NY State Assembly Bill 2009-A6888B

Date of Action	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jun 25, 2010	held for consideration in insurance
Jan 06, 2010	referred to insurance
Aug 07, 2009	print number 6888b
Aug 07, 2009	amend (t) and recommit to insurance
Jun 12, 2009	print number 6888a
Jun 12, 2009	amend and recommit to insurance
Mar 13, 2009	referred to insurance

2009-A6888 - Details

See Senate Version of this Bill:: S6123
Current Committee:: Assembly Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §3216, 3221 & 4303, Ins L
Versions Introduced in 2011-2012 Legislative Session:: A5723

2009-A6888 - Summary

Expands required health insurance coverage for the treatment and diagnosis of autism spectrum disorders.

2009-A6888 - Bill Text download pdf

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

                                  6888

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                             March 13, 2009
                               ___________

Introduced  by  M.  of  A.  KOON, REILLY, CAHILL, BING, SCHROEDER, MENG,
  SPANO, GUNTHER, BENEDETTO, ESPAILLAT, JAFFEE, COOK, EDDINGTON, COLTON,
  MAYERSOHN, DenDEKKER, TITONE -- Multi-Sponsored by -- M. of A. BARRON,
  GALEF, GREENE, McENENY, SWEENEY --  read  once  and  referred  to  the
  Committee on Insurance

AN  ACT  to  amend  the  insurance  law, in relation to requiring health
  insurance coverage of the diagnosis and treatment of  autism  spectrum
  disorders in persons under twenty-nine years of age

  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 RENDERED TO COVERED  PERSONS  UNDER
THE AGE OF TWENTY-NINE YEARS.
  (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  MOST  RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS, INCLUDING AUTISM,  ASPERGER'S  DISORDER  AND
PERVASIVE DEVELOPMENTAL 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  THAT  ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A
PHYSICIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOL-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10358-02-9

A. 6888                             2

OGIST LICENSED TO PRACTICE IN THIS STATE AND HAVING EXPERTISE  IN  DIAG-
NOSING 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  THE
FOLLOWING  CARE  PRESCRIBED, PROVIDED OR ORDERED FOR AN INDIVIDUAL DIAG-
NOSED 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) 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, AND
  6. SENSORY PROCESSING;
  (V) 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. 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) COVERAGE PURSUANT TO THIS PARAGRAPH SHALL  NOT  EXCEED  THIRTY-SIX
THOUSAND  DOLLARS  PER  YEAR,  PROVIDED  THAT  SUCH COVERAGE SHALL IN NO
MANNER LIMIT OR BE APPLIED AGAINST ANY  OTHER  COVERAGE  LIMIT  FOR  ANY
OTHER HEALTH CONDITION COVERED UNDER THE INSURANCE POLICY.  ANNUALLY, ON
OR  BEFORE  JANUARY  FIRST, SUCH COVERAGE LIMIT SHALL BE ADJUSTED BY THE
SUPERINTENDENT TO REFLECT INFLATION USING THE MEDICAL CARE COMPONENT  OF
THE UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN
CONSUMERS.   SUCH COVERAGE SHALL IN NO MANNER LIMIT THE NUMBER OF VISITS
FOR THE TREATMENT AND DIAGNOSIS OF AUTISM SPECTRUM DISORDERS.
  (E) THE DIAGNOSIS AND TREATMENT OF AUTISM SPECTRUM  DISORDERS  MAY  BE
SUBJECT TO REASONABLE DEDUCTIBLE, CO-PAYMENT AND CO-INSURANCE AMOUNTS TO
THE EXTENT THAT OTHER MEDICAL SERVICES ARE SUBJECT TO SUCH PROVISIONS.
  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:

A. 6888                             3

  (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 RENDERED TO COVERED PERSONS UNDER THE AGE OF TWENTY-NINE YEARS.
  (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 MOST RECENT EDITION OF  THE  DIAGNOSTIC  AND  STATISTICAL
MANUAL  OF  MENTAL  DISORDERS, INCLUDING AUTISM, ASPERGER'S DISORDER AND
PERVASIVE DEVELOPMENTAL 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 THAT ARE PRESCRIBED, PERFORMED OR ORDERED  BY  (I)  A
PHYSICIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOL-
OGIST  LICENSED  TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAG-
NOSING 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 THE
FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN  INDIVIDUAL  DIAG-
NOSED 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)  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, AND
  6. SENSORY PROCESSING;
  (V) 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. 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,

A. 6888                             4

FREQUENCY,  ANTICIPATED  DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES
STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN  WILL  BE
UPDATED.
  (D)  COVERAGE  PURSUANT  TO THIS PARAGRAPH SHALL NOT EXCEED THIRTY-SIX
THOUSAND DOLLARS PER YEAR, PROVIDED  THAT  SUCH  COVERAGE  SHALL  IN  NO
MANNER  LIMIT  OR  BE  APPLIED  AGAINST ANY OTHER COVERAGE LIMIT FOR ANY
OTHER HEALTH CONDITION COVERED UNDER THE INSURANCE POLICY.  ANNUALLY, ON
OR BEFORE JANUARY FIRST, SUCH COVERAGE LIMIT SHALL BE  ADJUSTED  BY  THE
SUPERINTENDENT  TO REFLECT INFLATION USING THE MEDICAL CARE COMPONENT OF
THE UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN
CONSUMERS.  SUCH COVERAGE SHALL IN NO MANNER LIMIT THE NUMBER OF  VISITS
FOR THE TREATMENT AND DIAGNOSIS OF AUTISM SPECTRUM DISORDERS.
  (E)  THE  DIAGNOSIS  AND TREATMENT OF AUTISM SPECTRUM DISORDERS MAY BE
SUBJECT TO REASONABLE DEDUCTIBLE, CO-PAYMENT AND CO-INSURANCE AMOUNTS TO
THE EXTENT THAT OTHER MEDICAL SERVICES ARE SUBJECT TO SUCH PROVISIONS.
  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  RENDERED  TO
COVERED PERSONS UNDER THE AGE OF TWENTY-NINE YEARS.
  (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  MOST  RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS, INCLUDING AUTISM,  ASPERGER'S  DISORDER  AND
PERVASIVE DEVELOPMENTAL 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 THAT ARE PRESCRIBED, PERFORMED OR ORDERED  BY  (I)  A
PHYSICIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOL-
OGIST  LICENSED  TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAG-
NOSING 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 THE
FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN  INDIVIDUAL  DIAG-
NOSED 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

A. 6888                             5

INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID-
UAL;
  (IV)  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, AND
  (VI) SENSORY PROCESSING;
  (V) 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. 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)  COVERAGE  PURSUANT TO THIS SUBSECTION SHALL NOT EXCEED THIRTY-SIX
THOUSAND DOLLARS PER YEAR, PROVIDED  THAT  SUCH  COVERAGE  SHALL  IN  NO
MANNER  LIMIT  OR  BE  APPLIED  AGAINST ANY OTHER COVERAGE LIMIT FOR ANY
OTHER HEALTH CONDITION COVERED UNDER THE INSURANCE POLICY.  ANNUALLY, ON
OR BEFORE JANUARY FIRST, SUCH COVERAGE LIMIT SHALL BE  ADJUSTED  BY  THE
SUPERINTENDENT  TO REFLECT INFLATION USING THE MEDICAL CARE COMPONENT OF
THE UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN
CONSUMERS.  SUCH COVERAGE SHALL IN NO MANNER LIMIT THE NUMBER OF  VISITS
FOR THE TREATMENT AND DIAGNOSIS OF AUTISM SPECTRUM DISORDERS.
  (5)  THE  DIAGNOSIS  AND TREATMENT OF AUTISM SPECTRUM DISORDERS MAY BE
SUBJECT TO REASONABLE DEDUCTIBLE, CO-PAYMENT AND CO-INSURANCE AMOUNTS TO
THE EXTENT THAT OTHER MEDICAL SERVICES ARE SUBJECT TO SUCH PROVISIONS.
  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.

