senate Bill S4005A

Signed By Governor
2011-2012 Legislative Session

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

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Archive: Last Bill Status Via A6305 - Signed by Governor


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed by Governor

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Actions

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Nov 01, 2011 signed chap.595
Oct 31, 2011 delivered to governor
Jun 17, 2011 returned to assembly
passed senate
3rd reading cal.1338
substituted for s4005a
Jun 17, 2011 substituted by a6305a
Jun 16, 2011 ordered to third reading cal.1338
Jun 13, 2011 reported and committed to rules
Jun 08, 2011 print number 4005a
amend (t) and recommit to finance
Apr 11, 2011 reported and committed to finance
Mar 11, 2011 referred to insurance

Votes

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Jun 14, 2011 - Finance committee Vote

S4005A
30
0
committee
30
Aye
0
Nay
4
Aye with Reservations
1
Absent
0
Excused
0
Abstained
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Apr 11, 2011 - Insurance committee Vote

S4005
13
0
committee
13
Aye
0
Nay
4
Aye with Reservations
0
Absent
1
Excused
0
Abstained
show committee vote details

Committee Vote: Apr 11, 2011

aye wr (4)
excused (1)

Bill Amendments

Original
A (Active)
Original
A (Active)

Co-Sponsors

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S4005 - Bill Details

See Assembly Version of this Bill:
A6305A
Law Section:
Insurance Law
Laws Affected:
Amd §§3216, 3221 & 4303, Ins L

S4005 - Bill Texts

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

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BILL NUMBER:S4005

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

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

SUMMARY OF PROVISIONS:
Amends Sections 3216, 3221 and 4303 of the
Insurance Law to provide coverage for the screening, diagnosis and
treatment of autism spectrum disorders.

Provides that coverage may be subject to annual deductibles,
copayments and coinsurance as may be deemed appropriate by the
superintendent and shall be consistent with those imposed on other
benefits under the contract.

Provides that the legislation shall not be construed as limiting the
benefits that are available to an individual under a health insurance
policy.

Provides that coverage may be subject to utilization and external
review of health care services, including case management and other
managed care provisions.

Defines "autism spectrum disorder" as a group of neurobiological
conditions including Autistic Disorder, Asperger's Disorder, Rett's
Disorder, Childhood Disintegrative Disorder, and Pervasive
Developmental Disorder Not Otherwise Specified, as defined in the
most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders.

Defines "diagnosis of autism spectrum disorders ", "behavioral health
treatment", "pharmacy care", "psychiatric care", "psychological
care"and "theraputic care".

Provides that licensed physician or psychologist are authorized to
prescribe care for the following: behavioral health treatment;
pharmacy care; psychiatric care; psychological care; therapeutic care
and other medical care prescribed by a licensed physician.

Provides that coverage shall not be denied on the basis that such
treatments are habilitative, non-restorative or educational in nature
unless such treatments are provided pursuant to an individualized
education program.

Provides that the provision of services pursuant to an individualized
family service plan, an individualized education program or an
individualized service plan shall not affect coverage under the
policy for services
provided on a supplemental basis outside of an educational setting if
such services are prescribed by a licensed physician or psychologist.


Provides that this legislation will not affect any obligation to
provide services to an individual under an individualized family
service plan or individualized education program or an individualized
service plan.

Provides that nothing in the legislation shall be construed to prevent
a contract from providing services through a network of participating
providers who shall meet certain requirements for participation,
including provider credentialing.

JUSTIFICATION:
Autism is a complex neurobiological disorder that
severely affects the way autistic individuals relate to others
socially and their ability to communicate and learn. Today the Centers
for Disease Control (CDC) estimate that the number of children with
autism is 1 in 110 nationwide, making it more common than pediatric
cancer, diabetes, and AIDS combined. It occurs in all racial, ethnic,
and social groups and is four times more likely to strike boys than
girls.

Existing state law requires that insurance coverage for autism "not
exclude" the diagnosis and treatment of autism spectrum disorder.
Current law does not provide sufficient clarity or an affirmative
obligation of health insurance to cover costs relating to autism
treatments. Moreover, parents are often faced with significant gaps
in treatments which may be needed over and above those provided
pursuant to an individualized family, education or service plan.
These families often pay as much as they can out-of-pocket for
services that can cost upwards of $50,000 per year. In the process,
many risk their homes and the education's of their unaffected
children essentially mortgaging their futures. This legislation would
expedite diagnosis and treatment by providing insurance parity for
autism sufferers by requiring equitable coverage of the disorder by
insurance companies.

If enacted, New York would join with 23 other states in requiring
coverage for conditions relating to autism spectrum disorder.

LEGISLATIVE HISTORY:

FISCAL IMPLICATIONS:
Treatment of autism spectrum disorders will
result in better long-term health outcomes for those afflicted with
this condition and should therefore lessen costs which are borne by
taxpayers.
There will be some minor cost to the State for coverage for it's own
employees and their families. Actuarial cost estimates provided by
independent actuaries retained by a leading national autism advocacy
organization, Autism Speaks, determined that expected impact upon
insurance costs were approximately one-half of one percent
after full
implementation of coverage over a number of years. Cost implications
for other 23 states which have enacted such legislation have been
very modest.

EFFECTIVE DATE:


This act shall take effect January 1 after enactment
and shall apply to insurance policies issued, renewed, altered,
or amended after that date.

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

    S. 4005                                                  A. 6305

                       2011-2012 Regular Sessions

                      S E N A T E - A S S E M B L Y

                             March 11, 2011
                               ___________

IN  SENATE  --  Introduced by Sens. FUSCHILLO, McDONALD, BRESLIN, DUANE,
  ADAMS, ADDABBO, AVELLA, BALL, BONACIC, DeFRANCISCO, DILAN,  ESPAILLAT,
  FARLEY,   FLANAGAN,   GALLIVAN,   GOLDEN,  GRIFFO,  GRISANTI,  HANNON,
  HASSELL-THOMPSON, JOHNSON,  KLEIN,  KRUEGER,  KRUGER,  LANZA,  LARKIN,
  LAVALLE,  LIBOUS,  LITTLE,  MARCELLINO,  MARTINS, MAZIARZ, MONTGOMERY,
  NOZZOLIO, O'MARA, OPPENHEIMER, PARKER, PERKINS, RITCHIE, ROBACH, SAMP-
  SON, SKELOS, STAVISKY, STEWART-COUSINS, VALESKY, ZELDIN -- read  twice
  and ordered printed, and when printed to be committed to the Committee
  on Insurance

IN ASSEMBLY -- Introduced by M. of A. MORELLE, SILVER, NOLAN, SCHROEDER,
  LAVINE, LUPARDO, GOTTFRIED, PERRY, HEVESI, CUSICK, J. RIVERA, SWEENEY,
  JAFFEE,  ZEBROWSKI,  GALEF,  MAISEL, SPANO, ROSENTHAL, ARROYO, TITONE,
  WEPRIN, ABINANTI -- Multi-Sponsored by -- M. of A.  BARCLAY,  CALHOUN,
  DESTITO,  ENGLEBRIGHT, JORDAN, LIFTON, MILLMAN, RAIA, SCHIMEL, TOBACCO
  -- read once and referred to the Committee on Insurance

AN ACT to amend the insurance law,  in  relation  to  coverage  for  the
  screening, 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) Every policy which provides coverage for hospital,  surgical,  or
medical  care  coverage  shall  [not  exclude]  PROVIDE coverage for THE
SCREENING, diagnosis and  treatment  of  [medical  conditions  otherwise
covered  by the policy solely because the treatment is provided to diag-
nose or treat] autism spectrum [disorder] DISORDERS IN  ACCORDANCE  WITH
THIS PARAGRAPH AND SHALL NOT EXCLUDE COVERAGE FOR THE SCREENING, DIAGNO-
SIS  OR  TREATMENT OF MEDICAL CONDITIONS OTHERWISE COVERED BY THE POLICY
BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AN  AUTISM  SPECTRUM  DISORDER.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08567-01-1

