NY State Assembly Bill 2009-A6001

Archive: Last Bill Status - In Assembly Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Date of Action	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2010	referred to insurance
Oct 13, 2009	print number 6001a
Oct 13, 2009	amend and recommit to insurance
Feb 23, 2009	referred to insurance

Bill Amendments

Original

A (Active)

2009-A6001 - Details

Current Committee:: Assembly Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 3221 & 4303, Ins L

2009-A6001 - Summary

Relates to autism spectrum disorders in individuals twenty-one years or less; directs the department of health to promulgate rules and regulations establishing standards for qualified autism services provider and upon such promulgation, payment for treatment of autism spectrum disorders covered shall only be made available to autism services providers who meet such standards; further directs the department of health shall further establish standards to be utilized by managed care plans for the credentialing of autism service providers and authorizes that the department of insurance may require that a managed care plan grant credentials to any autism service provider whom the department determines meets or exceeds the department's credentialing standards.

2009-A6001 - Bill Text download pdf

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  6001

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                            February 23, 2009
                               ___________

Introduced  by  M.  of  A.  WEISENBERG  -- read once and referred to the
  Committee on Insurance

AN ACT to amend the insurance law, in relation to autism spectrum disor-
  ders

  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)  Every  policy which provides coverage for hospital, surgical, or
medical care coverage shall  not  exclude  coverage  for  diagnosis  and
treatment  of  medical conditions otherwise covered by the policy solely
because the treatment is provided to diagnose or treat  autism  spectrum
disorder. IN INDIVIDUALS TWENTY-ONE YEARS OF AGE OR LESS, THERE SHALL BE
NO  LIMITS  ON  THE NUMBER OF VISITS AN INDIVIDUAL MAY MAKE TO AN AUTISM
PROVIDER. COVERAGE UNDER THIS SUBSECTION MAY BE  SUBJECT  TO  COPAYMENT,
DEDUCTIBLE  AND  COINSURANCE  PROVISIONS OF A HEALTH INSURANCE POLICY TO
THE EXTENT THAT OTHER MEDICAL SERVICE COVERED BY  THE  HEALTH  INSURANCE
POLICY  ARE  SUBJECT  TO  SUCH  PROVISIONS. THIS SUBSECTION SHALL NOT BE
CONSTRUED AS LIMITING THE BENEFITS THAT ARE AVAILABLE TO  AN  INDIVIDUAL
UNDER  A HEALTH INSURANCE POLICY. COVERAGE SHALL BE SUBJECT TO A MAXIMUM
BENEFIT OF THIRTY-SIX THOUSAND DOLLARS. AFTER DECEMBER THIRTY-FIRST, TWO
THOUSAND TEN, THE SUPERINTENDENT SHALL, ON AN ANNUAL BASIS,  ADJUST  THE
MAXIMUM  BENEFIT  FOR  INFLATION USING THE MEDICAL CARE COMPONENT OF THE
UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE  INDEX  FOR  ALL  URBAN
CONSUMERS.  THE SUPERINTENDENT SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT
FOR PUBLICATION ANNUALLY NO LATER THAN  APRIL  FIRST  OF  EACH  CALENDAR
YEAR, AND SUCH PUBLISHED ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN
THE FOLLOWING CALENDAR YEAR TO HEALTH INSURANCE POLICIES SUBJECT TO THIS
SECTION.  PAYMENTS  MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL
FOR ANY CARE, TREATMENT, INTERVENTION,  SERVICE  OR  ITEM  UNRELATED  TO

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD06364-03-9

A. 6001                             2

AUTISM SPECTRUM DISORDERS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM BENE-
FIT ESTABLISHED PURSUANT TO THIS SECTION. EXCEPT FOR INPATIENT SERVICES,
IF  AN  INDIVIDUAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS,
AN  INSURER  SHALL  HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT
NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDI-
VIDUAL'S LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT  A  MORE
FREQUENT  REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE
BORNE BY THE INSURER.
  (A) For purposes of this section[,]:
  (I) "autism spectrum disorder" means a neurobiological condition  that
includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
opmental disorder.
  (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)  "AUTISM  SERVICES  PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
  (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS  MEDICALLY  NECES-
SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
  (V)  "EVIDENCE-BASED  RESEARCH"  MEANS RESEARCH THAT APPLIES RIGOROUS,
SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE  RELEVANT
TO AUTISM SPECTRUM DISORDERS.
  (VI)  "HABILITATIVE  OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING  APPLIED
BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (VII)  "MEDICALLY  NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A  LICENSED
PHYSICIAN  OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY  OF
THE FOLLOWING:
  (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
  (2)  REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL,  OR DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
  (3) ASSIST TO ACHIEVE  OR  MAINTAIN  MAXIMUM  FUNCTIONAL  CAPACITY  IN
PERFORMING  DAILY  ACTIVITIES,  TAKING  INTO ACCOUNT BOTH THE FUNCTIONAL
CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
PRIATE FOR INDIVIDUALS OF THE SAME AGE.
  (VIII) "PHARMACY CARE" MEANS  MEDICATIONS  PRESCRIBED  BY  A  LICENSED
PHYSICIAN  AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
  (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (X)   "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (XI)  "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
  (XII) "TREATMENT FOR  AUTISM  SPECTRUM  DISORDERS"  WILL  INCLUDE  THE
FOLLOWING  CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED  PHYSICIAN

