Senate Bill S6123

2009-2010 Legislative Session

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

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Archive: Last Bill Status - In Senate Committee Insurance 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
Aug 10, 2009	referred to rules

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2009-S6123 (ACTIVE) - Details

See Assembly Version of this Bill:: A6888
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §3216, 3221 & 4303, Ins L
Versions Introduced in 2011-2012 Legislative Session:: A5723

2009-S6123 (ACTIVE) - Summary

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

2009-S6123 (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S6123

 TITLE OF BILL :
An act to amend the insurance law, in relation to requiring health
insurance coverage of the diagnosis and treatment of autism spectrum
disorders

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

 SUMMARY OF PROVISIONS :
Amends §3216-i(25), §3221-i(17) and §4303(ee) of the Insurance Law to
provide coverage in every policy, group policy, and/or medical
indemnity, hospital service or health service corporation, for the
diagnosis and treatment of autism spectrum disorders.

Defines "autism spectrum disorders" as pervasive developmental
disorders as defined in the Diagnostic and Statistical Manual of
Mental Disorders IV Revised, including autism, Asperger's disorder and
pervasive developmental disorders not otherwise specified.

Defines "diagnosis of autism spectrum disorders" as one or more tests,
evaluations or assessments to diagnose whether an individual has
autism spectrum disorders; which are performed or ordered by a
physician or psychologist licensed to practice medicine in the state

and having expertise in the diagnosis of autism spectrum disorders.

Defines medically necessary as any care, treatment, intervention,
service or item which will or is reasonably expected to prevent the
onset of an illness, condition, injury, disease, or disability; reduce
or ameliorate the physical, mental or development effects of said
illness; assist to achieve or maintain maximum functional activity in
performing daily activities.

Provides that treatment for autism spectrum disorders shall include
psychiatric care, including direct, consultative, and diagnostic
services; psychological care; habilitative or rehabilitative care;
pediatric and developmental pediatric care; anesthesiological care and
anesthetic services; neurological care; gastroenterologic care;
endocrinological care; therapeutic care, including behavioral, speech,
occupational and physical therapies as well as social skills education
training; and social skills education training.

Provides that upon request of the coverage provider, a treatment
provider shall furnish medical records, clinical notes or other
necessary data that substantiate that the initial and continued
medical treatment is medically necessary and resulting in improved
clinical status or the prevention of regression or loss of skills and
functioning. When treatment is anticipated to require continued
services to achieve demonstrable progress, the coverage provider may
request a treatment plan consisting of diagnosis, proposed treatment
by type, frequency, anticipated duration of treatment, the anticipated
outcomes stated as goals, and the frequency by which the treatment
plan will be updated.

Provides that a coverage provider shall have in place a procedure
under which a covered person with autism spectrum disorder whose
condition or disease requires specialized medical care over a
prolonged period of time shall receive a referral to a specialist; or
to a nonparticipating provider with appropriate training and
experience, if an appropriate specialist is not available within the
plan, at no additional cost to the enrollee beyond what the enrollee
would otherwise pay for services received within the network.


Provides that a coverage provider shall have in place a procedure
under which a covered person with autism spectrum disorder whose
condition or disease requires ongoing care from a specialist may
request and obtain a standing referral to such specialist for
treatment of such condition, upon the determination by the primary
care provider and the specialist (if any).

 JUSTIFICATION :
This legislation calls for health insurers regulated by the State of
New York to treat people with autism no differently than people with
any other health disorder. It calls for the provision of medically
necessary health interventions to treat sick people, primarily
children. No other health disorder treatment is limited by an annual
spending cap under New York State law, nor does New York State law
implement an age limit for the treatment of any other disorder.

Autism is the fastest growing disabling disorder affecting American
children, with diagnoses increasing by 500 percent over the past ten
years. In New York State, the autism rate for children has been
increasing by approximately 15% per year in that time span. Studies
from the year 2000 showed that 1 in 150 children are affected, but
more recent studies place the number closer to 1 in 90 children.
Currently, there are 17,000 students age 4 to 21 classified by New
York schools as having autism. The number of adults with autism has
not been well studied.

Historically, autism had been misidentified as a psychiatric disorder
and has been excluded from coverage by health insurance carriers.
Recent discoveries made possible by significantly increased public
investment in autism research has shown that there is a wide range of
serious physical health problems associated with autism, including
gastro-intestinal issues, seizures, immune disorders, allergies,
asthma, chronic inflammation and metabolic issues. Hundreds of studies
have shown that intensive behavioral therapies can result in
significant improvement in the cognition, communication and
functionality of people with autism.

