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS; (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ANESTHESIOLOGY; (VI) NEUROLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY; (VII) GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN GASTROENTEROLOGY; (VIII) ENDOCRINOLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ENDO CRINOLOGY; (IX) THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
1. SELF CARE AND FEEDING, 2. PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE, 3. COGNITIVE FUNCTIONING, 4. APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION, 5. MOTOR PLANNING, 6. SENSORY PROCESSING AND INTEGRATION, AND 7. ASSISTIVE TECHNOLOGY; (X) SOCIAL SKILLS EDUCATION TRAINING. (C) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR AUTISM SPECTRUM DISORDERS 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 CLIN ICAL STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES TO ACHIEVE DEMONSTRABLE PROGRESS, THE COVERAGE PROVIDER MAY REQUEST A TREATMENT PLAN CONSISTING OF DIAGNOSIS, PROPOSED TREATMENT BY TYPE, FREQUENCY, ANTICIPATED DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN WILL BE UPDATED. (D) AN INSURER PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL HAVE IN PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO IS COVERED UNDER SUCH POLICY AND WHOSE CONDITION OR DISEASE REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS PANEL OR NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL S. 6123 3 LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE BEYOND WHAT THE ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE FOR AND SHALL BE DEEMED CAPABLE OF PROVIDING AND COORDINATING THE ENROLLEE'S PRIMARY AND SPECIALTY CARE. (E) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRES ONGO ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION. IF THE PRIMARY CARE PROVIDER AND THE SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING REFERRAL IS APPROPRIATE, THE PLAN OR ISSUER SHALL AUTHORIZE SUCH A REFERRAL TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST ENT WITH A TREATMENT PLAN.

S 2. Paragraph 17 of subsection (l) of section 3221 of the insurance law, as added by chapter 557 of the laws of 2006, is amended to read as follows:
(17) (A) A group or blanket accident or health insurance policy or issuing a group or blanket policy for delivery in this state which provides coverage for hospital, surgical, or medical care coverage shall [not exclude] PROVIDE coverage for THE diagnosis and treatment of [medical conditions otherwise covered by the policy because the treat ment is provided to diagnose or treat] autism spectrum [disorder] DISOR DERS. (B) For purposes of this [section, "autism] PARAGRAPH:
(I) "AUTISM spectrum [disorder" means a neurobiological condition that includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel opmental disorder] DISORDERS" MEANS 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. (II) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS, EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM SPECTRUM DISORDERS OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A PHYSI CIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST LICENSED TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAGNOSING AUTISM SPECTRUM DISORDERS. (III) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM WHICH WILL OR IS REASONABLY EXPECTED TO DO ANY OF THE FOLLOWING:
(I) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; (II) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL OR DEVELOPMENTAL EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR (III) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL ACTIVITY IN PERFORMING DAILY ACTIVITIES. (IV) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE BUT NOT BE LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
(I) PSYCHIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY; (II) PSYCHOLOGICAL CARE, INCLUDING DIRECT OR CONSULTATIVE SERVICES PROVIDED BY A LICENSED PSYCHOLOGIST; S. 6123 4 (III) HABILITATIVE OR REHABILITATIVE CARE, INCLUDING PROFESSIONAL, COUNSELING AND GUIDANCE SERVICES AND TREATMENT PROGRAMS THAT ARE INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID UAL; (IV) PEDIATRIC AND DEVELOPMENTAL PEDIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS; (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ANESTHESIOLOGY; (VI) NEUROLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY; (VII) GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN GASTROENTEROLOGY; (VIII) ENDOCRINOLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ENDO CRINOLOGY; (IX) THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
1. SELF CARE AND FEEDING, 2. PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE, 3. COGNITIVE FUNCTIONING, 4. APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION, 5. MOTOR PLANNING, 6. SENSORY PROCESSING AND INTEGRATION, AND 7. ASSISTIVE TECHNOLOGY; (X) SOCIAL SKILLS EDUCATION TRAINING. (C) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR AUTISM SPECTRUM DISORDERS 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 CLIN ICAL STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES TO ACHIEVE DEMONSTRABLE PROGRESS, THE COVERAGE PROVIDER MAY REQUEST A TREATMENT PLAN CONSISTING OF DIAGNOSIS, PROPOSED TREATMENT BY TYPE, FREQUENCY, ANTICIPATED DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN WILL BE UPDATED. (D) AN INSURER PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL HAVE IN PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO IS COVERED UNDER SUCH POLICY AND WHOSE CONDITION OR DISEASE REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS PANEL OR NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE BEYOND WHAT THE ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE FOR AND SHALL BE DEEMED CAPABLE OF PROVIDING AND COORDINATING THE ENROLLEE'S PRIMARY AND SPECIALTY CARE. (E) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRES ONGO ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION. IF THE PRIMARY CARE S. 6123 5 PROVIDER AND THE SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING REFERRAL IS APPROPRIATE, THE PLAN OR ISSUER SHALL AUTHORIZE SUCH A REFERRAL TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST ENT WITH A TREATMENT PLAN.