A. 6001                             3

OR  A  LICENSED  PSYCHOLOGIST  WHO  DETERMINES  THE CARE TO BE MEDICALLY
NECESSARY:
  (1) HABILITATIVE OR REHABILITATIVE CARE;
  (2) PHARMACY CARE;
  (3) PSYCHIATRIC CARE;
  (4) PSYCHOLOGICAL CARE;
  (5) THERAPEUTIC CARE; AND
  (6)  ANY  CARE  FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
IS PUBLISHED IN THE REGISTER FOR RULEMAKING BY STATE AGENCIES. ANY  SUCH
CARE,  TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
COVERED WILL BE INCLUDED  IN  ANY  HEALTH  INSURANCE  POLICY  DELIVERED,
EXECUTED,  ISSUED,  AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
  (B) THIS PARAGRAPH SHALL NOT BE CONSTRUED AS TO AFFECT ANY  OBLIGATION
TO  PROVIDE  SERVICES  TO  AN  INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY
SERVICE PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR  AN  INDIVIDUALIZED
SERVICE PLAN.
  S  2.  Paragraph 17 of subsection (1) 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 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  coverage  for  diagnosis  and  treatment  of medical conditions
otherwise covered by the policy because the  treatment  is  provided  to
diagnose  or  treat  autism spectrum disorder. IN INDIVIDUALS TWENTY-ONE
YEARS OF AGE OR LESS, THERE SHALL BE NO LIMITS ON THE NUMBER  OF  VISITS
AN  INDIVIDUAL  MAY  MAKE  TO  AN  AUTISM  PROVIDER. COVERAGE UNDER THIS
SUBSECTION MAY BE  SUBJECT  TO  COPAYMENT,  DEDUCTIBLE  AND  COINSURANCE
PROVISIONS OF A HEALTH INSURANCE POLICY TO THE EXTENT THAT OTHER MEDICAL
SERVICE  COVERED  BY  THE  HEALTH  INSURANCE  POLICY ARE SUBJECT TO SUCH
PROVISIONS. THIS SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING THE BENE-
FITS THAT ARE AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH INSURANCE  POLI-
CY.  COVERAGE  SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOU-
SAND  DOLLARS.  AFTER  DECEMBER  THIRTY-FIRST,  TWO  THOUSAND  TEN,  THE
SUPERINTENDENT SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR
INFLATION  USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPART-
MENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS.  THE  SUPER-
INTENDENT  SHALL  SUBMIT  THE  ADJUSTED  MAXIMUM BENEFIT FOR PUBLICATION
ANNUALLY NO LATER THAN APRIL FIRST  OF  EACH  CALENDAR  YEAR,  AND  SUCH
PUBLISHED  ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING
CALENDAR YEAR TO HEALTH INSURANCE  POLICIES  SUBJECT  TO  THIS  SECTION.
PAYMENTS  MADE  BY  AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY
CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM UNRELATED TO AUTISM SPEC-
TRUM DISORDERS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM  BENEFIT  ESTAB-
LISHED  PURSUANT  TO  THIS SECTION. EXCEPT FOR INPATIENT SERVICES, IF AN
INDIVIDUAL IS RECEIVING TREATMENT  FOR  AUTISM  SPECTRUM  DISORDERS,  AN
INSURER  SHALL  HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT NOT
MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE  INDIVID-
UAL'S  LICENSED  PHYSICIAN  OR  LICENSED  PSYCHOLOGIST AGREE THAT A MORE
FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL  BE
BORNE BY THE INSURER.
  (A) For purposes of this section[,]:

A. 6001                             4

  (I)  "autism spectrum disorder" means a neurobiological condition that
includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
opmental disorder.
  (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)  "AUTISM  SERVICES  PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
  (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS  MEDICALLY  NECES-
SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
  (V)  "EVIDENCE-BASED  RESEARCH"  MEANS RESEARCH THAT APPLIES RIGOROUS,
SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE  RELEVANT
TO AUTISM SPECTRUM DISORDERS.
  (VI)  "HABILITATIVE  OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING  APPLIED
BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (VII)  "MEDICALLY  NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A  LICENSED
PHYSICIAN  OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY  OF
THE FOLLOWING:
  (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
  (2)  REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL,  OR DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
  (3) ASSIST TO ACHIEVE  OR  MAINTAIN  MAXIMUM  FUNCTIONAL  CAPACITY  IN
PERFORMING  DAILY  ACTIVITIES,  TAKING  INTO ACCOUNT BOTH THE FUNCTIONAL
CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
PRIATE FOR INDIVIDUALS OF THE SAME AGE.
  (VIII) "PHARMACY CARE" MEANS  MEDICATIONS  PRESCRIBED  BY  A  LICENSED
PHYSICIAN  AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
  (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (X)   "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (XI)  "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
  (XII) "TREATMENT FOR  AUTISM  SPECTRUM  DISORDERS"  WILL  INCLUDE  THE
FOLLOWING  CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED  PHYSICIAN
OR  A  LICENSED  PSYCHOLOGIST  WHO  DETERMINES  THE CARE TO BE MEDICALLY
NECESSARY:
  (1) HABILITATIVE OR REHABILITATIVE CARE;
  (2) PHARMACY CARE;
  (3) PSYCHIATRIC CARE;
  (4) PSYCHOLOGICAL CARE;
  (5) THERAPEUTIC CARE; AND
  (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM  DISORDERS  THAT  IS
DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST

A. 6001                             5

PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
IS  PUBLISHED  IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT  PREVIOUSLY
COVERED  WILL  BE  INCLUDED  IN  ANY  HEALTH INSURANCE POLICY DELIVERED,
EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER  SIXTY  DAYS
FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
  (B)  THIS PARAGRAPH SHALL NOT BE CONSTRUED AS TO AFFECT ANY OBLIGATION
TO PROVIDE SERVICES TO AN  INDIVIDUAL  UNDER  AN  INDIVIDUALIZED  FAMILY
SERVICE  PLAN,  AN INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED
SERVICE 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) 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  coverage
for  diagnosis  and treatment of medical conditions otherwise covered by
the policy solely because the treatment is provided to diagnose or treat
autism spectrum disorder. IN INDIVIDUALS  TWENTY-ONE  YEARS  OF  AGE  OR
LESS, THERE SHALL BE NO LIMITS ON THE NUMBER OF VISITS AN INDIVIDUAL MAY
MAKE  TO  AN  AUTISM  PROVIDER.  COVERAGE  UNDER  THIS SUBSECTION MAY BE
SUBJECT TO COPAYMENT, DEDUCTIBLE AND COINSURANCE PROVISIONS OF A  HEALTH
INSURANCE  POLICY  TO  THE EXTENT THAT OTHER MEDICAL SERVICES COVERED BY
THE HEALTH  INSURANCE  POLICY  ARE  SUBJECT  TO  SUCH  PROVISIONS.  THIS
SUBSECTION  SHALL  NOT  BE  CONSTRUED  AS LIMITING THE BENEFITS THAT ARE
AVAILABLE TO AN INDIVIDUAL UNDER A  HEALTH  INSURANCE  POLICY.  COVERAGE
SHALL  BE  SUBJECT  TO A MAXIMUM BENEFIT OF THIRTY-SIX THOUSAND DOLLARS.
AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND TEN, THE SUPERINTENDENT SHALL,
ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR INFLATION  USING  THE
MEDICAL CARE COMPONENT OF THE UNITED STATES DEPARTMENT OF LABOR CONSUMER
PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPERINTENDENT SHALL SUBMIT THE
ADJUSTED  MAXIMUM  BENEFIT  FOR PUBLICATION ANNUALLY NO LATER THAN APRIL
FIRST OF EACH CALENDAR YEAR, AND SUCH PUBLISHED ADJUSTED MAXIMUM BENEFIT
SHALL BE APPLICABLE IN THE FOLLOWING CALENDAR YEAR TO  HEALTH  INSURANCE
POLICIES SUBJECT TO THIS SECTION.  PAYMENTS MADE BY AN INSURER ON BEHALF
OF  A  COVERED INDIVIDUAL FOR ANY CARE, TREATMENT, INTERVENTION, SERVICE
OR ITEM UNRELATED TO AUTISM SPECTRUM  DISORDERS  SHALL  NOT  BE  APPLIED
TOWARDS ANY MAXIMUM BENEFIT ESTABLISHED PURSUANT TO THIS SECTION. EXCEPT
FOR  INPATIENT  SERVICES,  IF  AN  INDIVIDUAL IS RECEIVING TREATMENT FOR
AUTISM SPECTRUM DISORDERS, AN INSURER SHALL HAVE THE RIGHT TO REQUEST  A
REVIEW  OF  SUCH TREATMENT NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS
SUCH  INSURER  AND  THE  INDIVIDUAL'S  LICENSED  PHYSICIAN  OR  LICENSED
PSYCHOLOGIST AGREE THAT A MORE FREQUENT REVIEW IS NECESSARY. THE COST OF
OBTAINING ANY REVIEW SHALL BE BORNE BY THE INSURER.
  (A) For purposes of this section[,]:
  (I)  "autism spectrum disorder" means a neurobiological condition that
includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
opmental disorder.
  (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) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON,  ENTITY,  OR  GROUP
THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.