S. 4005                             2                            A. 6305

SUCH COVERAGE MAY BE SUBJECT TO ANNUAL DEDUCTIBLES, COPAYMENTS AND COIN-
SURANCE  AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT AND SHALL BE
CONSISTENT WITH THOSE IMPOSED ON OTHER BENEFITS UNDER THE  POLICY.  THIS
PARAGRAPH  SHALL  NOT  BE  CONSTRUED  AS  LIMITING THE BENEFITS THAT ARE
OTHERWISE AVAILABLE TO AN INDIVIDUAL UNDER THE POLICY. NO INSURER  SHALL
TERMINATE  COVERAGE OR REFUSE TO DELIVER, EXECUTE, ISSUE, AMEND, ADJUST,
OR RENEW COVERAGE TO AN INDIVIDUAL  SOLELY  BECAUSE  THE  INDIVIDUAL  IS
DIAGNOSED  WITH  ONE  OF  THE  AUTISM SPECTRUM DISORDERS OR HAS RECEIVED
TREATMENT FOR AUTISM SPECTRUM DISORDERS. COVERAGE SHALL  BE  SUBJECT  TO
UTILIZATION REVIEW AND EXTERNAL APPEALS OF HEALTH CARE SERVICES PURSUANT
TO  ARTICLE  FORTY-NINE OF THIS CHAPTER AS WELL AS, CASE MANAGEMENT, AND
OTHER MANAGED CARE PROVISIONS.
  (A) For purposes of this [section,] PARAGRAPH:
  (I) "autism  spectrum  disorder"  means  a  GROUP  OF  neurobiological
[condition  that includes autism, Asperger syndrome, Rett's syndrome, or
pervasive developmental  disorder.]  CONDITIONS  THAT  INCLUDE  AUTISTIC
DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
DISORDER,  AND  PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED
(PDD-NOS), AS DEFINED IN THE MOST RECENT EDITION OF THE  DIAGNOSTIC  AND
STATISTICAL MANUAL OF MENTAL DISORDERS.
  (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
EVALUATION  OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
CONSEQUENCES, TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN  HUMAN
BEHAVIOR,  INCLUDING  THE  USE  OF  DIRECT OBSERVATION, MEASUREMENT, AND
FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT  AND  BEHAV-
IOR.
  (III)  "BEHAVIORAL  HEALTH  TREATMENT" MEANS PROFESSIONAL, COUNSELING,
AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED BEHAVIOR
ANALYSIS WHEN PROVIDED OR  SUPERVISED  BY  A  BOARD  CERTIFIED  BEHAVIOR
ANALYST,  THAT  ARE  NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE, TO THE
MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS"  MEANS  THE  ASSESSMENT,
EVALUATIONS,  OR  TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS ONE OF THE
AUTISM SPECTRUM DISORDERS.
  (V) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED  PHYSI-
CIAN AND ANY HEALTH-RELATED SERVICES TO DETERMINE THE NEED OR EFFECTIVE-
NESS OF THE MEDICATIONS.
  (VI) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY  A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
TICES.
  (VII) "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
PROVIDED  BY  A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
OGIST PRACTICES.
  (VIII) "THERAPEUTIC CARE"  MEANS  SERVICES  PROVIDED  BY  LICENSED  OR
CERTIFIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS, OR
PHYSICAL THERAPISTS.
  (IX)  "TREATMENT  FOR  AUTISM  SPECTRUM  DISORDERS"  WILL  INCLUDE THE
FOLLOWING CARE AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR AN  INDI-
VIDUAL DIAGNOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED
PHYSICIAN OR A LICENSED PSYCHOLOGIST:
  (1) BEHAVIORAL HEALTH TREATMENT;
  (2) PHARMACY CARE;
  (3) PSYCHIATRIC CARE;
  (4) PSYCHOLOGICAL CARE;
  (5) THERAPEUTIC CARE; AND
  (6) ANY OTHER MEDICAL CARE PROVIDED BY A LICENSED PHYSICIAN.

S. 4005                             3                            A. 6305

  (B)  COVERAGE  UNDER  THIS  PARAGRAPH SHALL NOT BE DENIED ON THE BASIS
THAT THE TREATMENT IS HABILITATIVE, NON-RESTORATIVE, OR  EDUCATIONAL  IN
NATURE,  UNLESS SUCH TREATMENTS ARE BEING PROVIDED TO THE COVERED PERSON
PURSUANT TO AN INDIVIDUALIZED EDUCATION PLAN UNDER  ARTICLE  EIGHTY-NINE
OF  THE EDUCATION LAW. THE PROVISION OF SERVICES PURSUANT TO AN INDIVID-
UALIZED FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE
OF THE PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE
EIGHTY-NINE OF THE EDUCATION LAW,  OR  AN  INDIVIDUALIZED  SERVICE  PLAN
PURSUANT  TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL
DISABILITIES SHALL NOT AFFECT COVERAGE UNDER  THE  POLICY  FOR  SERVICES
PROVIDED  ON  A  SUPPLEMENTAL BASIS OUTSIDE OF AN EDUCATIONAL SETTING IF
SUCH SERVICES  ARE  PRESCRIBED  BY  A  LICENSED  PHYSICIAN  OR  LICENSED
PSYCHOLOGIST.
  (C)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT ANY OBLI-
GATION TO PROVIDE SERVICES TO  AN  INDIVIDUAL  UNDER  AN  INDIVIDUALIZED
FAMILY  SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF THE
PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT-
Y-NINE OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN  PURSUANT
TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILI-
TIES.
  (D) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT  ANY  OBLI-
GATION  TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON THE
BASIS THAT THE SERVICES CONSTITUTE EARLY INTERVENTION  PROGRAM  SERVICES
PURSUANT  TO  SECTION  THREE  THOUSAND TWO HUNDRED THIRTY-FIVE-A OF THIS
ARTICLE OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
  (E) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT  A  POLICY
FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
SHALL  MEET  CERTAIN  REQUIREMENTS FOR PARTICIPATION, INCLUDING PROVIDER
CREDENTIALING.
  (F) COVERAGE UNDER THIS SECTION SHALL NOT BE SUBJECT TO ANY LIMITS  ON
THE  NUMBER  OF  VISITS  AN  INDIVIDUAL MAY MAKE FOR TREATMENT OF AUTISM
SPECTRUM DISORDER. EXCEPT FOR INPATIENT SERVICES, IF  AN  INDIVIDUAL  IS
RECEIVING  TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER WILL HAVE
THE RIGHT TO REQUEST A REVIEW OF THAT TREATMENT NOT MORE THAN ONCE EVERY
TWELVE MONTHS UNLESS THE INSURER AND THE INDIVIDUAL'S LICENSED PHYSICIAN
OR LICENSED PSYCHOLOGIST AGREE, ON AN INDIVIDUALIZED BASIS, THAT A  MORE
FREQUENT  REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE
BORNE BY THE INSURER.
  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] EVERY group or blanket accident  [or]  AND  health  insurance
policy  [or  issuing  a group or blanket policy] DELIVERED OR ISSUED for
delivery in this state which provides coverage for  hospital,  surgical,
or  medical  care  coverage shall [not exclude] PROVIDE coverage for THE
SCREENING, diagnosis and  treatment  of  [medical  conditions  otherwise
covered  by  the policy because the treatment is provided to diagnose or
treat] autism spectrum [disorder]  DISORDERS  IN  ACCORDANCE  WITH  THIS
PARAGRAPH AND SHALL NOT EXCLUDE COVERAGE FOR THE SCREENING, DIAGNOSIS OR
TREATMENT  OF MEDICAL CONDITIONS OTHERWISE COVERED BY THE POLICY BECAUSE
THE INDIVIDUAL IS DIAGNOSED  WITH  AN  AUTISM  SPECTRUM  DISORDER.  SUCH
COVERAGE  MAY  BE  SUBJECT TO ANNUAL DEDUCTIBLES, COPAYMENTS AND COINSU-
RANCE AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT  AND  SHALL  BE
CONSISTENT  WITH  THOSE IMPOSED ON OTHER BENEFITS UNDER THE POLICY. THIS
PARAGRAPH SHALL NOT BE CONSTRUED  AS  LIMITING  THE  BENEFITS  THAT  ARE