There are substantial financial costs for failing to provide medically
necessary treatment for people with autism. Children denied intensive
early treatment will have a lower level of functionality and are much
more likely to need life-long support services. The lifetime costs of
placing an individual with autism in a group-home setting in the New
York City/Long Island area is estimated to be approximately $14
million. Conversely, cost analyses show that every dollar spent on
early treatment will save $5 to $7 in long-term costs.

In the absence of adequate health insurance coverage, a
disproportionate cost of autism is borne directly by the families of
those affected, many of whom do not have the resources to provide
adequate treatment (out-of pocket costs often run as high as $2,000 to
$4,000 per month, and the Autism Society of America estimates that the
lifetime cost of caring for a child with autism ranges from $3.5 to $5
million); or by the taxpayers, through Medicaid and increased demand
for services through the schools.

There have been a large number of actuarial studies performed to
assess the costs of state-level legislation that compels the inclusion
of autism within the range of required coverage. All of these studies
have indicated a worst-case scenario cost increase to policy holders
of 1% or less. Information on the real costs for mandatory autism
coverage from Aetna in Texas shows an increase of less than .1%, while
an actuarial analysis of legislation introduced in showed an estimated
worse case scenario cost increase of .8% per policy holder. None of
the cost analyses done include a quantification of the potential
long-term savings from providing appropriate treatment of autism,
which as indicated above, are significant.
New York State Insurance law regarding autism was significantly
changed in 2006 with the passage of Chapter 557 of the laws of 2006,
which requires insurers to provide all medical services to people with
autism that would be provided to people without autism. This law has
helped ameliorate the inequitable coverage provided to people with
autism by health insurers, but it does not specify health care
services specific to the treatment of autism. Nor does Timothy's Law
provide adequate provisions, pertaining only to specified psychiatric
disorders co-morbid with autism.

California. Texas, Pennsylvania, Florida, Illinois, Montana, Indiana,
Louisiana, Oregon, South Carolina and Arizona, all have laws requiring
health insurers to cover autism. And similar legislation is under
consideration in several dozen more states. Earlier this year,
legislation was introduced in the United States Senate (S.B. 819, the
Accelerating the Treatment of Autism Act) calling for modifications to
federal insurance law that would require autism coverage with no
annual spending caps or age limits.

 LEGISLATIVE HISTORY :
New bill.

 FISCAL IMPLICATIONS :
While the cost implications of this program have yet to be fully
determined, this legislation would provide relief to an already
overburdened Medicaid system by requiring more insurance coverage for
treatments associated with ASD. In addition, if we calculate that an
estimated one in ninety children in New York State is diagnosed with
some form of ASD, and we calculate that for every $1 we spend before
the age of 5 we save $7 on lifelong care, we will ultimately save the
state, insurance providers, victims and their families untold millions
of dollars over the long-term.

(Additionally, information on the real costs for mandatory autism
coverage from Aetna in Texas shows an increase of less than .1%, while
an actuarial analysis of legislation introduced in Massachusetts
showed an estimated worse case scenario cost increase of .8% per
policy holder)

 EFFECTIVE DATE :
This act shall take effect on the first day of January next succeeding
the date on which it shall have become law and shall apply to all
policies or contracts issued, renewed, modified, altered or amended on
and after such effective date.

2009-S6123 (ACTIVE) - Bill Text download pdf

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

                                  6123

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                             August 10, 2009
                               ___________

Introduced  by  Sen. HUNTLEY -- read twice and ordered printed, and when
  printed to be committed to the Committee on Rules

AN ACT to amend the insurance  law,  in  relation  to  requiring  health
  insurance  coverage  of the diagnosis and treatment of autism spectrum
  disorders