A. 6001                             6

  (IV)  "DIAGNOSIS  OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
  (V)  "EVIDENCE-BASED  RESEARCH"  MEANS RESEARCH THAT APPLIES RIGOROUS,
SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE  RELEVANT
TO AUTISM SPECTRUM DISORDERS.
  (VI)  "HABILITATIVE  OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING  APPLIED
BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (VII)  "MEDICALLY  NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A  LICENSED
PHYSICIAN  OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY  OF
THE FOLLOWING:
  (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
  (2)  REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL,  OR DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
  (3) ASSIST TO ACHIEVE  OR  MAINTAIN  MAXIMUM  FUNCTIONAL  CAPACITY  IN
PERFORMING  DAILY  ACTIVITIES,  TAKING  INTO ACCOUNT BOTH THE FUNCTIONAL
CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
PRIATE FOR INDIVIDUALS OF THE SAME AGE.
  (VIII) "PHARMACY CARE" MEANS  MEDICATIONS  PRESCRIBED  BY  A  LICENSED
PHYSICIAN  AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
  (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (X)   "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (XI)  "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
  (XII) "TREATMENT FOR  AUTISM  SPECTRUM  DISORDERS"  WILL  INCLUDE  THE
FOLLOWING  CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED  PHYSICIAN
OR  A  LICENSED  PSYCHOLOGIST  WHO  DETERMINES  THE CARE TO BE MEDICALLY
NECESSARY:
  (1) HABILITATIVE OR REHABILITATIVE CARE;
  (2) PHARMACY CARE;
  (3) PSYCHIATRIC CARE;
  (4) PSYCHOLOGICAL CARE;
  (5) THERAPEUTIC CARE; AND
  (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM  DISORDERS  THAT  IS
DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
IS  PUBLISHED  IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT  PREVIOUSLY
COVERED  WILL  BE  INCLUDED  IN  ANY  HEALTH INSURANCE POLICY DELIVERED,
EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER  SIXTY  DAYS
FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
  (B) THIS SUBSECTION SHALL NOT BE CONSTRUED AS TO AFFECT ANY OBLIGATION
TO  PROVIDE  SERVICES  TO  AN  INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY
SERVICE PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR  AN  INDIVIDUALIZED
SERVICE PLAN.

A. 6001                             7

  S  4.    This  act  shall take effect on the first of January after it
shall have become a law and shall apply to all  policies  and  contracts
issued,  renewed, modified, altered or amended on or after the effective
date; provided, however, that any rules and  regulations  necessary  for
the  implementation  of  this act shall be promulgated on or before such
effective date.

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2009-A6001A (ACTIVE) - Details

Current Committee:: Assembly Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3216, 3221 & 4303, Ins L

2009-A6001A (ACTIVE) - Summary

2009-A6001A (ACTIVE) - Sponsor Memo

                                BILL NUMBER:A6001A

TITLE OF BILL:  An act to amend the insurance law, in relation to autism
spectrum disorders

PURPOSE: Provides for insurance coverage of individuals 21 years or
younger for the diagnosis and treatment of autism spectrum disorder.

SUMMARY OF PROVISIONS:  Section 1. Amends section 3216 of the insurance
law to provide insurance coverage for applied behavior analysis therapy
for the treatment of autism spectrum disorders in individuals 21 years
of age or less, up to a maximum benefit of $36,000.

Section 2. Amends section 3221 of the insurance law to provide insurance
coverage for applied behavior analysis therapy for the treatment of
autism spectrum disorders in individuals 21 years of age or less, up to
a maximum benefit of $36,000.

Section 3. Amends section 4303 of the insurance law to provide insurance
coverage for applied behavior analysis therapy for the treatment of
autism spectrum disorders in individuals 21 years of age or less, up to
a maximum benefit of $36,000.

Section 4. Effective date.

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, 1 in 150 individuals
is diagnosed with autism, 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. Although
it is considered a life span disorder of varying severity, autism is
treatable. Early diagnosis and intense early intervention have been
proven to provide the same benefits to individuals with autism that
medication or medical procedures provide to individuals afflicted with
other similar physical or bioneurological disorders. However, many chil-
dren with autism are not properly diagnosed until years after the first
symptoms appear. Furthermore, although insurance companies and health
maintenance organizations routinely cover treatment for similar neurobi-
ological disorders, most health insurance plans in the state of New York
do not cover autism treatment.