S 3. Subsection (ee) of section 4303 of the insurance law, as added by chapter 557 of the laws of 2006, 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, surgical, or medical care coverage shall [not exclude] INCLUDE coverage for THE diagnosis and treatment of [medical conditions other wise covered by the policy solely because the treatment is provided to diagnose or treat] autism spectrum [disorder] DISORDERS. (2) For purposes of this [section, "autism] SUBSECTION:
(A) "AUTISM spectrum [disorder" means a neurobiological condition that includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel opmental disorder] DISORDERS" MEANS PERVASIVE DEVELOPMENTAL DISORDERS AS DEFINED IN THE THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV REVISED, INCLUDING AUTISM, ASPERGER'S DISORDER AND PERVASIVE DEVELOP MENTAL DISORDERS NOT OTHERWISE SPECIFIED. (B) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS, EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM SPECTRUM DISORDERS OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A PHYSI CIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST LICENSED TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAGNOSING AUTISM SPECTRUM DISORDERS. (C) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM WHICH WILL OR IS REASONABLY EXPECTED TO DO ANY OF THE FOLLOWING:
(I) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; (II) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL OR DEVELOPMENTAL EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR (III) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL ACTIVITY IN PERFORMING DAILY ACTIVITIES. (D) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE BUT NOT BE LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
(I) PSYCHIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY; (II) PSYCHOLOGICAL CARE, INCLUDING DIRECT OR CONSULTATIVE SERVICES PROVIDED BY A LICENSED PSYCHOLOGIST; (III) HABILITATIVE OR REHABILITATIVE CARE, INCLUDING PROFESSIONAL, COUNSELING AND GUIDANCE SERVICES AND TREATMENT PROGRAMS THAT ARE INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID UAL; (IV) PEDIATRIC AND DEVELOPMENTAL PEDIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS; (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ANESTHESIOLOGY; (VI) NEUROLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY; S. 6123 6 (VII) GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN GASTROENTEROLOGY; (VIII) ENDOCRINOLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ENDO CRINOLOGY; (IX) THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
(I) SELF CARE AND FEEDING, (II) PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE, (III) COGNITIVE FUNCTIONING, (IV) APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION, (V) MOTOR PLANNING, (VI) SENSORY PROCESSING AND INTEGRATION, AND (VII) ASSISTIVE TECHNOLOGY; (X) SOCIAL SKILLS EDUCATION TRAINING. (3) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR AUTISM SPECTRUM DISORDERS 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 CLIN ICAL STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES TO ACHIEVE DEMONSTRABLE PROGRESS, THE COVERAGE PROVIDER MAY REQUEST A TREATMENT PLAN CONSISTING OF DIAGNOSIS, PROPOSED TREATMENT BY TYPE, FREQUENCY, ANTICIPATED DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN WILL BE UPDATED. (4) AN INSURER PROVIDING COVERAGE UNDER THIS SUBSECTION SHALL HAVE IN PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO IS COVERED UNDER SUCH POLICY AND WHOSE CONDITION OR DISEASE REQUIRES SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS PANEL OR NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE BEYOND WHAT THE ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE FOR AND SHALL BE DEEMED CAPABLE OF PROVIDING AND COORDINATING THE ENROLLEE'S PRIMARY AND SPECIALITY CARE. (5) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRE ONGO ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION. IF THE PRIMARY CARE PROVIDER AND THE SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING REFERRAL IS APPROPRIATE, THE PLAN OR ISSUER SHALL AUTHORIZE SUCH A REFERRAL TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST ENT WITH A TREATMENT PLAN.

S 4. This act shall take effect on the first of January next succeed ing the date on which it shall have become a law and shall apply to all policies or contracts issued, renewed, modified, altered or amended on and after such effective date.

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