2009-A6888A - Details

See Senate Version of this Bill:: S6123
Current Committee:: Assembly Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §3216, 3221 & 4303, Ins L
Versions Introduced in 2011-2012 Legislative Session:: A5723

2009-A6888A - Summary

Expands required health insurance coverage for the treatment and diagnosis of autism spectrum disorders.

2009-A6888A - Sponsor Memo

                                BILL NUMBER:A6888A

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 in persons under twenty-nine years of age

PURPOSE OR GENERAL IDEA OF BILL:  To expand required health insurance
coverage for the treatment and Diagnosis of autism spectrum disorders.

SUMMARY OF SPECIFIC PROVISIONS:  Amends Insurance 3216-i(25),
§3221-i(17) and §4303(ee) 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
rendered to covered persons under the age of twenty-nine years.

Defines autism spectrum disorder (including neurobiological conditions
that include autism, Asperger syndrome, Rett's syndrome, or pervasive
developmental disorder), in accordance with the most recent edition of
the Diagnostic and Statistical Manual of Mental 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 would reasonably prevent the onset of an illness,

condition, injury, disease, or disability; reduce or ameliorate the
physical, mental or development effects of said illness; 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; ther-
apeutic care, including behavioral, speech, occupational and physical
therapies as well as social skills education training; providing cover-
age not to exceed thirty-six thousand dollars per year.

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 increas-
ing 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 treat-
ment 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 taxpay-
ers, 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 indi-
cated above, are significant.

New York State Insurance law regarding autism was significantly changed
in 2006 with the passage of A.699 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, pertain-
ing 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, legis-
lation was introduced in the United States Senate (S.B. 819, the Accel-
erating the Treatment of Autism Act) calling for modifications to feder-
al insurance law that would require autism coverage with no annual
spending caps or age limits.

PRIOR 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 cover-
age 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 cover-
age 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)

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.

2009-A6888A - Bill Text download pdf

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

                                 6888--A

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                             March 13, 2009
                               ___________

Introduced  by  M.  of  A.  KOON, REILLY, CAHILL, BING, SCHROEDER, MENG,
  SPANO, GUNTHER, BENEDETTO, ESPAILLAT, JAFFEE, COOK, EDDINGTON, COLTON,
  MAYERSOHN, DenDEKKER, TITONE, KELLNER, HYER-SPENCER,  FIELDS,  WEISEN-
  BERG  -- Multi-Sponsored by -- M. of A. BARRON, BOYLAND, CONTE, GALEF,
  HOOPER, LUPARDO, McENENY, SWEENEY -- 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  requiring  health
  insurance  coverage  of the diagnosis and treatment of autism spectrum
  disorders in persons under twenty-nine years of age

  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 RENDERED TO COVERED PERSONS UNDER
THE AGE OF TWENTY-NINE YEARS.
  (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 MOST RECENT EDITION OF  THE  DIAGNOSTIC  AND  STATISTICAL
MANUAL  OF  MENTAL  DISORDERS, INCLUDING AUTISM, ASPERGER'S DISORDER AND
PERVASIVE DEVELOPMENTAL 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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10358-03-9

