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See Summary
S T A T E O F N E W Y O R K
________________________________________________________________________
2366--A
2009-2010 Regular Sessions
I N S E N A T E
February 19, 2009
___________
Introduced by Sens. FUSCHILLO, C. JOHNSON, ADAMS, ADDABBO, ALESI, BONA-
CIC, DeFRANCISCO, DIAZ, DILAN, FARLEY, FLANAGAN, FOLEY, GOLDEN, GRIF-
FO, HANNON, HASSELL-THOMPSON, HUNTLEY, O. JOHNSON, KLEIN, KRUGER,
LANZA, LARKIN, LAVALLE, LIBOUS, LITTLE, MARCELLINO, MAZIARZ, McDONALD,
MONSERRATE, MONTGOMERY, MORAHAN, NOZZOLIO, ONORATO, OPPENHEIMER, PADA-
VAN, PARKER, PERKINS, RANZENHOFER, ROBACH, SALAND, SAMPSON, SCHNEIDER-
MAN, SERRANO, SKELOS, SQUADRON, STACHOWSKI, STAVISKY, STEWART-COUSINS,
VALESKY, VOLKER, WINNER, YOUNG -- read twice and ordered printed, and
when printed to be committed to the Committee on Insurance -- commit-
tee discharged, bill amended, ordered reprinted as amended and recom-
mitted 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
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD06364-14-9
S. 2366--A 2
1 DOLLARS. AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND ELEVEN, THE SUPER-
2 INTENDENT SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR
3 INFLATION USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPART-
4 MENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPER-
5 INTENDENT SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT FOR PUBLICATION
6 ANNUALLY NO LATER THAN APRIL FIRST OF EACH CALENDAR YEAR, AND SUCH
7 PUBLISHED ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING
8 CALENDAR YEAR TO HEALTH INSURANCE POLICIES SUBJECT TO THIS SECTION.
9 PAYMENTS MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY
10 CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM UNRELATED TO APPLIED
11 BEHAVIOR ANALYSIS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM BENEFIT
12 ESTABLISHED PURSUANT TO THIS PARAGRAPH. EXCEPT FOR INPATIENT SERVICES,
13 IF AN INDIVIDUAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS,
14 AN INSURER SHALL HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT
15 NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDI-
16 VIDUAL'S LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE
17 FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE
18 BORNE BY THE INSURER.
19 (A) For purposes of this section[,]:
20 (I) "autism spectrum disorder" means a neurobiological condition that
21 includes [autism, Asperger syndrome, Rett's syndrome, or] AUTISTIC
22 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, RETT'S DISORDER, CHILD-
23 HOOD DISINTEGRATIVE DISORDER, AND ANY pervasive developmental disorder
24 NOT OTHERWISE SPECIFIED.
25 (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
26 EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
27 CONSEQUENCES, TO PRODUCE SOCIALLY SIGNIFICANT IMPROVEMENT IN HUMAN
28 BEHAVIOR, INCLUDING THE USE OF DIRECT OBSERVATION, MEASUREMENT, AND
29 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
30 IOR.
31 (III) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
32 THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
33 (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
34 SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
35 HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
36 (V) "EVIDENCE-BASED RESEARCH" MEANS RESEARCH THAT APPLIES RIGOROUS,
37 SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE RELEVANT
38 TO AUTISM SPECTRUM DISORDERS.
39 (VI) "HABILITATIVE OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
40 SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
41 BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
42 TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
43 (VII) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
44 SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A LICENSED
45 PHYSICIAN OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
46 ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY OF
47 THE FOLLOWING:
48 (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
49 (2) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL, OR DEVELOPMENTAL
50 EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
51 (3) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL CAPACITY IN
52 PERFORMING DAILY ACTIVITIES, TAKING INTO ACCOUNT BOTH THE FUNCTIONAL
53 CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
54 PRIATE FOR INDIVIDUALS OF THE SAME AGE.
S. 2366--A 3
1 (VIII) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED
2 PHYSICIAN AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
3 DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
4 (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
5 BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
6 TICES.
7 (X) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE SERVICES
8 PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
9 OGIST PRACTICES.
10 (XI) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
11 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
12 (XII) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE
13 FOLLOWING CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
14 NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSICIAN
15 OR A LICENSED PSYCHOLOGIST WHO DETERMINES THE CARE TO BE MEDICALLY
16 NECESSARY:
17 (1) HABILITATIVE OR REHABILITATIVE CARE;
18 (2) PHARMACY CARE;
19 (3) PSYCHIATRIC CARE;
20 (4) PSYCHOLOGICAL CARE;
