NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A6888B
SPONSOR: Koon (MS) TITLE OF BILL: An act to amend the insurance law, in relation to
requiring health insurance coverage of the diagnosis and treatment of
autism spectrum disorders
PURPOSE OR GENERAL IDEA OF BILL: To expand required health insurance
coverage for the treatment and diagnosis of autism spectrum disorders.
SUMMARY OF SPECIFIC PROVISIONS: Amends §3216-i(25), §3221-i(17) and
§4303(ee) of the Insurance Law to provide coverage in every policy,
group policy, and/or medical indemnity, hospital service or health
service corporation, for the diagnosis and treatment of autism spectrum
disorders.
Defines "autism spectrum disorders" as pervasive developmental disorders
as defined in the Diagnostic and Statistical Manual of Mental Disorders
IV Revised, including autism, Asperger's disorder and pervasive develop-
mental disorders not otherwise specified.
Defines "diagnosis of autism spectrum disorders" as one or more tests,
evaluations or assessments to diagnose whether an individual has autism
spectrum disorders; which are performed or ordered by a physician or
psychologist licensed to practice medicine in the state and having
expertise in the diagnosis of autism spectrum disorders.
Defines medically necessary as any care, treatment, intervention,
service or item which will or is reasonably expected to prevent the
onset of an illness, condition, injury, disease, or disability; reduce
or ameliorate the physical, mental or development effects of said
illness; assist to achieve or maintain maximum functional activity in
performing daily activities.
Provides that treatment for autism spectrum disorders shall include
psychiatric care, including direct, consultative, and diagnostic
services; psychological care; habilitative or rehabilitative care;
pediatric and developmental pediatric care; anesthesiological care and
anesthetic services; neurological care; gastroenterologic care; endocri-
nological care; therapeutic care, including behavioral, speech, occupa-
tional and physical therapies as well as social skills education train-
ing; and social skills education training.
Provides that upon request of the coverage provider, a treatment provid-
er shall furnish medical records, clinical notes or other necessary data
that substantiate that the initial and continued medical treatment is
medically necessary and resulting in improved clinical status or the
prevention of regression or loss of skills and functioning. When treat-
ment is anticipated to require continued services to achieve demonstra-
ble progress, the coverage provider may request a treatment plan
consisting of diagnosis, proposed treatment by type, frequency, antic-
ipated duration of treatment, the anticipated outcomes stated as goals,
and the frequency by which the treatment plan will be updated.
Provides that a coverage provider shall have in place a procedure under
which a covered person with autism spectrum disorder whose condition or
disease requires specialized medical care over a prolonged period of
time shall receive a referral to a specialist; or to a nonparticipating
provider with appropriate training and experience, if an appropriate
specialist is not available within the plan, at no additional cost to
the enrollee beyond what the enrollee would otherwise pay for services
received within the network.
Provides that a coverage provider shall have in place a procedure under
which a covered person with autism spectrum disorder whose condition or
disease requires ongoing care from a specialist may request and obtain a
standing referral to such specialist for treatment of such condition,
upon the determination by the primary care provider and the specialist
(if any).
JUSTIFICATION: This legislation calls for health insurers regulated
by the State of New York to treat people with autism no differently than
people with any other health disorder. It calls for the provision of
medically necessary health interventions to treat sick people, primarily
children. No other health disorder treatment is limited by an annual
spending cap under New York State law, nor does New York State law
implement an age limit for the treatment of any other disorder.
Autism is the fastest growing disabling disorder affecting American
children, with diagnoses increasing by 500 percent over the past ten
years. In New York State, the autism rate for children has been increas-
ing by approximately 15% per year in that time span. Studies from the
year 2000 showed that 1 in 150 children are affected, but more recent
studies place the number closer to 1 in 90 children. Currently, there
are 17,000 students age 4 to 21 classified by New York schools as having
autism. The number of adults with autism has not been well studied.
Historically, autism had been misidentified as a psychiatric disorder
and has been excluded from coverage by health insurance carriers.