In the absence of coverage, 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 unaf-
fected children - essentially mortgaging their futures. This bill would
expedite diagnosis and treatment by providing insurance parity for
autism sufferers by requiring equitable coverage of the disorder by
insurance companies for individuals 21 years or younger.

LEGISLATIVE HISTORY: New Bill.

FISCAL IMPLICATIONS:  None.

EFFECTIVE DATE: The first of January after it shall have become law.

2009-A6001A (ACTIVE) - Bill Text download pdf

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 6001--A

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                            February 23, 2009
                               ___________

Introduced  by M. of A. WEISENBERG, REILLY, CASTRO, GUNTHER, COOK, PHEF-
  FER, COLTON, BENEDETTO, TITONE, SCHROEDER, CUSICK,  SPANO,  ZEBROWSKI,
  ROBINSON,  CARROZZA,  HOOPER,  PAULIN,  HEVESI,  DenDEKKER, EDDINGTON,
  MILLER, JAFFEE, BENJAMIN, BROOK-KRASNY, KELLNER, ENGLEBRIGHT,  LATIMER
  --  Multi-Sponsored  by  --  M.  of  A. BALL, BARRA, BRADLEY, BURLING,
  CONTE, DUPREY, ERRIGO, FINCH,  HYER-SPENCER,  KOLB,  LUPARDO,  MAISEL,
  MARKEY,  McDONOUGH,  McKEVITT, MILLMAN, MOLINARO, RABBITT, RAIA, SCHI-
  MEL, SWEENEY, THIELE, TOBACCO, WALKER -- read once and referred to the
  Committee on Insurance -- committee discharged, bill amended,  ordered
  reprinted as amended and recommitted to said committee

AN ACT to amend the insurance law, in relation to autism spectrum disor-
  ders

  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) Every policy which provides coverage for hospital,  surgical,  or
medical  care  coverage  shall  not  exclude  coverage for diagnosis and
treatment of medical conditions otherwise covered by the  policy  solely
because  the  treatment is provided to diagnose or treat autism spectrum
disorder. IN INDIVIDUALS TWENTY-ONE YEARS OF AGE OR LESS, THERE SHALL BE
NO LIMITS ON THE NUMBER OF VISITS AN INDIVIDUAL MAY MAKE  TO  AN  AUTISM
PROVIDER.  COVERAGE  UNDER  THIS SUBSECTION MAY BE SUBJECT TO COPAYMENT,
DEDUCTIBLE AND COINSURANCE PROVISIONS OF A HEALTH  INSURANCE  POLICY  TO
THE  EXTENT  THAT  OTHER MEDICAL SERVICE COVERED BY THE HEALTH INSURANCE
POLICY ARE SUBJECT TO SUCH PROVISIONS.  THIS  SUBSECTION  SHALL  NOT  BE
CONSTRUED  AS  LIMITING THE BENEFITS THAT ARE AVAILABLE TO AN INDIVIDUAL
UNDER A HEALTH INSURANCE POLICY. COVERAGE FOR APPLIED BEHAVIOR  ANALYSIS
THERAPY  MAY  BE  SUBJECT  TO  A  MAXIMUM BENEFIT OF THIRTY-SIX THOUSAND
DOLLARS. AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND  ELEVEN,  THE  SUPER-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD06364-15-9