S. 4005                             4                            A. 6305

OTHERWISE  AVAILABLE TO AN INDIVIDUAL UNDER THE POLICY. NO INSURER SHALL
TERMINATE COVERAGE OR REFUSE TO DELIVER, EXECUTE, ISSUE, AMEND,  ADJUST,
OR  RENEW  COVERAGE  TO  AN  INDIVIDUAL SOLELY BECAUSE THE INDIVIDUAL IS
DIAGNOSED  WITH  ONE  OF  THE  AUTISM SPECTRUM DISORDERS OR HAS RECEIVED
TREATMENT FOR AUTISM SPECTRUM DISORDERS. COVERAGE SHALL  BE  SUBJECT  TO
UTILIZATION REVIEW AND EXTERNAL APPEALS OF HEALTH CARE SERVICES PURSUANT
TO  ARTICLE  FORTY-NINE  OF THIS CHAPTER AS WELL AS CASE MANAGEMENT, AND
OTHER MANAGED CARE PROVISIONS.
  (A) [For] FOR purposes of this [section,] PARAGRAPH:
  (1) "autism  spectrum  disorder"  means  a  GROUP  OF  neurobiological
[condition  that includes autism, Asperger syndrome, Rett's syndrome, or
pervasive  developmental  disorder]  CONDITIONS  THAT  INCLUDE  AUTISTIC
DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
DISORDER,  AND  PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED
(PDD-NOS), AS DEFINED IN THE MOST RECENT EDITION OF THE  DIAGNOSTIC  AND
STATISTICAL MANUAL OF MENTAL DISORDERS.
  (2)  "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI  AND
CONSEQUENCES,  TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN HUMAN
BEHAVIOR, INCLUDING THE USE  OF  DIRECT  OBSERVATION,  MEASUREMENT,  AND
FUNCTIONAL  ANALYSIS  OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
IOR.
  (3) "BEHAVIORAL HEALTH TREATMENT" MEANS PROFESSIONAL, COUNSELING,  AND
GUIDANCE  SERVICES  AND  TREATMENT  PROGRAMS, INCLUDING APPLIED BEHAVIOR
ANALYSIS WHEN PROVIDED OR  SUPERVISED  BY  A  BOARD  CERTIFIED  BEHAVIOR
ANALYST,  THAT  ARE  NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE, TO THE
MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (4) "DIAGNOSIS OF AUTISM SPECTRUM  DISORDERS"  MEANS  THE  ASSESSMENT,
EVALUATIONS,  OR  TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS ONE OF THE
AUTISM SPECTRUM DISORDERS.
  (5) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED  PHYSI-
CIAN AND ANY HEALTH-RELATED SERVICES TO DETERMINE THE NEED OR EFFECTIVE-
NESS OF THE MEDICATIONS.
  (6)  "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (7)   "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (8)  "THERAPEUTIC  CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS OR PHYS-
ICAL THERAPISTS.
  (9) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE FOLLOW-
ING CARE AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR  AN  INDIVIDUAL
DIAGNOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSI-
CIAN OR A LICENSED PSYCHOLOGIST:
  (I) BEHAVIORAL HEALTH TREATMENT;
  (II) PHARMACY CARE;
  (III) PSYCHIATRIC CARE;
  (IV) PSYCHOLOGICAL CARE;
  (V) THERAPEUTIC CARE; AND
  (VI) ANY OTHER MEDICAL CARE PROVIDED BY A LICENSED PHYSICIAN.
  (B)  COVERAGE  UNDER  THIS  PARAGRAPH SHALL NOT BE DENIED ON THE BASIS
THAT THE TREATMENT IS HABILITATIVE, NON-RESTORATIVE, OR  EDUCATIONAL  IN
NATURE,  UNLESS SUCH TREATMENTS ARE BEING PROVIDED TO THE COVERED PERSON
PURSUANT TO AN INDIVIDUALIZED EDUCATION PLAN UNDER  ARTICLE  EIGHTY-NINE

S. 4005                             5                            A. 6305

OF  THE EDUCATION LAW. THE PROVISION OF SERVICES PURSUANT TO AN INDIVID-
UALIZED FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE
OF THE PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE
EIGHTY-NINE  OF  THE  EDUCATION  LAW,  OR AN INDIVIDUALIZED SERVICE PLAN
PURSUANT TO REGULATIONS OF THE OFFICE  FOR  PERSONS  WITH  DEVELOPMENTAL
DISABILITIES  SHALL  NOT  AFFECT  COVERAGE UNDER THE POLICY FOR SERVICES
PROVIDED ON A SUPPLEMENTAL BASIS OUTSIDE OF AN  EDUCATIONAL  SETTING  IF
SUCH  SERVICES  ARE  PRESCRIBED  BY  A  LICENSED  PHYSICIAN  OR LICENSED
PSYCHOLOGIST.
  (C) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT  ANY  OBLI-
GATION  TO  PROVIDE  SERVICES  TO  AN INDIVIDUAL UNDER AN INDIVIDUALIZED
FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF  THE
PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT-
Y-NINE  OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT
TO REGULATIONS OF THE OFFICE FOR PERSONS  WITH  DEVELOPMENTAL  DISABILI-
TIES.
  (D)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT ANY OBLI-
GATION TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON  THE
BASIS  THAT  THE SERVICES CONSTITUTE EARLY INTERVENTION PROGRAM SERVICES
PURSUANT TO SECTION THREE THOUSAND TWO  HUNDRED  THIRTY-FIVE-A  OF  THIS
ARTICLE OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
  (E)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT A POLICY
FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
SHALL MEET CERTAIN REQUIREMENTS FOR  PARTICIPATION,  INCLUDING  PROVIDER
CREDENTIALING.
  (F)  COVERAGE  UNDER THIS PARAGRAPH SHALL NOT BE SUBJECT TO ANY LIMITS
ON THE NUMBER OF VISITS AN INDIVIDUAL MAY MAKE FOR TREATMENT  OF  AUTISM
SPECTRUM  DISORDER.  EXCEPT  FOR INPATIENT SERVICES, IF AN INDIVIDUAL IS
RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER WILL  HAVE
THE RIGHT TO REQUEST A REVIEW OF THAT TREATMENT NOT MORE THAN ONCE EVERY
TWELVE MONTHS UNLESS THE INSURER AND THE INDIVIDUAL'S LICENSED PHYSICIAN
OR  LICENSED PSYCHOLOGIST AGREE, ON AN INDIVIDUALIZED BASIS, THAT A MORE
FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL  BE
BORNE BY THE INSURER.
  S 3. Subsection (ee) of section 4303 of the insurance law, as added by
chapter 557 of the laws of 2006, is amended to read as follows:
  (ee)  A  medical  expense  indemnity  corporation,  a hospital service
corporation or a health service corporation which provides coverage  for
hospital, surgical, or medical care coverage shall [not exclude] PROVIDE
coverage  for  THE SCREENING, diagnosis and treatment of [medical condi-
tions otherwise covered by the policy solely because  the  treatment  is
provided  to  diagnose or treat] autism spectrum [disorder] DISORDERS IN
ACCORDANCE WITH THIS SUBSECTION AND SHALL NOT EXCLUDE COVERAGE  FOR  THE
SCREENING,  DIAGNOSIS  OR  TREATMENT  OF  MEDICAL  CONDITIONS  OTHERWISE
COVERED BY THE POLICY BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AN AUTISM
SPECTRUM DISORDER. SUCH COVERAGE MAY BE SUBJECT TO  ANNUAL  DEDUCTIBLES,
COPAYMENTS  AND  COINSURANCE  AS MAY BE DEEMED APPROPRIATE BY THE SUPER-
INTENDENT AND SHALL BE CONSISTENT WITH THOSE IMPOSED ON  OTHER  BENEFITS
UNDER  THE  CONTRACT. THIS SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING
THE BENEFITS THAT ARE OTHERWISE AVAILABLE TO  AN  INDIVIDUAL  UNDER  THE
CONTRACT.  NO  INSURER  CAN  TERMINATE  COVERAGE  OR  REFUSE TO DELIVER,
EXECUTE, ISSUE, AMEND, ADJUST, OR RENEW COVERAGE TO AN INDIVIDUAL SOLELY
BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH  ONE  OF  THE  AUTISM  SPECTRUM
DISORDERS  OR  HAS  RECEIVED  TREATMENT  FOR  AUTISM SPECTRUM DISORDERS.
COVERAGE SHALL BE SUBJECT TO UTILIZATION REVIEW AND EXTERNAL APPEALS  OF