A. 6888--A                          2

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;
  (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) 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
  7. ASSISTIVE TECHNOLOGY;
  (V) 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) COVERAGE PURSUANT TO THIS PARAGRAPH SHALL  NOT  EXCEED  THIRTY-SIX
THOUSAND  DOLLARS  PER  YEAR,  PROVIDED  THAT  SUCH COVERAGE SHALL IN NO
MANNER LIMIT OR BE APPLIED AGAINST ANY  OTHER  COVERAGE  LIMIT  FOR  ANY
OTHER HEALTH CONDITION COVERED UNDER THE INSURANCE POLICY.  ANNUALLY, ON
OR  BEFORE  JANUARY  FIRST, SUCH COVERAGE LIMIT SHALL BE ADJUSTED BY THE
SUPERINTENDENT TO REFLECT INFLATION USING THE MEDICAL CARE COMPONENT  OF
THE UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN
CONSUMERS.   SUCH COVERAGE SHALL IN NO MANNER LIMIT THE NUMBER OF VISITS
FOR THE TREATMENT AND DIAGNOSIS OF AUTISM SPECTRUM DISORDERS.

A. 6888--A                          3

  (E) THE DIAGNOSIS AND TREATMENT OF AUTISM SPECTRUM  DISORDERS  MAY  BE
SUBJECT TO REASONABLE DEDUCTIBLE, CO-PAYMENT AND CO-INSURANCE AMOUNTS TO
THE EXTENT THAT OTHER MEDICAL SERVICES ARE SUBJECT TO SUCH PROVISIONS.
  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 RENDERED TO COVERED PERSONS UNDER THE AGE OF TWENTY-NINE YEARS.
  (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  MOST  RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS, INCLUDING AUTISM,  ASPERGER'S  DISORDER  AND
PERVASIVE DEVELOPMENTAL 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;
  (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) 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
  7. ASSISTIVE TECHNOLOGY;

A. 6888--A                          4

  (V) 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) COVERAGE PURSUANT TO THIS PARAGRAPH SHALL  NOT  EXCEED  THIRTY-SIX
THOUSAND  DOLLARS  PER  YEAR,  PROVIDED  THAT  SUCH COVERAGE SHALL IN NO
MANNER LIMIT OR BE APPLIED AGAINST ANY  OTHER  COVERAGE  LIMIT  FOR  ANY
OTHER HEALTH CONDITION COVERED UNDER THE INSURANCE POLICY.  ANNUALLY, ON
OR  BEFORE  JANUARY  FIRST, SUCH COVERAGE LIMIT SHALL BE ADJUSTED BY THE
SUPERINTENDENT TO REFLECT INFLATION USING THE MEDICAL CARE COMPONENT  OF
THE UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN
CONSUMERS.   SUCH COVERAGE SHALL IN NO MANNER LIMIT THE NUMBER OF VISITS
FOR THE TREATMENT AND DIAGNOSIS OF AUTISM SPECTRUM DISORDERS.
  (E) THE DIAGNOSIS AND TREATMENT OF AUTISM SPECTRUM  DISORDERS  MAY  BE
SUBJECT TO REASONABLE DEDUCTIBLE, CO-PAYMENT AND CO-INSURANCE AMOUNTS TO
THE EXTENT THAT OTHER MEDICAL SERVICES ARE SUBJECT TO SUCH PROVISIONS.
  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 RENDERED TO
COVERED PERSONS UNDER THE AGE OF TWENTY-NINE YEARS.
  (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 MOST RECENT EDITION OF  THE  DIAGNOSTIC  AND  STATISTICAL
MANUAL  OF  MENTAL  DISORDERS, INCLUDING AUTISM, ASPERGER'S DISORDER AND
PERVASIVE DEVELOPMENTAL 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.

