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See Summary
S T A T E O F N E W Y O R K
________________________________________________________________________
6001--A
2009-2010 Regular Sessions
I N A S S E M B L Y
February 23, 2009
___________
Introduced by M. of A. WEISENBERG, REILLY, CASTRO, GUNTHER, COOK, PHEF-
FER, COLTON, BENEDETTO, TITONE, SCHROEDER, CUSICK, SPANO, ZEBROWSKI,
ROBINSON, CARROZZA, HOOPER, PAULIN, HEVESI, DenDEKKER, EDDINGTON,
MILLER, JAFFEE, BENJAMIN, BROOK-KRASNY, KELLNER, ENGLEBRIGHT, LATIMER
-- Multi-Sponsored by -- M. of A. BALL, BARRA, BRADLEY, BURLING,
CONTE, DUPREY, ERRIGO, FINCH, HYER-SPENCER, KOLB, LUPARDO, MAISEL,
MARKEY, McDONOUGH, McKEVITT, MILLMAN, MOLINARO, RABBITT, RAIA, SCHI-
MEL, SWEENEY, THIELE, TOBACCO, WALKER -- read once and referred to the
Committee on Insurance -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee
AN ACT to amend the insurance law, in relation to autism spectrum disor-
ders
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Paragraph 25 of subsection (i) of section 3216 of the
2 insurance law, as added by chapter 557 of the laws of 2006, is amended
3 to read as follows:
4 (25) Every policy which provides coverage for hospital, surgical, or
5 medical care coverage shall not exclude coverage for diagnosis and
6 treatment of medical conditions otherwise covered by the policy solely
7 because the treatment is provided to diagnose or treat autism spectrum
8 disorder. IN INDIVIDUALS TWENTY-ONE YEARS OF AGE OR LESS, THERE SHALL BE
9 NO LIMITS ON THE NUMBER OF VISITS AN INDIVIDUAL MAY MAKE TO AN AUTISM
10 PROVIDER. COVERAGE UNDER THIS SUBSECTION MAY BE SUBJECT TO COPAYMENT,
11 DEDUCTIBLE AND COINSURANCE PROVISIONS OF A HEALTH INSURANCE POLICY TO
12 THE EXTENT THAT OTHER MEDICAL SERVICE COVERED BY THE HEALTH INSURANCE
13 POLICY ARE SUBJECT TO SUCH PROVISIONS. THIS SUBSECTION SHALL NOT BE
14 CONSTRUED AS LIMITING THE BENEFITS THAT ARE AVAILABLE TO AN INDIVIDUAL
15 UNDER A HEALTH INSURANCE POLICY. COVERAGE FOR APPLIED BEHAVIOR ANALYSIS
16 THERAPY MAY BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOUSAND
17 DOLLARS. AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND ELEVEN, THE SUPER-
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD06364-15-9
A. 6001--A 2
1 INTENDENT SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR
2 INFLATION USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPART-
3 MENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPER-
4 INTENDENT SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT FOR PUBLICATION
5 ANNUALLY NO LATER THAN APRIL FIRST OF EACH CALENDAR YEAR, AND SUCH
6 PUBLISHED ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING
7 CALENDAR YEAR TO HEALTH INSURANCE POLICIES SUBJECT TO THIS SECTION.
8 PAYMENTS MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY
9 CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM UNRELATED TO APPLIED
10 BEHAVIOR ANALYSIS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM BENEFIT
11 ESTABLISHED PURSUANT TO THIS PARAGRAPH. EXCEPT FOR INPATIENT SERVICES,
12 IF AN INDIVIDUAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS,
13 AN INSURER SHALL HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT
14 NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDI-
15 VIDUAL'S LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE
16 FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE
17 BORNE BY THE INSURER.
18 (A) For purposes of this section[,]:
19 (I) "autism spectrum disorder" means a neurobiological condition that
20 includes [autism, Asperger syndrome, Rett's syndrome, or] AUTISTIC
21 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, RETT'S DISORDER, CHILD-