S. 4005                             6                            A. 6305

HEALTH  CARE  SERVICES PURSUANT TO ARTICLE FORTY-NINE OF THIS CHAPTER AS
WELL AS CASE MANAGEMENT, OR OTHER MANAGED CARE PROVISIONS.
  (A)(1)  For  purposes  of  this [section] SUBSECTION, "autism spectrum
disorder" means a GROUP  OF  neurobiological  [condition  that  includes
autism,  Asperger  syndrome, Rett's syndrome, or pervasive developmental
disorder] CONDITIONS THAT INCLUDE AUTISTIC DISORDER,  ASPERGER'S  DISOR-
DER,  RETT'S  DISORDER, CHILDHOOD DISINTEGRATIVE DISORDER, AND PERVASIVE
DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED (PDD-NOS), AS DEFINED  IN
THE  MOST  RECENT  EDITION  OF  THE DIAGNOSTIC AND STATISTICAL MANUAL OF
MENTAL DISORDERS.
  (2) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION,  AND
EVALUATION  OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
CONSEQUENCES, TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN  HUMAN
BEHAVIOR,  INCLUDING  THE  USE  OF  DIRECT OBSERVATION, MEASUREMENT, AND
FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT  AND  BEHAV-
IOR.
  (3)  "BEHAVIORAL HEALTH TREATMENT" MEANS PROFESSIONAL, COUNSELING, AND
GUIDANCE SERVICES AND TREATMENT  PROGRAMS,  INCLUDING  APPLIED  BEHAVIOR
ANALYSIS  WHEN  PROVIDED  OR  SUPERVISED  BY  A BOARD CERTIFIED BEHAVIOR
ANALYST, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND  RESTORE,  TO  THE
MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
  (4)  "DIAGNOSIS  OF  AUTISM  SPECTRUM DISORDERS" MEANS THE ASSESSMENT,
EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS ONE  OF  THE
AUTISM SPECTRUM DISORDERS.
  (5)  "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED PHYSI-
CIAN AND ANY HEALTH-RELATED SERVICES TO DETERMINE THE NEED OR EFFECTIVE-
NESS OF THE MEDICATIONS.
  (6) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES  PROVIDED
BY  A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
TICES.
  (7)  "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE   SERVICES
PROVIDED  BY  A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
OGIST PRACTICES.
  (8) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED  OR  CERTI-
FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS OR PHYS-
ICAL THERAPISTS.
  (9) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE FOLLOW-
ING  CARE  AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR AN INDIVIDUAL
DIAGNOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSI-
CIAN OR A LICENSED PSYCHOLOGIST:
  (I) BEHAVIORAL HEALTH TREATMENT;
  (II) PHARMACY CARE;
  (III) PSYCHIATRIC CARE;
  (IV) PSYCHOLOGICAL CARE;
  (V) THERAPEUTIC CARE; AND
  (VI) ANY OTHER MEDICAL CARE PROVIDED BY A LICENSED PHYSICIAN.
  (B) COVERAGE UNDER THIS SUBSECTION SHALL NOT BE DENIED  ON  THE  BASIS
THAT  THE  TREATMENT IS HABILITATIVE, NON-RESTORATIVE, OR EDUCATIONAL IN
NATURE, UNLESS SUCH TREATMENTS ARE BEING PROVIDED TO THE COVERED  PERSON
PURSUANT  TO  AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHTY-NINE
OF THE EDUCATION LAW. THE PROVISION OF SERVICES PURSUANT TO AN  INDIVID-
UALIZED FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE
OF  THE  PUBLIC  HEALTH  LAW, AN INDIVIDUAL EDUCATION PLAN UNDER ARTICLE
EIGHTY-NINE OF THE EDUCATION LAW,  OR  AN  INDIVIDUALIZED  SERVICE  PLAN
PURSUANT  TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL
DISABILITIES SHALL NOT AFFECT COVERAGE UNDER  THE  POLICY  FOR  SERVICES

S. 4005                             7                            A. 6305

PROVIDED  ON  A  SUPPLEMENTAL BASIS OUTSIDE OF AN EDUCATIONAL SETTING IF
SUCH SERVICES  ARE  PRESCRIBED  BY  A  LICENSED  PHYSICIAN  OR  LICENSED
PSYCHOLOGIST.
  (C)  NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO AFFECT ANY OBLI-
GATION TO PROVIDE SERVICES TO  AN  INDIVIDUAL  UNDER  AN  INDIVIDUALIZED
FAMILY  SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF THE
PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT-
Y-NINE OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN  PURSUANT
TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILI-
TIES.
  (D) NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO AFFECT ANY  OBLI-
GATION  TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON THE
BASIS THAT THE SERVICES CONSTITUTE EARLY INTERVENTION  PROGRAM  SERVICES
PURSUANT  TO  SECTION  THREE  THOUSAND TWO HUNDRED THIRTY-FIVE-A OF THIS
CHAPTER OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
  (E) NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO PREVENT A  POLICY
FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
SHALL  MEET  CERTAIN  REQUIREMENTS FOR PARTICIPATION, INCLUDING PROVIDER
CREDENTIALING.
  (F) COVERAGE UNDER THIS SUBSECTION SHALL NOT BE SUBJECT TO ANY  LIMITS
ON  THE  NUMBER OF VISITS AN INDIVIDUAL MAY MAKE FOR TREATMENT OF AUTISM
SPECTRUM DISORDER. EXCEPT FOR INPATIENT SERVICES, IF  AN  INDIVIDUAL  IS
RECEIVING  TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER WILL HAVE
THE RIGHT TO REQUEST A REVIEW OF THAT TREATMENT NOT MORE THAN ONCE EVERY
TWELVE MONTHS UNLESS THE INSURER AND INDIVIDUAL'S LICENSED PHYSICIAN  OR
LICENSED  PSYCHOLOGIST  AGREE,  ON  AN INDIVIDUALIZED BASIS, THAT A MORE
FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL  BE
BORNE BY THE INSURER.
  S 4. Severability clause. If any clause, sentence, paragraph, subdivi-
sion,  section  or  part  of  this act shall be adjudged by any court of
competent jurisdiction to be invalid, such judgement shall  not  affect,
impair,  or  invalidate  the remainder thereof, but shall be confined in
its operation to the clause, sentence, paragraph,  subdivision,  section
or part thereof directly involved in the controversy in which such judg-
ment  shall have rendered. It is hereby declared to be the intent of the
legislature that this act would have been enacted even if  such  invalid
provisions had not been included herein.
  S  5. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to  all
policies  and contracts issued, renewed, modified, altered or amended on
or after such date.

Co-Sponsors

view additional co-sponsors

S4005A (ACTIVE) - Bill Details

See Assembly Version of this Bill:
A6305A
Law Section:
Insurance Law
Laws Affected:
Amd §§3216, 3221 & 4303, Ins L

S4005A (ACTIVE) - Bill Texts

view summary

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

view sponsor memo
BILL NUMBER:S4005A

TITLE OF BILL:
An act
to amend the insurance law, in relation to coverage for the
screening, diagnosis and
treatment of autism spectrum disorder

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

SUMMARY OF PROVISIONS:
Amends sections 3216, 3221 and 4303 of the
Insurance Law to provide coverage for the screening, diagnosis and
treatment of autism spectrum disorders.

Provides that coverage may be subject to annual deductibles,
copayments and coinsurance consistent with those imposed on other
benefits under the contract.

Provides that the legislation shall not be construed as limiting the
benefits that are available to an individual under a health insurance
policy.

Provides that coverage may be subject to utilization and external
review of health care services, including case management and other
managed care provisions.

Defines "autism spectrum disorder" as Pervasive Developmental
Disorders including Autistic Disorder, Asperger's Disorder, Rett's
Disorder, Childhood Disintegrative Disorder, and pervasive
Developmental Disorder Not otherwise specified, as defined in the
most recent edition of the Diagnostic and statistical Manual of
Mental Disorders.

Defines "diagnosis of autism spectrum disorders", "behavioral health
treatment", "applied behavioral analysis", "treatment of autism
spectrum disorder", "pharmacy care", "psychiatric care",
"psychological care" and "therapeutic care".

