Amd SS3216, 3221 & 4303, Ins L; amd S2500-j, Pub Health L
Requires that individual accident and health insurance policies shall provide coverage for screening, diagnosis and treatment of autism spectrum disorder.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A5365
SPONSOR: Morelle (MS) TITLE OF BILL: An act to amend the insurance law and the public
health law, in relation to coverage for the screening, diagnosis and
treatment of autism spectrum disorder
PURPOSE OR GENERAL IDEA OF BILL: To expand health insurance coverage
for the screening, diagnosis and treatment of autism spectrum disorders.
SUMMARY OF SPECIFIC 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 review of health-
care services, including the review of medical necessity, case manage-
ment, and other managed care provisions.
Defines "autism spectrum disorder" as a group of neurobiological condi-
tions defined in the Diagnostic and Statistical Manual of Mental Disor-
ders IV Revised, or its successor, as pervasive developmental disorders,
or a group possessing substantially the same characteristics as perva-
sive developmental disorders.
Provides that the commissioner of health, in consultation with the
superintendent of insurance, commissioner of the office of mental retar-
dation and developmental disabilities and commissioner of the office of
mental health shall promulgate regulations which establish which treat-
ment and therapy options insurers shall cover for the diagnosis and
treatment of autism spectrum disorders no later than twelve months after
the effective date of the legislation.
Provides that coverage for behavioral therapies required pursuant to the
legislation shall not be denied on the basis that such therapies are
educational or habilitative 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 individ-
ualized 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 deemed medically necessary.
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, includ-
ing provider credentialing.
JUSTIFICATION:
This legislation will close a significant gap in insurance coverage for
individuals with autism. The Centers for Disease Control (CDC) have now
estimated that the number of children with autism is 1 in 110 nation-
wide. (Prior CDC estimates had been 1 in 1.50). Existing state law
requires that insurance coverage for autism "not exclude' the diagnosis
and treatment of autism spectrum disorder. Current law does not provide
clarity to consumers or insurers as to the scope of required coverage
and does not establish a regulatory process whereby the Commissioner of
Health is authorized to promulgate rules which identify treatment and
therapy options.
This bill affirmatively requires policies to provide such coverage for
individuals with autism spectrum disorder throughout their entire life
span. The bill also provides for an updated definition of the term
"autism spectrum disorder". The bill amends existing provisions of the
insurance law to require coverage under health insurance policies issued
by indemnity and nonprofit insurers, as well as health maintenance
organizations. Coverage would specifically be required for the group of
neurological conditions know as "autism spectrum disorder", limited only
by whatever restrictions are otherwise contained in the policy. Coverage
would also be subject to utilization review, medical necessity determi-
nations and appropriate case management.
The Commissioner of Health, in consultation with the Insurance Super-
intendent and the Commissioners of Mental Health and Mental Retardation
and Developmental Disabilities, is charged with responsibility for
promulgating regulations identifying treatment and therapy options.
Until such time as such regulations are issued, coverage will be accord-
ing to treatment guidelines issued by the American Academy of Pedia-
trics. The legislation insures that only those treatments and therapies
which have been determined by recognized medical authority as evidence
based and clinically proven will be covered.
PRIOR LEGISLATIVE HISTORY: A10372A of 2009-2010 - DELIVERED TO GOVER-
NOR; VETOED MEMO. 6832
FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS: Anticipated to
result in savings to the state.
EFFECTIVE DATE: This act shall take effect immediately, provided that
sections one, two and three of this act shall take effect upon the
promulgation of either emergency or permanent rules and regulations by
the commissioner of health outlining the treatment insurers are required
to provide to cover autism spectrum disorder as provided for in this act
and shall apply to all policies or contracts issued, renewed, modified,
altered or amended on and after such effective date; provided that the
commissioner of health shall notify the legislative bill drafting
commission upon the promulgation of such emergency or permanent rules
and regulations in order that the commission may maintain an accurate
and timely effective data base of the official text of the laws of the
state of New York in furtherance of effectuating the provisions of
section 44 of the legislative law and section 70-b of the public offi-
cers law.