Recent discoveries made possible by significantly increased public
investment in autism research has shown that there is a wide range of
serious physical health problems associated with autism, including
gastro-intestinal issues, seizures, immune disorders, allergies, asthma,
chronic inflammation and metabolic issues. Hundreds of studies have
shown that intensive behavioral therapies can result in significant
improvement in the cognition, communication and functionality of people
with autism.
There are substantial financial costs for failing to provide medically
necessary treatment for people with autism. Children denied intensive
early treatment will have a lower level of functionality and are much
more likely to need life-long support services. The lifetime costs of
placing an individual with autism in a group-home setting in the New
York City/Long Island area is estimated to be approximately $14 million.
Conversely, cost analyses show that every dollar spent on early treat-
ment will save $5 to $7 in long-term costs.
In the absence of adequate health insurance coverage, a disproportionate
cost of autism is borne directly by the families of those affected, many
of whom do not have the resources to provide adequate treatment (out-of
pocket costs often run as high as $2,000 to $4,000 per month, and the
Autism Society of America estimates that the lifetime cost of caring for
a child with autism ranges from $3.5 to $5 million); or by the taxpay-
ers, through Medicaid and increased demand for services through the
schools.
There have been a large number of actuarial studies performed to assess
the costs of state-level legislation that compels the inclusion of
autism within the range of required coverage. All of these studies have
indicated a worst-case scenario cost increase to policy holders of 1% or
less. Information on the real costs for mandatory autism coverage from
Aetna in Texas shows an increase of less than .1%, while an actuarial
analysis of legislation introduced in showed an estimated worse case
scenario cost increase of .8% per policy holder. None of the cost
analyses done include a quantification of the potential long-term
savings from providing appropriate treatment of autism, which as indi-
cated above, are significant.
New York State Insurance law regarding autism was significantly changed
in 2006 with the passage of Chapter 557 of the laws of 2006, which
requires insurers to provide all medical services to people with autism
that would be provided to people without autism. This law has helped
ameliorate the inequitable coverage provided to people with autism by
health insurers, but it does not specify health care services specific
to the treatment of autism. Nor does Timothy's Law provide adequate
provisions, pertaining only to specified psychiatric disorders co-morbid
with autism.
California, Texas, Pennsylvania, Florida, Illinois, Montana, Indiana,
Louisiana, Oregon, South Carolina and Arizona, all have laws requiring
health insurers to cover autism. And similar legislation is under
consideration in several dozen more states. Earlier this year, legis-
lation was introduced in the United States Senate (S.B. 819, the Accel-
erating the Treatment of Autism Act) calling for modifications to feder-
al insurance law that would require autism coverage with no annual
spending caps or age limits.
PRIOR LEGISLATIVE HISTORY: New bill.
FISCAL IMPLICATIONS: While the cost implications of this program have
yet to be fully determined, this legislation would provide relief to an
already overburdened Medicaid system by requiring more insurance cover-
age for treatments associated with ASD. In addition, if we calculate
that an estimated one in ninety children in New York State is diagnosed
with some form of ASD, and we calculate that for every $1 we spend
before the age of 5 we save $7 on lifelong care, we will ultimately save
the state, insurance providers, victims and their families untold
millions of dollars over the long-term.
(Additionally, information on the real costs for mandatory autism cover-
age from Aetna in Texas shows an increase of less than .1%, while an
actuarial analysis of legislation introduced in Massachusetts showed an
estimated worse case scenario cost increase of .8% per policy holder)
EFFECTIVE DATE: This act shall take effect on the first day of Janu-
ary next succeeding the date on which it shall have become law and shall
apply to all policies or contracts issued, renewed, modified, altered or
amended on and after such effective date.