21 (5) THERAPEUTIC CARE; AND
22 (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
23 DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
24 PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
25 IS PUBLISHED IN THE REGISTER FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
26 CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
27 COVERED WILL BE INCLUDED IN ANY HEALTH INSURANCE POLICY DELIVERED,
28 EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
29 FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
30 (B) THIS PARAGRAPH SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
31 PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
32 PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED SERVICE
33 PLAN.
34 S 2. Paragraph 17 of subsection (l) of section 3221 of the insurance
35 law, as added by chapter 557 of the laws of 2006, is amended to read as
36 follows:
37 (17) A group or blanket accident or health insurance policy or issuing
38 a group or blanket policy for delivery in this state which provides
39 coverage for hospital, surgical, or medical care coverage shall not
40 exclude coverage for diagnosis and treatment of medical conditions
41 otherwise covered by the policy because the treatment is provided to
42 diagnose or treat autism spectrum disorder. IN INDIVIDUALS TWENTY-ONE
43 YEARS OF AGE OR LESS, THERE SHALL BE NO LIMITS ON THE NUMBER OF VISITS
44 AN INDIVIDUAL MAY MAKE TO AN AUTISM PROVIDER. COVERAGE UNDER THIS
45 SUBSECTION MAY BE SUBJECT TO COPAYMENT, DEDUCTIBLE AND COINSURANCE
46 PROVISIONS OF A HEALTH INSURANCE POLICY TO THE EXTENT THAT OTHER MEDICAL
47 SERVICE COVERED BY THE HEALTH INSURANCE POLICY ARE SUBJECT TO SUCH
48 PROVISIONS. THIS SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING THE BENE-
49 FITS THAT ARE AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH INSURANCE POLI-
50 CY. COVERAGE SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOU-
51 SAND DOLLARS. AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND ELEVEN, THE
52 SUPERINTENDENT SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR
53 INFLATION USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPART-
54 MENT OF LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPER-
55 INTENDENT SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT FOR PUBLICATION
56 ANNUALLY NO LATER THAN APRIL FIRST OF EACH CALENDAR YEAR, AND SUCH
S. 2366--A 4
1 PUBLISHED ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING
2 CALENDAR YEAR TO HEALTH INSURANCE POLICIES SUBJECT TO THIS SECTION.
3 PAYMENTS MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY
4 CARE, TREATMENT, INTERVENTION, SERVICE OR ITEM UNRELATED TO APPLIED
5 BEHAVIOR ANALYSIS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM BENEFIT
6 ESTABLISHED PURSUANT TO THIS PARAGRAPH. EXCEPT FOR INPATIENT SERVICES,
7 IF AN INDIVIDUAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS,
8 AN INSURER SHALL HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT
9 NOT MORE THAN ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDI-
10 VIDUAL'S LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE
11 FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE
12 BORNE BY THE INSURER.
13 (A) For purposes of this section[,]:
14 (I) "autism spectrum disorder" means a neurobiological condition that
15 includes [autism, Asperger syndrome, Rett's syndrome, or] AUTISTIC
16 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
17 DISORDER, AND ANY pervasive developmental disorder NOT OTHERWISE SPECI-
18 FIED.
19 (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
20 EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
21 CONSEQUENCES, TO PRODUCE SOCIALLY SIGNIFICANT IMPROVEMENT IN HUMAN
22 BEHAVIOR, INCLUDING THE USE OF DIRECT OBSERVATION, MEASUREMENT, AND
23 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
24 IOR.
25 (III) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
26 THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
27 (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
28 SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
29 HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
30 (V) "EVIDENCE-BASED RESEARCH" MEANS RESEARCH THAT APPLIES RIGOROUS,
31 SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE RELEVANT
32 TO AUTISM SPECTRUM DISORDERS.
33 (VI) "HABILITATIVE OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
34 SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
35 BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
36 TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
37 (VII) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
38 SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A LICENSED
39 PHYSICIAN OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
40 ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY OF
41 THE FOLLOWING:
42 (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
43 (2) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL, OR DEVELOPMENTAL
44 EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
45 (3) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL CAPACITY IN
46 PERFORMING DAILY ACTIVITIES, TAKING INTO ACCOUNT BOTH THE FUNCTIONAL
47 CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
48 PRIATE FOR INDIVIDUALS OF THE SAME AGE.
49 (VIII) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED
50 PHYSICIAN AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
51 DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
52 (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
53 BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
54 TICES.
S. 2366--A 5
1 (X) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE SERVICES
2 PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
3 OGIST PRACTICES.
4 (XI) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
5 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
6 (XII) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE
7 FOLLOWING CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
8 NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSICIAN
9 OR A LICENSED PSYCHOLOGIST WHO DETERMINES THE CARE TO BE MEDICALLY
10 NECESSARY:
11 (1) HABILITATIVE OR REHABILITATIVE CARE;
12 (2) PHARMACY CARE;
13 (3) PSYCHIATRIC CARE;
14 (4) PSYCHOLOGICAL CARE;
15 (5) THERAPEUTIC CARE; AND
16 (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
17 DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
18 PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
19 IS PUBLISHED IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
20 CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
21 COVERED WILL BE INCLUDED IN ANY HEALTH INSURANCE POLICY DELIVERED,
22 EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
23 FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
24 (B) THIS PARAGRAPH SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
25 PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
26 PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED SERVICE
27 PLAN.
28 S 3. Subsection (ee) of section 4303 of the insurance law, as added by
29 chapter 557 of the laws of 2006, is amended to read as follows:
30 (ee) A medical expense indemnity corporation, a hospital service
31 corporation or a health service corporation which provides coverage for
32 hospital, surgical, or medical care coverage shall not exclude coverage
33 for diagnosis and treatment of medical conditions otherwise covered by
34 the policy solely because the treatment is provided to diagnose or treat
35 autism spectrum disorder. IN INDIVIDUALS TWENTY-ONE YEARS OF AGE OR
36 LESS, THERE SHALL BE NO LIMITS ON THE NUMBER OF VISITS AN INDIVIDUAL MAY
37 MAKE TO AN AUTISM PROVIDER. COVERAGE UNDER THIS SUBSECTION MAY BE
38 SUBJECT TO COPAYMENT, DEDUCTIBLE AND COINSURANCE PROVISIONS OF A HEALTH
39 INSURANCE POLICY TO THE EXTENT THAT OTHER MEDICAL SERVICES COVERED BY
40 THE HEALTH INSURANCE POLICY ARE SUBJECT TO SUCH PROVISIONS. THIS
41 SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING THE BENEFITS THAT ARE
42 AVAILABLE TO AN INDIVIDUAL UNDER A HEALTH INSURANCE POLICY. COVERAGE
43 SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF THIRTY-SIX THOUSAND DOLLARS.
44 AFTER DECEMBER THIRTY-FIRST, TWO THOUSAND ELEVEN, THE SUPERINTENDENT
45 SHALL, ON AN ANNUAL BASIS, ADJUST THE MAXIMUM BENEFIT FOR INFLATION
46 USING THE MEDICAL CARE COMPONENT OF THE UNITED STATES DEPARTMENT OF
47 LABOR CONSUMER PRICE INDEX FOR ALL URBAN CONSUMERS. THE SUPERINTENDENT
48 SHALL SUBMIT THE ADJUSTED MAXIMUM BENEFIT FOR PUBLICATION ANNUALLY NO
49 LATER THAN APRIL FIRST OF EACH CALENDAR YEAR, AND SUCH PUBLISHED
50 ADJUSTED MAXIMUM BENEFIT SHALL BE APPLICABLE IN THE FOLLOWING CALENDAR
51 YEAR TO HEALTH INSURANCE POLICIES SUBJECT TO THIS SUBSECTION. PAYMENTS
52 MADE BY AN INSURER ON BEHALF OF A COVERED INDIVIDUAL FOR ANY CARE,
53 TREATMENT, INTERVENTION, SERVICE OR ITEM UNRELATED TO APPLIED BEHAVIOR
54 ANALYSIS SHALL NOT BE APPLIED TOWARDS ANY MAXIMUM BENEFIT ESTABLISHED
55 PURSUANT TO THIS SECTION. EXCEPT FOR INPATIENT SERVICES, IF AN INDIVID-
56 UAL IS RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER
S. 2366--A 6
1 SHALL HAVE THE RIGHT TO REQUEST A REVIEW OF SUCH TREATMENT NOT MORE THAN
2 ONCE EVERY TWELVE MONTHS UNLESS SUCH INSURER AND THE INDIVIDUAL'S
3 LICENSED PHYSICIAN OR LICENSED PSYCHOLOGIST AGREE THAT A MORE FREQUENT
4 REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE BORNE BY
5 THE INSURER.
6 (A) For purposes of this section[,]:
7 (I) "autism spectrum disorder" means a neurobiological condition that
8 includes [autism, Asperger syndrome, Rett's syndrome, or] AUTISTIC
9 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
10 DISORDER, AND ANY pervasive developmental disorder.
11 (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
12 EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
13 CONSEQUENCES, TO PRODUCE SOCIALLY SIGNIFICANT IMPROVEMENT IN HUMAN
14 BEHAVIOR, INCLUDING THE USE OF DIRECT OBSERVATION, MEASUREMENT, AND
15 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV-
16 IOR.
17 (III) "AUTISM SERVICES PROVIDER" MEANS ANY PERSON, ENTITY, OR GROUP
18 THAT PROVIDES TREATMENT OF AUTISM SPECTRUM DISORDERS.
19 (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS MEDICALLY NECES-
20 SARY ASSESSMENT, EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL
21 HAS ONE OF THE AUTISM SPECTRUM DISORDERS.
22 (V) "EVIDENCE-BASED RESEARCH" MEANS RESEARCH THAT APPLIES RIGOROUS,
23 SYSTEMATIC, AND OBJECTIVE PROCEDURES TO OBTAIN VALID KNOWLEDGE RELEVANT
24 TO AUTISM SPECTRUM DISORDERS.
25 (VI) "HABILITATIVE OR REHABILITATIVE CARE" MEANS PROFESSIONAL, COUN-
26 SELING, AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED
27 BEHAVIOR ANALYSIS, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE,
28 TO THE MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
29 (VII) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
30 SERVICE, OR ITEM THAT IS PRESCRIBED, PROVIDED, OR ORDERED BY A LICENSED
31 PHYSICIAN OR A LICENSED PSYCHOLOGIST IN ACCORDANCE WITH ACCEPTED STAND-
32 ARDS OF PRACTICE AND THAT WILL, OR IS REASONABLY EXPECTED TO, DO ANY OF
33 THE FOLLOWING:
34 (1) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY;
35 (2) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL, OR DEVELOPMENTAL
36 EFFECTS OF AN ILLNESS, CONDITION, INJURY, OR DISABILITY; OR
37 (3) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL CAPACITY IN
38 PERFORMING DAILY ACTIVITIES, TAKING INTO ACCOUNT BOTH THE FUNCTIONAL
39 CAPACITY OF THE INDIVIDUAL AND THE FUNCTIONAL CAPACITIES THAT ARE APPRO-
40 PRIATE FOR INDIVIDUALS OF THE SAME AGE.
41 (VIII) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED
42 PHYSICIAN AND ANY HEALTH-RELATED SERVICES DEEMED MEDICALLY NECESSARY TO
43 DETERMINE THE NEED OR EFFECTIVENESS OF THE MEDICATIONS.
44 (IX) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
45 BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC-
46 TICES.
47 (X) "PSYCHOLOGICAL CARE" MEANS DIRECT OR CONSULTATIVE SERVICES
48 PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL-
49 OGIST PRACTICES.
50 (XI) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI-
51 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, OR PHYSICAL THERAPISTS.
52 (XII) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE
53 FOLLOWING CARE PRESCRIBED, PROVIDED, OR ORDERED FOR AN INDIVIDUAL DIAG-
54 NOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSICIAN
55 OR A LICENSED PSYCHOLOGIST WHO DETERMINES THE CARE TO BE MEDICALLY
56 NECESSARY:
S. 2366--A 7
1 (1) HABILITATIVE OR REHABILITATIVE CARE;
2 (2) PHARMACY CARE;
3 (3) PSYCHIATRIC CARE;
4 (4) PSYCHOLOGICAL CARE;
5 (5) THERAPEUTIC CARE; AND
6 (6) ANY CARE FOR INDIVIDUALS WITH AUTISM SPECTRUM DISORDERS THAT IS
7 DETERMINED BY THE STATE HEALTH DEPARTMENT, BASED UPON ITS REVIEW OF BEST
8 PRACTICES OR EVIDENCE-BASED RESEARCH, TO BE MEDICALLY NECESSARY AND THAT
9 IS PUBLISHED IN THE GAZETTE FOR RULEMAKING BY STATE AGENCIES. ANY SUCH
10 CARE, TREATMENT, INTERVENTION, SERVICE, OR ITEM THAT WAS NOT PREVIOUSLY
11 COVERED WILL BE INCLUDED IN ANY HEALTH INSURANCE POLICY DELIVERED,
12 EXECUTED, ISSUED, AMENDED, ADJUSTED, OR RENEWED ON OR AFTER SIXTY DAYS
13 FOLLOWING THE DATE OF ITS PUBLICATION IN THE STATE REGISTER.
14 (B) THIS SUBSECTION SHALL NOT BE CONSTRUED TO AFFECT ANY OBLIGATION TO
15 PROVIDE SERVICES TO AN INDIVIDUAL UNDER AN INDIVIDUALIZED FAMILY SERVICE
16 PLAN, AN INDIVIDUALIZED EDUCATION PROGRAM OR AN INDIVIDUALIZED SERVICE
17 PLAN.
18 S 4. This act shall take effect on the first of January next succeed-
19 ing the date on which it shall have become a law and shall apply to all
20 policies and contracts issued, renewed, modified, altered or amended on
21 or after the effective date; provided, however, that any rules and regu-
22 lations necessary for the implementation of this act shall be promulgat-
23 ed on or before such effective date.
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