STATE OF NEW YORK
________________________________________________________________________
5365
2011-2012 Regular Sessions
IN ASSEMBLY
February 16, 2011
___________
Introduced by M. of A. MORELLE, SILVER, NOLAN, SCHROEDER, LAVINE, LUPAR-
DO, GOTTFRIED, PERRY, HEVESI, CUSICK, J. RIVERA, SWEENEY, JAFFEE,
ZEBROWSKI, GALEF, MAISEL, SPANO, ROSENTHAL, ARROYO, TITONE, WEPRIN --
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 and the public health law, in relation
to coverage for the screening, diagnosis and treatment of autism spec-
trum disorder
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] provide coverage for the
6 screening, diagnosis and treatment of [medical conditions otherwise
7 covered by the policy solely because the treatment is provided to diag-
8 nose or treat] autism spectrum disorder in accordance with this para-
9 graph and shall not exclude coverage for the treatment of medical condi-
10 tions otherwise covered by the policy because the individual is
11 diagnosed with an autism spectrum disorder. Such coverage may be
12 subject to annual deductibles, copayments and coinsurance as may be
13 deemed appropriate by the superintendent and shall be consistent with
14 those imposed on other benefits under the policy. This paragraph shall
15 not be construed as limiting the benefits that are otherwise available
16 to an individual under the policy. Coverage may be subject to utiliza-
17 tion review of health care services, including the review of medical
18 necessity, case management, and other managed care provisions.
19 (A) For purposes of this [section] paragraph, "autism spectrum disor-
20 der" means a group of neurobiological [condition that includes autism,
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD05243-01-1
A. 5365 2
1 Asperger syndrome, Rett's syndrome, or pervasive developmental disorder]
2 conditions defined in the Diagnostic and Statistical Manual of Mental
3 Disorders IV Revised, or its successor, as pervasive developmental
4 disorders.
5 (B) The commissioner of health, in consultation with the superinten-
6 dent, the commissioner of the office of mental health and the commis-
7 sioner of the office for people with developmental disabilities shall,
8 no later than twelve months after the effective date of this subpara-
9 graph, promulgate and thereafter regularly update, regulations which
10 shall identify treatment and therapy options for which coverage shall be
11 required for the screening, diagnosis and treatment of autism spectrum
12 disorder pursuant to this paragraph. Such treatment and therapy options
13 shall be evidence-based, peer-reviewed and clinically proven. Coverage
14 for behavioral therapies required pursuant to this subparagraph shall
15 not be denied on the basis that such therapies are educational or habi-
16 litative in nature, unless such treatments are being provided to the
17 covered person pursuant to an individualized education plan under arti-
18 cle eighty-nine of the education law. The provision of services pursu-
19 ant to an individualized family service plan under section two thousand
20 five hundred forty-five of the public health law, an individualized
21 education plan under article eighty-nine of the education law or an
22 individualized service plan pursuant to regulations of the office for
23 people with developmental disabilities shall not affect coverage under
24 the policy for services provided on a supplemental basis outside of an
25 educational setting if such services are deemed medically necessary.
26 (C) Nothing in this paragraph shall be construed to affect any obli-
27 gation to provide services to an individual under an individualized
28 family service plan under section two thousand five hundred forty-five
29 of the public health law, an individualized education plan under article
30 eighty-nine of the education law or an individualized service plan
31 pursuant to regulations of the office for people with developmental
32 disabilities.
33 (D) Nothing in this paragraph shall be construed to affect any obli-
34 gation to provide coverage for otherwise covered services solely on the
35 basis that the services constitute early intervention program services
36 pursuant to section three thousand two hundred thirty-five-a of this
37 article or an individualized service plan pursuant to regulations of the
38 office for people with developmental disabilities.
39 (E) Nothing in this paragraph shall be construed to prevent a policy
40 from providing services through a network of participating providers who
41 shall meet certain requirements for participation, including provider
42 credentialing.