STATE OF NEW YORK
________________________________________________________________________
6888--B
2009-2010 Regular Sessions
IN ASSEMBLY
March 13, 2009
___________
Introduced by M. of A. KOON, REILLY, CAHILL, BING, SCHROEDER, MENG,
SPANO, GUNTHER, BENEDETTO, ESPAILLAT, JAFFEE, COOK, EDDINGTON, COLTON,
MAYERSOHN, DenDEKKER, TITONE, KELLNER, HYER-SPENCER, FIELDS, WEISEN-
BERG -- Multi-Sponsored by -- M. of A. BARRON, BOYLAND, CONTE, GALEF,
HOOPER, LUPARDO, McENENY, SWEENEY -- read once and referred to the
Committee on Insurance -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee -- again
reported from said committee with amendments, ordered reprinted as
amended and recommitted to said committee
AN ACT to amend the insurance law, in relation to requiring health
insurance coverage of the diagnosis and treatment of autism spectrum
disorders
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
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) (A) Every policy which provides coverage for hospital, surgical,
5 or medical care coverage shall [not exclude] provide coverage for the
6 diagnosis and treatment of [medical conditions otherwise covered by the
7 policy solely because the treatment is provided to diagnose or treat]
8 autism spectrum [disorder] disorders.
9 (B) For purposes of this [section, "autism] paragraph:
10 (i) "Autism spectrum [disorder" means a neurobiological condition that
11 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
12 opmental disorder] disorders" means pervasive developmental disorders as
13 defined in the Diagnostic and Statistical Manual of Mental Disorders IV
14 Revised, including autism, Asperger's disorder and pervasive develop-
15 mental disorders not otherwise specified.
16 (ii) "Diagnosis of autism spectrum disorders" means one or more tests,
17 evaluations or assessments to diagnose, whether an individual has autism
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD10358-04-9
A. 6888--B 2
1 spectrum disorders or early indications in children younger than three
2 years of age that are prescribed, performed or ordered by (I) a physi-
3 cian licensed to practice medicine in this state or (II) a psychologist
4 licensed to practice in this state and having expertise in diagnosing
5 autism spectrum disorders.
6 (iii) "Medically necessary" means any care, treatment, intervention,
7 service or item which will or is reasonably expected to do any of the
8 following:
9 (I) prevent the onset of an illness, condition, injury, disease or
10 disability;
11 (II) reduce or ameliorate the physical, mental or developmental
12 effects of an illness, condition, injury, disease or disability; or
13 (III) assist to achieve or maintain maximum functional activity in
14 performing daily activities.
15 (iv) "Treatment for autism spectrum disorders" shall include but not
16 be limited to the following care prescribed, provided or ordered for an
17 individual diagnosed with autism spectrum disorders:
18 (I) psychiatric care, including direct, consultative or diagnostic
19 services provided by a licensed physician specializing in psychiatry;
20 (II) psychological care, including direct or consultative services
21 provided by a licensed psychologist;
22 (III) habilitative or rehabilitative care, including professional,
23 counseling and guidance services and treatment programs that are
24 intended to develop, maintain and restore the functioning of an individ-
25 ual;
26 (IV) pediatric and developmental pediatric care, including direct,
27 consultative or diagnostic services provided by a licensed physician
28 specializing in pediatrics and developmental pediatrics;
29 (V) anesthesiological care and anesthetic services, including direct,
30 consultative or diagnostic services provided by a licensed physician
31 specializing in anesthesiology;
32 (VI) neurological care including direct, consultative or diagnostic
33 services provided by a licensed physician specializing in neurology;
34 (VII) gastro-enterologic care including direct, consultative or diag-
35 nostic services provided by a licensed physician specializing in
36 gastroenterology;
37 (VIII) endocrinological care including direct, consultative or diag-
38 nostic services provided by a licensed physician specializing in endo-
39 crinology;
40 (IX) therapeutic care, including behavioral, speech, occupational and
41 physical therapies that provide treatment in the following areas:
42 1. self care and feeding,
43 2. pragmatic, receptive and expressive language,
44 3. cognitive functioning,
45 4. applied behavior analysis, intervention and modification,
46 5. motor planning,
47 6. sensory processing and integration, and
48 7. assistive technology;
49 (X) social skills education training.
50 (C) Upon request of the coverage provider, a provider of treatment for
51 autism spectrum disorders shall furnish medical records, clinical notes
52 or other necessary data that substantiate that the initial and continued
53 medical treatment is medically necessary and resulting in improved clin-
54 ical status or the prevention of regression or loss of skills and func-
55 tioning. When treatment is anticipated to require continued services to
56 achieve demonstrable progress, the coverage provider may request a
A. 6888--B 3
1 treatment plan consisting of diagnosis, proposed treatment by type,
2 frequency, anticipated duration of treatment, the anticipated outcomes
3 stated as goals, and the frequency by which the treatment plan will be
4 updated.