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Paragraph  25  of  subsection  (i) of section 3216 of the
insurance law, as added by chapter 557 of the laws of 2006,  is  amended
to read as follows:
  (25)  (A) Every policy which provides coverage for hospital, surgical,
or medical care coverage shall [not exclude] PROVIDE  coverage  for  THE
diagnosis  and treatment of [medical conditions otherwise covered by the
policy solely because the treatment is provided to  diagnose  or  treat]
autism spectrum [disorder] DISORDERS.
  (B) For purposes of this [section, "autism] PARAGRAPH:
  (I) "AUTISM spectrum [disorder" means a neurobiological condition that
includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
opmental disorder] DISORDERS" MEANS PERVASIVE DEVELOPMENTAL DISORDERS AS
DEFINED  IN THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV
REVISED, INCLUDING AUTISM, ASPERGER'S DISORDER  AND  PERVASIVE  DEVELOP-
MENTAL DISORDERS NOT OTHERWISE SPECIFIED.
  (II) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS,
EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM
SPECTRUM  DISORDERS  OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE
YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I)  A  PHYSI-
CIAN  LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST
LICENSED TO PRACTICE IN THIS STATE AND HAVING  EXPERTISE  IN  DIAGNOSING
AUTISM SPECTRUM DISORDERS.
  (III)  "MEDICALLY  NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
SERVICE OR ITEM WHICH WILL OR IS REASONABLY EXPECTED TO DO  ANY  OF  THE
FOLLOWING:
  (I)  PREVENT  THE  ONSET  OF AN ILLNESS, CONDITION, INJURY, DISEASE OR
DISABILITY;

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10358-05-9

S. 6123                             2

  (II) REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL  OR  DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR
  (III)  ASSIST  TO  ACHIEVE  OR MAINTAIN MAXIMUM FUNCTIONAL ACTIVITY IN
PERFORMING DAILY ACTIVITIES.
  (IV) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE  BUT  NOT
BE  LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN
INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
  (I) PSYCHIATRIC CARE, INCLUDING  DIRECT,  CONSULTATIVE  OR  DIAGNOSTIC
SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY;
  (II)  PSYCHOLOGICAL  CARE,  INCLUDING  DIRECT OR CONSULTATIVE SERVICES
PROVIDED BY A LICENSED PSYCHOLOGIST;
  (III) HABILITATIVE OR  REHABILITATIVE  CARE,  INCLUDING  PROFESSIONAL,
COUNSELING  AND  GUIDANCE  SERVICES  AND  TREATMENT  PROGRAMS  THAT  ARE
INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID-
UAL;
  (IV) PEDIATRIC AND DEVELOPMENTAL  PEDIATRIC  CARE,  INCLUDING  DIRECT,
CONSULTATIVE  OR  DIAGNOSTIC  SERVICES  PROVIDED BY A LICENSED PHYSICIAN
SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS;
  (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING  DIRECT,
CONSULTATIVE  OR  DIAGNOSTIC  SERVICES  PROVIDED BY A LICENSED PHYSICIAN
SPECIALIZING IN ANESTHESIOLOGY;
  (VI) NEUROLOGICAL CARE INCLUDING DIRECT,  CONSULTATIVE  OR  DIAGNOSTIC
SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY;
  (VII)  GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
NOSTIC  SERVICES  PROVIDED  BY  A  LICENSED  PHYSICIAN  SPECIALIZING  IN
GASTROENTEROLOGY;
  (VIII)  ENDOCRINOLOGICAL  CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING  IN  ENDO-
CRINOLOGY;
  (IX)  THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND
PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
  1. SELF CARE AND FEEDING,
  2. PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE,
  3. COGNITIVE FUNCTIONING,
  4. APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION,
  5. MOTOR PLANNING,
  6. SENSORY PROCESSING AND INTEGRATION, AND
  7. ASSISTIVE TECHNOLOGY;
  (X) SOCIAL SKILLS EDUCATION TRAINING.
  (C) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR
AUTISM SPECTRUM DISORDERS SHALL FURNISH MEDICAL RECORDS, CLINICAL  NOTES
OR OTHER NECESSARY DATA THAT SUBSTANTIATE THAT THE INITIAL AND CONTINUED
MEDICAL TREATMENT IS MEDICALLY NECESSARY AND RESULTING IN IMPROVED CLIN-
ICAL  STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC-
TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES  TO
ACHIEVE  DEMONSTRABLE  PROGRESS,  THE  COVERAGE  PROVIDER  MAY REQUEST A
TREATMENT PLAN CONSISTING OF  DIAGNOSIS,  PROPOSED  TREATMENT  BY  TYPE,
FREQUENCY,  ANTICIPATED  DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES
STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN  WILL  BE
UPDATED.
  (D)  AN  INSURER PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL HAVE IN
PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO
IS COVERED UNDER SUCH POLICY AND WHOSE  CONDITION  OR  DISEASE  REQUIRES
SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A
REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS
PANEL  OR  NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL-