Provides that licensed physician or psychologist are authorized to
prescribe care for the following: behavioral health treatment;
pharmacy care; psychiatric care; psychological care; therapeutic care
and other medical care prescribed by a licensed health care provider.

Provides that the provision of services pursuant to an individualized
family service plan, an individualized education program or an
individualized service plan shall not affect coverage under the
policy for services provided on a supplemental basis outside of an
educational setting if such services are prescribed by a licensed
physician or psychologist.

Provides that this legislation will not affect any obligation to
provide services to an individual under an individualized family


service plan or individualized education program or an individualized
service plan.

Provides that nothing in the legislation shall be construed to prevent
a contract from providing services through a network of participating
providers who shall meet certain requirements for participation,
including provider credentialing.

JUSTIFICATION:
Autism is a complex neurobiological disorder that
severely affects the way autistic individuals relate to others
socially and their ability to communicate and learn. Today the
Centers for Disease Control (CDC) estimate that the number of
children with autism is 1 in 110 nationwide, making it more common
than pediatric cancer, diabetes, and AIDS combined. It occurs in all
racial, ethnic, and social groups and is four times more likely to
strike boys than girls.

Existing state law requires that insurance coverage for autism "not
exclude" the diagnosis and treatment of autism spectrum disorder.
Current law does not provide sufficient clarity or an affirmative
obligation of health insurance to cover costs relating to autism
treatments. Moreover, parents are often faced with significant gaps
in treatments which may be needed over and above those provided
pursuant to an individualized family, education or service plan.
These families often pay as much as they can out-of-pocket for
services that can cost upwards of $50,000 per year. In the process,
many risk their homes and the education's of their unaffected
children essentially mortgaging their futures. This legislation would
expedite diagnosis and treatment by providing insurance parity for
autism sufferers by requiring equitable coverage of the disorder by
insurance companies.

If enacted, New York would join with 23 other states in requiring
coverage for conditions relating to autism spectrum disorder.

LEGISLATIVE HISTORY:

FISCAL IMPLICATIONS:
Treatment of autism spectrum disorders will
result in better long-term health outcomes for those afflicted with
this condition and should therefore lessen costs which are borne by
taxpayers. There will be some minor cost to the State for coverage
for it's own employees and their families. Actuarial cost estimates
provided by independent actuaries retained by a leading national
autism advocacy organization, Autism Speaks, determined that expected
impact upon insurance costs were approximately one-half of one
percent after full implementation of coverage over a number of years.
Cost implications for other 23 states which have enacted such
legislation have been very modest.

EFFECTIVE DATE:
This act shall take effect January 1 after enactment
and shall apply to insurance policies issued or renewed after that
date.


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

    S. 4005--A                                            A. 6305--A

                       2011-2012 Regular Sessions

                      S E N A T E - A S S E M B L Y

                             March 11, 2011
                               ___________

IN  SENATE  --  Introduced by Sens. FUSCHILLO, McDONALD, BRESLIN, DUANE,
  ADAMS, ADDABBO, AVELLA, BALL, BONACIC, DeFRANCISCO, DILAN,  ESPAILLAT,
  FARLEY,   FLANAGAN,   GALLIVAN,   GOLDEN,  GRIFFO,  GRISANTI,  HANNON,
  HASSELL-THOMPSON, JOHNSON, KENNEDY,  KLEIN,  KRUEGER,  KRUGER,  LANZA,
  LARKIN,  LAVALLE,  LIBOUS, LITTLE, MARCELLINO, MARTINS, MAZIARZ, MONT-
  GOMERY,  NOZZOLIO,  O'MARA,  OPPENHEIMER,  PARKER,  PERALTA,  PERKINS,
  RITCHIE,   RIVERA,   ROBACH,   SAMPSON,   SAVINO,   SKELOS,  STAVISKY,
  STEWART-COUSINS, VALESKY, ZELDIN -- read twice  and  ordered  printed,
  and  when  printed  to  be  committed to the Committee on Insurance --
  reported favorably from said committee and committed to the  Committee
  on Finance -- committee discharged, bill amended, ordered reprinted as
  amended and recommitted to said committee

IN ASSEMBLY -- Introduced by M. of A. MORELLE, SILVER, NOLAN, SCHROEDER,
  LAVINE, LUPARDO, GOTTFRIED, PERRY, HEVESI, CUSICK, J. RIVERA, SWEENEY,
  JAFFEE,  ZEBROWSKI,  GALEF,  MAISEL, SPANO, ROSENTHAL, ARROYO, TITONE,
  WEPRIN,  ABINANTI,  P. RIVERA,  BENEDETTO,  PEOPLES-STOKES,   PRETLOW,
  WRIGHT,  MOYA,  LINARES, McENENY, COLTON, ROBERTS, GUNTHER, BRAUNSTEIN
  -- Multi-Sponsored by -- M. of A.  BARCLAY,  CALHOUN,  DUPREY,  ENGLE-
  BRIGHT,  JORDAN, LIFTON, McDONOUGH, McKEVITT, MENG, MILLMAN, MOLINARO,
  MONTESANO, PAULIN, RAIA, SALADINO, SAYWARD, SCHIMEL, TEDISCO, TOBACCO,
  WEINSTEIN -- 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  coverage  for  the
  screening, diagnosis and treatment of autism spectrum disorder

  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:

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08567-03-1

S. 4005--A                          2                         A. 6305--A

  (25) (A) Every policy  which  provides  coverage  for  hospital[,]  OR
surgical[,  or  medical  care]  coverage  shall not exclude coverage for
SCREENING, diagnosis  and  treatment  of  medical  conditions  otherwise
covered  by the policy solely because the treatment is provided to diag-
nose  or  treat autism spectrum disorder. [For purposes of this section,
"autism  spectrum  disorder"  means  a  neurobiological  condition  that
includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
opmental disorder.]
  (B)  EVERY  POLICY  WHICH  PROVIDES PHYSICIAN SERVICES, MEDICAL, MAJOR
MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE  SHALL  PROVIDE  COVERAGE
FOR  THE  SCREENING, DIAGNOSIS AND TREATMENT OF AUTISM SPECTRUM DISORDER
IN ACCORDANCE WITH THIS PARAGRAPH AND SHALL NOT EXCLUDE COVERAGE FOR THE
SCREENING,  DIAGNOSIS  OR  TREATMENT  OF  MEDICAL  CONDITIONS  OTHERWISE
COVERED  BY  THE  POLICY BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AUTISM
SPECTRUM DISORDER. SUCH COVERAGE MAY BE SUBJECT TO  ANNUAL  DEDUCTIBLES,
COPAYMENTS  AND  COINSURANCE  AS MAY BE DEEMED APPROPRIATE BY THE SUPER-
INTENDENT AND SHALL BE CONSISTENT WITH THOSE IMPOSED ON  OTHER  BENEFITS
UNDER  THE POLICY. THIS PARAGRAPH SHALL NOT BE CONSTRUED AS LIMITING THE
BENEFITS THAT ARE OTHERWISE AVAILABLE TO AN INDIVIDUAL UNDER THE POLICY,
PROVIDED HOWEVER THAT SUCH POLICY SHALL NOT CONTAIN ANY  LIMITATIONS  ON
VISITS  THAT  ARE  SOLELY  APPLIED  TO  THE TREATMENT OF AUTISM SPECTRUM
DISORDER. NO INSURER SHALL TERMINATE  COVERAGE  OR  REFUSE  TO  DELIVER,
EXECUTE, ISSUE, AMEND, ADJUST, OR RENEW COVERAGE TO AN INDIVIDUAL SOLELY
BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AUTISM SPECTRUM DISORDER OR HAS
RECEIVED  TREATMENT  FOR  AUTISM  SPECTRUM  DISORDER.  COVERAGE SHALL BE
SUBJECT TO UTILIZATION  REVIEW  AND  EXTERNAL  APPEALS  OF  HEALTH  CARE
SERVICES PURSUANT TO ARTICLE FORTY-NINE OF THIS CHAPTER AS WELL AS, CASE
MANAGEMENT, AND OTHER MANAGED CARE PROVISIONS.
  (C) FOR PURPOSES OF THIS PARAGRAPH:
  (I)  "AUTISM  SPECTRUM  DISORDER"  MEANS  ANY  PERVASIVE DEVELOPMENTAL
DISORDER AS DEFINED IN THE MOST RECENT EDITION  OF  THE  DIAGNOSTIC  AND
STATISTICAL  MANUAL  OF  MENTAL  DISORDERS, INCLUDING AUTISTIC DISORDER,
ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE DISORDER,
OR PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED (PDD-NOS).
  (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI  AND
CONSEQUENCES,  TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN HUMAN
BEHAVIOR, INCLUDING THE USE  OF  DIRECT  OBSERVATION,  MEASUREMENT,  AND
FUNCTIONAL  ANALYSIS  OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
IOR.
  (III) "BEHAVIORAL HEALTH TREATMENT"  MEANS  COUNSELING  AND  TREATMENT
PROGRAMS,  WHEN  PROVIDED  BY  A LICENSED PROVIDER, AND APPLIED BEHAVIOR
ANALYSIS, WHEN PROVIDED OR SUPERVISED BY A  BEHAVIOR  ANALYST  CERTIFIED
PURSUANT TO THE BEHAVIOR ANALYST CERTIFICATION BOARD, THAT ARE NECESSARY
TO DEVELOP, MAINTAIN, OR RESTORE, TO THE MAXIMUM EXTENT PRACTICABLE, THE
FUNCTIONING OF AN INDIVIDUAL. INDIVIDUALS THAT PROVIDE BEHAVIORAL HEALTH
TREATMENT UNDER THE SUPERVISION OF A CERTIFIED BEHAVIOR ANALYST PURSUANT
TO  THIS  PARAGRAPH SHALL BE SUBJECT TO STANDARDS OF PROFESSIONALISM AND
RELEVANT EXPERIENCE PURSUANT TO REGULATIONS PROMULGATED  BY  THE  SUPER-
INTENDENT IN CONSULTATION WITH THE COMMISSIONER OF HEALTH.
  (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDER" MEANS ASSESSMENTS, EVALU-
ATIONS,  OR  TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS AUTISM SPECTRUM
DISORDER.
  (V) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED  HEALTH
CARE  PROVIDER  LEGALLY AUTHORIZED TO PRESCRIBE UNDER TITLE EIGHT OF THE
EDUCATION LAW.