5 (D) An insurer providing coverage under this paragraph shall have in
6 place a procedure under which a person with autism spectrum disorder who
7 is covered under such policy and whose condition or disease requires
8 specialized medical care over a prolonged period of time shall receive a
9 referral to a specialist with appropriate training and experience in its
10 panel or network to meet the particular health care needs of an enrol-
11 lee, or if not available with the plan, to a nonparticipating provider
12 with appropriate training and experience to meet the particular health
13 care needs of an enrollee, at no additional cost to the enrollee beyond
14 what the enrollee would otherwise pay for services received within the
15 network. Such specialist may be responsible for and shall be deemed
16 capable of providing and coordinating the enrollee's primary and
17 specialty care.
18 (E) Such insurer shall have a procedure by which a person with autism
19 spectrum disorder whose condition, disability, or disease requires ongo-
20 ing care from a specialist may request and obtain a standing referral to
21 such specialist for treatment of such condition. If the primary care
22 provider and the specialist (if any), determines that such a standing
23 referral is appropriate, the plan or issuer shall authorize such a
24 referral to such a specialist. Such standing referral shall be consist-
25 ent with a treatment plan.
26 § 2. Paragraph 17 of subsection (l) of section 3221 of the insurance
27 law, as added by chapter 557 of the laws of 2006, is amended to read as
28 follows:
29 (17) (A) A group or blanket accident or health insurance policy or
30 issuing a group or blanket policy for delivery in this state which
31 provides coverage for hospital, surgical, or medical care coverage shall
32 [not exclude] provide coverage for the diagnosis and treatment of
33 [medical conditions otherwise covered by the policy because the treat-
34 ment is provided to diagnose or treat] autism spectrum [disorder] disor-
35 ders.
36 (B) For purposes of this [section, "autism] paragraph:
37 (i) "Autism spectrum [disorder" means a neurobiological condition that
38 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
39 opmental disorder] disorders" means pervasive developmental disorders as
40 defined in the Diagnostic and Statistical Manual of Mental Disorders IV
41 Revised, including autism, Asperger's disorder and pervasive develop-
42 mental disorders not otherwise specified.
43 (ii) "Diagnosis of autism spectrum disorders" means one or more tests,
44 evaluations or assessments to diagnose, whether an individual has autism
45 spectrum disorders or early indications in children younger than three
46 years of age that are prescribed, performed or ordered by (I) a physi-
47 cian licensed to practice medicine in this state or (II) a psychologist
48 licensed to practice in this state and having expertise in diagnosing
49 autism spectrum disorders.
50 (iii) "Medically necessary" means any care, treatment, intervention,
51 service or item which will or is reasonably expected to do any of the
52 following:
53 (I) prevent the onset of an illness, condition, injury, disease or
54 disability;
55 (II) reduce or ameliorate the physical, mental or developmental
56 effects of an illness, condition, injury, disease or disability; or
A. 6888--B 4
1 (III) assist to achieve or maintain maximum functional activity in
2 performing daily activities.