S. 6123                             3

LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A  NONPARTICIPATING  PROVIDER
WITH  APPROPRIATE  TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH
CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE  BEYOND
WHAT  THE  ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE
NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE  FOR  AND  SHALL  BE  DEEMED
CAPABLE  OF  PROVIDING  AND  COORDINATING  THE  ENROLLEE'S  PRIMARY  AND
SPECIALTY CARE.
  (E) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH  AUTISM
SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRES ONGO-
ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO
SUCH  SPECIALIST  FOR  TREATMENT  OF SUCH CONDITION. IF THE PRIMARY CARE
PROVIDER AND THE SPECIALIST (IF ANY), DETERMINES THAT  SUCH  A  STANDING
REFERRAL  IS  APPROPRIATE,  THE  PLAN  OR  ISSUER SHALL AUTHORIZE SUCH A
REFERRAL TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE  CONSIST-
ENT WITH A TREATMENT PLAN.
  S  2.  Paragraph 17 of subsection (l) of section 3221 of the insurance
law, as added by chapter 557 of the laws of 2006, is amended to read  as
follows:
  (17)  (A)  A  group  or blanket accident or health insurance policy or
issuing a group or blanket policy  for  delivery  in  this  state  which
provides coverage for hospital, surgical, or medical care coverage shall
[not  exclude]  PROVIDE  coverage  for  THE  diagnosis  and treatment of
[medical conditions otherwise covered by the policy because  the  treat-
ment is provided to diagnose or treat] autism spectrum [disorder] DISOR-
DERS.
  (B) For purposes of this [section, "autism] PARAGRAPH:
  (I) "AUTISM spectrum [disorder" means a neurobiological condition that
includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
opmental disorder] DISORDERS" MEANS PERVASIVE DEVELOPMENTAL DISORDERS AS
DEFINED  IN THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV
REVISED, INCLUDING AUTISM, ASPERGER'S DISORDER  AND  PERVASIVE  DEVELOP-
MENTAL DISORDERS NOT OTHERWISE SPECIFIED.
  (II) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS,
EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM
SPECTRUM  DISORDERS  OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE
YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I)  A  PHYSI-
CIAN  LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST
LICENSED TO PRACTICE IN THIS STATE AND HAVING  EXPERTISE  IN  DIAGNOSING
AUTISM SPECTRUM DISORDERS.
  (III)  "MEDICALLY  NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
SERVICE OR ITEM WHICH WILL OR IS REASONABLY EXPECTED TO DO  ANY  OF  THE
FOLLOWING:
  (I)  PREVENT  THE  ONSET  OF AN ILLNESS, CONDITION, INJURY, DISEASE OR
DISABILITY;
  (II) REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL  OR  DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR
  (III)  ASSIST  TO  ACHIEVE  OR MAINTAIN MAXIMUM FUNCTIONAL ACTIVITY IN
PERFORMING DAILY ACTIVITIES.
  (IV) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE  BUT  NOT
BE  LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN
INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
  (I) PSYCHIATRIC CARE, INCLUDING  DIRECT,  CONSULTATIVE  OR  DIAGNOSTIC
SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY;
  (II)  PSYCHOLOGICAL  CARE,  INCLUDING  DIRECT OR CONSULTATIVE SERVICES
PROVIDED BY A LICENSED PSYCHOLOGIST;