A. 6888--A                          5

  (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)  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
  (VII) ASSISTIVE TECHNOLOGY;
  (V) 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)  COVERAGE  PURSUANT TO THIS SUBSECTION SHALL NOT EXCEED THIRTY-SIX
THOUSAND DOLLARS PER YEAR, PROVIDED  THAT  SUCH  COVERAGE  SHALL  IN  NO
MANNER  LIMIT  OR  BE  APPLIED  AGAINST ANY OTHER COVERAGE LIMIT FOR ANY
OTHER HEALTH CONDITION COVERED UNDER THE INSURANCE POLICY.  ANNUALLY, ON
OR BEFORE JANUARY FIRST, SUCH COVERAGE LIMIT SHALL BE  ADJUSTED  BY  THE
SUPERINTENDENT  TO REFLECT INFLATION USING THE MEDICAL CARE COMPONENT OF
THE UNITED STATES DEPARTMENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN
CONSUMERS.  SUCH COVERAGE SHALL IN NO MANNER LIMIT THE NUMBER OF  VISITS
FOR THE TREATMENT AND DIAGNOSIS OF AUTISM SPECTRUM DISORDERS.
  (5)  THE  DIAGNOSIS  AND TREATMENT OF AUTISM SPECTRUM DISORDERS MAY BE
SUBJECT TO REASONABLE DEDUCTIBLE, CO-PAYMENT AND CO-INSURANCE AMOUNTS TO
THE EXTENT THAT OTHER MEDICAL SERVICES ARE SUBJECT TO SUCH PROVISIONS.
  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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multi-Sponsors

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2009-A6888B (ACTIVE) - Details

See Senate Version of this Bill:: S6123
Current Committee:: Assembly Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §3216, 3221 & 4303, Ins L
Versions Introduced in 2011-2012 Legislative Session:: A5723

2009-A6888B (ACTIVE) - Summary

Expands required health insurance coverage for the treatment and diagnosis of autism spectrum disorders.

2009-A6888B (ACTIVE) - Sponsor Memo

                                BILL NUMBER:A6888B

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 OR GENERAL IDEA OF BILL:  To expand required health insurance
coverage for the treatment and diagnosis of autism spectrum disorders.

SUMMARY OF SPECIFIC 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 develop-
mental 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; endocri-
nological care; therapeutic care, including behavioral, speech, occupa-
tional and physical therapies as well as social skills education train-
ing; and social skills education training.

Provides that upon request of the coverage provider, a treatment provid-
er 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 treat-
ment is anticipated to require continued services to achieve demonstra-
ble progress, the coverage provider may request a treatment plan
consisting of diagnosis, proposed treatment by type, frequency, antic-
ipated 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 increas-
ing 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 treat-
ment 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 taxpay-
ers, 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 indi-
cated 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, legis-
lation was introduced in the United States Senate (S.B. 819, the Accel-
erating the Treatment of Autism Act) calling for modifications to feder-
al insurance law that would require autism coverage with no annual
spending caps or age limits.

PRIOR 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 cover-
age 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 cover-
age 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.

2009-A6888B (ACTIVE) - Bill Text download pdf

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

                                 6888--B

                       2009-2010 Regular Sessions

                          I N  A S S E M B L Y

                             March 13, 2009
                               ___________

Introduced  by  M.  of  A.  KOON, REILLY, CAHILL, BING, SCHROEDER, MENG,
  SPANO, GUNTHER, BENEDETTO, ESPAILLAT, JAFFEE, COOK, EDDINGTON, COLTON,
  MAYERSOHN, DenDEKKER, TITONE, KELLNER, HYER-SPENCER,  FIELDS,  WEISEN-
  BERG  -- Multi-Sponsored by -- M. of A. BARRON, BOYLAND, CONTE, GALEF,
  HOOPER, LUPARDO, McENENY, SWEENEY -- read once  and  referred  to  the
  Committee  on Insurance -- committee discharged, bill amended, ordered
  reprinted as amended  and  recommitted  to  said  committee  --  again
  reported  from  said  committee  with amendments, ordered reprinted as
  amended and recommitted to said committee

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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10358-04-9

A. 6888--B                          2

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;
  (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

A. 6888--B                          3

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
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

A. 6888--B                          4

  (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-
LEE,  OR  IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER
WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE  PARTICULAR  HEALTH

A. 6888--B                          5

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 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;

A. 6888--B                          6

  (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:
  (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.

A. 6888--B                          7

  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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Mark J.F. Schroeder

multi-Sponsors

George Amedore

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William Boyland

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