3 (iv) "Treatment for autism spectrum disorders" shall include but not
4 be limited to the following care prescribed, provided or ordered for an
5 individual diagnosed with autism spectrum disorders:
6 (I) psychiatric care, including direct, consultative or diagnostic
7 services provided by a licensed physician specializing in psychiatry;
8 (II) psychological care, including direct or consultative services
9 provided by a licensed psychologist;
10 (III) habilitative or rehabilitative care, including professional,
11 counseling and guidance services and treatment programs that are
12 intended to develop, maintain and restore the functioning of an individ-
13 ual;
14 (IV) pediatric and developmental pediatric care, including direct,
15 consultative or diagnostic services provided by a licensed physician
16 specializing in pediatrics and developmental pediatrics;
17 (V) anesthesiological care and anesthetic services, including direct,
18 consultative or diagnostic services provided by a licensed physician
19 specializing in anesthesiology;
20 (VI) neurological care including direct, consultative or diagnostic
21 services provided by a licensed physician specializing in neurology;
22 (VII) gastro-enterologic care including direct, consultative or diag-
23 nostic services provided by a licensed physician specializing in
24 gastroenterology;
25 (VIII) endocrinological care including direct, consultative or diag-
26 nostic services provided by a licensed physician specializing in endo-
27 crinology;
28 (IX) therapeutic care, including behavioral, speech, occupational and
29 physical therapies that provide treatment in the following areas:
30 1. self care and feeding,
31 2. pragmatic, receptive and expressive language,
32 3. cognitive functioning,
33 4. applied behavior analysis, intervention and modification,
34 5. motor planning,
35 6. sensory processing and integration, and
36 7. assistive technology;
37 (X) social skills education training.
38 (C) Upon request of the coverage provider, a provider of treatment for
39 autism spectrum disorders shall furnish medical records, clinical notes
40 or other necessary data that substantiate that the initial and continued
41 medical treatment is medically necessary and resulting in improved clin-
42 ical status or the prevention of regression or loss of skills and func-
43 tioning. When treatment is anticipated to require continued services to
44 achieve demonstrable progress, the coverage provider may request a
45 treatment plan consisting of diagnosis, proposed treatment by type,
46 frequency, anticipated duration of treatment, the anticipated outcomes
47 stated as goals, and the frequency by which the treatment plan will be
48 updated.
49 (D) An insurer providing coverage under this paragraph shall have in
50 place a procedure under which a person with autism spectrum disorder who
51 is covered under such policy and whose condition or disease requires
52 specialized medical care over a prolonged period of time shall receive a
53 referral to a specialist with appropriate training and experience in its
54 panel or network to meet the particular health care needs of an enrol-
55 lee, or if not available with the plan, to a nonparticipating provider
56 with appropriate training and experience to meet the particular health
A. 6888--B 5
1 care needs of an enrollee, at no additional cost to the enrollee beyond
2 what the enrollee would otherwise pay for services received within the
3 network. Such specialist may be responsible for and shall be deemed
4 capable of providing and coordinating the enrollee's primary and
5 specialty care.
6 (E) Such insurer shall have a procedure by which a person with autism
7 spectrum disorder whose condition, disability, or disease requires ongo-
8 ing care from a specialist may request and obtain a standing referral to
9 such specialist for treatment of such condition. If the primary care
10 provider and the specialist (if any), determines that such a standing
11 referral is appropriate, the plan or issuer shall authorize such a
12 referral to such a specialist. Such standing referral shall be consist-
13 ent with a treatment plan.
14 § 3. Subsection (ee) of section 4303 of the insurance law, as added by
15 chapter 557 of the laws of 2006, is amended to read as follows:
16 (ee) (1) A medical expense indemnity corporation, a hospital service
17 corporation or a health service corporation which provides coverage for
18 hospital, surgical, or medical care coverage shall [not exclude] include
19 coverage for the diagnosis and treatment of [medical conditions other-
20 wise covered by the policy solely because the treatment is provided to
21 diagnose or treat] autism spectrum [disorder] disorders.
22 (2) For purposes of this [section, "autism] subsection:
23 (A) "Autism spectrum [disorder" means a neurobiological condition that
24 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
25 opmental disorder] disorders" means pervasive developmental disorders as
26 defined in the the Diagnostic and Statistical Manual of Mental Disorders
27 IV Revised, including autism, Asperger's disorder and pervasive develop-
28 mental disorders not otherwise specified.
29 (B) "Diagnosis of autism spectrum disorders" means one or more tests,
30 evaluations or assessments to diagnose, whether an individual has autism
31 spectrum disorders or early indications in children younger than three
32 years of age that are prescribed, performed or ordered by (i) a physi-
33 cian licensed to practice medicine in this state or (ii) a psychologist
34 licensed to practice in this state and having expertise in diagnosing
35 autism spectrum disorders.