S. 4005--A                          3                         A. 6305--A

  (VI) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (VII)  "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (VIII)  "THERAPEUTIC  CARE"  MEANS  SERVICES  PROVIDED  BY LICENSED OR
CERTIFIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS, OR
PHYSICAL THERAPISTS.
  (IX) "TREATMENT OF AUTISM SPECTRUM DISORDER" SHALL INCLUDE THE FOLLOW-
ING CARE AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR  AN  INDIVIDUAL
DIAGNOSED  WITH  AUTISM  SPECTRUM  DISORDER BY A LICENSED PHYSICIAN OR A
LICENSED PSYCHOLOGIST:
  (1) BEHAVIORAL HEALTH TREATMENT;
  (2) PSYCHIATRIC CARE;
  (3) PSYCHOLOGICAL CARE;
  (4) MEDICAL CARE PROVIDED BY A LICENSED HEALTH CARE PROVIDER;
  (5) THERAPEUTIC CARE, INCLUDING THERAPEUTIC CARE WHICH IS DEEMED HABI-
LITATIVE OR NONRESTORATIVE, IN THE EVENT THAT THE POLICY PROVIDES COVER-
AGE FOR THERAPEUTIC CARE; AND
  (6) PHARMACY CARE IN THE EVENT THAT THE POLICY PROVIDES  COVERAGE  FOR
PRESCRIPTION DRUGS.
  (D)  COVERAGE  MAY BE DENIED ON THE BASIS THAT SUCH TREATMENT IS BEING
PROVIDED TO THE COVERED PERSON PURSUANT TO AN  INDIVIDUALIZED  EDUCATION
PLAN  UNDER  ARTICLE  EIGHTY-NINE OF THE EDUCATION LAW. THE PROVISION OF
SERVICES PURSUANT TO AN INDIVIDUALIZED FAMILY SERVICE PLAN UNDER SECTION
TWENTY-FIVE HUNDRED FORTY-FIVE OF THE PUBLIC HEALTH LAW, AN  INDIVIDUAL-
IZED  EDUCATION  PLAN UNDER ARTICLE EIGHTY-NINE OF THE EDUCATION LAW, OR
AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE OFFICE FOR
PERSONS WITH DEVELOPMENTAL DISABILITIES SHALL NOT AFFECT COVERAGE  UNDER
THE  POLICY  FOR SERVICES PROVIDED ON A SUPPLEMENTAL BASIS OUTSIDE OF AN
EDUCATIONAL SETTING IF SUCH SERVICES ARE PRESCRIBED BY A LICENSED PHYSI-
CIAN OR LICENSED PSYCHOLOGIST.
  (E) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT  ANY  OBLI-
GATION  TO  PROVIDE  SERVICES  TO  AN INDIVIDUAL UNDER AN INDIVIDUALIZED
FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF  THE
PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT-
Y-NINE  OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT
TO REGULATIONS OF THE OFFICE FOR PERSONS  WITH  DEVELOPMENTAL  DISABILI-
TIES.
  (F)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT ANY OBLI-
GATION TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON  THE
BASIS  THAT  THE SERVICES CONSTITUTE EARLY INTERVENTION PROGRAM SERVICES
PURSUANT TO SECTION THREE THOUSAND TWO  HUNDRED  THIRTY-FIVE-A  OF  THIS
ARTICLE OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
  (G)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT A POLICY
FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
SHALL MEET CERTAIN REQUIREMENTS FOR  PARTICIPATION,  INCLUDING  PROVIDER
CREDENTIALING.
  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) EVERY group or blanket accident [or] AND health insurance
policy  [or  issuing  a group or blanket policy] DELIVERED OR ISSUED for
delivery in this state which provides coverage for hospital[,] OR surgi-