S. 6123                             4

  (III) HABILITATIVE OR  REHABILITATIVE  CARE,  INCLUDING  PROFESSIONAL,
COUNSELING  AND  GUIDANCE  SERVICES  AND  TREATMENT  PROGRAMS  THAT  ARE
INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID-
UAL;
  (IV)  PEDIATRIC  AND  DEVELOPMENTAL  PEDIATRIC CARE, INCLUDING DIRECT,
CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED  BY  A  LICENSED  PHYSICIAN
SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS;
  (V)  ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING DIRECT,
CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED  BY  A  LICENSED  PHYSICIAN
SPECIALIZING IN ANESTHESIOLOGY;
  (VI)  NEUROLOGICAL  CARE  INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC
SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY;
  (VII) GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR  DIAG-
NOSTIC  SERVICES  PROVIDED  BY  A  LICENSED  PHYSICIAN  SPECIALIZING  IN
GASTROENTEROLOGY;
  (VIII) ENDOCRINOLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE  OR  DIAG-
NOSTIC  SERVICES  PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ENDO-
CRINOLOGY;
  (IX) THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL  AND
PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
  1. SELF CARE AND FEEDING,
  2. PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE,
  3. COGNITIVE FUNCTIONING,
  4. APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION,
  5. MOTOR PLANNING,
  6. SENSORY PROCESSING AND INTEGRATION, AND
  7. ASSISTIVE TECHNOLOGY;
  (X) SOCIAL SKILLS EDUCATION TRAINING.
  (C) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR
AUTISM  SPECTRUM DISORDERS SHALL FURNISH MEDICAL RECORDS, CLINICAL NOTES
OR OTHER NECESSARY DATA THAT SUBSTANTIATE THAT THE INITIAL AND CONTINUED
MEDICAL TREATMENT IS MEDICALLY NECESSARY AND RESULTING IN IMPROVED CLIN-
ICAL STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND  FUNC-
TIONING.  WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES TO
ACHIEVE DEMONSTRABLE PROGRESS,  THE  COVERAGE  PROVIDER  MAY  REQUEST  A
TREATMENT  PLAN  CONSISTING  OF  DIAGNOSIS,  PROPOSED TREATMENT BY TYPE,
FREQUENCY, ANTICIPATED DURATION OF TREATMENT, THE  ANTICIPATED  OUTCOMES
STATED  AS  GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN WILL BE
UPDATED.
  (D) AN INSURER PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL  HAVE  IN
PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO
IS  COVERED  UNDER  SUCH  POLICY AND WHOSE CONDITION OR DISEASE REQUIRES
SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A
REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS
PANEL OR NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF  AN  ENROL-
LEE,  OR  IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER
WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE  PARTICULAR  HEALTH
CARE  NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE BEYOND
WHAT THE ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED  WITHIN  THE
NETWORK.  SUCH  SPECIALIST  MAY  BE  RESPONSIBLE FOR AND SHALL BE DEEMED
CAPABLE  OF  PROVIDING  AND  COORDINATING  THE  ENROLLEE'S  PRIMARY  AND
SPECIALTY CARE.
  (E)  SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH AUTISM
SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRES ONGO-
ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO
SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION.  IF  THE  PRIMARY  CARE

S. 6123                             5

PROVIDER  AND  THE  SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING
REFERRAL IS APPROPRIATE, THE PLAN  OR  ISSUER  SHALL  AUTHORIZE  SUCH  A
REFERRAL  TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST-
ENT WITH A TREATMENT PLAN.
  S 3. Subsection (ee) of section 4303 of the insurance law, as added by
chapter 557 of the laws of 2006, is amended to read as follows:
  (ee)  (1)  A medical expense indemnity corporation, a hospital service
corporation or a health service corporation which provides coverage  for
hospital, surgical, or medical care coverage shall [not exclude] INCLUDE
coverage  for  THE diagnosis and treatment of [medical conditions other-
wise covered by the policy solely because the treatment is  provided  to
diagnose or treat] autism spectrum [disorder] DISORDERS.
  (2) For purposes of this [section, "autism] SUBSECTION:
  (A) "AUTISM spectrum [disorder" means a neurobiological condition that
includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
opmental disorder] DISORDERS" MEANS PERVASIVE DEVELOPMENTAL DISORDERS AS
DEFINED IN THE THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS
IV REVISED, INCLUDING AUTISM, ASPERGER'S DISORDER AND PERVASIVE DEVELOP-
MENTAL DISORDERS NOT OTHERWISE SPECIFIED.
  (B)  "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS,
EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM
SPECTRUM DISORDERS OR EARLY INDICATIONS IN CHILDREN YOUNGER  THAN  THREE
YEARS  OF  AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A PHYSI-
CIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A  PSYCHOLOGIST
LICENSED  TO  PRACTICE  IN THIS STATE AND HAVING EXPERTISE IN DIAGNOSING
AUTISM SPECTRUM DISORDERS.
  (C) "MEDICALLY NECESSARY" MEANS  ANY  CARE,  TREATMENT,  INTERVENTION,
SERVICE  OR  ITEM  WHICH WILL OR IS REASONABLY EXPECTED TO DO ANY OF THE
FOLLOWING:
  (I) PREVENT THE ONSET OF AN ILLNESS,  CONDITION,  INJURY,  DISEASE  OR
DISABILITY;
  (II)  REDUCE  OR  AMELIORATE  THE  PHYSICAL,  MENTAL  OR DEVELOPMENTAL
EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR
  (III) ASSIST TO ACHIEVE OR MAINTAIN  MAXIMUM  FUNCTIONAL  ACTIVITY  IN
PERFORMING DAILY ACTIVITIES.
  (D) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE BUT NOT BE
LIMITED  TO  THE  FOLLOWING  CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN
INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
  (I) PSYCHIATRIC CARE, INCLUDING   DIRECT, CONSULTATIVE  OR  DIAGNOSTIC
SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY;
  (II)  PSYCHOLOGICAL  CARE,  INCLUDING  DIRECT OR CONSULTATIVE SERVICES
PROVIDED BY A LICENSED PSYCHOLOGIST;
  (III) HABILITATIVE OR  REHABILITATIVE  CARE,  INCLUDING  PROFESSIONAL,
COUNSELING  AND  GUIDANCE  SERVICES  AND  TREATMENT  PROGRAMS  THAT  ARE
INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID-
UAL;
  (IV) PEDIATRIC AND DEVELOPMENTAL  PEDIATRIC  CARE,  INCLUDING  DIRECT,
CONSULTATIVE  OR  DIAGNOSTIC  SERVICES  PROVIDED BY A LICENSED PHYSICIAN
SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS;
  (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING  DIRECT,
CONSULTATIVE  OR  DIAGNOSTIC  SERVICES  PROVIDED BY A LICENSED PHYSICIAN
SPECIALIZING IN ANESTHESIOLOGY;
  (VI) NEUROLOGICAL CARE INCLUDING DIRECT,  CONSULTATIVE  OR  DIAGNOSTIC
SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY;