36 (C) "Medically necessary" means any care, treatment, intervention,
37 service or item which will or is reasonably expected to do any of the
38 following:
39 (i) prevent the onset of an illness, condition, injury, disease or
40 disability;
41 (ii) reduce or ameliorate the physical, mental or developmental
42 effects of an illness, condition, injury, disease or disability; or
43 (iii) assist to achieve or maintain maximum functional activity in
44 performing daily activities.
45 (D) "Treatment for autism spectrum disorders" shall include but not be
46 limited to the following care prescribed, provided or ordered for an
47 individual diagnosed with autism spectrum disorders:
48 (i) psychiatric care, including direct, consultative or diagnostic
49 services provided by a licensed physician specializing in psychiatry;
50 (ii) psychological care, including direct or consultative services
51 provided by a licensed psychologist;
52 (iii) habilitative or rehabilitative care, including professional,
53 counseling and guidance services and treatment programs that are
54 intended to develop, maintain and restore the functioning of an individ-
55 ual;
A. 6888--B 6
1 (iv) pediatric and developmental pediatric care, including direct,
2 consultative or diagnostic services provided by a licensed physician
3 specializing in pediatrics and developmental pediatrics;
4 (v) anesthesiological care and anesthetic services, including direct,
5 consultative or diagnostic services provided by a licensed physician
6 specializing in anesthesiology;
7 (vi) neurological care including direct, consultative or diagnostic
8 services provided by a licensed physician specializing in neurology;
9 (vii) gastro-enterologic care including direct, consultative or diag-
10 nostic services provided by a licensed physician specializing in
11 gastroenterology;
12 (viii) endocrinological care including direct, consultative or diag-
13 nostic services provided by a licensed physician specializing in endo-
14 crinology;
15 (ix) therapeutic care, including behavioral, speech, occupational and
16 physical therapies that provide treatment in the following areas:
17 (I) self care and feeding,
18 (II) pragmatic, receptive and expressive language,
19 (III) cognitive functioning,
20 (IV) applied behavior analysis, intervention and modification,
21 (V) motor planning,
22 (VI) sensory processing and integration, and
23 (VII) assistive technology;
24 (x) social skills education training.
25 (3) Upon request of the coverage provider, a provider of treatment for
26 autism spectrum disorders shall furnish medical records, clinical notes
27 or other necessary data that substantiate that the initial and continued
28 medical treatment is medically necessary and resulting in improved clin-
29 ical status or the prevention of regression or loss of skills and func-
30 tioning. When treatment is anticipated to require continued services to
31 achieve demonstrable progress, the coverage provider may request a
32 treatment plan consisting of diagnosis, proposed treatment by type,
33 frequency, anticipated duration of treatment, the anticipated outcomes
34 stated as goals, and the frequency by which the treatment plan will be
35 updated.
36 (4) An insurer providing coverage under this subsection shall have in
37 place a procedure under which a person with autism spectrum disorder who
38 is covered under such policy and whose condition or disease requires
39 specialized medical care over a prolonged period of time shall receive a
40 referral to a specialist with appropriate training and experience in its
41 panel or network to meet the particular health care needs of an enrol-
42 lee, or if not available with the plan, to a nonparticipating provider
43 with appropriate training and experience to meet the particular health
44 care needs of an enrollee, at no additional cost to the enrollee beyond
45 what the enrollee would otherwise pay for services received within the
46 network. Such specialist may be responsible for and shall be deemed
47 capable of providing and coordinating the enrollee's primary and
48 speciality care.
49 (5) Such insurer shall have a procedure by which a person with autism
50 spectrum disorder whose condition, disability, or disease require ongo-
51 ing care from a specialist may request and obtain a standing referral to
52 such specialist for treatment of such condition. If the primary care
53 provider and the specialist (if any), determines that such a standing
54 referral is appropriate, the plan or issuer shall authorize such a
55 referral to such a specialist. Such standing referral shall be consist-
56 ent with a treatment plan.
A. 6888--B 7
1 § 4. This act shall take effect on the first of January next succeed-
2 ing the date on which it shall have become a law and shall apply to all
3 policies or contracts issued, renewed, modified, altered or amended on
4 and after such effective date.