22 HOOD DISINTEGRATIVE DISORDER, AND ANY pervasive developmental disorder
23 NOT OTHERWISE SPECIFIED.
24 (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
25 EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
26 CONSEQUENCES, TO PRODUCE SOCIALLY SIGNIFICANT IMPROVEMENT IN HUMAN
27 BEHAVIOR, INCLUDING THE USE OF DIRECT OBSERVATION, MEASUREMENT, AND
28 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
29 IOR.
30 (III) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
31 THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
32 (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
33 SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
34 HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
35 (V) "EVIDENCE-BASED RESEARCH" MEANS RESEARCH THAT APPLIES RIGOROUS,
36 SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE RELEVANT
37 TO AUTISM SPECTRUM DISORDERS.
38 (VI) "HABILITATIVE OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
39 SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
40 BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
41 TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
42 (VII) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
43 SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A LICENSED
44 PHYSICIAN OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
45 ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY OF
46 THE FOLLOWING:
47 (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
48 (2) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL, OR DEVELOPMENTAL
49 EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
50 (3) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL CAPACITY IN
51 PERFORMING DAILY ACTIVITIES, TAKING INTO ACCOUNT BOTH THE FUNCTIONAL
52 CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
53 PRIATE FOR INDIVIDUALS OF THE SAME AGE.
54 (VIII) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED
55 PHYSICIAN AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
56 DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
A. 6001--A 3
1 (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
2 BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
3 TICES.
4 (X) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE SERVICES
5 PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
6 OGIST PRACTICES.
7 (XI) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
8 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
9 (XII) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE
10 FOLLOWING CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
11 NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSICIAN
12 OR A LICENSED PSYCHOLOGIST WHO DETERMINES THE CARE TO BE MEDICALLY
13 NECESSARY:
14 (1) HABILITATIVE OR REHABILITATIVE CARE;
15 (2) PHARMACY CARE;
16 (3) PSYCHIATRIC CARE;
17 (4) PSYCHOLOGICAL CARE;
18 (5) THERAPEUTIC CARE; AND
19 (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
20 DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
21 PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
22 IS PUBLISHED IN THE REGISTER FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
23 CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
24 COVERED WILL BE INCLUDED IN ANY HEALTH INSURANCE POLICY DELIVERED,
25 EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
26 FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
27 (B) THIS PARAGRAPH SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
28 PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
29 PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED SERVICE
30 PLAN.
31 S 2. Paragraph 17 of subsection (l) of section 3221 of the insurance
32 law, as added by chapter 557 of the laws of 2006, is amended to read as
33 follows:
34 (17) A group or blanket accident or health insurance policy or issuing
35 a group or blanket policy for delivery in this state which provides
36 coverage for hospital, surgical, or medical care coverage shall not
37 exclude coverage for diagnosis and treatment of medical conditions
38 otherwise covered by the policy because the treatment is provided to
39 diagnose or treat autism spectrum disorder. IN INDIVIDUALS TWENTY-ONE
40 YEARS OF AGE OR LESS, THERE SHALL BE NO LIMITS ON THE NUMBER OF VISITS
41 AN INDIVIDUAL MAY MAKE TO AN AUTISM PROVIDER. COVERAGE UNDER THIS
42 SUBSECTION MAY BE SUBJECT TO COPAYMENT, DEDUCTIBLE AND COINSURANCE
43 PROVISIONS OF A HEALTH INSURANCE POLICY TO THE EXTENT THAT OTHER MEDICAL
44 SERVICE COVERED BY THE HEALTH INSURANCE POLICY ARE SUBJECT TO SUCH
45 PROVISIONS. THIS SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING THE BENE-
46 FITS THAT ARE AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH INSURANCE POLI-
47 CY. COVERAGE SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOU-
48 SAND DOLLARS. AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND ELEVEN, THE
49 SUPERINTENDENT SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR
50 INFLATION USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPART-
51 MENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPER-
52 INTENDENT SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT FOR PUBLICATION
53 ANNUALLY NO LATER THAN APRIL FIRST OF EACH CALENDAR YEAR, AND SUCH
54 PUBLISHED ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING
55 CALENDAR YEAR TO HEALTH INSURANCE POLICIES SUBJECT TO THIS SECTION.
56 PAYMENTS MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY
A. 6001--A 4
1 CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM UNRELATED TO APPLIED
2 BEHAVIOR ANALYSIS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM BENEFIT
3 ESTABLISHED PURSUANT TO THIS PARAGRAPH. EXCEPT FOR INPATIENT SERVICES,
4 IF AN INDIVIDUAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS,
5 AN INSURER SHALL HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT
6 NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDI-
7 VIDUAL'S LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE
8 FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE
9 BORNE BY THE INSURER.
10 (A) For purposes of this section[,]:
11 (I) "autism spectrum disorder" means a neurobiological condition that
12 includes [autism, Asperger syndrome, Rett's syndrome, or] AUTISTIC
13 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
14 DISORDER, AND ANY pervasive developmental disorder NOT OTHERWISE SPECI-
15 FIED.
16 (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
17 EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
18 CONSEQUENCES, TO PRODUCE SOCIALLY SIGNIFICANT IMPROVEMENT IN HUMAN
19 BEHAVIOR, INCLUDING THE USE OF DIRECT OBSERVATION, MEASUREMENT, AND
20 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
21 IOR.
22 (III) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
23 THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
24 (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
25 SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
26 HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
27 (V) "EVIDENCE-BASED RESEARCH" MEANS RESEARCH THAT APPLIES RIGOROUS,
28 SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE RELEVANT
29 TO AUTISM SPECTRUM DISORDERS.
30 (VI) "HABILITATIVE OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
31 SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
32 BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
33 TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
34 (VII) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
35 SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A LICENSED
36 PHYSICIAN OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
37 ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY OF
38 THE FOLLOWING:
39 (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
40 (2) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL, OR DEVELOPMENTAL
41 EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
42 (3) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL CAPACITY IN
43 PERFORMING DAILY ACTIVITIES, TAKING INTO ACCOUNT BOTH THE FUNCTIONAL
44 CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
45 PRIATE FOR INDIVIDUALS OF THE SAME AGE.
46 (VIII) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED
47 PHYSICIAN AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
48 DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
49 (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
50 BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
51 TICES.
52 (X) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE SERVICES
53 PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
54 OGIST PRACTICES.
55 (XI) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
56 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
A. 6001--A 5
1 (XII) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE
2 FOLLOWING CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
3 NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSICIAN
4 OR A LICENSED PSYCHOLOGIST WHO DETERMINES THE CARE TO BE MEDICALLY
5 NECESSARY:
6 (1) HABILITATIVE OR REHABILITATIVE CARE;
7 (2) PHARMACY CARE;
8 (3) PSYCHIATRIC CARE;
9 (4) PSYCHOLOGICAL CARE;
10 (5) THERAPEUTIC CARE; AND
11 (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
12 DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
13 PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
14 IS PUBLISHED IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
15 CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
16 COVERED WILL BE INCLUDED IN ANY HEALTH INSURANCE POLICY DELIVERED,
17 EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
18 FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
19 (B) THIS PARAGRAPH SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
20 PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
21 PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED SERVICE
22 PLAN.
23 S 3. Subsection (ee) of section 4303 of the insurance law, as added by
24 chapter 557 of the laws of 2006, is amended to read as follows:
25 (ee) A medical expense indemnity corporation, a hospital service
26 corporation or a health service corporation which provides coverage for
27 hospital, surgical, or medical care coverage shall not exclude coverage
28 for diagnosis and treatment of medical conditions otherwise covered by
29 the policy solely because the treatment is provided to diagnose or treat
30 autism spectrum disorder. IN INDIVIDUALS TWENTY-ONE YEARS OF AGE OR
31 LESS, THERE SHALL BE NO LIMITS ON THE NUMBER OF VISITS AN INDIVIDUAL MAY
32 MAKE TO AN AUTISM PROVIDER. COVERAGE UNDER THIS SUBSECTION MAY BE
33 SUBJECT TO COPAYMENT, DEDUCTIBLE AND COINSURANCE PROVISIONS OF A HEALTH
34 INSURANCE POLICY TO THE EXTENT THAT OTHER MEDICAL SERVICES COVERED BY
35 THE HEALTH INSURANCE POLICY ARE SUBJECT TO SUCH PROVISIONS. THIS
36 SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING THE BENEFITS THAT ARE
37 AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH INSURANCE POLICY. COVERAGE
38 SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOUSAND DOLLARS.
39 AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND ELEVEN, THE SUPERINTENDENT
40 SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR INFLATION
41 USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPARTMENT OF
42 LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPERINTENDENT
43 SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT FOR PUBLICATION ANNUALLY NO
44 LATER THAN APRIL FIRST OF EACH CALENDAR YEAR, AND SUCH PUBLISHED
45 ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING CALENDAR
46 YEAR TO HEALTH INSURANCE POLICIES SUBJECT TO THIS SUBSECTION. PAYMENTS
47 MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY CARE,
48 TREATMENT, INTERVENTION, SERVICE OR ITEM UNRELATED TO APPLIED BEHAVIOR
49 ANALYSIS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM BENEFIT ESTABLISHED
50 PURSUANT TO THIS SECTION. EXCEPT FOR INPATIENT SERVICES, IF AN INDIVID-
51 UAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER
52 SHALL HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT NOT MORE THAN
53 ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDIVIDUAL'S
54 LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE FREQUENT
55 REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE BORNE BY
56 THE INSURER.
A. 6001--A 6
1 (A) For purposes of this section[,]:
2 (I) "autism spectrum disorder" means a neurobiological condition that
3 includes [autism, Asperger syndrome, Rett's syndrome, or] AUTISTIC
4 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
5 DISORDER, AND ANY pervasive developmental disorder.
6 (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
7 EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
8 CONSEQUENCES, TO PRODUCE SOCIALLY SIGNIFICANT IMPROVEMENT IN HUMAN
9 BEHAVIOR, INCLUDING THE USE OF DIRECT OBSERVATION, MEASUREMENT, AND
10 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
11 IOR.
12 (III) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
13 THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
14 (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
15 SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
16 HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
17 (V) "EVIDENCE-BASED RESEARCH" MEANS RESEARCH THAT APPLIES RIGOROUS,
18 SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE RELEVANT
19 TO AUTISM SPECTRUM DISORDERS.
20 (VI) "HABILITATIVE OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
21 SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
22 BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
23 TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
24 (VII) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
25 SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A LICENSED
26 PHYSICIAN OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
27 ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY OF
28 THE FOLLOWING:
29 (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
30 (2) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL, OR DEVELOPMENTAL
31 EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
32 (3) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL CAPACITY IN
33 PERFORMING DAILY ACTIVITIES, TAKING INTO ACCOUNT BOTH THE FUNCTIONAL
34 CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
35 PRIATE FOR INDIVIDUALS OF THE SAME AGE.
36 (VIII) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED
37 PHYSICIAN AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
38 DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
39 (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
40 BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
41 TICES.
42 (X) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE SERVICES
43 PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
44 OGIST PRACTICES.
45 (XI) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
46 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
47 (XII) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE
48 FOLLOWING CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
49 NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSICIAN
50 OR A LICENSED PSYCHOLOGIST WHO DETERMINES THE CARE TO BE MEDICALLY
51 NECESSARY:
52 (1) HABILITATIVE OR REHABILITATIVE CARE;
53 (2) PHARMACY CARE;
54 (3) PSYCHIATRIC CARE;
55 (4) PSYCHOLOGICAL CARE;
56 (5) THERAPEUTIC CARE; AND
A. 6001--A 7
1 (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
2 DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
3 PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
4 IS PUBLISHED IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
5 CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
6 COVERED WILL BE INCLUDED IN ANY HEALTH INSURANCE POLICY DELIVERED,
7 EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
8 FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
9 (B) THIS SUBSECTION SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
10 PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
11 PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED SERVICE
12 PLAN.
13 S 4. This act shall take effect on the first of January next succeed-
14 ing the date on which it shall have become a law and shall apply to all
15 policies and contracts issued, renewed, modified, altered or amended on
16 or after the effective date; provided, however, that any rules and regu-
17 lations necessary for the implementation of this act shall be promulgat-
18 ed on or before such effective date.
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