A. 6001--A                          2

INTENDENT  SHALL,  ON  AN  ANNUAL  BASIS, ADJUST THE MAXIMUM BENEFIT FOR
INFLATION USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES  DEPART-
MENT  OF  LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPER-
INTENDENT  SHALL  SUBMIT  THE  ADJUSTED  MAXIMUM BENEFIT FOR PUBLICATION
ANNUALLY NO LATER THAN APRIL FIRST  OF  EACH  CALENDAR  YEAR,  AND  SUCH
PUBLISHED  ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING
CALENDAR YEAR TO HEALTH INSURANCE  POLICIES  SUBJECT  TO  THIS  SECTION.
PAYMENTS  MADE  BY  AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY
CARE, TREATMENT, INTERVENTION, SERVICE  OR  ITEM  UNRELATED  TO  APPLIED
BEHAVIOR  ANALYSIS  SHALL  NOT  BE  APPLIED  TOWARDS ANY MAXIMUM BENEFIT
ESTABLISHED PURSUANT TO THIS PARAGRAPH.  EXCEPT FOR INPATIENT  SERVICES,
IF  AN  INDIVIDUAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS,
AN INSURER SHALL HAVE THE RIGHT TO REQUEST A REVIEW  OF  SUCH  TREATMENT
NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDI-
VIDUAL'S  LICENSED  PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE
FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL  BE
BORNE BY THE INSURER.
  (A) For purposes of this section[,]:
  (I)  "autism spectrum disorder" means a neurobiological condition that
includes [autism,  Asperger  syndrome,  Rett's  syndrome,  or]  AUTISTIC
DISORDER,  ASPERGER'S DISORDER, RETT'S DISORDER, RETT'S DISORDER, CHILD-
HOOD DISINTEGRATIVE DISORDER, AND ANY pervasive  developmental  disorder
NOT OTHERWISE SPECIFIED.
  (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)  "AUTISM  SERVICES  PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
  (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS  MEDICALLY  NECES-
SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
  (V)  "EVIDENCE-BASED  RESEARCH"  MEANS RESEARCH THAT APPLIES RIGOROUS,
SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE  RELEVANT
TO AUTISM SPECTRUM DISORDERS.
  (VI)  "HABILITATIVE  OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING  APPLIED
BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (VII)  "MEDICALLY  NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A  LICENSED
PHYSICIAN  OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY  OF
THE FOLLOWING:
  (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
  (2)  REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL,  OR DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
  (3) ASSIST TO ACHIEVE  OR  MAINTAIN  MAXIMUM  FUNCTIONAL  CAPACITY  IN
PERFORMING  DAILY  ACTIVITIES,  TAKING  INTO ACCOUNT BOTH THE FUNCTIONAL
CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
PRIATE FOR INDIVIDUALS OF THE SAME AGE.
  (VIII) "PHARMACY CARE" MEANS  MEDICATIONS  PRESCRIBED  BY  A  LICENSED
PHYSICIAN  AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.

A. 6001--A                          3

  (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (X)   "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (XI)  "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
  (XII) "TREATMENT FOR  AUTISM  SPECTRUM  DISORDERS"  WILL  INCLUDE  THE
FOLLOWING  CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED  PHYSICIAN
OR  A  LICENSED  PSYCHOLOGIST  WHO  DETERMINES  THE CARE TO BE MEDICALLY
NECESSARY:
  (1) HABILITATIVE OR REHABILITATIVE CARE;
  (2) PHARMACY CARE;
  (3) PSYCHIATRIC CARE;
  (4) PSYCHOLOGICAL CARE;
  (5) THERAPEUTIC CARE; AND
  (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM  DISORDERS  THAT  IS
DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
IS  PUBLISHED IN THE REGISTER FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT  PREVIOUSLY
COVERED  WILL  BE  INCLUDED  IN  ANY  HEALTH INSURANCE POLICY DELIVERED,
EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER  SIXTY  DAYS
FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
  (B)  THIS PARAGRAPH SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN  INDIVIDUALIZED  SERVICE
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 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  coverage  for  diagnosis  and  treatment  of medical conditions
otherwise covered by the policy because the  treatment  is  provided  to
diagnose  or  treat  autism spectrum disorder. IN INDIVIDUALS TWENTY-ONE
YEARS OF AGE OR LESS, THERE SHALL BE NO LIMITS ON THE NUMBER  OF  VISITS
AN  INDIVIDUAL  MAY  MAKE  TO  AN  AUTISM  PROVIDER. COVERAGE UNDER THIS
SUBSECTION MAY BE  SUBJECT  TO  COPAYMENT,  DEDUCTIBLE  AND  COINSURANCE
PROVISIONS OF A HEALTH INSURANCE POLICY TO THE EXTENT THAT OTHER MEDICAL
SERVICE  COVERED  BY  THE  HEALTH  INSURANCE  POLICY ARE SUBJECT TO SUCH
PROVISIONS. THIS SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING THE BENE-
FITS THAT ARE AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH INSURANCE  POLI-
CY.  COVERAGE  SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOU-
SAND DOLLARS. AFTER DECEMBER  THIRTY-FIRST,  TWO  THOUSAND  ELEVEN,  THE
SUPERINTENDENT SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR
INFLATION  USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPART-
MENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS.  THE  SUPER-
INTENDENT  SHALL  SUBMIT  THE  ADJUSTED  MAXIMUM BENEFIT FOR PUBLICATION
ANNUALLY NO LATER THAN APRIL FIRST  OF  EACH  CALENDAR  YEAR,  AND  SUCH
PUBLISHED  ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING
CALENDAR YEAR TO HEALTH INSURANCE  POLICIES  SUBJECT  TO  THIS  SECTION.
PAYMENTS  MADE  BY  AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY

A. 6001--A                          4

CARE, TREATMENT, INTERVENTION, SERVICE  OR  ITEM  UNRELATED  TO  APPLIED
BEHAVIOR  ANALYSIS  SHALL  NOT  BE  APPLIED  TOWARDS ANY MAXIMUM BENEFIT
ESTABLISHED PURSUANT TO THIS PARAGRAPH. EXCEPT FOR  INPATIENT  SERVICES,
IF  AN  INDIVIDUAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS,
AN INSURER SHALL HAVE THE RIGHT TO REQUEST A REVIEW  OF  SUCH  TREATMENT
NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDI-
VIDUAL'S  LICENSED  PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE
FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL  BE
BORNE BY THE INSURER.
  (A) For purposes of this section[,]:
  (I)  "autism spectrum disorder" means a neurobiological condition that
includes [autism,  Asperger  syndrome,  Rett's  syndrome,  or]  AUTISTIC
DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
DISORDER,  AND ANY pervasive developmental disorder NOT OTHERWISE SPECI-
FIED.
  (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) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON,  ENTITY,  OR  GROUP
THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
  (IV)  "DIAGNOSIS  OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
  (V) "EVIDENCE-BASED RESEARCH" MEANS RESEARCH  THAT  APPLIES  RIGOROUS,
SYSTEMATIC,  AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE RELEVANT
TO AUTISM SPECTRUM DISORDERS.
  (VI) "HABILITATIVE OR REHABILITATIVE CARE" MEANS  PROFESSIONAL,  COUN-
SELING,  AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (VII) "MEDICALLY NECESSARY" MEANS ANY CARE,  TREATMENT,  INTERVENTION,
SERVICE,  OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A LICENSED
PHYSICIAN OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED  STAND-
ARDS  OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY OF
THE FOLLOWING:
  (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
  (2) REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL,  OR  DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
  (3)  ASSIST  TO  ACHIEVE  OR  MAINTAIN  MAXIMUM FUNCTIONAL CAPACITY IN
PERFORMING DAILY ACTIVITIES, TAKING INTO  ACCOUNT  BOTH  THE  FUNCTIONAL
CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
PRIATE FOR INDIVIDUALS OF THE SAME AGE.
  (VIII)  "PHARMACY  CARE"  MEANS  MEDICATIONS  PRESCRIBED BY A LICENSED
PHYSICIAN AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY  TO
DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
  (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY  A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
TICES.
  (X)  "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE   SERVICES
PROVIDED  BY  A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
OGIST PRACTICES.
  (XI) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR  CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.

A. 6001--A                          5

  (XII)  "TREATMENT  FOR  AUTISM  SPECTRUM  DISORDERS"  WILL INCLUDE THE
FOLLOWING CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL  DIAG-
NOSED  WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSICIAN
OR A LICENSED PSYCHOLOGIST WHO  DETERMINES  THE  CARE  TO  BE  MEDICALLY
NECESSARY:
  (1) HABILITATIVE OR REHABILITATIVE CARE;
  (2) PHARMACY CARE;
  (3) PSYCHIATRIC CARE;
  (4) PSYCHOLOGICAL CARE;
  (5) THERAPEUTIC CARE; AND
  (6)  ANY  CARE  FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
IS PUBLISHED IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES.  ANY  SUCH
CARE,  TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
COVERED WILL BE INCLUDED  IN  ANY  HEALTH  INSURANCE  POLICY  DELIVERED,
EXECUTED,  ISSUED,  AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
  (B) THIS PARAGRAPH SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION  TO
PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
PLAN,  AN  INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED SERVICE
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) 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  coverage
for  diagnosis  and treatment of medical conditions otherwise covered by
the policy solely because the treatment is provided to diagnose or treat
autism spectrum disorder. IN INDIVIDUALS  TWENTY-ONE  YEARS  OF  AGE  OR
LESS, THERE SHALL BE NO LIMITS ON THE NUMBER OF VISITS AN INDIVIDUAL MAY
MAKE  TO  AN  AUTISM  PROVIDER.  COVERAGE  UNDER  THIS SUBSECTION MAY BE
SUBJECT TO COPAYMENT, DEDUCTIBLE AND COINSURANCE PROVISIONS OF A  HEALTH
INSURANCE  POLICY  TO  THE EXTENT THAT OTHER MEDICAL SERVICES COVERED BY
THE HEALTH  INSURANCE  POLICY  ARE  SUBJECT  TO  SUCH  PROVISIONS.  THIS
SUBSECTION  SHALL  NOT  BE  CONSTRUED  AS LIMITING THE BENEFITS THAT ARE
AVAILABLE TO AN INDIVIDUAL UNDER A  HEALTH  INSURANCE  POLICY.  COVERAGE
SHALL  BE  SUBJECT  TO A MAXIMUM BENEFIT OF THIRTY-SIX THOUSAND DOLLARS.
AFTER DECEMBER THIRTY-FIRST, TWO  THOUSAND  ELEVEN,  THE  SUPERINTENDENT
SHALL,  ON  AN  ANNUAL  BASIS,  ADJUST THE MAXIMUM BENEFIT FOR INFLATION
USING THE MEDICAL CARE COMPONENT OF  THE  UNITED  STATES  DEPARTMENT  OF
LABOR  CONSUMER  PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPERINTENDENT
SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT FOR  PUBLICATION  ANNUALLY  NO
LATER  THAN  APRIL  FIRST  OF  EACH  CALENDAR  YEAR,  AND SUCH PUBLISHED
ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE  FOLLOWING  CALENDAR
YEAR  TO HEALTH INSURANCE POLICIES SUBJECT TO THIS SUBSECTION.  PAYMENTS
MADE BY AN INSURER ON BEHALF OF  A  COVERED  INDIVIDUAL  FOR  ANY  CARE,
TREATMENT,  INTERVENTION,  SERVICE OR ITEM UNRELATED TO APPLIED BEHAVIOR
ANALYSIS SHALL NOT BE APPLIED TOWARDS ANY  MAXIMUM  BENEFIT  ESTABLISHED
PURSUANT  TO THIS SECTION. EXCEPT FOR INPATIENT SERVICES, IF AN INDIVID-
UAL IS RECEIVING TREATMENT FOR AUTISM  SPECTRUM  DISORDERS,  AN  INSURER
SHALL HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT NOT MORE THAN
ONCE  EVERY  TWELVE  MONTHS  UNLESS  SUCH  INSURER  AND THE INDIVIDUAL'S
LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A  MORE  FREQUENT
REVIEW  IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE BORNE BY
THE INSURER.