S. 6123                             6

  (VII)  GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
NOSTIC  SERVICES  PROVIDED  BY  A  LICENSED  PHYSICIAN  SPECIALIZING  IN
GASTROENTEROLOGY;
  (VIII)  ENDOCRINOLOGICAL  CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING  IN  ENDO-
CRINOLOGY;
  (IX)  THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND
PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
  (I) SELF CARE AND FEEDING,
  (II) PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE,
  (III) COGNITIVE FUNCTIONING,
  (IV) APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION,
  (V) MOTOR PLANNING,
  (VI) SENSORY PROCESSING AND INTEGRATION, AND
  (VII) ASSISTIVE TECHNOLOGY;
  (X) SOCIAL SKILLS EDUCATION TRAINING.
  (3) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR
AUTISM SPECTRUM DISORDERS SHALL FURNISH MEDICAL RECORDS, CLINICAL  NOTES
OR OTHER NECESSARY DATA THAT SUBSTANTIATE THAT THE INITIAL AND CONTINUED
MEDICAL TREATMENT IS MEDICALLY NECESSARY AND RESULTING IN IMPROVED CLIN-
ICAL  STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC-
TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES  TO
ACHIEVE  DEMONSTRABLE  PROGRESS,  THE  COVERAGE  PROVIDER  MAY REQUEST A
TREATMENT PLAN CONSISTING OF  DIAGNOSIS,  PROPOSED  TREATMENT  BY  TYPE,
FREQUENCY,  ANTICIPATED  DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES
STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN  WILL  BE
UPDATED.
  (4)  AN INSURER PROVIDING COVERAGE UNDER THIS SUBSECTION SHALL HAVE IN
PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO
IS COVERED UNDER SUCH POLICY AND WHOSE  CONDITION  OR  DISEASE  REQUIRES
SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A
REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS
PANEL  OR  NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL-
LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A  NONPARTICIPATING  PROVIDER
WITH  APPROPRIATE  TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH
CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE  BEYOND
WHAT  THE  ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE
NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE  FOR  AND  SHALL  BE  DEEMED
CAPABLE  OF  PROVIDING  AND  COORDINATING  THE  ENROLLEE'S  PRIMARY  AND
SPECIALITY CARE.
  (5) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH  AUTISM
SPECTRUM  DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRE ONGO-
ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO
SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION.  IF  THE  PRIMARY  CARE
PROVIDER  AND  THE  SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING
REFERRAL IS APPROPRIATE, THE PLAN  OR  ISSUER  SHALL  AUTHORIZE  SUCH  A
REFERRAL  TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST-
ENT WITH A TREATMENT PLAN.
  S 4. This act shall take effect on the first of January next  succeed-
ing  the date on which it shall have become a law and shall apply to all
policies or contracts issued, renewed, modified, altered or  amended  on
and after such effective date.

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Senate Bill S6123

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Archive: Last Bill Status - In Senate Committee Insurance Committee

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Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

Actions

co-Sponsors

2009-S6123 (ACTIVE) - Details

2009-S6123 (ACTIVE) - Summary

2009-S6123 (ACTIVE) - Sponsor Memo

2009-S6123 (ACTIVE) - Bill Text download pdf

Comments