43 § 2. Paragraph 17 of subsection (l) of section 3221 of the insurance
44 law, as added by chapter 557 of the laws of 2006, is amended to read as
45 follows:
46 (17) [A] Every group or blanket accident [or] and health insurance
47 policy [or issuing a group or blanket policy for delivery in this state]
48 delivered or issued for delivery in this state which provides coverage
49 for hospital, surgical, or medical care coverage shall [not exclude]
50 provide coverage for the screening, diagnosis and treatment of [medical
51 conditions otherwise covered by the policy because the treatment is
52 provided to diagnose or treat] autism spectrum disorder in accordance
53 with this paragraph and shall not exclude coverage for the treatment of
54 medical conditions otherwise covered by the policy because the individ-
55 ual is diagnosed with an autism spectrum disorder. Such coverage may be
56 subject to annual deductibles, copayments and coinsurance as may be
A. 5365 3
1 deemed appropriate by the superintendent and shall be consistent with
2 those imposed on other benefits under the policy. This paragraph shall
3 not be construed as limiting the benefits that are otherwise available
4 to an individual under the policy. Coverage may be subject to utiliza-
5 tion review of health care services, including the review of medical
6 necessity, case management, and other managed care provisions.
7 (A) For purposes of this [section] paragraph, "autism spectrum disor-
8 der" means a group of neurobiological [condition that includes autism,
9 Asperger syndrome, Rett's syndrome, or pervasive developmental disorder]
10 conditions defined in the Diagnostic and Statistical Manual of Mental
11 Disorders IV Revised, or its successor, as pervasive developmental
12 disorders.
13 (B) The commissioner of health, in consultation with the superinten-
14 dent, the commissioner of the office of mental health and the commis-
15 sioner of the office for people with developmental disabilities shall,
16 no later than twelve months after the effective date of this subpara-
17 graph, promulgate and thereafter regularly update, regulations which
18 shall identify treatment and therapy options for which coverage shall be
19 required for the screening, diagnosis and treatment of autism spectrum
20 disorder pursuant to this paragraph. Such treatment and therapy options
21 shall be evidence-based, peer-reviewed and clinically proven. Coverage
22 for behavioral therapies required pursuant to this subparagraph shall
23 not be denied on the basis that such therapies are educational or habi-
24 litative in nature, unless such treatments are being provided to the
25 covered person pursuant to an individualized education plan under arti-
26 cle eighty-nine of the education law. The provision of services pursu-
27 ant to an individualized family service plan under section two thousand
28 five hundred forty-five of the public health law, an individualized
29 education plan under article eighty-nine of the education law or an
30 individualized service plan pursuant to regulations of the office for
31 people with developmental disabilities shall not affect coverage under
32 the policy for services provided on a supplemental basis outside of an
33 educational setting if such services are deemed medically necessary.
34 (C) Nothing in this paragraph shall be construed to affect any obli-
35 gation to provide services to an individual under an individualized
36 family service plan under section two thousand five hundred forty-five
37 of the public health law, an individualized education plan under article
38 eighty-nine of the education law or an individualized service plan
39 pursuant to regulations of the office for people with developmental
40 disabilities.
41 (D) Nothing in this paragraph shall be construed to affect any obli-
42 gation to provide coverage for otherwise covered services solely on the
43 basis that the services constitute early intervention program services
44 pursuant to section three thousand two hundred thirty-five-a of this
45 article or an individualized service plan pursuant to regulations of the
46 office for people with developmental disabilities.
47 (E) Nothing in this paragraph shall be construed to prevent a policy
48 from providing services through a network of participating providers who
49 shall meet certain requirements for participation, including provider
50 credentialing.
51 § 3. Subsection (ee) of section 4303 of the insurance law, as added by
52 chapter 557 of the laws of 2006, is amended to read as follows:
53 (ee) A medical expense indemnity corporation, a hospital service
54 corporation or a health service corporation which provides coverage for
55 hospital, surgical, or medical care coverage shall [not exclude] provide
56 coverage for the screening, diagnosis and treatment of [medical condi-
A. 5365 4
1 tions otherwise covered by the policy solely because the treatment is
2 provided to diagnose or treat] autism spectrum disorder in accordance
3 with this subsection and shall not exclude coverage for the treatment of
4 medical conditions otherwise covered by the policy because the individ-
5 ual is diagnosed with an autism spectrum disorder. Such coverage may be
6 subject to annual deductibles, copayments and coinsurance as may be
7 deemed appropriate by the superintendent and shall be consistent with
8 those imposed on other benefits under the contract. This subsection
9 shall not be construed as limiting the benefits that are otherwise
10 available to an individual under the contract. Coverage may be subject
11 to utilization review of health care services, including the review of
12 medical necessity, case management, and other managed care provisions.