A. 6001--A                          6

  (A) For purposes of this section[,]:
  (I)  "autism spectrum disorder" means a neurobiological condition that
includes [autism,  Asperger  syndrome,  Rett's  syndrome,  or]  AUTISTIC
DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
DISORDER, AND ANY pervasive developmental disorder.
  (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)  "AUTISM  SERVICES  PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
  (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS  MEDICALLY  NECES-
SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
  (V)  "EVIDENCE-BASED  RESEARCH"  MEANS RESEARCH THAT APPLIES RIGOROUS,
SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE  RELEVANT
TO AUTISM SPECTRUM DISORDERS.
  (VI)  "HABILITATIVE  OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING  APPLIED
BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (VII)  "MEDICALLY  NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A  LICENSED
PHYSICIAN  OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY  OF
THE FOLLOWING:
  (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
  (2)  REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL,  OR DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
  (3) ASSIST TO ACHIEVE  OR  MAINTAIN  MAXIMUM  FUNCTIONAL  CAPACITY  IN
PERFORMING  DAILY  ACTIVITIES,  TAKING  INTO ACCOUNT BOTH THE FUNCTIONAL
CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
PRIATE FOR INDIVIDUALS OF THE SAME AGE.
  (VIII) "PHARMACY CARE" MEANS  MEDICATIONS  PRESCRIBED  BY  A  LICENSED
PHYSICIAN  AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
  (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (X)   "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (XI)  "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
  (XII) "TREATMENT FOR  AUTISM  SPECTRUM  DISORDERS"  WILL  INCLUDE  THE
FOLLOWING  CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED  PHYSICIAN
OR  A  LICENSED  PSYCHOLOGIST  WHO  DETERMINES  THE CARE TO BE MEDICALLY
NECESSARY:
  (1) HABILITATIVE OR REHABILITATIVE CARE;
  (2) PHARMACY CARE;
  (3) PSYCHIATRIC CARE;
  (4) PSYCHOLOGICAL CARE;
  (5) THERAPEUTIC CARE; AND

A. 6001--A                          7

  (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM  DISORDERS  THAT  IS
DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
IS  PUBLISHED  IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
CARE,  TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
COVERED WILL BE INCLUDED  IN  ANY  HEALTH  INSURANCE  POLICY  DELIVERED,
EXECUTED,  ISSUED,  AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
  (B) THIS SUBSECTION SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN  INDIVIDUALIZED  SERVICE
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 and contracts issued, renewed, modified, altered or amended  on
or after the effective date; provided, however, that any rules and regu-
lations necessary for the implementation of this act shall be promulgat-
ed on or before such effective date.

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Assembly Bill A6001

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Sponsored By

WEISENBERG

Archive: Last Bill Status - In Assembly Committee

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co-Sponsors

Robert Reilly

Nelson Castro

Aileen Gunther

Vivian Cook

multi-Sponsors

Greg Ball

Robert Barra

Daniel Burling

Robert Castelli

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