S. 4005--A                          4                         A. 6305--A

cal[, or medical] care coverage shall not exclude coverage  for  SCREEN-
ING,  diagnosis and treatment of medical conditions otherwise covered by
the policy because the treatment is provided to diagnose or treat autism
spectrum  disorder.  [For  purposes  of  this  section, "autism spectrum
disorder" means a neurobiological condition that includes autism, Asper-
ger syndrome, Rett's syndrome, or pervasive developmental disorder.]
  (B) EVERY GROUP OR BLANKET POLICY WHICH PROVIDES  PHYSICIAN  SERVICES,
MEDICAL,  MAJOR  MEDICAL  OR  SIMILAR  COMPREHENSIVE-TYPE COVERAGE SHALL
PROVIDE COVERAGE FOR THE SCREENING, DIAGNOSIS AND  TREATMENT  OF  AUTISM
SPECTRUM  DISORDER  IN  ACCORDANCE  WITH  THIS  PARAGRAPH  AND SHALL NOT
EXCLUDE COVERAGE FOR THE SCREENING, DIAGNOSIS OR  TREATMENT  OF  MEDICAL
CONDITIONS  OTHERWISE  COVERED  BY  THE POLICY BECAUSE THE INDIVIDUAL IS
DIAGNOSED WITH AUTISM SPECTRUM DISORDER. SUCH COVERAGE MAY BE SUBJECT TO
ANNUAL DEDUCTIBLES, COPAYMENTS AND COINSURANCE AS MAY BE  DEEMED  APPRO-
PRIATE  BY THE SUPERINTENDENT AND SHALL BE CONSISTENT WITH THOSE IMPOSED
ON OTHER BENEFITS UNDER THE GROUP  OR  BLANKET  POLICY.  THIS  PARAGRAPH
SHALL  NOT  BE  CONSTRUED  AS  LIMITING  THE BENEFITS THAT ARE OTHERWISE
AVAILABLE TO AN INDIVIDUAL UNDER THE GROUP OR BLANKET  POLICY,  PROVIDED
HOWEVER  THAT  SUCH  POLICY  SHALL NOT CONTAIN ANY LIMITATIONS ON VISITS
THAT ARE SOLELY APPLIED TO THE TREATMENT OF AUTISM SPECTRUM DISORDER. NO
INSURER SHALL TERMINATE COVERAGE OR REFUSE TO DELIVER,  EXECUTE,  ISSUE,
AMEND,  ADJUST,  OR  RENEW  COVERAGE TO AN INDIVIDUAL SOLELY BECAUSE THE
INDIVIDUAL IS DIAGNOSED WITH AUTISM SPECTRUM DISORDER  OR  HAS  RECEIVED
TREATMENT  FOR  AUTISM  SPECTRUM  DISORDER. COVERAGE SHALL BE SUBJECT TO
UTILIZATION REVIEW AND EXTERNAL APPEALS OF HEALTH CARE SERVICES PURSUANT
TO ARTICLE FORTY-NINE OF THIS CHAPTER AS WELL AS, CASE  MANAGEMENT,  AND
OTHER MANAGED CARE PROVISIONS.
  (C) FOR PURPOSES OF THIS PARAGRAPH:
  (I)  "AUTISM  SPECTRUM  DISORDER"  MEANS  ANY  PERVASIVE DEVELOPMENTAL
DISORDER AS DEFINED IN THE MOST RECENT EDITION  OF  THE  DIAGNOSTIC  AND
STATISTICAL  MANUAL  OF  MENTAL  DISORDERS, INCLUDING AUTISTIC DISORDER,
ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE DISORDER,
OR PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED (PDD-NOS).
  (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI  AND
CONSEQUENCES,  TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN HUMAN
BEHAVIOR, INCLUDING THE USE  OF  DIRECT  OBSERVATION,  MEASUREMENT,  AND
FUNCTIONAL  ANALYSIS  OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
IOR.
  (III) "BEHAVIORAL HEALTH TREATMENT"  MEANS  COUNSELING  AND  TREATMENT
PROGRAMS,  WHEN  PROVIDED  BY  A LICENSED PROVIDER, AND APPLIED BEHAVIOR
ANALYSIS, WHEN PROVIDED OR SUPERVISED BY A  BEHAVIOR  ANALYST  CERTIFIED
PURSUANT TO THE BEHAVIOR ANALYST CERTIFICATION BOARD, THAT ARE NECESSARY
TO DEVELOP, MAINTAIN, OR RESTORE, TO THE MAXIMUM EXTENT PRACTICABLE, THE
FUNCTIONING OF AN INDIVIDUAL. INDIVIDUALS THAT PROVIDE BEHAVIORAL HEALTH
TREATMENT UNDER THE SUPERVISION OF A CERTIFIED BEHAVIOR ANALYST PURSUANT
TO  THIS  PARAGRAPH SHALL BE SUBJECT TO STANDARDS OF PROFESSIONALISM AND
RELEVANT EXPERIENCE PURSUANT TO REGULATIONS PROMULGATED  BY  THE  SUPER-
INTENDENT IN CONSULTATION WITH THE COMMISSIONER OF HEALTH.
  (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDER" MEANS ASSESSMENTS, EVALU-
ATIONS,  OR  TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS AUTISM SPECTRUM
DISORDER.
  (V) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED  HEALTH
CARE  PROVIDER  LEGALLY AUTHORIZED TO PRESCRIBE UNDER TITLE EIGHT OF THE
EDUCATION LAW.

S. 4005--A                          5                         A. 6305--A

  (VI) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC-
TICES.
  (VII)  "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE SERVICES
PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL-
OGIST PRACTICES.
  (VIII)  "THERAPEUTIC  CARE"  MEANS  SERVICES  PROVIDED  BY LICENSED OR
CERTIFIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS, OR
PHYSICAL THERAPISTS.
  (IX) "TREATMENT OF AUTISM SPECTRUM DISORDER" SHALL INCLUDE THE FOLLOW-
ING CARE AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR  AN  INDIVIDUAL
DIAGNOSED  WITH  AUTISM  SPECTRUM  DISORDER BY A LICENSED PHYSICIAN OR A
LICENSED PSYCHOLOGIST:
  (1) BEHAVIORAL HEALTH TREATMENT;
  (2) PSYCHIATRIC CARE;
  (3) PSYCHOLOGICAL CARE;
  (4) MEDICAL CARE PROVIDED BY A LICENSED HEALTH CARE PROVIDER;
  (5) THERAPEUTIC CARE, INCLUDING THERAPEUTIC CARE WHICH IS DEEMED HABI-
LITATIVE OR NONRESTORATIVE, IN THE EVENT THAT THE POLICY PROVIDES COVER-
AGE FOR THERAPEUTIC CARE; AND
  (6) PHARMACY CARE IN THE EVENT THAT THE POLICY PROVIDES  COVERAGE  FOR
PRESCRIPTION DRUGS.
  (D)  COVERAGE  MAY BE DENIED ON THE BASIS THAT SUCH TREATMENT IS BEING
PROVIDED TO THE COVERED PERSON PURSUANT TO AN  INDIVIDUALIZED  EDUCATION
PLAN  UNDER  ARTICLE  EIGHTY-NINE OF THE EDUCATION LAW. THE PROVISION OF
SERVICES PURSUANT TO AN INDIVIDUALIZED FAMILY SERVICE PLAN UNDER SECTION
TWENTY-FIVE HUNDRED FORTY-FIVE OF THE PUBLIC HEALTH LAW, AN  INDIVIDUAL-
IZED  EDUCATION  PLAN UNDER ARTICLE EIGHTY-NINE OF THE EDUCATION LAW, OR
AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE OFFICE FOR
PERSONS WITH DEVELOPMENTAL DISABILITIES SHALL NOT AFFECT COVERAGE  UNDER
THE  POLICY  FOR SERVICES PROVIDED ON A SUPPLEMENTAL BASIS OUTSIDE OF AN
EDUCATIONAL SETTING IF SUCH SERVICES ARE PRESCRIBED BY A LICENSED PHYSI-
CIAN OR LICENSED PSYCHOLOGIST.
  (E) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT  ANY  OBLI-
GATION  TO  PROVIDE  SERVICES  TO  AN INDIVIDUAL UNDER AN INDIVIDUALIZED
FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF  THE
PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT-
Y-NINE  OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT
TO REGULATIONS OF THE OFFICE FOR PERSONS  WITH  DEVELOPMENTAL  DISABILI-
TIES.
  (F)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT ANY OBLI-
GATION TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON  THE
BASIS  THAT  THE SERVICES CONSTITUTE EARLY INTERVENTION PROGRAM SERVICES
PURSUANT TO SECTION THREE THOUSAND TWO  HUNDRED  THIRTY-FIVE-A  OF  THIS
ARTICLE OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
  (G) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT A GROUP OR
BLANKET  POLICY FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPAT-
ING PROVIDERS WHO SHALL MEET  CERTAIN  REQUIREMENTS  FOR  PARTICIPATION,
INCLUDING PROVIDER CREDENTIALING.
  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[,]  OR  surgical[,  or medical] care coverage shall not exclude
coverage for SCREENING, diagnosis and treatment  of  medical  conditions