13 (1) For purposes of this [section] subsection, "autism spectrum disor-
14 der" means a group of neurobiological [condition that includes autism,
15 Asperger syndrome, Rett's syndrome, or pervasive developmental disorder]
16 conditions defined in the Diagnostic and Statistical Manual of Mental
17 Disorders IV Revised, or its successor, as pervasive developmental
18 disorders.
19 (2) The commissioner of health, in consultation with the superinten-
20 dent, the commissioner of the office of mental health and the commis-
21 sioner of the office for people with developmental disabilities shall,
22 no later than twelve months after the effective date of this subpara-
23 graph, promulgate and thereafter regularly update, regulations which
24 shall identify treatment and therapy options for which coverage shall be
25 required for the screening, diagnosis and treatment of autism spectrum
26 disorder pursuant to this subsection. Such treatment and therapy options
27 shall be evidence-based, peer-reviewed and clinically proven. Coverage
28 for behavioral therapies required pursuant to this paragraph shall not
29 be denied on the basis that such therapies are educational or habilita-
30 tive in nature, unless such treatments are being provided to the covered
31 person pursuant to an individualized education plan under article eight-
32 y-nine of the education law. The provision of services pursuant to an
33 individualized family service plan under section two thousand five
34 hundred forty-five of the public health law, an individualized education
35 plan under article eighty-nine of the education law or an individualized
36 service plan pursuant to regulations of the office for people with
37 developmental disabilities shall not affect coverage under the contract
38 for services provided on a supplemental basis outside of an educational
39 setting if such services are deemed medically necessary.
40 (3) Nothing in this subsection shall be construed to affect any obli-
41 gation to provide services to an individual under an individualized
42 family service plan under section two thousand five hundred forty-five
43 of the public health law, an individualized education plan under article
44 eighty-nine of the education law or an individualized service plan
45 pursuant to regulations of the office for people with developmental
46 disabilities.
47 (4) Nothing in this subsection shall be construed to affect any obli-
48 gation to provide coverage for otherwise covered services solely on the
49 basis that the services constitute early intervention program services
50 pursuant to section three thousand two hundred thirty-five-a of this
51 chapter or an individualized service plan pursuant to regulations of the
52 office for people with developmental disabilities.
53 (5) Nothing in this subsection shall be construed to prevent a
54 contract from providing services through a network of participating
55 providers who shall meet certain requirements for participation, includ-
56 ing provider credentialing.
A. 5365 5
1 § 4. Section 2500-j of the public health law is amended by adding a
2 new subdivision 4 to read as follows:
3 4. The commissioner, in consultation with the superintendent of insur-
4 ance, the commissioner of the office of mental health and the commis-
5 sioner of the office for people with developmental disabilities, shall
6 promulgate no later than twelve months after the effective date of this
7 subdivision, and regularly update, regulations which shall identify
8 treatment and therapy options for which coverage shall be required for
9 the screening, diagnosis and treatment of autism spectrum disorder
10 pursuant to sections three thousand two hundred sixteen, three thousand
11 two hundred twenty-one and four thousand three hundred three of the
12 insurance law.
13 § 5. Severability clause. If any clause, sentence, paragraph, subdivi-
14 sion, section or part of this act shall be adjudged by any court of
15 competent jurisdiction to be invalid, such judgment shall not affect,
16 impair, or invalidate the remainder thereof, but shall be confined in
17 its operation to the clause, sentence, paragraph, subdivision, section
18 or part thereof directly involved in the controversy in which such judg-
19 ment shall have been rendered. It is hereby declared to be the intent of
20 the legislature that this act would have been enacted even if such
21 invalid provisions had not been included herein.
22 § 6. This act shall take effect immediately, provided that sections
23 one, two and three of this act shall take effect upon the promulgation
24 of either emergency or permanent rules and regulations by the commis-
25 sioner of health outlining the treatment insurers are required to
26 provide to cover autism spectrum disorder as provided for in this act
27 and shall apply to all policies or contracts issued, renewed, modified,
28 altered or amended on and after such effective date; provided that the
29 commissioner of health shall notify the legislative bill drafting
30 commission upon the promulgation of such emergency or permanent rules
31 and regulations in order that the commission may maintain an accurate
32 and timely effective data base of the official text of the laws of the
33 state of New York in furtherance of effectuating the provisions of
34 section 44 of the legislative law and section 70-b of the public offi-
35 cers law.