S. 4005--A                          6                         A. 6305--A

otherwise covered by the policy solely because the treatment is provided
to  diagnose  or  treat  autism spectrum disorder. [For purposes of this
section, "autism spectrum disorder" means  a  neurobiological  condition
that  includes  autism, Asperger syndrome, Rett's syndrome, or pervasive
developmental disorder.]
  (2) EVERY POLICY WHICH PROVIDES  PHYSICIAN  SERVICES,  MEDICAL,  MAJOR
MEDICAL  OR  SIMILAR  COMPREHENSIVE-TYPE COVERAGE SHALL PROVIDE COVERAGE
FOR THE SCREENING, DIAGNOSIS AND TREATMENT OF AUTISM  SPECTRUM  DISORDER
IN  ACCORDANCE  WITH  THIS SUBSECTION AND SHALL NOT EXCLUDE COVERAGE FOR
THE SCREENING, DIAGNOSIS OR TREATMENT OF  MEDICAL  CONDITIONS  OTHERWISE
COVERED  BY  THE  POLICY BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AUTISM
SPECTRUM DISORDER. SUCH COVERAGE MAY BE SUBJECT TO  ANNUAL  DEDUCTIBLES,
COPAYMENTS  AND  COINSURANCE  AS MAY BE DEEMED APPROPRIATE BY THE SUPER-
INTENDENT AND SHALL BE CONSISTENT WITH THOSE IMPOSED ON  OTHER  BENEFITS
UNDER  THE POLICY. THIS PARAGRAPH SHALL NOT BE CONSTRUED AS LIMITING THE
BENEFITS THAT ARE OTHERWISE AVAILABLE TO AN INDIVIDUAL UNDER THE POLICY,
PROVIDED HOWEVER THAT SUCH POLICY SHALL NOT CONTAIN ANY  LIMITATIONS  ON
VISITS  THAT  ARE  SOLELY  APPLIED  TO  THE TREATMENT OF AUTISM SPECTRUM
DISORDER. NO INSURER SHALL TERMINATE  COVERAGE  OR  REFUSE  TO  DELIVER,
EXECUTE, ISSUE, AMEND, ADJUST, OR RENEW COVERAGE TO AN INDIVIDUAL SOLELY
BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AUTISM SPECTRUM DISORDER OR HAS
RECEIVED  TREATMENT  FOR  AUTISM  SPECTRUM  DISORDER.  COVERAGE SHALL BE
SUBJECT TO UTILIZATION  REVIEW  AND  EXTERNAL  APPEALS  OF  HEALTH  CARE
SERVICES PURSUANT TO ARTICLE FORTY-NINE OF THIS CHAPTER AS WELL AS, CASE
MANAGEMENT, AND OTHER MANAGED CARE PROVISIONS.
  (3) FOR PURPOSES OF THIS SUBSECTION:
  (A)  "AUTISM  SPECTRUM  DISORDER"  MEANS  ANY  PERVASIVE DEVELOPMENTAL
DISORDER AS DEFINED IN THE MOST RECENT EDITION  OF  THE  DIAGNOSTIC  AND
STATISTICAL  MANUAL  OF  MENTAL  DISORDERS, INCLUDING AUTISTIC DISORDER,
ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE DISORDER,
OR PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED (PDD-NOS).
  (B) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION,  AND
EVALUATION  OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
CONSEQUENCES, TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN  HUMAN
BEHAVIOR,  INCLUDING  THE  USE  OF  DIRECT OBSERVATION, MEASUREMENT, AND
FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT  AND  BEHAV-
IOR.
  (C)  "BEHAVIORAL  HEALTH  TREATMENT"  MEANS  COUNSELING  AND TREATMENT
PROGRAMS, WHEN PROVIDED BY A LICENSED  PROVIDER,  AND  APPLIED  BEHAVIOR
ANALYSIS,  WHEN  PROVIDED  OR SUPERVISED BY A BEHAVIOR ANALYST CERTIFIED
PURSUANT TO THE BEHAVIOR ANALYST CERTIFICATION BOARD, THAT ARE NECESSARY
TO DEVELOP, MAINTAIN, OR RESTORE, TO THE MAXIMUM EXTENT PRACTICABLE, THE
FUNCTIONING OF AN INDIVIDUAL. INDIVIDUALS THAT PROVIDE BEHAVIORAL HEALTH
TREATMENT UNDER THE SUPERVISION OF A CERTIFIED BEHAVIOR ANALYST PURSUANT
TO THIS SUBSECTION SHALL BE SUBJECT TO STANDARDS OF PROFESSIONALISM  AND
RELEVANT  EXPERIENCE  PURSUANT  TO REGULATIONS PROMULGATED BY THE SUPER-
INTENDENT IN CONSULTATION WITH THE COMMISSIONER OF HEALTH.
  (D) "DIAGNOSIS OF AUTISM SPECTRUM DISORDER" MEANS ASSESSMENTS,  EVALU-
ATIONS,  OR  TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS AUTISM SPECTRUM
DISORDER.
  (E) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED  HEALTH
CARE  PROVIDER  LEGALLY AUTHORIZED TO PRESCRIBE UNDER TITLE EIGHT OF THE
EDUCATION LAW.
  (F) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES  PROVIDED
BY  A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
TICES.

S. 4005--A                          7                         A. 6305--A

  (G)  "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE   SERVICES
PROVIDED  BY  A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
OGIST PRACTICES.
  (H)  "THERAPEUTIC  CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
FIED SPEECH THERAPISTS,  OCCUPATIONAL  THERAPISTS,  SOCIAL  WORKERS,  OR
PHYSICAL THERAPISTS.
  (I)  "TREATMENT OF AUTISM SPECTRUM DISORDER" SHALL INCLUDE THE FOLLOW-
ING CARE AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR  AN  INDIVIDUAL
DIAGNOSED  WITH  AUTISM  SPECTRUM  DISORDER BY A LICENSED PHYSICIAN OR A
LICENSED PSYCHOLOGIST:
  (I) BEHAVIORAL HEALTH TREATMENT;
  (II) PSYCHIATRIC CARE;
  (III) PSYCHOLOGICAL CARE;
  (IV) MEDICAL CARE PROVIDED BY A LICENSED HEALTH CARE PROVIDER;
  (V) THERAPEUTIC CARE, INCLUDING THERAPEUTIC CARE WHICH IS DEEMED HABI-
LITATIVE OR NONRESTORATIVE, IN THE EVENT THAT THE POLICY PROVIDES COVER-
AGE FOR THERAPEUTIC CARE; AND
  (VI) PHARMACY CARE IN THE EVENT THAT THE POLICY PROVIDES COVERAGE  FOR
PRESCRIPTION DRUGS.
  (4)  COVERAGE  MAY BE DENIED ON THE BASIS THAT SUCH TREATMENT IS BEING
PROVIDED TO THE COVERED PERSON PURSUANT TO AN  INDIVIDUALIZED  EDUCATION
PLAN  UNDER  ARTICLE  EIGHTY-NINE OF THE EDUCATION LAW. THE PROVISION OF
SERVICES PURSUANT TO AN INDIVIDUALIZED FAMILY SERVICE PLAN UNDER SECTION
TWENTY-FIVE HUNDRED FORTY-FIVE OF THE PUBLIC HEALTH LAW, AN  INDIVIDUAL-
IZED  EDUCATION  PLAN UNDER ARTICLE EIGHTY-NINE OF THE EDUCATION LAW, OR
AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE OFFICE FOR
PERSONS WITH DEVELOPMENTAL DISABILITIES SHALL NOT AFFECT COVERAGE  UNDER
THE  POLICY  FOR SERVICES PROVIDED ON A SUPPLEMENTAL BASIS OUTSIDE OF AN
EDUCATIONAL SETTING IF SUCH SERVICES ARE PRESCRIBED BY A LICENSED PHYSI-
CIAN OR LICENSED PSYCHOLOGIST.
  (5) NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO AFFECT ANY  OBLI-
GATION  TO  PROVIDE  SERVICES  TO  AN INDIVIDUAL UNDER AN INDIVIDUALIZED
FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF  THE
PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT-
Y-NINE  OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT
TO REGULATIONS OF THE OFFICE FOR PERSONS  WITH  DEVELOPMENTAL  DISABILI-
TIES.
  (6)  NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO AFFECT ANY OBLI-
GATION TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON  THE
BASIS  THAT  THE SERVICES CONSTITUTE EARLY INTERVENTION PROGRAM SERVICES
PURSUANT TO SECTION THREE THOUSAND TWO  HUNDRED  THIRTY-FIVE-A  OF  THIS
ARTICLE OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
  (7)  NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO PREVENT A POLICY
FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
SHALL MEET CERTAIN REQUIREMENTS FOR  PARTICIPATION,  INCLUDING  PROVIDER
CREDENTIALING.
  S 4. Severability clause. If any clause, sentence, paragraph, subdivi-
sion,  section  or  part  of  this act shall be adjudged by any court of
competent jurisdiction to be invalid, such judgement shall  not  affect,
impair,  or  invalidate  the remainder thereof, but shall be confined in
its operation to the clause, sentence, paragraph,  subdivision,  section
or part thereof directly involved in the controversy in which such judg-
ment  shall have rendered. It is hereby declared to be the intent of the
legislature that this act would have been enacted even if  such  invalid
provisions had not been included herein.

S. 4005--A                          8                         A. 6305--A

  S  5. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to  all
policies  and contracts issued, renewed, modified, altered or amended on
or after such date.

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